Hydrocortisone decreases apoptosis in jejunum of horses subjected to experimental ischemia and reperfusion / Hidrocortisona diminui a apoptose no jejuno de equinos sujeitos a isquemia e reperfusão experimentais

In order to evaluate the effect of hydrocortisone on apoptosis in the jejunum of horses subjected to ischemia and reperfusion, ten horses were paired and grouped into two groups - treated (n=5) and non treated (n=5). Segments of the jejunum were used as controls (C), or as venous ischemia (VIsc), which were subjected to 2h of ischemia followed by 2 or 12h of reperfusion. C samples were collected at time zero (prior to ischemia) and VIsc samples were collected at 2h of ischemia and at 2 and 12h of reperfusion. TUNEL positive apoptotic cells were counted in 10 microscopical fields in deep mucosa from each horse throughout the time course. After 12h of reperfusion, the number of apoptotic cells in treated group were significantly lower than in untreated animals, indicating that hydrocortisone inhibits apoptosis. These results indicate that hydrocortisone has a beneficial effects favoring the maintenance of jejunal integrity in horses with ischemia and reperfusion injuries by preventing apoptotic cell death.

Com o objetivo de avaliar o efeito da hidrocortisona sobre a apoptose no jejuno de equinos submetidos à is-quemia e reperfusão, dez cavalos foram agrupados em dois grupos: tratado (n=5) e não-tratado (n=5). Foi utilizado um segmento do jejuno como controle (C) e outro foi submetido a isquemia venosa (VIsc) por 2h seguida de 2 ou 12 h de re-perfusão. Amostras de C foram coletadas no tempo zero (antes da isquemia) e amostras de VIsc foram coletadas após 2h de isquemia e a 2 e 12h de reperfusão. Células apoptóticas TUNEL positivas foram contadas em 10 campos microscópicos da mucosa na região das criptas de cada animal em cada tempo. Após 12h de reperfusão, o número de células apoptóticas no grupo tratado foram significativamente menores do que no grupo não-tratado, indicando que a hidrocortiso-na inibe a apoptose. Esses resultados mostram que a hidro-cortisona tem efeito benéfico favorecendo a manutenção da integridade do jejuno em cavalos com lesão de isquemia e reperfusão por prevenir a morte celular por apoptose.

Clinical applications and techniques of cinedefecography.

BACKGROUND: Cinedefecography is of value in routine examination of functional disorders of the pelvic floor. Interest in this technique has rapidly expanded owing to the increased availability of colorectal physiologic testing and better understanding of the multifactorial pathophysiology involving evacuation disorders. METHODS: A summary of the available techniques, methodology, and indications for cinedefecography was undertaken. In addition, information was provided on interpretation of these images particularly in the context of anatomic abnormalities and clinical applications. RESULTS: Cinedefecography can be rapidly and easily performed using standard radiographic equipment. Effective radiation dose is significantly lower than for other intestinal contrast studies. The technique has been found most useful for measurements of perineal descent, puborectalis length, and ascertaining the function of the puborectalis muscle and pelvic floor. Common diagnoses that can be made by this test include nonrelaxing puborectalis syndrome, perineal descent, rectocele, enterocele, sigmoidocele, and rectoanal intussusception. CONCLUSION: Cinedefecography provides a wide range of information to assist the surgeon with the evaluation and management of patients with evacuatory and other associated pelvic floor disorders.

The value of sphincter asymmetry index in anal incontinence.

We tested the value of the sphincter asymmetry index (SAI), an adjunct study of vectormanometry for detecting sphincter defects of difficult clinical diagnosis, in patients with anal incontinence referred for anal manometry. Patients were prospectively classified as having no previous anal trauma (group I, n = 13), those with possible trauma (including previous vaginal delivery and anorectal surgery unrelated to the onset of incontinence; group II, n = 53), and those with previous anal trauma directly related by the patient to the onset of symptoms (group III, n = 39). These were compared to 30 healthy volunteers. Clinical data were compiled to obtain an incontinence score, sphincter defect, mean and maximal pressures, functional anal canal length, and SAI for both resting and squeeze pressure profiles. SAI values for the control group were 7.2 +/- 2.3% and 5.8 +/- 2.4% for resting and squeeze pressures, respectively. Female controls had shorter anal canals (P = 0.0001) and higher SAI during squeeze (P < 0.005) than male controls. Incontinence scores were 6.1 +/- 3.1, 8.6 +/- 3.9, and 12.5 +/- 4.9, in groups I, II, and III, respectively (P < 0.001). Mean SAI values at rest were 10.3 +/- 4.9% in group I, 19.0 +/- 10.6% in group II, and 23.6 +/- 14.0% in group III (P < 0.001); corresponding values during squeeze were 8.6 +/- 5.3%, 13.9 +/- 7.9%, and 16.8 +/- 8.0% (P < 0.01). Pressure profiles both at rest and during squeeze were inversely correlated with SAI; therefore the accuracy of SAI was not affected in patients with severe incontinence. Incontinent patients with a previous history of sphincter trauma thus had more severe incontinence, both clinically and manometrically, and higher SAI values than patients without prior trauma. The analysis of the SAI is a valuable tool for determining a traumatic cause of anal incontinence.

Anatomy and physiology of the rectum and anus.

Anorectal physiology is complex and involves the interaction of multiple mechanisms. Advances in physiological testing have led to a great deal of research, which has increased our knowledge of normal and disordered physiology, and modified our therapeutic approach. As a consequence, many concepts in anatomy have been revised. We have reviewed aspects of the anatomy and physiology of the rectum and anus together with the applications of the new concepts.

[Prevalence of fecal incontinence in diabetic patients: epidemiological study of patients assisted as outpatients at the Clinical Hospital of the Medical School at the University of São Paulo]. / Prevalência da incontinência anal no diabético: estudo epidemiológico com base na população atendida em regime ambulatorial no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo.

The object of this research was to establish the prevalence of fecal incontinence in those diabetics attended as outpatients at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Individual verbal interviewing was the an adopted method. The classification of diabetes mellitus of World Health Organization was employed (1985). Data was aggregated relative sex, age, color, type of diabetes mellitus, fecal incontinence, duration of diabetes mellitus, peripheral neuropathy, intestinal habits (normal, constipation and diarrhea), urgency to evacuate, sensation of incomplete evacuation, urinary incontinence, vaginal deliveries and its characteristics. The study involved 258 diabetics, 167 of female sex having an average age of 56.2 years (17 to 78 years of age) and 91 of the male sex having average age of 55.8 years (10 to 74 years of age). With relation to color, 57% were white, 28.7% mullato, 11.2% black and 3.1% yellow. Fecal incontinence was prevalent in 18.6% of the cases studied. It occurred also in types I and II diabetics with predominance in the male sex. It also occurred in diabetics having an average history of 10.8 years to onset of illness. Peripheral neuropathy was observed in 8.5% of the diabetics investigated however no association was observed between the peripheral neuropathy and fecal incontinence. Constipation occurred in 29.5% of the patients and diarrhea in 21.3%. Incomplete evacuation was apparent in 15.1% of diabetics and urgency to evacuate in 12.8%. A relationship was identified between fecal incontinence with diarrhea and incomplete evacuation in the group investigated. Total vaginal deliveries was 458 with 70 episiotomies and 25 by forceps. There was no statistical evidence of association between the average number of vaginal deliveries, episiotomies and forceps in diabetics demonstrating or not demonstrating fecal incontinence. Urinary incontinence was more prevalent that fecal incontinence. No relationship was determined between urinary and fecal incontinence for the purpose of the present study.

Incidence and clinical significance of sigmoidoceles as determined by a new classification system.

PURPOSE: A study was undertaken to assess the incidence and clinical significance of sigmoidocele as a finding during cinedefecography. METHODS: All patients who underwent cinedefecography between July 1988 and July 1992 were prospectively evaluated. Clinical data were assessed by a standardized questionnaire. Sigmoidocele was classified based on the degree of descent of the lowest portion of the sigmoid: 1 degree = above the pubococcygeal line; 2 degrees = below the pubococcygeal line and above the ischiococcygeal line; 3 degrees = below the ischiococcygeal line. This classification was then correlated with the patient's symptoms and percentage of redundancy relative to rectal length. RESULTS: Twenty-four sigmoidoceles (5.2 percent) were noted in 463 cinedefecographic studies; 289 of these patients had constipation. These five males and 19 females were of a mean age of 57 (range, 20-77) years. Nine patients had 1 degree sigmoidocele, seven had 2 degrees, and eight had 3 degrees. Percentage of sigmoid redundancy was 51 percent, 65 percent, and 88 percent for 1 degree, 2 degrees, and 3 degrees, respectively (P = 0.0001). Impaired rectal emptying was present in 16 patients (67 percent). Five of eight patients with 3 degrees sigmoidocele underwent colonic resection with or without rectopexy. The other three patients were conservatively managed. One of seven patients with 2 degrees sigmoidocele underwent colectomy, and the other six were conservatively managed as were all nine patients with 1 degree. Posttreatment improvement was noted in 100 percent (6 of 6) of patients operated on but in only 33 percent (6 of 18) of patients conservatively treated. Thus, this proposed classification system yielded excellent correlation among the mean of level of the sigmoidocele, percentage of redundancy, and clinical symptoms. Furthermore, clinical significance of 3 degrees sigmoidocele is supported by the fact that all five of 3 degrees patients who underwent colonic resection reported symptomatic improvement at a mean follow-up of 23 (range, 15-39) months. CONCLUSION: Sigmoidocele may account for symptoms of obstructed defecation, and, therefore, it must be considered in the differential diagnosis and evaluation of constipation. Staging of sigmoidocele is useful in determining both clinical significance and optimal treatment.

Recovery of anal sphincter function after the ileoanal reservoir procedure in patients over the age of fifty.

PURPOSE: This study was undertaken to postoperatively assess the progression of anal sphincter function and clinical outcome in patients > or = 50 years old (Group I) compared with those < 50 years old (Group II). METHODS: Clinical data were assessed after ileostomy closure by a questionnaire. These data were compiled to obtain an incontinence score, which ranged from 0 (perfect continence) to 20 (total incontinence). Anorectal manometry was performed preoperatively (MN1) and postoperatively, before (MN2) and after (MN3) ileostomy closure. Wilcoxon and paired t-test were used to compare the clinical and functional results, respectively. RESULTS: Group I consisted of 22 patients (mean age, 56 years) and Group II, 50 patients (mean age, 32 years). No differences were found relative to either preoperative pressures or clinical outcome. However, both the mean and high resting pressures were significantly lower in Group I at the MN2 examination. CONCLUSION: The effect on anal sphincters of ileoanal reservoir in patients over the age of 50 years is similar to that noted in younger patients. Transient impairment of internal anal sphincter function observed after ileoanal reservoir is more severe in older patients (P = 0.01). However, as in younger patients, it does completely recover after ileostomy closure.

Patient position during cinedefecography. Influence on perineal descent and other measurements.

PURPOSE: This study was undertaken to assess the reproducibility of cinedefecography measurements and abnormal findings between the left lateral decubitus and seated positions. METHODS: Prospective patient evaluation included all patients who had lateral radiographs of the pelvis taken at rest, during squeezing, and pushing in both positions. Anorectal angle, perineal descent, and puborectalis length measurements were calculated for each set of radiographs. Pelvic floor dynamics during evacuation were measured as the changes between rest and pushing. Abnormal findings included both increased dynamic and fixed perineal descent, nonrelaxing puborectalis, and premature evacuation. RESULTS: One hundred five consecutive patients underwent cinedefecography. There were statistically significant differences between the positions with regard to anorectal angle (P < 0.0001), perineal descent (P = 0.0001), and puborectalis length (P = 0.0001). Dynamic changes of the anorectal angle, perineal descent, and puborectalis length were not significantly different (P > 0.05). However, 6 of 22 (27 percent) patients with fecal incontinence had premature evacuation severe enough to impede measurement only when seated (P = 0.05). CONCLUSION: Because of the statistically significant differences between the two positions, centers should always employ the same position for a given diagnostic group.

The lactulose hydrogen breath test as a measure of orocaecal transit time.

OBJECTIVE: To establish normal values and assess the reproducibility of the lactulose hydrogen breath test in measuring orocaecal transit time in control subjects, and to report results in a group of patients with chronic constipation as a result of colonic inertia. DESIGN: Open study. SETTING: Academic clinic. SUBJECTS: 42 Control subjects (29 women and 13 men) in 25 of whom the test was repeated within 2-4 weeks, and 19 patients. INTERVENTIONS: Lactulose hydrogen breath test. MAIN OUTCOME MEASURES: Sustained increase in hydrogen production of 3 ppm or more. RESULTS: Coefficient of variation within subjects was 8% compared with 38% between subjects; 3 of the control subjects (7%) and 3 of the patients (16%) did not ferment lactulose, the the incidence was similar in men (1/13, 8%) and women (2/29, 7%). Mean (SD) orocaecal transit time was significantly shorter among the 29 women (60 (27) minutes) than among the 11 men (89 (24) minutes) (p < 0.005). There were no significant differences between men in the control group and those with constipation. CONCLUSIONS: The lactulose hydrogen breath test is valuable to assess orocaecal transit time. It is simple, non-invasive, and reproducible, and may be of value in differentiating between generalised hypomotility and colonic inertia.

Discrepancies in anal manometric pressure measurement--important or inconsequential?

PURPOSE: Maximum resting and squeeze pressures have been the most widely employed parameters for manometric assessment of the anal sphincters. However, a single maximum value may not always be the best assessment. METHODS: The aim of this study was to compare mean and maximum resting and mean and maximum squeeze pressures in a large sample population. All manometric pressure profiles were reviewed by a single individual blinded to the patient's age and diagnosis. RESULTS: Four hundred sixty-six patients with a measurable high-pressure zone were included in this study. The study population was comprised of 279 females and 186 males. A significant difference was found between mean (56.26 mmHg) and maximum (79.2 mmHg) resting pressures (P < 0.01) and also between mean (81.25 mmHg) and maximum (119.50 mmHg) squeeze pressures (P < 0.01). A significant difference (P < 0.01) was also observed when compared by length of the high-pressure zone. CONCLUSION: The measurement, documentation, and reporting of mean resting and mean squeeze pressures provide a better perspective of anal manometric results, since the two sets of values are significantly different (P < 0.01), regardless of the anal canal length. Therefore, these data support the standardized evaluation of both mean and maximum pressures in individual patients and in published series.

Optimization of sphincter function after the ileoanal reservoir procedure. A prospective, randomized trial.

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: high-pressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17-69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (delta = 2.6) in Group 1 and from 0.2 to 2.0 (delta = 1.8) in Group 2 (P = 0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P > 0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.

Colorectal physiological tests: use or abuse of technology?

OBJECTIVE: To assess the value of colorectal physiological tests in patients with functional disorders of defecation. DESIGN: Prospective study. SETTING: Academic hospital. SUBJECTS: 308 consecutive patients. INTERVENTIONS: Routine history and physical examination, followed by colonic transit study, and manometry, cinedefecography, electromyography of the anal sphincter, and assessment of terminal motor latency of the pudendal nerve. MAIN OUTCOME MEASURES: Number of diagnoses made after physiological tests compared with routine history and examination alone. RESULTS: Definitive diagnoses were made after history and physical examination alone in 15/180 (8%) with constipation, 9/80 (11%) with incontinence, and 11/48 (23%) with intractable rectal pain. The figures after physiological tests were 135/180 (75%), 53/80 (66%), and 20/48 (42%), respectively. Among the diagnoses made by physiological testing alone were: in patients with constipation, paradoxical puborectalis contraction (n = 59), colonic inertia (n = 31), rectocele (n = 19), and intussusception (n = 18); in those with incontinence, loss of muscle fiber (n = 21), neuropathy (n = 10), and both (n = 15); and in those with rectal pain, neuropathy (n = 6) and paradoxical puborectalis contraction (n = 3). The numbers of patients that remained undiagnosed in the three groups were 45 (25%), 27 (34%), and 28 (58%), respectively. Treatable conditions were diagnosed by physiological testing in 120/180 patients with constipation (67%) and 44 patients with incontinence (55%). Only 9 patients with rectal pain had treatable causes identified by physiologic testing. CONCLUSION: The value of colorectal physiological tests is greatest in patients who present with constipation or incontinence; they are of little value in those with chronic intractable rectal pain.

Anorectal manometry in the diagnosis of paradoxical puborectalis syndrome.

This prospective study was undertaken to compare the utility of anorectal manometry (ARM) with that of anal electromyography (EMG) and cinedefecography (CD) in the diagnosis of paradoxical puborectalis syndrome (PPS). One hundred sixteen consecutive patients with a history of chronic constipation were prospectively assessed. These 35 males and 81 females were of a mean age of 60 years, ranging from 18 to 84 years. The incidences of PPS were 63 percent for ARM, 38 percent for EMG, and 36 percent for CD. The correlations of PPS were suboptimal: ARM and EMG, 70 percent; and ARM and CD, 61 percent. A two-tiered system for the manometric classification of PPS was developed. First, the evacuation pressure curve pattern was classified as a normal relaxed downward (Type A; n = 43), a nonrelaxed flat or equivocal (Type B; n = 36), and a paradoxical upward (Type C; n = 37). PPS was noted with increasing incidence within curve types (21 percent in Type A, 64 percent in Type B, and 95 percent in Type C). Second, an evacuation index (EI = evacuation pressure/squeeze pressure) was defined: Group I (EI < 0; n = 43), Group II (0 < or = EI < 0.25; n = 24), Group III (0.25 < or = EI < 0.5; n = 27), and Group IV (EI > or = 0.5; n = 18). The finding of PPS also correlated with the EI group: 21 percent in Group I, 67 percent in Group II, 74 percent in Group III, and 100 percent in Group IV. This subdivision of curve types and EI groups may provide a role in the diagnosis of PPS.

Anorectal manometry: techniques and clinical applications.

Anorectal manometry has gained wide acceptance as a helpful method to objectively assess the apparatus of defecation provided by the anorectal sphincter. The standard manometric evaluation enables measurement of resting and squeeze pressures, as well as of the length of the functional anal canal (high pressure zone [HPZ]). More detailed assessment of radial and longitudinal pressure profiles can also be generated from vector volume and vector symmetry index assessment. Adjuvant techniques using an intrarectal balloon allow assessment of the rectoanal inhibitory reflex (RAIR), rectal sensitivity, capacity, and compliance. Although anorectal manometry can be used as a diagnostic test in diseases such as Hirschsprung's disease, more often it is used to assess common disorders such as chronic idiopathic constipation and fecal incontinence. Anorectal manometry has also been considered as a preoperative evaluation in patients having abdominal and anorectal procedures during which the state of continence can be jeopardized.

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

Does perineal descent correlate with pudendal neuropathy?

A prospective study was undertaken to assess the potential correlation between increased perineal descent (IPD) and pudendal neuropathy (PN) in 213 consecutive patients. These 165 females and 48 males of a mean age of 62 (range, 18-87) years had constipation (n = 115), idiopathic fecal incontinence (n = 58), or chronic intractable rectal pain (n = 40). All 213 patients underwent cinedefecography (CD) and bilateral pudendal nerve terminal motor latency (PNTML) assessment. Perineal descent (PD) of more than the upper limit of normal of 3.0 cm during evacuation was considered increased. Pudendal neuropathy was diagnosed when PNTML exceeded the upper limit of normal of 2.2 milliseconds. Although 65 patients (31 percent) had PD, only 16 (25 percent) of these 65 patients had neuropathy. Moreover, PN was also found in 42 (28 percent) of 148 patients without IPD. Conversely, only 16 (28 percent) of the 58 patients who had PN also had IPD, and IPD was present in 49 (32 percent) of 155 patients without PN. The frequency of PN according to the degree of IPD was: 3.0 to 4.0 cm, 6 of 27 patients (22 percent); 4.1 to 5.0 cm, 4 of 15 (27 percent); 5.1 to 6.0 cm, 4 of 12 (25 percent); 6.1 to 7.0 cm, 2 of 8 (25 percent); and > 7.0 cm, 0 of 3 (0 percent). Linear regression analysis was undertaken to compare the relationships between measurements of PD at rest (R), push (P), and change (C = P-R) and values of PNTML. These values for all 213 patients were: R, r = 0.048; P, r = 0.031; and C, r = -0.050. The correlation coefficients were equally poor for all the individual subgroups analyzed, including the patient's sex or diagnosis. In summary, no correlation was found between PD and PNTML. The lack of a relationship was seen for the entire group as well as for those patients with either neuropathy or increased perineal descent. Therefore, the often espoused relationship between increased PD and PN was not supported by this prospective evaluation. Although increased PD and prolonged PNTML are frequently observed in patients with disordered defecation, they may represent independent findings.

Evaluation and treatment of chronic intractable rectal pain--a frustrating endeavor.

A study was undertaken to assess the evaluation and treatment of chronic intractable rectal pain. Sixty consecutive patients, 23 males and 37 females with a mean age of 69 (range, 29-87) years and a mean length of symptoms of 4.5 years, were evaluated by questionnaire, office examination, anal manometry, electromyography, cinedefecography, and pudendal nerve study. In all cases, organic abdominopelvic and anorectal etiologies for the pain were excluded by extensive radiologic and endoscopic evaluation. All patients had failed conservative and medical therapy. Ninety-five percent of patients had one or more associated factors: constipation or dyschezia (57 percent), prior pelvic surgery (43 percent), prior anal surgery (32 percent), prior spinal surgery (8 percent), irritable bowel syndrome (10 percent), or psychiatric disorders (depression or anxiety; 25 percent). Possible etiologies for the pain included levator spasm or anismus in 62 percent, coccygodynia in 8 percent, and pudendal neuropathy in 24 percent of patients. Therapy for pain control included electrogalvanic stimulation (EGS) in 29, biofeedback (BF) in 14, and steroid caudal block (SCB) in 11 patients. Pain control was assessed by an independent observer at a mean of 15 (range, 2-36) months after completion of therapy. Continued successful pain relief was classified by patients as good or excellent after EGS in 38 percent, after BF in 43 percent, and after SCB in 18 percent; overall success was reported by 47 percent of patients. The presence of levator spasm, coccygodynia, or pudendal neuropathy did not influence outcome. The routine use of physiologic investigation of rectal pain may not be justifiable. Moreover, more than half of the patients were refractory to all three therapeutic options used in this study.

Etiology and management of fecal incontinence.

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives. The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.

How reliable are currently available methods of measuring the anorectal angle?

A prospective study was undertaken to compare two different methods of measuring the anorectal angle (ARA), balloon proctography (BP) and cinedefecography (CD), as well as to evaluate the reproducibility of this measurement using each technique. One hundred four consecutive patients (75 women and 29 men) with constipation (63 patients), fecal incontinence (25 patients), or rectal pain (16 patients) underwent both BP and CD. The ARA was measured by taking lateral radiographs of the pelvis during rest (R), squeeze (S), and push (P). The same interpretation process was performed 2 to 12 months later by the same observer, blinded as to diagnosis and initial measurements. There were highly significant differences in each measurement category, R (P less than 0.0001), S (P less than 0.0001), and P (P less than 0.0004) between BP and CD. However, the correlation between the first and second measurements was excellent (P less than 0.0001). BP was consistently more difficult to interpret because of balloon configuration. Although BP and CD have poor correlation with each other, each examination can be reliably interpreted. CD appears to be a superior examination because of the added ability to delineate rectoceles, intussusceptions, and other structural defects.