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Cerdán Miguel J, Arroyo Sebastián A, Codina Cazador A, de la Portilla de Juan F, de Miguel Velasco M, de San Ildefonso Pereira A, Jiménez Escovar F, Marinello F, Millán Scheiding M, Muñoz Duyos A, Ortega López M, Roig Vila JV, Salgado Mijaiel G. Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology. Cir Esp 2024; 102:158-173. [PMID: 38242231 DOI: 10.1016/j.cireng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 01/21/2024]
Abstract
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
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Affiliation(s)
| | - Antonio Arroyo Sebastián
- Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - Antonio Codina Cazador
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain
| | | | | | | | | | - Franco Marinello
- Unidad de Cirugía Colorrectal, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mónica Millán Scheiding
- Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Arantxa Muñoz Duyos
- Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Mario Ortega López
- Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Pinta T, Ruohonen J, Kallio-Packalen M, Zhabin I, Kirss J. 3T external phased-array magnetic resonance imaging in detection of obstetric anal sphincter lesions: a pilot study. Acta Radiol 2023; 64:1238-1244. [PMID: 35787708 DOI: 10.1177/02841851221109139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Three-dimensional endoanal ultrasound (3D EAUS) has been the gold standard for detecting anal sphincter lesions in patients with a history of obstetric anal sphincter injury (OASI). Advances in imaging technologies have facilitated the detection of these lesions with external phased-array magnetic resonance imaging (MRI), which could offer an alternative imaging modality for the diagnosis of residual OASI (ROASI) in centers where 3D EAUS imaging is not available. PURPOSE To compare two diagnostic modalities: the 3D EAUS and 3T external phased-array MRI in the detection of residual anal sphincter lesions. MATERIAL AND METHODS A total of 24 women with a history of OASI were imaged with both 3D EAUS and 3T external phased-array MRI after primary repair of the injury. Intraclass correlation (ICC) and interrater reliability (IRR) values were calculated for the grade and circumference of the sphincter lesion. Sphincter lesions were graded according to the Sultan classification. RESULTS There was an almost perfect agreement between 3D EAUS and 3T external phased-array MRI in determining the extent of the sphincter lesions according to the Sultan classification (κ = 0.881; P < 0.001) and the circumference of the external anal sphincter defects, measured in degrees (κ = 0.896; P < 0.001). CONCLUSION The results of this study indicate that 3T external phased-array MRI and 3D EAUS yield comparable results in the diagnosis of ROASI. These findings suggest that 3T external phased-array MRI could serve as an alternative diagnostic modality to 3D EAUS in the diagnosis of ROASI.
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Affiliation(s)
- Tarja Pinta
- 176490Seinäjoki Central Hospital, Seinäjoki, Finland
- 8058University of Turku, Turku, Finland
| | | | | | - Ivan Zhabin
- 176490Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Jaan Kirss
- 8058University of Turku, Turku, Finland
- West Tallinn Central Hospital, Tallinn, Estonia
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Markaryan DR, Lukyanov AM, Garmanova TN, Agapov MA, Kubyshkin VA. [Postpartum fecal incontinence. State of the problem]. Khirurgiia (Mosk) 2022:127-132. [PMID: 35658144 DOI: 10.17116/hirurgia2022061127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.
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Affiliation(s)
| | - A M Lukyanov
- Lomonosov Moscow State University, Moscow, Russia
| | | | - M A Agapov
- Lomonosov Moscow State University, Moscow, Russia
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Khatri G, Bhosale PR, Robbins JB, Akin EA, Ascher SM, Brook OR, Dassel M, Glanc P, Henrichsen TL, Learman LA, Sadowski EA, Saphier CJ, Wasnik AP, Maturen KE. ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females. J Am Coll Radiol 2022; 19:S137-S155. [PMID: 35550798 DOI: 10.1016/j.jacr.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Gaurav Khatri
- Division Chief, Body MRI; Associate Division Chief, Abdominal Imaging, UT Southwestern Medical Center, Dallas, Texas; Program Director, Body MRI Fellowship.
| | | | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Section Chief of Abdominal Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mark Dassel
- Director Endometriosis and Chronic Pelvic Pain, Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Lee A Learman
- Dean, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Elizabeth A Sadowski
- University of Wisconsin, Madison, Wisconsin; and ACR O-RADS MRI Education Subcommittee Chair
| | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | - Ashish P Wasnik
- Division Chief, Abdominal Radiology, University of Michigan, Ann Arbor, Michigan
| | - Katherine E Maturen
- Associate Chair for Ambulatory Care and Specialty Chair, University of Michigan, Ann Arbor, Michigan
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Spinelli A, Laurenti V, Carrano FM, Gonzalez-Díaz E, Borycka-Kiciak K. Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives. J Clin Med 2021; 10:jcm10153261. [PMID: 34362045 PMCID: PMC8347477 DOI: 10.3390/jcm10153261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries—OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Correspondence:
| | - Virginia Laurenti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Francesco Maria Carrano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Enrique Gonzalez-Díaz
- Pelvic Floor Unit, Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain;
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain
| | - Katarzyna Borycka-Kiciak
- Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, 80, Ceglowska Street, 01810 Warsaw, Poland;
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Hölscher M, Gräf C, Stickelmann AL, Stickeler E, Najjari L. Perianal ultrasound (PAUS): visualization of sphincter muscles and comparison with digital-rectal examination (DRE) in females. BMC WOMENS HEALTH 2021; 21:247. [PMID: 34144688 PMCID: PMC8214294 DOI: 10.1186/s12905-021-01387-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022]
Abstract
Background The aim of this study was to determine the reproducibility and tolerance of perianal ultrasound (PAUS) and detect differences in sphincter muscles between various measuring positions and different maneuvers. PAUS was compared to digital-rectal examination (DRE) to see if sphincter contraction is visible and gradable in ultrasound volumes.
Methods Fifty women underwent a medical history, DRU and PAUS by two uro-gynecologists in a prospective trial. PAUS volumes were measured via different parameters in different maneuvers. Examiners’ DRE impressions of sphincter tone were scaled with the DRESS-score. All patients completed a questionnaire. Results Thirty-five patients with complete PAUS and DRE were included in the study. Fifteen patients were excluded due to poor ultrasound volume quality or sphincter defects. Comparison of sphincter muscle thickness at different positions in PAUS showed significant differences between 6 and 12 o’clock positions (12 > 6 o’clock) and diameters (horizontal > vertical). No difference was found between the examiners. In comparison of rest and contraction only the vertical diameter changed. There was a negative but not significant correlation between PAUS measurements and DRESS-scores. Twenty-six patients completed the questionnaire that revealed women preferred PAUS over DRE. Conclusion PAUS is a reproducible and good tool to visualize the anal canal. It is comfortable for patients and easily handled by examiners. Sphincter muscle contraction is iso-volumetric. Vertical diameter changes during contraction leading the anal canal change its shape to oval due to external influence. PAUS is the ideal additional tool to visualize relevant structures that are palpable on DRE.
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Affiliation(s)
- Miriam Hölscher
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Charlotte Gräf
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Anna-Lena Stickelmann
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Elmar Stickeler
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Laila Najjari
- Department of Gynecology and Obstetrics, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
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Sbeit W, Khoury T, Mari A. Diagnostic approach to faecal incontinence: What test and when to perform? World J Gastroenterol 2021; 27:1553-1562. [PMID: 33958842 PMCID: PMC8058654 DOI: 10.3748/wjg.v27.i15.1553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/01/2021] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Naharia 2210001, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Naharia 2210001, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Amir Mari
- Gastroenterology and Endoscopy Unit, The Nazareth Hospital, EMMS, Nazareth 464000, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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Heitmann PT, Rabbitt P, Schloithe AC, Wattchow DA, Scott SM, Dinning PG. The relationships between the results of contemporary tests of anorectal structure and sensorimotor function and the severity of fecal incontinence. Neurogastroenterol Motil 2020; 32:e13946. [PMID: 32683767 DOI: 10.1111/nmo.13946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/24/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnostic investigations for fecal incontinence (FI) assess the structure and sensorimotor function of the anorectum. Investigations include anorectal manometry, anorectal sensory testing, pudendal nerve terminal motor latencies (PNTML), and endoanal sonography. The severity of FI and results of investigations are often discordant and the rate of symptom resolution following treatment remains <40%. High-resolution anorectal manometry (HRAM) and three-dimensional endoanal ultrasound (3D-US) have been introduced during the last decade. This study aims to assess the strength of relationships between contemporary investigation results and FI severity. METHODS Adults presenting for investigation of FI were assessed using the St Mark's FI severity score (SMIS), HRAM, anorectal sensory testing, PNTML, and 3D-US. KEY RESULTS 246 patients were included. There were significant relationships between the SMIS and HRAM (resting pressure rs = -0.23, 95% CI = (-0.34, -0.11), P < .001; squeeze pressure (rs = -0.26, 95% CI = (-0.37, -0.14), P < .001) and 3D-US (anterior EAS length rs = -0.22, 95% CI = (-0.34, -0.09), P = .001). The relationships between SMIS and HRAM had a greater effect size in those with urge-predominant symptoms (resting pressure: rs = -0.40, 95% CI = (-0.57, -0.20), P < .001, squeeze pressure: rs = -0.34, 95% CI = (-0.52, -0.12), P = .003). Overall, the variance in SMIS accounted for by anorectal investigations was 8.6% (R2 = 0.098, adjusted R2 = 0.086, P < .001). CONCLUSIONS AND INFERENCES Anorectal investigations are not strong predictors of FI severity. These findings may reflect the multifactorial, heterogeneous pathophysiology of FI, the limitations of the SMIS and anorectal investigations, and contributing factors extrinsic to the anorectum.
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Affiliation(s)
- Paul T Heitmann
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Philippa Rabbitt
- Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Ann C Schloithe
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - David A Wattchow
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
| | - S Mark Scott
- Blizard Institute, Centre for Neuroscience, Surgery and Trauma, Queen Mary University, London, UK
| | - Phil G Dinning
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Departments of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, SA, Australia
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Jiang AC, Panara A, Yan Y, Rao SSC. Assessing Anorectal Function in Constipation and Fecal Incontinence. Gastroenterol Clin North Am 2020; 49:589-606. [PMID: 32718572 DOI: 10.1016/j.gtc.2020.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.
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Affiliation(s)
- Alice C Jiang
- Division of Gastroenterology, Department of Internal Medicine, Rush University Medical Center, 600 S Paulina St, Chicago, IL 60612, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Internal Medicine, University of Miami Leonard M. Miller School of Medicine, 1601 NW 12th Ave, Miami, FL, USA
| | - Yun Yan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Augusta University Medical Center, 1120 15th Street, AD 2226, Augusta, GA 30912, USA.
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10
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Transanale (3D‑)Ultraschalldiagnostik von Sphinkterdefekten und rektovaginalen Fisteln. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00450-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Pelvic floor dysfunctions: how to image patients? Jpn J Radiol 2019; 38:47-63. [DOI: 10.1007/s11604-019-00903-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 11/21/2019] [Indexed: 12/13/2022]
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12
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Kirss J, Huhtinen H, Niskanen E, Ruohonen J, Kallio-Packalen M, Victorzon S, Victorzon M, Pinta T. Comparison of 3D endoanal ultrasound and external phased array magnetic resonance imaging in the diagnosis of obstetric anal sphincter injuries. Eur Radiol 2019; 29:5717-5722. [PMID: 30915565 PMCID: PMC6717181 DOI: 10.1007/s00330-019-06125-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 01/28/2019] [Accepted: 02/22/2019] [Indexed: 12/17/2022]
Abstract
Objectives The gold standard of postpartum anal sphincter imaging has been the 3D endoanal ultrasound (EAUS). Development of magnetic resonance imaging (MRI) has allowed anal sphincter evaluation without the use of endoanal coils. The aim of this study is to compare these two modalities in diagnosing residual sphincter lesions post obstetric anal sphincter injury (OASI). Methods Forty women were followed up after primary repair of OASI with both 3D EAUS and external phased array MRI. Details of the anal sphincter injury and sphincter musculature were gathered and analysed. Results There was a moderate interrater reliability (κ = 0.510) between the two imaging modalities in detecting sphincter lesions, with more lesions detected by MRI. There was a moderate intraclass correlation (ICC) between the circumference of the tear (κ = 0.506) and a fair ICC between the external anal sphincter thickness measurements at locations 3 and 9 on the proctologic clock face (κ = 0.320) and (κ = 0.336). Conclusions The results of our study indicate that the use of external phased array MRI is feasible for detecting obstetric anal sphincter lesions postpartum. This allows for imaging of the sphincter defects in centres where EAUS imaging is not available. Key Points • A two centre prospective study that showed external phased array MRI to be a valid imaging modality for diagnosing obstetric anal sphincter injuries. Electronic supplementary material The online version of this article (10.1007/s00330-019-06125-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jaan Kirss
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland. .,University of Turku, Turku, Finland.
| | - Heikki Huhtinen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Eini Niskanen
- Department of Radiology, Vaasa Central Hospital, Vaasa, Finland
| | - Jyrki Ruohonen
- Department of Radiology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | | | | | | | - Tarja Pinta
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
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Nuernberg D, Saftoiu A, Barreiros AP, Burmester E, Ivan ET, Clevert DA, Dietrich CF, Gilja OH, Lorentzen T, Maconi G, Mihmanli I, Nolsoe CP, Pfeffer F, Rafaelsen SR, Sparchez Z, Vilmann P, Waage JER. EFSUMB Recommendations for Gastrointestinal Ultrasound Part 3: Endorectal, Endoanal and Perineal Ultrasound. Ultrasound Int Open 2019; 5:E34-E51. [PMID: 30729231 PMCID: PMC6363590 DOI: 10.1055/a-0825-6708] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 11/23/2018] [Accepted: 12/01/2018] [Indexed: 02/07/2023] Open
Abstract
This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.
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Affiliation(s)
- Dieter Nuernberg
- Medical School Brandenburg Theodor Fontane, Gastroenterology, Neuruppin, Germany
| | - Adrian Saftoiu
- Research Center in Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Ana Paula Barreiros
- Deutsche Stiftung Organtransplantation, Head of Organisation Center Middle, Frankfurt, Germany
| | - Eike Burmester
- Department of Internal Medicine/Gastroenterology, Sana-Kliniken Lübeck, Lübeck, Germany
| | - Elena Tatiana Ivan
- Research Center in Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Dirk-André Clevert
- Department of Clinical Radiology, Interdisciplinary Ultrasound-Center, University of Munich-Grosshadern Campus, Munich, Germany
| | | | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Torben Lorentzen
- Ultrasound Section, Division of Surgery, Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, "L.Sacco" University Hospital, Milan, Italy
| | - Ismail Mihmanli
- Istanbul University - Cerrahpasa, Cerrahpasa Medical Faculty, Department of Radiology and ALKA Radyoloji Tani Merkezi, Istanbul, Turkey
| | - Christian Pallson Nolsoe
- Ultrasound Section, Division of Surgery, Department of Gastroenterology, Herlev Hospital and Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen, Denmark
| | - Frank Pfeffer
- Department of Surgery, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Søren Rafael Rafaelsen
- Colorectal Centre of Excellence, Clinical Cancer Centre, University Hospital of Southern Denmark, Vejle, Denmark
| | - Zeno Sparchez
- 3rd Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Peter Vilmann
- Endoscopy Department, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Jo Erling Riise Waage
- Department of Surgery, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Xue YH, Ding SQ, Ding YJ, Pan LQ. Role of three-dimensional endoanal ultrasound in assessing the anal sphincter morphology of female patients with chronic proctalgia. World J Gastroenterol 2017; 23:3900-3906. [PMID: 28638230 PMCID: PMC5467076 DOI: 10.3748/wjg.v23.i21.3900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 02/07/2017] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the role of three-dimensional endoanal ultrasound (3D-EAUS) for morphological assessment of the anal sphincter of female patients with chronic proctalgia (CP).
METHODS In this unmatched case control study, 30 consecutive female patients with CP and 25 normal women (control group) were enrolled. 3D-EAUS was performed in all subjects. Thickness and length of internal anal sphincter (IAS), thickness of puborectalis muscle (PR), length of the external anal sphincter (EAS) plus PR, and puborectalis angle were measured and compared between the two groups.
RESULTS Patients with CP had significantly shorter IAS length and greater PR thickness, as compared to those in normal individuals (26.28 ± 3.59 mm vs 28.87 ± 4.84 mm, P < 0.05 and 9.67 ± 1.57 mm vs 8.85 ± 0.97 mm, P < 0.05, respectively). No significant between-group differences were observed with respect to IAS thickness and the EAS plus PR length (P > 0.05). Puborectalis angle in the CP group was significantly decreased, both in resting (88.23° ± 1.81° vs 89.94° ± 2.07° in control group, P < 0.05) and straining (88.47° ± 3.32° vs 90.72° ± 1.87° in control group, P < 0.05) phases, which suggest the presence of paradoxical contraction of PR in patients with CP. In the CP group, no significant difference in puborectalis angle was observed between the resting and straining phases (88.23° ± 1.81° vs 88.47° ± 3.32° respectively, P > 0.05).
CONCLUSION The association of greater PR thickness and paradoxical contraction of PR with CP suggest their potential value as markers of CP.
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Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Functional Anorectal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00175-X. [PMID: 27144630 PMCID: PMC5035713 DOI: 10.1053/j.gastro.2016.02.009 10.1053/j.gastro.2016.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 01/11/2024]
Abstract
This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.
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Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Functional Anorectal Disorders. Gastroenterology 2016; 150:S0016-5085(16)00175-X. [PMID: 27144630 PMCID: PMC5035713 DOI: 10.1053/j.gastro.2016.02.009] [Citation(s) in RCA: 259] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 12/12/2022]
Abstract
This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.
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Pucciani F, Altomare DF, Dodi G, Falletto E, Frasson A, Giani I, Martellucci J, Naldini G, Piloni V, Sciaudone G, Bove A, Bocchini R, Bellini M, Alduini P, Battaglia E, Galeazzi F, Rossitti P, Usai Satta P. Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists. Dig Liver Dis 2015; 47:628-45. [PMID: 25937624 DOI: 10.1016/j.dld.2015.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/08/2015] [Accepted: 03/28/2015] [Indexed: 02/06/2023]
Abstract
Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.
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Affiliation(s)
| | - Filippo Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Italy.
| | | | - Giuseppe Dodi
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Ezio Falletto
- I Division of Surgical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Alvise Frasson
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Iacopo Giani
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | - Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Gabriele Naldini
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | | | - Guido Sciaudone
- General and Geriatric Surgery Unit, School of Medicine, Second University of Naples, Italy
| | | | - Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology - AORN "A. Cardarelli", Naples, Italy
| | - Renato Bocchini
- Gastrointestinal Physiopathology, Gastroenterology Department, Malatesta Novello Private Hospital, Cesena, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Gastroenterology, University of Pisa, Italy
| | - Pietro Alduini
- Digestive Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | | | - Piera Rossitti
- Gastroenterology Unit, S.M. della Misericordia University Hospital, Udine, Italy
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18
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ACR Appropriateness Criteria pelvic floor dysfunction. J Am Coll Radiol 2014; 12:134-42. [PMID: 25652300 DOI: 10.1016/j.jacr.2014.10.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 10/29/2014] [Indexed: 01/23/2023]
Abstract
Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient's symptoms, the clinical information desired, and the usefulness of the test. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Soerensen MM, Pedersen BG, Santoro GA, Buntzen S, Bek K, Laurberg S. Long-term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury. Colorectal Dis 2014; 16:O347-55. [PMID: 24502361 DOI: 10.1111/codi.12579] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 10/29/2013] [Indexed: 12/24/2022]
Abstract
AIM More than 50% of women experience deteriorating continence over time following primary repair of obstetric anal sphincter injuries. The objectives of this study were to assess the function and morphology of the anal sphincters and pelvic floor in women with long-term faecal incontinence after sphincter repair (primary end-point) and to evaluate their correlation with severity of incontinence (secondary end-point). METHOD The participants in this prospective study were recruited from a cohort of all women who sustained third or fourth degree obstetric sphincter injury reconstruction (cases) from January 1976 to November 1991. The women who delivered immediately before and after each case, without sustaining obstetric damage, were included as controls. Cases and controls were stratified into three categories: (i) continent; (ii) minor incontinence; and (iii) severe incontinence. The function and morphology of the anal sphincters and pelvic floor were evaluated by MRI, three-dimensional endoanal ultrasonography and anorectal physiology tests. RESULTS Fifty-nine women (29 cases/30 controls; mean age 51/53 years; mean follow-up 23.7/24.1 years, respectively) were assessed. Morphologically, cases had a significantly shorter anterior external anal sphincter length compared with controls when evaluated by three-dimensional endoanal ultrasonography (8.6 vs 10.2 mm; P = 0.03). Functionally, cases with severe incontinence had a significantly shorter anterior sphincter length compared with cases with minor incontinence (7.7 vs 10.4 mm; P = 0.04). No correlation could be found between anal pressures and severity of incontinence in the case group. CONCLUSIONS Cases had a significantly shorter anterior external anal sphincter length. Functionally, anterior sphincter length correlated with increased severity of incontinence.
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Affiliation(s)
- M M Soerensen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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MURAD-REGADAS SM, DEALCANFREITAS ID, REGADAS FSP, RODRIGUES LV, FERNANDES GODS, PEREIRA JDJR. DO CHANGES IN ANAL SPHINCTER ANATOMY CORRELATE WITH ANAL FUNCTION IN WOMEN WITH A HISTORY OF VAGINAL DELIVERY? ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:198-204. [DOI: 10.1590/s0004-28032014000300006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 12/27/2013] [Indexed: 11/21/2022]
Abstract
Objectives To evaluate anal sphincter anatomy using three-dimensional ultrasonography (3-DAUS) in incontinent women with vaginal delivery, correlate anatomical findings with symptoms of fecal incontinence and determine the effect of vaginal delivery on anal canal anatomy and function. Methods Female with fecal incontinence and vaginal delivery were assessed with Wexner’s score, manometry, and 3DAUS. A control group comprising asymptomatic nulliparous was included. Anal pressure, the angle of the defect and length of the external anal sphincter (EAS), the anterior and posterior internal anal sphincter (IAS), the EAS + puborectal and the gap were measured and correlated with score. Results Of the 62, 49 had fecal incontinence and 13 were asymptomatic. Twenty five had EAS defects, 8 had combined EAS+IAS defects, 16 had intact sphincters and continence scores were similar. Subjects with sphincter defects had a shorter anterior EAS, IAS and longer gap than women without defects. Those with a vaginal delivery and intact sphincters had a shorter anterior EAS and longer gap than nulliparous. We found correlations between resting pressure and anterior EAS and IAS length in patients with defects. Conclusions Avaliar a anatomia do esfíncter anal usando ultra-sonografia tridimensional (3D-US) em mulheres incontinentes com parto vaginal, correlacionar os achados anatômicos com sintomas de incontinência fecal e, determinar o efeito do parto vaginal sobre a anatomia e função do canal anal.
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Affiliation(s)
| | | | | | - Lusmar Veras RODRIGUES
- Faculdade de Medicina da Universidade Federal do Ceará, Brasil; Universidade Federal do Ceará, Brasil
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Abstract
BACKGROUND Atrophy of the external anal sphincter, a pathologic muscle volume anomaly associated with fecal incontinence, has been shown to be a negative predictor of the outcome of surgery for defects of the external anal sphincter. It is unclear whether external anal sphincter atrophy also affects the outcome of sacral nerve stimulation for fecal incontinence. OBJECTIVE Our aim was to assess the effectiveness of sacral nerve stimulation in patients with fecal incontinence and external anal sphincter atrophy and to determine whether severity of atrophy and concomitant presence of a sphincter defect are negative predictors of outcome. DESIGN This was a prospective observational study of treatment outcome. SETTING The study was conducted from November 2004 through November 2010 at a regional hospital in Italy. PATIENTS Consecutive patients with fecal incontinence and external anal sphincter atrophy were included. By means of MRI, patients were determined to have either moderate (<50%) or severe (≥ 50%) thinning of and/or replacement of sphincter muscle by fat. The concomitant presence of defects of the external anal sphincter was also detected by MRI. INTERVENTION All patients underwent sacral nerve stimulation through a staged implantation procedure. MAIN OUTCOME MEASURES The main outcome measures were improvement in the Cleveland Clinic Florida Fecal Incontinence Scale (Wexner score), number of episodes of incontinence per week, and the Fecal Incontinence Quality of Life Scale. RESULTS A total of 28 patients underwent definitive implantation of the sacral nerve stimulation device. Wexner scores decreased from a median of 16 (range, 10-20) at baseline to 3 (range, 0-8) at 6-month follow-up (p < 0.001). Weekly incontinence episodes decreased from a mean (SD) of 14.7 (12.5) to 0.40 (0.82); p < 0.001. Improvement was significantly related to severity of fecal incontinence (r = 0.86; p < 0.001). Overall quality-of-life scores improved from a mean of 1.8 (0.6) to 3.8 (0.4);p < 0.001. Sacral nerve stimulation was effective in both moderate (n = 16) and severe (n = 12) atrophy and in patients with (n = 8) or without (n = 20) external anal sphincter defects. LIMITATIONS The study was limited by its observational nature and relatively small sample size. CONCLUSIONS Sacral nerve stimulation can be effective in restoring continence and improving quality of life in patients with fecal incontinence related to atrophy of the external anal sphincter, regardless of the severity of atrophy. Moreover, the presence of EAS atrophy does not influence the success of the outcome of SNS in patients with a sphincter defect. These findings are consistent with the hypothesis that the effects of SNS are not achieved solely by its action on the anal sphincter complex.
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Techniques of image enhancement in EUS (with videos). Gastrointest Endosc 2011; 74:645-55. [PMID: 21679945 DOI: 10.1016/j.gie.2011.03.1246] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 03/25/2011] [Indexed: 02/08/2023]
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Wasserberg N, Mazaheri A, Petrone P, Tulchinsky H, Kaufman HS. Three-dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry. Colorectal Dis 2011; 13:449-53. [PMID: 20070325 DOI: 10.1111/j.1463-1318.2010.02208.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Anal sphincter anatomy on two-dimensional endoanal -ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three-dimensional (3D) measurements yield a better correlation. METHOD The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2-year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF-FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. RESULTS Sixty-one patients of median age 53 years (range 15-82) were evaluated. Thirty-two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF-FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact-sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF-FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. CONCLUSION Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.
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Affiliation(s)
- N Wasserberg
- Department of Surgery, Division of Colorectal and Pelvic Floor Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Etienney I, de Parades V. Three-dimensional endoanal ultrasonography in daily proctological practice. Clin Res Hepatol Gastroenterol 2011; 35:260-70. [PMID: 21393087 DOI: 10.1016/j.clinre.2010.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 02/10/2010] [Accepted: 10/18/2010] [Indexed: 02/04/2023]
Abstract
Three-dimensional endoanal ultrasonography (3D-EAUS) provides unequalled quality in terms of the anatomical image of the anal canal and sphincter complex. In less than one minute it produces a three-dimensional "cube" that can be manipulated in all spatial dimensions, then archived. In just a few years it has become a new gold standard exploration in proctology. In addition to image quality, 3D-EAUS has the advantage of being easily and rapidly performed, well-tolerated and moderate in cost. For anal incontinence, 3D-EAUS contributes to the identification of sphincter defects. The anatomy of the sphincters can be evaluated spatially. Simple scoring systems with good reproducibility and readily applicable in routine practice can be used to evaluate the "damaged" sphincter volume. For the management of anoperineal suppurations, 3D-EAUS provides information on the fistulous track(s) and on potential collections. These data are crucial as the choice of treatment and its efficacy depend on accurate topographic assessment of the suppuration and the state of the sphincter apparatus.
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Affiliation(s)
- Isabelle Etienney
- Proctologie médico-interventionnelle, centre hospitalier Diaconesses-Croix-Saint-Simon, site Reuilly, 18, rue du Sergent-Bauchat, 75012 Paris, France.
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Olsen IP, Wilsgaard T, Kiserud T. Transvaginal three-dimensional ultrasound: a method of studying anal anatomy and function. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:353-360. [PMID: 21337656 DOI: 10.1002/uog.8873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To explore the possibility of using transvaginal 3D ultrasound as a method of assessing the compartments of the anal canal during rest, to determine the effect of squeeze, and to compare these findings with those obtained using the endoanal technique in the same women. METHODS Transvaginal 3D ultrasound was used in a cross-sectional study measuring the anal mucosa and sphincters during rest and squeeze in 20 nulligravida women, comparing the results with those of endoanal measurements. Measurements were also performed of the anal mucosa, anorectal curvature (ARC), and anovaginal angle (AVA) and distance (AVD). RESULTS Volume measurements of the anal mucosa were only possible using transvaginal ultrasound. The mean volume of the anal canal using the transvaginal technique was 7.93 (SD 2.26) and 7.34 (1.54) cm(3) during rest and squeeze, respectively (P = 0.082). The ARC became more acute (3.46 vs. 4.12°/mm, P = 0.031) during squeeze and AVA increased (31.7° vs. 35.8°, P = 0.010). The volume of the anal mucosa (3.12 cm(3)) did not change (P = 0.193), but was distorted during squeeze at the level of the puborectalis sling (P < 0.001 for upper cross-section and diameter). The anal canal was 1 cm longer (P < 0.001), the IAS volume larger (2.97 and 2.08 cm(3), P = 0.003), and the EAS volume smaller (1.85 and 3.96 cm(3), P < 0.001) using the 3D transvaginal technique compared with the endoanal measurements at rest, with similar differences observed on squeeze. CONCLUSION In contrast to the endoanal method, transvaginal 3D ultrasound provides a complete assessment of the anal canal, including the mucosa. This method seems suitable for functional studies such as in the present one, which shows that voluntary squeeze increases the angulation of the anal canal and distorts the bowel cross-section at the level of the puborectal muscle.
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Affiliation(s)
- I P Olsen
- Department of Obstetrics and Gynecology, Hammerfest Hospital, Hammerfest, Norway.
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Sajid MS, Khatri K, Siddiqui MRS, Baig MK. Endo-anal ultrasound versus endo-anal magnetic resonance imaging for the depiction of external anal sphincter pathology in patients with faecal incontinence: a systematic review. Magy Seb 2010; 63:9-15. [PMID: 20156788 DOI: 10.1556/maseb.63.2010.1.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abstract
Objective: To evaluate the endo-anal ultrasound (EAUS) versus endo-anal magnetic resonance imaging (EAMRI) in the diagnosis of external anal sphincter defects (EAS) in patients with faecal incontinence (FI). Methods: Studies on EAUS and EAMRI were selected and analyzed to generate summative data. Results: Five studies encompassing 347 patients of FI were included in this review. Three studies validated the results of EAUS and EAMRI by surgery (61 patients). In the fixed effect model, EAUS was superior to EAMRI in the depiction of EAS defects. On combined analysis of five studies using fixed effect model, both EAUS and EAMRI were equally effective. However, there was a significant heterogeneity between studies. Conclusion: EAUS and EAMRI are comparable in the diagnosis of EAS defects in patients of FI. Since EAUS is an economical, quicker and easily available imaging modality, it may be used a preferable investigation for the diagnosis of EAS defects in patients of FI.
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Affiliation(s)
- MS Sajid
- 1 Washington Suite, North Wing, Worthing Hospital, West Sussex, BN11 2DH, UK
| | - K Khatri
- 1 Washington Suite, North Wing, Worthing Hospital, West Sussex, BN11 2DH, UK
| | - MRS Siddiqui
- 1 Washington Suite, North Wing, Worthing Hospital, West Sussex, BN11 2DH, UK
| | - MK Baig
- 1 Washington Suite, North Wing, Worthing Hospital, West Sussex, BN11 2DH, UK
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27
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Abstract
Pelvic floor function and structure are complex, and imaging (integrated with an understanding of physiology) is central to guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. Multimodal imaging techniques such as static and dynamic imaging techniques (sometimes combined in a single sitting) have revolutionised our understanding of functional anatomy. The advent of endo-luminal imaging has increased our spatial resolution by its closer proximity to the area of interest. Dynamic imaging gives us a near physiological data set which helps us to simulate what is likely to happen in real life and gives us a better understanding of the multifactorial causes, and consequences, of pelvic floor dysfunction.
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Affiliation(s)
- Stuart A Taylor
- Clinical Radiology, University College London, 235 Euston Road, London NW1 2BU, UK.
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Comparison of anorectal manometry to endoanal ultrasound in the evaluation of fecal incontinence. Am J Med Sci 2009; 337:336-9. [PMID: 19440055 DOI: 10.1097/maj.0b013e318198caca] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Fecal incontinence (FI) is a common clinical condition with a negative impact on the quality of life. Commonly performed tests to evaluate FI include anorectal manometry (ARM) and endoanal ultrasonography (EAU). Objective of our study was to compare the results of these 2 tests in a cohort of patients with FI. METHODS Retrospective study of 27 patients (20 women) referred to the gastrointestinal motility clinic for FI. EAU and ARM were performed in all patients. Demographic data and information regarding etiology of FI was also recorded. RESULTS Mean age of the patients was 56 years (range 26-87 years). Etiology of FI was obstetric trauma in 4, pelvic surgery in 9, pelvic trauma in 3, pelvic radiation in 1, and idiopathic in 8. Based on the ARM data, 14 of 27 had a weak external sphincter squeeze pressure and 3 had impaired rectal sensation, whereas with the EAU there was thinning of the external anal sphincter in 3 and complete disruption in 1, and abnormalities of the internal anal sphincter (IAS) in 7 of 27 with thinning, and defects. Overall, only 2 of 27 had normal findings by combined ARM and EAU. CONCLUSIONS Although the yield of finding major sphincter defects was low, only a small percentage of patients had a normal ARM or EAU. When there are degrees of external anal sphincter thinning or partial or complete disruption of the sphincters, a good correlation with ARM is achieved. EAU and ARM are complimentary investigations for the thorough assessment of the anal sphincter apparatus.
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Felt-Bersma RJF. Endoanal ultrasound in benign anorectal disorders: clinical relevance and possibilities. Expert Rev Gastroenterol Hepatol 2008; 2:587-606. [PMID: 19072406 DOI: 10.1586/17474124.2.4.587] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Endoanal ultrasound is a well-established technique used to evaluate benign anorectal disorders. The technique is easy to perform, has a short learning curve and causes very little discomfort. Reconstruction of 3D images is possible. The clinical indications for endoanal ultrasound in benign anorectal diseases are fecal incontinence and peri-anal fistula. Sphincter defects can be depicted with precision and correlate perfectly with surgical findings. Furthermore, an impression of sphincter atrophy can be established. With perianal fistula the tracts can be visualized. Introducing hydrogen peroxide via the external fistula opening improves imaging. Endoanal ultrasound and MRI have comparable results in diagnosing anorectal disorders.
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Affiliation(s)
- Richelle J F Felt-Bersma
- VU University Medical Center, Department of Gastroenterology and Hepatology, De Boelelaan 1117, 1081 HV, PO Box 7057, Amsterdam, The Netherlands.
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Keshtgar AS, Athanasakos E, Clayden GS, Ward HC. Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography. Pediatr Surg Int 2008; 24:885-92. [PMID: 18512062 DOI: 10.1007/s00383-008-2181-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2008] [Indexed: 10/22/2022]
Abstract
The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.
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Affiliation(s)
- A S Keshtgar
- Department of Paediatric Surgery, University Hospital Lewisham, NHS Trust, Lewisham High Street, London, SE13 6LH, UK.
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Tan E, Anstee A, Koh DM, Gedroyc W, Tekkis PP. Diagnostic precision of endoanal MRI in the detection of anal sphincter pathology: a meta-analysis. Int J Colorectal Dis 2008; 23:641-51. [PMID: 18330582 DOI: 10.1007/s00384-008-0449-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2008] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aims to evaluate the diagnostic precision of endoanal magnetic resonance imaging in identifying anal sphincter injury and/or atrophy when compared with either endoanal ultrasound or surgical diagnosis. MATERIALS AND METHODS Quantitative meta-analysis was performed on nine studies, comparing endoanal MRI with endoanal ultrasound or surgical diagnosis in 157 patients. Sensitivity, specificity, and diagnostic odds ratio were calculated for each study. Summary receiver operating characteristic curves (SROC) and subgroup analysis were undertaken. RESULTS The overall sensitivity and specificity of endoanal MRI for external sphincter injury was 0.78 (95%CI: 0.66-0.84) and 0.66 (95%CI: 0.51-0.79), respectively. For internal sphincter injury detection, this was 0.63 (95%CI: 0.50-0.74) and 0.71 (95%CI: 0.60-0.81), respectively. For detection of atrophy, this was 0.86 (95%CI: 0.71-0.95) and 0.82 (95%CI: 0.65-0.93), respectively. The area under the SROC curve and diagnostic odds ratio were 0.84 (SE = 0.07) and 6.14 (95%CI: 2.17-17.4) for external sphincter injury, 0.79 (SE = 0.07) and 4.60 (95%CI: 1.75-12.15) for internal sphincter injury, and 0.92 (SE = 0.08) and 21.49 (95%CI: 2.87-160.64) for sphincter atrophy. CONCLUSION Endoanal MRI was sensitive and specific for the detection of external sphincter injury and especially sphincter atrophy. It may be useful as an alternative to endoanal ultrasound in patients presenting with fecal incontinence, although further clinical studies are needed to identify its best application in clinical practice.
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Affiliation(s)
- Emile Tan
- Department of Biosurgery & Surgical Technology, Imperial College, QEQM Wing, St Mary's Hospital, London, UK
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The role of three-dimensional endoluminal ultrasound imaging in the evaluation of anorectal diseases: a review. Surg Endosc 2008; 22:1570-8. [PMID: 18401655 DOI: 10.1007/s00464-008-9865-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Revised: 12/29/2007] [Accepted: 01/19/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND The authors conducted a review of the available English literature to evaluate the advantages of three-dimensional ultrasound for assessing anorectal pathology, to provide a state-of-the-art approach, and to compare this technique with conventional endoluminal ultrasound and other imaging methods. METHODS All studies describing results obtained with three-dimensional ultrasound in the evaluation of anorectal pathologies, both alone and compared with other techniques, were selected. RESULTS Since 1996, 32 articles have been published. In tumor staging, specific data derived by three-dimensional reconstruction for the assessment of T invasion and nodal involvement were more accurate than endoluminal ultrasound and computed tomography. For evaluating perianal sepsis, the detection of secondary fistula tracts and fluid collections and the location of internal openings were superior to endoanal magnetic resonance imaging. In the evaluation of anal incontinence, the results for sphincter defects were similar to those obtained with endoanal magnetic resonance imaging. CONCLUSION Analysis of the literature confirmed that three-dimensional ultrasound is a valuable technique for assessing anorectal disorders, facilitating the interpretation of the images obtained, and providing additional data that in many cases have changed the operative approach.
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Cross-Sectional Imaging of the Anal Sphincter in Fecal Incontinence. AJR Am J Roentgenol 2008; 190:671-82. [DOI: 10.2214/ajr.07.2920] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Thekkinkattil DK, Lim M, Stojkovic SG, Finan PJ, Sagar PM, Burke D. A classification system for faecal incontinence based on anorectal investigations. Br J Surg 2007; 95:222-8. [DOI: 10.1002/bjs.5933] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Faecal incontinence is a socially disabling condition that affects a heterogeneous population of patients. There is no standardization of investigations, and treatment outcomes are variable. The major limitation for comparing the results from different studies is the lack of a pretreatment classification of incontinence. The aim of this study was to review the anorectal investigation findings and propose a simple, repeatable classification for faecal incontinence.
Methods
Patients who had anorectal investigations for defaecatory disorders from February 2000 to September 2006 were analysed retrospectively. All patients had anorectal manometry, anal mucosal electrosensitivity testing and endoanal ultrasonography.
Results
Of a total of 1294 patients, 135 were excluded, leaving 1159 (460 continent and 699 incontinent) for analysis. The patients were divided into four groups: traumatic incontinence, neuropathic faecal incontinence, combined faecal incontinence and idiopathic faecal incontinence. The manometric variables and demographics were distinct in these groups.
Conclusion
Patients with faecal incontinence can be classified into different groups with distinct pathophysiological variables. Such a classification system will enable comparison and interpretation of the outcomes of different studies and also help in the selection of patients for appropriate treatments.
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Affiliation(s)
- D K Thekkinkattil
- Division of Coloproctology, The General Infirmary at Leeds, Leeds, UK
| | - M Lim
- Division of Coloproctology, The General Infirmary at Leeds, Leeds, UK
| | - S G Stojkovic
- Division of Coloproctology, The General Infirmary at Leeds, Leeds, UK
| | - P J Finan
- Division of Coloproctology, The General Infirmary at Leeds, Leeds, UK
| | - P M Sagar
- Division of Coloproctology, The General Infirmary at Leeds, Leeds, UK
| | - D Burke
- Division of Coloproctology, The General Infirmary at Leeds, Leeds, UK
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Terra MP, Stoker J. The current role of imaging techniques in faecal incontinence. Eur Radiol 2006; 16:1727-36. [PMID: 16688456 DOI: 10.1007/s00330-006-0225-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Revised: 02/12/2006] [Accepted: 02/28/2006] [Indexed: 01/12/2023]
Abstract
Faecal incontinence is a common multifactorial disorder. Major causes of faecal incontinence are related to vaginal delivery and prior anorectal surgery. In addition to medical history and physical examination, several anorectal functional tests and imaging techniques can be used to assess the underlying pathophysiology and to guide treatment planning in faecal incontinent patients. Anorectal functional tests provide functional information, but the potential strength comes from combining test results. Imaging techniques, including defecography, endoanal sonography, and magnetic resonance (MR) imaging, provide structural information about the anorectal region with a direct clinical impact. The major role of imaging techniques in faecal incontinence is visualising the structural and functional integrity of the anal sphincter complex. Both two-dimensional endoanal sonography and endoanal MR imaging are accurate tools to depict anal sphincter defects. The major advantage of endoanal MR imaging is the accurate demonstration of external anal sphincter atrophy. Recent studies have suggested that external phased array MR imaging and three-dimensional endoanal sonography are also valuable tools in the diagnostic work up of faecal incontinence. Decisions about the preferred technique will mainly be determined by availability and local expertise. This article demonstrates the current role of tests, predominantly imaging tests, in the diagnostic work up of faecal incontinence.
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Affiliation(s)
- M P Terra
- Department of Radiology, G1-229, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Engin G. Endosonographic imaging of anorectal diseases. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2006; 25:57-73. [PMID: 16371556 DOI: 10.7863/jum.2006.25.1.57] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography compared with magnetic resonance imaging are reviewed. Methods. Endosonographic imaging was performed with a Siemens (Erlangen, Germany) FI 400 ultrasound scanner with an end-fire 7.5-MHz biplane endorectal probe and a B-K Medical (Sandhoften, Denmark) scanner with an 1850 axial-type side-fire 5.0- to 10.0-MHz rotating endoscopic probe. RESULTS Rectal carcinoma appears on endorectal sonography as a low-echogenicity lesion that abruptly interrupts the normal sequence of layers. The internal anal sphincter is seen very clearly on endoanal sonography, and it is easy to appreciate atrophy and small tears of this sphincter. Endoanal sonography cannot accurately show thinning of the external anal sphincter. Peroxide-enhanced endoanal sonography is especially useful for patients with recurrent perianal fistulas in whom scarring should be distinguished from recurrent fistulas and detection of the internal opening. However, sonography does not provide an adequate deep and global display of all adjacent pelvic and perineal spaces. CONCLUSIONS Endosonography can accurately stage primary rectal tumors and assess the internal anal sphincter. Peroxide-enhanced 3-dimensional imaging can increase the utility of endoanal sonography in detection and characterization of perianal fistulas and planning of optimal therapy. However, magnetic resonance imaging can be used a complementary modality to endosonography, especially for evaluation of external anal sphincter atrophy and deep pelvic inflammation.
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Affiliation(s)
- Gulgun Engin
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Capa, Turkey.
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Abstract
Fecal incontinence related to pregnancy is an underreported and debilitating physical problem that has psychosocial ramifications. Disruption of the external and internal anal sphincters, which may occur during vaginal delivery, is the most common etiologic factor. Endoanal ultrasound is a minimally invasive, simple, and accurate diagnostic tool used to confirm and guide management of sphincter complex disruption.
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Affiliation(s)
- André K H Chong
- Department of Gastroenterology, Fremantle Hospital, Fremantle, WA, Australia.
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