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Magnetic resonance imaging of the anal sphincter and spine in patients with anorectal malformations after posterior sagittal anorectoplasty: a late follow-up cross-sectional study. Pediatr Surg Int 2021; 37:85-91. [PMID: 33141917 DOI: 10.1007/s00383-020-04774-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE We aimed to assess the association of fecal incontinence to the anatomy of the anal sphincter complex and lower bony spinal anomalies as investigated with magnetic resonance imaging (MRI) in adolescents and adults with anorectal malformations (ARM) after posterior sagittal anorectoplasty (PSARP). METHODS We conducted a cross-sectional study in 20 patients with ARM after PSARP. Anatomy of the anorectum and spine were examined with MRI and functional outcome assessed with the Wexner incontinence score. RESULTS We included 20 patient (12 males) had a median age of 19.5 years (14-27). One patient was excluded leaving 19 patients for outcome analysis. Fecal incontinence was found in 12 out of 19 patients (63%). Interposed fat was present in 9 patients (47%). The presence (r = 0.597, p = 0.012) and thickness of interposed fat (r = 0.832, p = 0.005) between the anal sphincter complex and bowel were positively correlated to the Wexner fecal incontinence score. No correlation was found between lower bony spinal anomalies and fecal incontinence. CONCLUSIONS A positive correlation between interposed fat and higher Wexner fecal incontinence score was found indicating a more severe fecal incontinence but no other correlation between anatomy of the anal sphincter complex and neorectum to functional bowel outcome was observed.
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Two-dimensional Endoanal Ultrasound Scan Correlates with External Anal Sphincter Structure and Function, but not with Puborectalis. J Med Ultrasound 2015. [DOI: 10.1016/j.jmu.2015.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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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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Papaconstantinou HT. Evaluation of anal incontinence: minimal approach, maximal effectiveness. Clin Colon Rectal Surg 2010; 18:9-16. [PMID: 20011334 DOI: 10.1055/s-2005-864076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Anal incontinence is a symptom represented by the impaired ability to control the elimination of gas and stool, with an estimated incidence of 2.2 to 7.1% of the population. These numbers likely under-represent the true prevalence because physicians and patients are reluctant to discuss this problem. Evaluation of the patient with anal incontinence requires a fundamental knowledge of the etiologic factors. Careful history and physical examination is essential in every patient and can identify the cause of most cases of incontinence. Incontinence scoring systems are tools that provide objective data regarding the severity and quality of anal incontinence. Supplemental special tests for evaluating incontinence should be aimed at achieving three goals: (1) provide additional and confirmatory information regarding the diagnosis and cause of incontinence; (2) select appropriate treatment; and (3) predict treatment outcome. Numerous studies to evaluate anal incontinence exist; however, the most useful tests to achieve these goals are anal manometry, pudendal nerve terminal motor latency, and anal endosonography, because these studies can identify physiologic, neurologic, and anatomic abnormalities of the anorectum for which there may be effective treatments.
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Affiliation(s)
- Harry T Papaconstantinou
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX 75390-9156, USA.
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Abstract
The bladder has only two essential functions. It stores and periodically empties liquid waste. Yet it is unique as a visceral organ, allowing integrated volitional and autonomous control of continence and voiding. Normal function tests the integrity of the nervous system at all levels, extending from the neuroepithelium of the bladder wall to the frontal cortex of the brain. Thus, dysfunction is common with impairment of either the central or peripheral nervous system. This monograph presents an overview of the neural control of the bladder as it is currently understood. A description of pertinent peripheral anatomy and neuroanatomy is provided, followed by an explanation of common neurophysiological tests of the lower urinary tract and associated structures, including both urodynamic and electrodiagnostic approaches. Clinical applications are included to illustrate the impact of nervous system dysfunction on the bladder and to provide indications for testing.
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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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Pelvic floor muscle lesions at endoanal MR imaging in female patients with faecal incontinence. Eur Radiol 2008; 18:1892-901. [PMID: 18389245 DOI: 10.1007/s00330-008-0951-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 02/22/2008] [Accepted: 02/22/2008] [Indexed: 01/12/2023]
Abstract
To evaluate the frequency and spectrum of lesions of different pelvic floor muscles at endoanal MRI in women with severe faecal incontinence and to study their relation with incontinence severity and manometric findings. In 105 women MRI examinations were evaluated for internal anal sphincter (IAS), external anal sphincter (EAS), puborectal muscle (PM) and levator ani (LA) lesions. The relative contribution of lesions to differences in incontinence severity and manometric findings was studied. IAS (n = 59) and EAS (n = 61) defects were more common than PM (n = 23) and LA (n = 26) defects. PM and LA defects presented mainly with IAS and/or EAS defects (isolated n = 2 and n = 3). EAS atrophy (n = 73) was more common than IAS (n = 19), PM (n = 16) and LA (n = 9) atrophy and presented mainly isolated. PM and LA atrophy presented primarily with EAS atrophy (isolated n = 3 and n = 1). Patients with IAS and EAS lesions had a lower resting and squeeze pressure, respectively; no other associations were found. PM and LA lesions are relatively common in patients with severe faecal incontinence, but the majority of lesions are found in women who also have IAS and/or EAS lesions. Only an association between anal sphincter lesions and manometry was observed.
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Abstract
BACKGROUND AND AIMS Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management. METHOD This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists. RESULTS A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality. CONCLUSIONS Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.
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Emblem R, Mørkrid L, Bjørnland K. Anal endosonography is useful for postoperative assessment of anorectal malformations. J Pediatr Surg 2007; 42:1549-54. [PMID: 17848247 DOI: 10.1016/j.jpedsurg.2007.04.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM This study aimed to develop and evaluate a scoring system for anal endosonography to assess anal canal structures after repair of anorectal malformations (ARM). METHODS Forty patients with ARM aged 16 years (range, 1-22 years) and 20 controls aged 17 years (range, 0.5-20 years) were examined. Anal function was assessed clinically and by anal canal manometry. The anal canal structures were imaged by anal endosonography using a 7.5-MHz transducer. A scoring system was developed to assess the anal sphincters as visualized on the endosonographic images. RESULTS Continence was significantly correlated to anal canal pressures. The estimated extent of muscle defect (measured in quadrants) and the number of disruptions in the internal and external anal sphincters correlated significantly to the rest and squeeze pressures, respectively. Thus, patients (>4 years) with squeeze pressure of less than 80 cm H2O were characterized by more than 1 disruption in the external anal sphincter ring and 2 or more quadrants with scar tissue. CONCLUSION The extent of scar tissue and the number of disruptions in the anal sphincters correlate with anal canal pressures and continence after ARM repair. Anal endosonography may be used to study the results after different surgical techniques and for prognosis on continence in patients with ARM.
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Affiliation(s)
- Ragnhild Emblem
- Service of Pediatric Surgery, Department of Surgery, Rikshospitalet-Radiumhospitalet Medical Center and Faculty of Medicine University of Oslo, 0027 Oslo, Norway.
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Hall RJ, Rogers RG, Saiz L, Qualls C. Translabial ultrasound assessment of the anal sphincter complex: normal measurements of the internal and external anal sphincters at the proximal, mid-, and distal levels. Int Urogynecol J 2007; 18:881-8. [PMID: 17221149 DOI: 10.1007/s00192-006-0254-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 10/23/2006] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to measure the internal and external anal sphincters using translabial ultrasound (TLU) at the proximal, mid, and distal levels of the anal sphincter complex. The human review committee approval was obtained and all women gave written informed consent. Sixty women presenting for gynecologic ultrasound for symptoms other than pelvic organ prolapse or urinary or anal incontinence underwent TLU. Thirty-six (60%) were asymptomatic and intact, 13 symptomatic and intact, and 11 disrupted. Anterior-posterior diameters of the internal anal sphincter at all levels and the external anal sphincter at the distal level were measured in four quadrants. Mean sphincter measurements are given for symptomatic and asymptomatic intact women and are comparable to previously reported endoanal MRI and ultrasound measurements.
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Affiliation(s)
- Rebecca J Hall
- Department of Ob/Gyn, Division of Urogynecology, University of New Mexico HSC, Albuquerque, NM, USA.
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11
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Terra MP, Beets-Tan RGH, van der Hulst VPM, Deutekom M, Dijkgraaf MGW, Bossuyt PMM, Dobben AC, Baeten CGMI, Stoker J. MRI in evaluating atrophy of the external anal sphincter in patients with fecal incontinence. AJR Am J Roentgenol 2006; 187:991-9. [PMID: 16985148 DOI: 10.2214/ajr.05.0386] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE External anal sphincter atrophy seen at endoanal MRI may predict poor outcome of surgical anal sphincter repair for an external anal sphincter defect. The purposes of this study were to compare external phased-array MRI to endoanal MRI for depicting external anal sphincter atrophy in patients with fecal incontinence and to evaluate observer reproducibility in detecting external anal sphincter atrophy with these techniques. SUBJECTS AND METHODS Thirty patients with fecal incontinence (23 women, seven men; mean age, 58.7 years; age range, 37-78 years) underwent both endoanal and external phased-array MRI. Images were evaluated for external anal sphincter atrophy by three radiologists. Measures of differences and agreement between both MRI techniques and of interobserver and intraobserver agreement of both techniques were calculated. RESULTS The MRI techniques did not significantly differ in their ability to depict external anal sphincter atrophy (p = 0.63) with good agreement (kappa = 0.72). Interobserver agreement was moderate (kappa = 0.53-0.56) for endoanal MRI and moderate to good (kappa = 0.55-0.8) for external phased-array MRI. Intraobserver agreement was moderate to very good (kappa = 0.57-0.86) for endoanal MRI and fair to very good (kappa = 0.31-0.86) for external phased-array MRI. CONCLUSION External phased-array MRI is comparable to endoanal MRI in depicting external anal sphincter atrophy and, thereby, in selecting patients for anal sphincter repair. Because results among interpreters varied considerably depending on the experience level, both techniques can be recommended in the diagnostic workup of fecal incontinence only if sufficient experience is available.
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Affiliation(s)
- Maaike P Terra
- Department of Radiology, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands 1105 AZ.
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Terra MP, Deutekom M, Beets-Tan RGH, Engel AF, Janssen LWM, Boeckxstaens GEE, Dobben AC, Baeten CGMI, de Priester JA, Bossuyt PMM, Stoker J. Relationship between external anal sphincter atrophy at endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence. Dis Colon Rectum 2006; 49:668-78. [PMID: 16583292 DOI: 10.1007/s10350-006-0507-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE External anal sphincter atrophy at endoanal magnetic resonance imaging has been associated with poor outcome of anal sphincter repair. We studied the relationship between external anal sphincter atrophy on endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence. METHODS In 200 patients (mean Vaizey score, 18 (+/-2.9 standard deviation)) magnetic resonance images were evaluated for external anal sphincter atrophy (none, mild, or severe) by radiologists blinded to anorectal functional test results and details from medical history. Subgroups of patients with and without atrophy were compared for medical history, anal manometry, pudendal nerve latency testing, anal sensitivity testing, external anal sphincter thickness, and external anal sphincter defects. Whenever significant differences were detected, we tested for differences between patients with mild and severe atrophy. RESULTS External anal sphincter atrophy was demonstrated in 123 patients (62 percent): graded as mild in 79 (40 percent), and severe in 44 patients (22 percent). Patients with atrophy were more often female (P < 0.001) and older (P = 0.003). They had a lower maximal squeeze (P = 0.01) and squeeze increment pressure (P < 0.001). Patients with severe atrophy had a lower maximal squeeze (P = 0.003) and squeeze increment pressure (P < 0.001) than patients with mild atrophy. These effects were not attenuated by potential confounding variables. Patients with atrophy could not be identified a priori by other characteristics. CONCLUSIONS External anal sphincter atrophy at endoanal magnetic resonance imaging was depicted in 62 percent of patients, varying from mild to severe. Because increasing levels of atrophy were associated with impaired squeeze function, further studies are needed to evaluate whether grading atrophy is clinically valuable in selecting patients for anal sphincter repair.
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Affiliation(s)
- Maaike P Terra
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Cazemier M, Terra MP, Stoker J, de Lange-de Klerk ESM, Boeckxstaens GEE, Mulder CJJ, Felt-Bersma RJF. Atrophy and defects detection of the external anal sphincter: comparison between three-dimensional anal endosonography and endoanal magnetic resonance imaging. Dis Colon Rectum 2006; 49:20-7. [PMID: 16328609 DOI: 10.1007/s10350-005-0220-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Using endoanal magnetic resonance imaging, atrophy of the external anal sphincter can be established. This aspect has not been thoroughly investigated using three-dimensional anal endosonography. The purpose of this study was to compare prospectively three-dimensional anal endosonography to magnetic resonance imaging in the detection of atrophy and defects of the external anal sphincter in patients with fecal incontinence. In addition, we compared both techniques for anal sphincter thickness and length measurements. MATERIALS AND METHODS Patients with fecal incontinence underwent three-dimensional anal endosonography and magnetic resonance imaging. Images of both endoluminal techniques were evaluated for atrophy and defects of the external anal sphincter. External anal sphincter atrophy scoring with three-dimensional anal endosonography depended on the distinction of the external anal sphincter and its reflectivity. External anal sphincter atrophy scoring with magnetic resonance imaging depended on the amount of muscle and the presence of fat replacement. Atrophy score was defined as none, moderate, and severe. A defect was defined at anal endosonography by a hypoechogenic zone and at magnetic resonance imaging as a discontinuity of the sphincteric ring and/or scar tissue. Differences between three-dimensional anal endosonography and magnetic resonance imaging for the detection of external anal sphincter atrophy and defects were calculated. In addition, we compared external anal sphincter thickness and length measurements in three-dimensional anal endosonography and magnetic resonance imaging. RESULTS Eighteen patients were included (median age, 58 years; range, 27-80; 15 women). Three-dimensional anal endosonography and magnetic resonance imaging did not significantly differ for the detection of external anal sphincter atrophy (P = 0.25) and defects (P = 0.38). Three-dimensional anal endosonography demonstrated atrophy in 16 patients, magnetic resonance imaging detected atrophy in 13 patients. Three-dimensional anal endosonography agreed with magnetic resonance imaging in 15 of 18 patients for the detection of external anal sphincter atrophy. Using the grading system, 8 of the 18 patients scored the same grade. Three-dimensional anal endosonography detected seven external anal sphincter defects and magnetic resonance imaging detected ten. Three-dimensional anal endosonography and magnetic resonance imaging agreed on the detection of external anal sphincter defects in 13 of 18 patients. Comparison between three-dimensional anal endosonography and magnetic resonance imaging for sphincter thickness and length measurements showed no statistically significant concordance and had no correlation with external anal sphincter atrophy. CONCLUSION This is the first study that shows that three-dimensional anal endosonography can be used for detecting external anal sphincter atrophy. Both endoanal techniques are comparable in detecting atrophy and defects of the external anal sphincter, although there is a substantial difference in grading of external anal sphincter atrophy. Correlation between three-dimensional anal endosonography and magnetic resonance imaging for thickness and length measurements is poor. Inconsistency between the two methods needs to be evaluated further.
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Affiliation(s)
- Marcel Cazemier
- Department of Gastroenterology and Hepatology, VU Medical Center, Amsterdam, The Netherlands.
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West RL, Dwarkasing S, Briel JW, Hansen BE, Hussain SM, Schouten WR, Kuipers EJ. Can three-dimensional endoanal ultrasonography detect external anal sphincter atrophy? A comparison with endoanal magnetic resonance imaging. Int J Colorectal Dis 2005; 20:328-33. [PMID: 15666154 DOI: 10.1007/s00384-004-0693-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2004] [Indexed: 02/04/2023]
Abstract
PURPOSE Anal sphincter atrophy is associated with a poor clinical outcome of sphincter repair in patients with faecal incontinence. Preoperative assessment of the sphincters is therefore relevant. External anal sphincter (EAS) atrophy can be detected by endoanal magnetic resonance imaging (MRI), but not by conventional endoanal ultrasonography (EUS). Three-dimensional EUS allows multiplanar imaging of the anal sphincters and thus enables more reliable anal sphincter measurements. The aim of the present study was to establish whether 3D EUS measurements can be used to detect EAS atrophy. For this purpose 3D EUS measurements were compared with endoanal MRI measurements. METHODS Patients with symptoms of faecal incontinence underwent 3D EUS and endoanal MRI. Internal anal sphincter (IAS) and EAS defects were assessed on 3D EUS and endoanal MRI. EAS atrophy was determined on endoanal MRI. The following measurements were performed: EAS length, thickness and area. Furthermore, EAS volume was determined on 3D EUS and compared with EAS thickness and area measured on endoanal MRI. RESULTS Eighteen parous women (median age 56 years, range 32-80) with symptoms of faecal incontinence were included. Agreement between 3D EUS and endoanal MRI was 61% for IAS defects and 88% for EAS defects. EAS atrophy was seen in all patients on endoanal MRI. Correlation between the two methods for EAS thickness, length and area was poor. In addition, correlation was also poor for EAS volume determined on 3D EUS, and EAS thickness and area measured on endoanal MRI. CONCLUSION Three-dimensional EUS and endoanal MRI are comparable for detecting EAS defects. However, correlation between the two methods for EAS thickness, length and area is poor. This is also the case for EAS volume determined on 3D EUS and EAS thickness and area measured on endoanal MRI. Three-dimensional EUS can be used for detecting EAS defects, but no 3D EUS measurements are suitable parameters for assessing EAS atrophy.
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Affiliation(s)
- R L West
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, 3000 Rotterdam, The Netherlands.
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West RL, Felt-Bersma RJF, Hansen BE, Schouten WR, Kuipers EJ. Volume measurements of the anal sphincter complex in healthy controls and fecal-incontinent patients with a three-dimensional reconstruction of endoanal ultrasonography images. Dis Colon Rectum 2005; 48:540-8. [PMID: 15747081 DOI: 10.1007/s10350-004-0811-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to determine sphincter volume, length, and external anal sphincter thickness in healthy controls and fecal incontinent patients by use of a three-dimensional reconstruction of endoanal ultrasonography images. METHODS Forty-four controls (15 males, 15 females, and 14 parous females) and 28 incontinent parous females (with and without a sphincter defect) were studied. Internal anal sphincter, external anal sphincter and puborectalis volume, sphincter length, and external anal sphincter thickness were measured. Intraobserver and interobserver variability were assessed. Anal pressure profile was also determined. RESULTS Internal anal sphincter and external anal sphincter volumes were larger in males than in females (P = 0.001 and P = 0.04), and external anal sphincter volume was smaller in parous females but this was not significant (P = 0.084). Anterior sphincter length was longer in males (P = 0.004) and shorter in parous females (P = 0.06). Males had a larger anterior external anal sphincter thickness (P = 0.018); parity made no difference. Sphincter volumes were not smaller in incontinent females. Incontinent females with a sphincter defect had a shorter anterior sphincter length than that of continent (P = 0.001) and incontinent females without a sphincter defect (P < 0.001). Anterior external anal sphincter thickness was smaller in incontinent females with a sphincter defect (P = 0.006), and posterior and right external anal sphincter thickness was smaller in incontinent females without a sphincter defect (P = 0.02 and P = 0.03). Intraobserver variability was seen for internal anal sphincter volume and sphincter length, but there was no interobserver variability. Correlation between anal pressures and endoanal ultrasonography measurements was poor. CONCLUSIONS Differences in anal sphincter volumes are seen for gender but not for parity. Fecal incontinence is not associated with loss of sphincter volume. However, anterior sphincter length and external anal sphincter thickness are smaller.
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Affiliation(s)
- Rachel L West
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Abstract
Radiological imaging of the pelvis adds an important dimension to our understanding of rectal and perianal disease. By integrating relevant information obtained from these investigations into planning and conduct of surgical procedures, outcomes for patients may be optimised. This review focuses on three areas from a clinical viewpoint. (1) With the increased use of neoadjuvant treatments pretherapeutic staging strategies become central to the management of rectal cancer patients. At present, transrectal ultrasound (TRUS), computerised tomography and magnetic resonance imaging (MRI) serve in combination to provide the essential informations. (2) The advent of endoanal ultrasound and MRI in the diagnostic workup of patients with faecal incontinence has caused a paradigm shift both conceptionally and in the way treatments are tailored to individual patients. (3) Concerning primary perianal fistulas there is little place for endoanal ultrasound or MRI. However, when a recurrent or Crohn's fistula is present, a combination of surgical exploration with either endoanal ultrasound or MRI depending on local expertise and availability may be the optimal approach to maximise benefit for these patients.
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Affiliation(s)
- Friedrich Herbst
- Department of General Surgery, Vienna General Hospital-AKH, University of Vienna, Waehringer Guertel 18-20, 1090 Wien, Austria.
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17
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Abstract
PURPOSE OF REVIEW Apart from histopathology, electrophysiological methods are the only tests to reveal neuromuscular involvement in the absence of gross anatomical lesions. They have played a major role in establishing the neuromuscular lesion due to vaginal delivery as a risk factor for incontinence and pelvic organ prolapse, but there is no consensus on the usefulness of different methods. It is timely to reevaluate their validity, and their role in urogynecology. RECENT FINDINGS The most important development is the move towards standardization of the diagnostic approach, based on computer assisted quantified techniques of concentric needle electromyography. Studies using less operator biased techniques have confirmed subtle pelvic floor muscle changes in parous women. Reports on usefulness of different tests as predictors of treatment outcome are controversial. SUMMARY Standardization of concentric needle electromyography strengthened the position of this test as practical and informative. Neuromuscular changes following vaginal delivery have been reconfirmed, but the usefulness of particular electrophysiological tests in the individual patient needs to be further researched. Valid clinical neurophysiological methods remain valuable as research tools for incontinence and prolapse pathophysiology.
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Affiliation(s)
- David B Vodusek
- Division of Neurology, University Medical Centre, Ljubljana, Slovenia.
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Frudinger A, Halligan S, Bartram CI, Price AB, Kamm MA, Winter R. Female anal sphincter: age-related differences in asymptomatic volunteers with high-frequency endoanal US. Radiology 2002; 224:417-23. [PMID: 12147837 DOI: 10.1148/radiol.2242010985] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate endoanal ultrasonographic (US) anatomy in a large group of nulliparous women by using a high-frequency 10-MHz transducer to define normal age-related differences in sphincter morphology. MATERIALS AND METHODS One hundred fifty asymptomatic nulliparous women (mean age, 31 years; range, 19-80 years) underwent endoanal US with a high-frequency 10-MHz transducer. Anal canal structures were measured at high, middle, and low levels and were correlated with age by using the Pearson simple linear correlation coefficient. RESULTS Internal sphincter thickness showed a highly significant positive correlation with age at both sites at which it was measured (high anal canal, r = 0.34, P <.001; middle anal canal, r = 0.33, P <.001). External sphincter thickness showed a highly significant negative correlation with age at all sites measured (high anal canal, r = -0.65, P <.001; middle anal canal, r = -0.49, P <.001; low anal canal, r = -0.21, P =.012). There was no significant correlation between age and thickness of subepithelial tissue, longitudinal muscle, or puborectalis muscle. Subjects whose internal sphincter showed mixed echogenicity were significantly older than those whose internal sphincter was uniformly hypoechoic (mean, 47.4 vs 34.6 years; P <.001). Subjects with mixed internal sphincter echogenicity also had a significantly thinner external sphincter at high (mean thickness, 3.8 vs 4.6 mm; P <.001) and middle (mean thickness, 3.7 vs 4.1 mm; P =.03) anal canal levels. CONCLUSION At older ages there are increased internal anal sphincter thickness and decreased external anal sphincter thickness. Diagnosis of external sphincter atrophy on the basis of sphincter thinning requires that one distinguish between abnormal thinning and age-related differences.
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Affiliation(s)
- Andrea Frudinger
- Intestinal Imaging Centre, St Mark's Hospital, Level 4V, Northwick Park, Watford Rd, Harrow, London HA1 3UJ, England
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