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Heinze T, Heimke M, Stelzner S, Wedel T. [Surgical anatomy of the anorectum]. CHIRURGIE (HEIDELBERG, GERMANY) 2025; 96:431-444. [PMID: 40047909 DOI: 10.1007/s00104-025-02244-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/15/2025] [Indexed: 04/23/2025]
Abstract
The anorectum corresponds to the last segment of the gastrointestinal tract and is responsible for mediating fecal continence and controlled defecation. An understanding of the complex topographic anatomy is an indispensable prerequisite for the surgical treatment of benign and malignant diseases in the anorectal region. The detailed description of perirectal fascia, anorectal blood supply and lymph vessel drainage, pelvic autonomic nerves and components of the anal canal and anal sphincter complex has significantly contributed to improvement of the oncological and functional surgical outcome. In this article the state of knowledge relating to the anorectal anatomy is outlined providing a practical basis for rectal and proctological surgical procedures.
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Affiliation(s)
- Tillmann Heinze
- Anatomisches Institut, Zentrum für Klinische Anatomie, Kurt-Semm-Zentrum für laparoskopische und roboterassistierte Chirurgie, Universität Kiel, Otto-Hahn-Platz 8, 24118, Kiel, Deutschland
| | - Marvin Heimke
- Anatomisches Institut, Zentrum für Klinische Anatomie, Kurt-Semm-Zentrum für laparoskopische und roboterassistierte Chirurgie, Universität Kiel, Otto-Hahn-Platz 8, 24118, Kiel, Deutschland
| | - Sigmar Stelzner
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Thilo Wedel
- Anatomisches Institut, Zentrum für Klinische Anatomie, Kurt-Semm-Zentrum für laparoskopische und roboterassistierte Chirurgie, Universität Kiel, Otto-Hahn-Platz 8, 24118, Kiel, Deutschland.
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Iyer A, Alizadeh M, Mariano JM, Kontrogianni-Konstantopoulos A, Raufman JP. The Impact of Heritable Myopathies on Gastrointestinal Skeletal Muscle Function. Cell Mol Gastroenterol Hepatol 2025:101522. [PMID: 40268053 DOI: 10.1016/j.jcmgh.2025.101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Revised: 04/11/2025] [Accepted: 04/16/2025] [Indexed: 04/25/2025]
Abstract
Among other contributions to gastrointestinal (GI) function, skeletal muscles regulate transit at both ends of the GI tract by providing propulsive forces for ingested nutrients and controlling the excretion of waste products. At the oropharynx, skeletal muscles provide necessary forces for effective mastication and the transfer of food boluses from the mouth into the proximal esophagus, where skeletal muscle-mediated peristalsis initiates propulsion of food boluses towards the stomach, a function supplanted by the upper esophagus smooth muscle. Consequently, the most prominent manifestation of proximal GI tract skeletal muscle dysfunction is transfer and oropharyngeal dysphagia that may result in repeated episodes of life-threatening choking and pulmonary aspiration. At the anal canal, the external anal sphincter controls the release of gas, liquids, and solids. Skeletal muscles within the pelvic floor play a synergistic role in regulating defection. Hence, distal GI tract skeletal muscle dysfunction may result in the leakage of flatus and fecal matter, whereas, in contrast, pelvic floor dysfunction may contribute to constipation. The balance between such defects may severely impact nutritional status and quality of life. Herein, we provide a comprehensive review of the genetics, molecular biology, and mechanisms underlying heritable disorders of skeletal muscle and how these may impact GI tract function and overall well-being. For organizational purposes, we separate discussions of congenital, mitochondrial, and myofibrillar myopathies and muscular dystrophies. For the sake of completeness, we also briefly consider acquired myopathies that affect GI tract function. As treatment options are currently limited, disorders of skeletal muscle function provide exciting therapeutic opportunities, including innovative approaches to target specific gene modifications.
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Affiliation(s)
- Aishwarya Iyer
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Madeline Alizadeh
- The Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer Megan Mariano
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Jean-Pierre Raufman
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, Maryland; Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland; VA Maryland Healthcare System, Baltimore, Maryland; Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland.
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3
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Burns JB, Haraki AE, Crawford J, Parker-Autry CY. Fecal Incontinence Outcomes Following Transvaginal Posterior Vaginal Wall Repair. Int Urogynecol J 2025:10.1007/s00192-025-06096-z. [PMID: 40119891 DOI: 10.1007/s00192-025-06096-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 02/07/2025] [Indexed: 03/25/2025]
Abstract
INTRODUCTION AND HYPOTHESIS Knowledge regarding rates of improvement of fecal incontinence (FI) after repair of posterior compartment prolapse is limited. We aimed to estimate the rate of resolution or improvement of fecal incontinence postoperatively following transvaginal posterior compartment repair. METHODS This was a retrospective cohort study including patients with diagnosis of fecal incontinence who underwent transvaginal posterior repair at a single academic institution between 1/2016 and 1/2022. Patients who underwent concomitant anal sphincteroplasty served as controls. The primary outcome was resolution of FI symptoms within 6-weeks postoperatively. Secondary outcomes included improvement of FI symptoms and preoperative anorectal manometry characteristics. Univariate and bivariate analysis were performed to describe and compare outcomes between groups with multivariable regression performed to address potential confounders. RESULTS Of 179 patients included, 91 had posterior repair alone, while 88 had concomitant anal sphincteroplasty. Demographic and clinical characteristics were similar between groups. Overall, 143 (80%) patients did not report any FI symptoms at their 6-week postoperative visit. An additional 28 (16%) reported improvement in FI symptoms. Among patients who underwent posterior repair alone, 76 (84%) had resolution of their FI compared to 67 (76%) in patients with concomitant anal sphincteroplasty (P = 0.6); 71 patients underwent anorectal manometry preoperatively. There were no significant differences in mean average resting pressures or mean maximum squeeze pressures between groups. CONCLUSIONS Posterior compartment repair resulted in resolution or improvement of fecal incontinence symptoms within 6-weeks postoperatively. The mechanism for FI symptoms in women with rectoceles may be independent of the anal sphincter complex.
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Affiliation(s)
- Jersey B Burns
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Amr El Haraki
- Department of Urology, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Jesseca Crawford
- Department of Urology, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Candace Y Parker-Autry
- Department of Urology, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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Mundet L, Karunaratne TB, Ortega O, Raventós A, Clavé P. Study of the Corticoanorectal Neurophysiology in Women With Fecal Incontinence. Am J Gastroenterol 2025:00000434-990000000-01541. [PMID: 39791557 DOI: 10.14309/ajg.0000000000003295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 12/23/2024] [Indexed: 01/12/2025]
Abstract
INTRODUCTION Fecal incontinence (FI) is a prevalent condition that disproportionately affects women. Although sphincter biomechanics are well studied, the integrity of the corticoanal motor pathway remains elusive. We evaluated the corticospinoanorectal pathway in women with FI against age-matched (AM-HV) and young healthy (Y-HV) volunteers. METHODS Observational study with 18 women with FI (mean age: 63.4 ± 11.1), 15 AM-HV (60.7 ± 9.01), and 15 Y-HV (24.2 ± 5.39) conducted in a tertiary hospital. Patients underwent clinical evaluation, high-resolution anorectal manometry, endoanal ultrasound, and transcranial/translumbosacral magnetic stimulation to assess anorectal motor-evoked potentials (MEP). Clinical severity was measured with St. Mark score and quality of life with Fecal Incontinence Quality of Life and EQ5D. RESULTS Patients had longer MEP latencies than AM-HV in the cortico-anal (25.93 ± 3.67 ms vs 22.89 ± 1.38 ms) and right lumbo-rectal segments (5.64 ± 1.35 ms vs 4.39 ± 1.27 ms; P < 0.05), but not in the tibial segment (control) (33.35 ± 2.88 ms vs 32.08 ± 2.05 ms; P > 0.05). However, tibial latencies were longer in AM-HV compared with Y-HV (32.08 ± 2.05 ms vs 29.21 ± 2.75 ms; P = 0.003). In FI, 41.1% had corticoanorectal impairments, 50% lumboanal, and 44.4% sacral. Overall, 82.4% showed delayed latencies in at least one of the 12 segments. High-resolution anorectal manometry revealed 83.24% had external anal sphincter dysfunction, 40% internal sphincter dysfunction, and 23.57% both. MEP latencies inversely correlated with external anal sphincter squeeze strength. FI patients had significantly poorer EQ5D scores compared with both control groups. DISCUSSION Women with FI show significant neuropathy in the corticospinoanorectal pathway linked to impaired anorectal function. These findings underscore the brain-gut axis's role in FI pathophysiology, advocating for advanced neurophysiological diagnostics and targeted interventions.
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Affiliation(s)
- Lluís Mundet
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autònoma de Barcelona), Mataró, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Tennekoon Buddhika Karunaratne
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autònoma de Barcelona), Mataró, Spain
| | - Omar Ortega
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autònoma de Barcelona), Mataró, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Alba Raventós
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autònoma de Barcelona), Mataró, Spain
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Department of Surgery, Hospital de Mataró (Universitat Autònoma de Barcelona), Mataró, Spain
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Kobayashi Y, Fukunaga S, Kanamori A, Kono M, Ochiai T, Ominami M, Otani K, Hosomi S, Tanaka F, Fujiwara Y. Effects on anorectal function of endoscopic submucosal dissection for rectal tumors involving the dentate line. Scand J Gastroenterol 2024; 59:1120-1129. [PMID: 39145809 DOI: 10.1080/00365521.2024.2390011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/24/2024] [Accepted: 08/02/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) is a specific procedure that uses an electrosurgical knife for en-bloc resectioning large tumors. However, no study has examined the effect of ESD on the defecation function of patients with rectal tumors. We aimed to investigate the potential effects caused by ESD by analyzing changes in the morphology and movement of the anorectum pre- and post-ESD. METHODS This prospective observational study included 11 patients with anorectal tumors who underwent ESD between April 2020 and February 2022. Pre-ESD assessments included anorectal manometry and defecography. Post-ESD assessments were conducted 2 months later, including anorectal manometry, defecography, and proctoscopy for ulcer and stenosis evaluation. RESULTS The median patient age was 73 years, including seven males and four females. Eight patients (73%) had a tumor in the lower rectum, and the extent of resection was less than 50% of the rectal lumen. Resection reached the dentate line in six cases (55%). In the patients with post-ESD mucosal defects involving the dentate line, the median of functional anal canal length significantly decreased from (3.4 cm pre-ESD to 2.8 cm post-ESD, p = 0.04). Defecography revealed one case with incomplete evacuation (<50%) and incontinence post-ESD. Interestingly, patients with pre-existing rectoceles noted resolution of lesions post-ESD. None of the patients reported daily constipation or fecal incontinence. CONCLUSIONS While rectal ESD is unlikely to cause significant real-world defecation difficulties, alterations in rectal and anal canal morphology and function may occur if the dentate line is involved in the resection range.
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Affiliation(s)
- Yumie Kobayashi
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Kanamori
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Mitsuhiro Kono
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Tadashi Ochiai
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Shahsavari D, Rao SSC. Review article: advances in the diagnosis and management of anorectal motility disorders. Aliment Pharmacol Ther 2024; 60:701-714. [PMID: 39051556 DOI: 10.1111/apt.18170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/27/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Anorectal motility disorders such as dyssynergic defecation (DD), faecal incontinence (FI) and anorectal pain affect 40% of the population and are a frequent reason for gastroenterology consultation. They significantly affect the quality of life and lead to psychological distress. Lack of understanding of these problems compounded by a lack of availability and knowledge of diagnostic tools in most medical centres and/or trained physicians has significantly hampered this field. AIMS To discuss the latest advances in pathophysiology, diagnostic tests and therapeutic options for these disorders using an evidence-based approach. METHODS We reviewed the published literature over the past 20 years on DD, FI and anorectal pain and distilled these into a narrative review. RESULTS A detailed history, prospective stool diary and digital rectal exam, together with diagnostic tests such as anorectal manometry, balloon expulsion test, translumbosacral anorectal magnetic stimulation test for assessing neuropathy, defecography and anal ultrasound, can provide detailed mechanistic and structural information. Such knowledge can pave the way for a meaningful and pathophysiologic-based management approach. This could include biofeedback therapy for DD or FI, sensory training for rectal hyposensitivity or sensory adaptation training for rectal hypersensitivity or sphincter bulking agents or neuromodulation therapies. These treatments are effective and safe. CONCLUSIONS Anorectal motility disorders are common, but either less well recognized or poorly managed by most gastroenterologists. Equipped with the practical and up-to-date knowledge provided in this review, physicians could provide improved health care for these patients.
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Affiliation(s)
- Dariush Shahsavari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
| | - Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
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Grosman Y, Kalichman L. Bidirectional Relationships between Sarcopenia and Pelvic Floor Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:879. [PMID: 39063456 PMCID: PMC11276977 DOI: 10.3390/ijerph21070879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/03/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024]
Abstract
Sarcopenia and pelvic floor disorders (PFDs) are prevalent and often cooccurring conditions in the aging population. However, their bidirectional relationship and underlying mechanisms remain underexplored. This narrative review aims to elucidate this relationship by exploring potential causative interplays, shared pathophysiological mechanisms, and common risk factors. A comprehensive literature search was conducted to identify relevant studies focusing on epidemiological associations, interaction mechanisms, and implications for patient care. While epidemiological studies demonstrate associations between sarcopenia and PFDs, our findings reveal a cyclical relationship where sarcopenia may exacerbate PFDs through mechanisms such as decreased muscle strength and mobility. Conversely, the presence of PFDs often leads to reduced physical activity due to discomfort and mobility issues, which in turn exacerbate the muscle atrophy associated with sarcopenia. Additionally, shared risk factors such as physical inactivity, nutritional deficiencies, metabolic syndrome, and menopausal hormonal changes likely contribute to the onset and progression of both conditions. These interactions underscore the importance of concurrently integrated care approaches that address both conditions. Effective management requires comprehensive screening, the recognition of contributing factors, and tailored exercise regimens supported by a multidisciplinary approach. Future research should focus on longitudinal studies tracking disease progression and evaluating the efficacy of multidisciplinary care models in optimizing patient outcomes.
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Affiliation(s)
- Yacov Grosman
- Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva 84105, Israel
- Department of Physical Therapy, Meuhedet Health Maintenance Organization, Hadera 3824242, Israel
| | - Leonid Kalichman
- Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva 84105, Israel
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8
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Luo MY, Chen WP, Chen HX, Yang XY, Wan XY, Xiao GZ, Zheng YH, Ren DL, Peng H, Lin HC. Stapled transperineal rectovaginal fistula repair for low- and mid-level rectovaginal fistulas: A comparison study with rectal mucosal advancement flap repair. Asian J Surg 2024; 47:1756-1762. [PMID: 38228457 DOI: 10.1016/j.asjsur.2023.12.186] [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: 08/30/2023] [Revised: 11/15/2023] [Accepted: 12/29/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND As an innovative treatment, stapled transperineal rectovaginal fistula repair (STR) for rectovaginal fistula (RVF) has demonstrated effectiveness in preliminary reports. This study aims to compare STR with rectal mucosal advancement flap repair (RAF), a widely utilized surgical procedure, for the surgical outcome of the low- and mid-level RVF. METHODS In this retrospective cohort study, patients with low- and mid-level RVF who underwent STR or RAF were included from both the Sixth Affiliated Hospital of Sun Yat-sen University and Xi'an Daxing Hospital. Among the 99 total patients, 77 underwent STR and 22 underwent RAF. Patient demographics, operative data, and outcomes were collected and analyzed. Recurrence rate and associated risk factors were evaluated. RESULTS There were no statistically significant differences among patients in terms of clinical characteristics like age, BMI, aetiology, and fistula features. During the follow-up period of 20 months (interquartile range 3.0-41.8 months), a total of 28 patients relapsed, with a significantly lower recurrence rate in the STR group (20.8 %) than in the RAF group (54.6 %) (P = 0.005). In the multivariate Cox analysis, STR was an independent protective factor against recurrence (HR: 0.37, 95%CI: 0.17-0.79, P = 0.01). Logistic regression indicated that there was no statistically significant difference between these two procedures in terms of surgical complications (OR: 0.53, 95%CI: 0.19-1.48, P = 0.23). CONCLUSION For low- and mid-level RVF, STR may be an alternative option for treatment modality that offers a lower recurrence rate, without observed disadvantage in terms of surgical complication rates.
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Affiliation(s)
- Min-Yi Luo
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Wen-Ping Chen
- Department of Anorectal and Pelvic Floor Surgery, Xi'an Daxing Hospital, China
| | - Hua-Xian Chen
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Xiao-Yuan Yang
- Department of Anorectal and Pelvic Floor Surgery, Xi'an Daxing Hospital, China
| | - Xing-Yang Wan
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Guo-Zhong Xiao
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Yi-Hui Zheng
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Dong-Lin Ren
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China
| | - Hui Peng
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China.
| | - Hong-Cheng Lin
- Department of Coloproctology, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, China; Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, China.
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Dexter E, Walshaw J, Wynn H, Dimashki S, Leo A, Lindsey I, Yiasemidou M. Faecal incontinence-a comprehensive review. Front Surg 2024; 11:1340720. [PMID: 38362459 PMCID: PMC10867159 DOI: 10.3389/fsurg.2024.1340720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Faecal incontinence (FI) is a distressing and often stigmatizing condition characterised as the recurrent involuntary passage of liquid or solid faeces. The reported prevalence of FI exhibits considerable variation, ranging from 7 to 15% in the general population, with higher rates reported among older adults and women. This review explores the pathophysiology mechanisms, the diagnostic modalities and the efficiency of treatment options up to date. Methods A review of the literature was conducted to identify the pathophysiological pathways, investigation and treatment modalities. Result and discussion This review provides an in-depth exploration of the intricate physiological processes that maintain continence in humans. It then guides the reader through a detailed examination of diagnostic procedures and a thorough analysis of the available treatment choices, including their associated success rates. This review is an ideal resource for individuals with a general medical background and colorectal surgeons who lack specialized knowledge in pelvic floor disorders, as it offers a comprehensive understanding of the mechanisms, diagnosis, and treatment of faecal incontinence (FI).
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Affiliation(s)
- Eloise Dexter
- Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Josephine Walshaw
- Leeds Institute of Medical Research, St James’ University Hospital, University of Leeds, Leeds, United Kingdom
- Department of Health Research, University of York, York, United Kingdom
| | - Hannah Wynn
- Upper Gastrointestinal Surgery, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Safaa Dimashki
- Plastic Surgery, Mid Yorkshire Teaching NHS Trust, Wakefield, United Kingdom
| | - Alex Leo
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ian Lindsey
- Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Marina Yiasemidou
- Colorectal Surgery, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
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10
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Garcia LE, Tassinari S, Azadi J, Chung H, Gearhart S. Anorectal Anatomy Quiz: Practical Review. J Gastrointest Surg 2023; 27:2931-2945. [PMID: 38135807 DOI: 10.1007/s11605-023-05862-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/09/2023] [Indexed: 12/24/2023]
Abstract
Understanding anorectal and pelvic floor anatomy can be challenging but is paramount for every physician managing patients with anorectal pathology. Knowledge of anorectal anatomy is essential for managing benign, malignant, traumatic, and infectious diseases affecting the anorectum. This quiz is intended to provide a practical teaching guide for medical students, medical and surgical residents, and may serve as a review for practicing general surgeons and specialists.
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Affiliation(s)
- Leonardo E Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefano Tassinari
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Javad Azadi
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haniee Chung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Varghese C, Harvey X, Gharibans AA, Du P, Collinson R, Bissett IP, Stinear CM, O'Grady G, Paskaranandavadivel N. Clinical utility of trans-sacral magnetic stimulation-evoked sphincter potentials and high-density electromyography in pelvic floor assessment: Technical evaluation. Colorectal Dis 2023; 25:2257-2265. [PMID: 37800177 DOI: 10.1111/codi.16753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 10/07/2023]
Abstract
AIM Faecal incontinence is common and of multifactorial aetiologies, yet current diagnostic tools are unable to assess nerve and sphincter function objectively. We developed an anorectal high-density electromyography (HD-EMG) probe to evaluate motor-evoked potentials induced via trans-sacral magnetic stimulation (TSMS). METHOD Anorectal probes with an 8 × 8 array of electrodes spaced 1 cm apart were developed for recording HD-EMG of the external anal sphincter. These HD-EMG probes were used to map MEP amplitudes and latencies evoked via TSMS delivered through the Magstim Rapid2 (MagStim Company). Patients undergoing pelvic floor investigations were recruited for this IDEAL Stage 2a pilot study. RESULTS Eight participants (median age 49 years; five female) were recruited. Methodological viability, safety and diagnostic workflow were established. The test was well tolerated with median discomfort scores ≤2.5/10, median pain scores ≤1/10 and no adverse events. Higher Faecal Incontinence Severity Index scores correlated with longer MEP latencies (r = 0.58, p < 0.001) and lower MEP amplitudes (r = -0.32, p = 0.046), as did St. Mark's Incontinence Scores with both MEP latencies (r = 0.49, p = 0.001) and MEP amplitudes (r = -0.47, p = 0.002). CONCLUSION This HD-EMG probe in conjunction with TSMS presents a novel diagnostic tool for anorectal function assessment. Spatiotemporal assessment of magnetically stimulated MEPs correlated well with symptoms and offers a feasible, safe and patient-tolerable method of evaluating pudendal nerve and external anal sphincter function. Further clinical development and evaluation of these techniques is justified.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Xavier Harvey
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Armen A Gharibans
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Rowan Collinson
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Cathy M Stinear
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Remes-Troche JM, Coss-Adame E, García-Zermeño KR, Gómez-Escudero O, Amieva-Balmori M, Gómez-Castaños PC, Charúa-Guindic L, Icaza-Chávez ME, López-Colombo A, Morel-Cerda EC, Pérez Y López N, Rodríguez-Leal MC, Salgado-Nesme N, Sánchez-Avila MT, Valdovinos-García LR, Vergara-Fernández O, Villar-Chávez AS. The Mexican consensus on fecal incontinence. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:404-428. [PMID: 38097437 DOI: 10.1016/j.rgmxen.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 01/01/2024]
Abstract
Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence» and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.
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Affiliation(s)
- J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico.
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City, Mexico
| | - K R García-Zermeño
- Gastroenterología y Motilidad Digestiva, CIGMA, Boca del Río, Veracruz, Mexico
| | - O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopía Digestiva y Motilidad Gastrointestinal, Hospital Ángeles de Puebla, Puebla, Mexico
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Mexico
| | - P C Gómez-Castaños
- Centro de Investigación y Docencia en Ciencias de la Salud, Universidad Autónoma de Sinaloa, Culiacán, Sinaloa, Mexico
| | - L Charúa-Guindic
- Práctica privada, Coloproctología del Hospital Ángeles Lomas, Mexico City, Mexico
| | - M E Icaza-Chávez
- Hospital Christus Muguerza Faro del Mayab, Mérida, Yucatán, Mexico
| | - A López-Colombo
- UMAE Hospital de Especialidades, Centro Médico Nacional Manuel Ávila Camacho, IMSS Puebla, Puebla, Mexico
| | - E C Morel-Cerda
- Laboratorio de Motilidad Gastrointestinal, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - M C Rodríguez-Leal
- Hospital Ángeles Valle Oriente, IMSS UMAE 25, Monterrey, Nuevo León, Mexico
| | - N Salgado-Nesme
- Departamento de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Mexico City,Mexico
| | - M T Sánchez-Avila
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, Monterrey, Nuevo León, Mexico
| | - L R Valdovinos-García
- Laboratorio de Motilidad Gastrointestinal Fundación Clínica Médica Sur, Mexico City, Mexico
| | - O Vergara-Fernández
- Departamento de Cirugía Colorrectal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, Mexico
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Young S, Lee B, Smukalla S, Axelrad J, Chang S. Anorectal Manometry in Patients With Fecal Incontinence After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Cohort Study. CROHN'S & COLITIS 360 2023; 5:otad063. [PMID: 38077748 PMCID: PMC10708921 DOI: 10.1093/crocol/otad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Indexed: 02/12/2024] Open
Abstract
Background Fecal incontinence commonly occurs in patients with ulcerative colitis and ileal pouch-anal anastomosis. There is a paucity of manometric data in pouch patients. We aimed to better define manometric parameters in pouch patients with fecal incontinence. Methods We compared clinical and manometric variables in ulcerative colitis patients with pouch and fecal incontinence to ulcerative colitis patients with pouch without fecal incontinence and to non-ulcerative colitis patients with fecal incontinence. Manometric data for the 3 cohorts were compared to established normative data. An independent-samples t-test was performed for continuous variables, and chi-square test was used for categorical variables. Logistic regression was performed to identify predictors of incontinence in pouch patients (P < .05). Results Among 26 pouch patients with fecal incontinence (73% female), 26 pouch patients without fecal incontinence (35% female), and 84 patients with fecal incontinence without ulcerative colitis (68% female), there were no differences in anorectal pressures between patients with fecal incontinence. Lower pressures were observed in pouch patients with fecal incontinence compared to those without fecal incontinence. Resting pressure was similar between pouch patients with fecal incontinence and healthy controls (60.9 ± 36.1 mmHg vs. 66.9 ± 3.2 mmHg, P = .40). Female sex (P = .019) and defecatory disorders (P = .033) each independently predicted fecal incontinence in pouch patients. Conclusions Pouch patients with fecal incontinence have lower anorectal pressures compared to pouch patients without incontinence, though have similar pressures to non-ulcerative colitis patients with fecal incontinence. Pouch patients with fecal incontinence have similar resting pressures as healthy controls. Distinct manometric normative values for pouch patients are needed.
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Affiliation(s)
- Sigrid Young
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Briton Lee
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott Smukalla
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
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Sun G, Trzpis M, Ding H, Gao X, Broens PMA, Zhang W. Co-occurrence of fecal incontinence with constipation or irritable bowel syndrome indicates the need for personalized treatment. Neurogastroenterol Motil 2023; 35:e14633. [PMID: 37427541 DOI: 10.1111/nmo.14633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND This study aimed to compare the prevalence and symptoms of fecal incontinence (FI) in relation to irritable bowel syndrome (IBS-associated FI), constipation (constipation-associated FI), and isolation (isolated FI). METHODS Data were analyzed from 3145 respondents without organic comorbidities known to influence defecation function from the general Chinese population who filled in the online Groningen Defecation and Fecal Continence questionnaire. FI, IBS, and constipation were evaluated with the Rome IV criteria. KEY RESULTS The prevalence of FI was 10.5% (n = 329) in the non-comorbidity group. After multivariable logistic regression analysis, IBS (odds ratio [OR]: 12.55, 95% confidence interval [CI]: 9.06-17.36) and constipation (OR: 4.38, 95% CI: 3.27-5.85) were the most significant factors contributing to FI. Based on this finding, 106/329 (32.2%) had IBS-associated FI, 119/329 (36.2%) had constipation-associated FI, and 104/329 (31.6%) had isolated FI. Among the 329 FI respondents, there was a high prevalence of IBS and constipation-related symptoms, including abdominal pain (81.5%) and abdominal bloating (77.8%) for IBS and straining during defecation (75.4%), incomplete defecation (72.3%), defecation blockage (63.2%), anal pain during defecation (59.3%), and hard stools (24%) for constipation. The patients with IBS-associated FI asked for specialists' help less frequently than those with isolated FI. Interestingly, among the patients with constipation-associated FI, 56.3% used anti-diarrhea medicine. CONCLUSIONS AND INFERENCES The prevalence of IBS-associated FI, constipation-associated FI, and isolated FI is comparably high. It is important to diagnose and target the cause of FI to provide personalized and cause-targeting care instead of treating only the FI symptoms.
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Affiliation(s)
- Ge Sun
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Haibo Ding
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xianhua Gao
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Paul M A Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Naval Medical University, Shanghai, China
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Badri H, Fowler G, Lane S. Follow up of women after obstetric anal sphincter injuries (OASI)-What is the role of anorectal testing? Neurourol Urodyn 2023; 42:1374-1380. [PMID: 37269480 DOI: 10.1002/nau.25220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 03/09/2023] [Accepted: 05/19/2023] [Indexed: 06/05/2023]
Abstract
AIMS To evaluate the benefit of performing anorectal studies on all women following primary obstetric anal sphincter injury (OASI) repair over performing them on symptomatic women only. METHODS Women who attended perineal clinic between 2007 and 2020 underwent symptom assessment and anorectal studies at 6 weeks and 6 months postpartum. Anorectal studies including endo anal ultrasound (EAUS) and anal manometry (AM) were performed. The anorectal studies of symptomatic women who were the case group, were compared with asymptomatic women who were the control group. RESULTS A total of 1348 women were seen in the perineal clinic over 13 years. A total of 454 (33.7%) women were symptomatic. A total of 894 (66.3%) women were asymptomatic. A total of 313 (35%) asymptomatic women had two abnormal anorectal studies, 274 (31%) had abnormal AM alone, and 86 (9.6%) had abnormal EAUS alone. A total of 221 (24.7%) asymptomatic women had normal anorectal studies. CONCLUSION Almost 70% of women were asymptomatic 6 months following primary OASI repair. Most had at least one abnormal anorectal study result. Selectively performing anorectal tests on symptomatic women would not identify asymptomatic women at risk of future faecal incontinence following further vaginal birth. Without anorectal study results, women would not receive accurate counseling about the risks of vaginal birth. Anorectal studies should be offered to all women following OASI where resources allow.
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Affiliation(s)
- Hawra Badri
- Department of Urogynaecology, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Gillian Fowler
- Department of Urogynaecology, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Steven Lane
- Department of Biostatistics, University of Liverpool, Liverpool, UK
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16
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Shan S, Li Q, Criswell T, Atala A, Zhang Y. Stem cell therapy combined with controlled release of growth factors for the treatment of sphincter dysfunction. Cell Biosci 2023; 13:56. [PMID: 36927578 PMCID: PMC10018873 DOI: 10.1186/s13578-023-01009-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023] Open
Abstract
Sphincter dysfunction often occurs at the end of tubule organs such as the urethra, anus, or gastroesophageal sphincters. It is the primary consequence of neuromuscular impairment caused by trauma, inflammation, and aging. Despite intensive efforts to recover sphincter function, pharmacological treatments have not achieved significant improvement. Cell- or growth factor-based therapy is a promising approach for neuromuscular regeneration and the recovery of sphincter function. However, a decrease in cell retention and viability, or the short half-life and rapid degradation of growth factors after implantation, remain obstacles to the translation of these therapies to the clinic. Natural biomaterials provide unique tools for controlled growth factor delivery, which leads to better outcomes for sphincter function recovery in vivo when stem cells and growth factors are co-administrated, in comparison to the delivery of single therapies. In this review, we discuss the role of stem cells combined with the controlled release of growth factors, the methods used for delivery, their potential therapeutic role in neuromuscular repair, and the outcomes of preclinical studies using combination therapy, with the hope of providing new therapeutic strategies to treat incontinence or sphincter dysfunction of the urethra, anus, or gastroesophageal tissues, respectively.
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Affiliation(s)
- Shengzhou Shan
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Tracy Criswell
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Anthony Atala
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| | - Yuanyuan Zhang
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
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Farag A, Mashhour AN, Raslan MM, Khalifa AS, Elbarmelgi MY. The Functional Luminal Imaging Probe (FLIP): A Good Tool for Adjustment of anal Canal Dimensions During Operative Management of Fecal Incontinence. Surg Innov 2023:15533506231157438. [PMID: 36790084 DOI: 10.1177/15533506231157438] [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: 02/16/2023]
Abstract
PURPOSE Fecal incontinence is a troublesome problem in the field of colorectal surgery. The main aim of this study was to adjust the anal canal resistance during operative management of anal incontinence using Endo-FLIP. METHODS This was a prospective cohort study held at Cairo university hospital. Hundred forty-eight incontinent patients treated by different surgical procedures were included. During the procedure the Endo-FLIP was applied to adjust the anal canal dimensions (ACL and ACD) so the ACR could be adjusted based on the flow equation. These were also assessed pre-operatively with Endo-FLIP system and the flow equation calculator. The clinical severity of the disease and outcome after surgical procedures were assessed and correlated to the physiologic parameters. RESULTS ACL, ACD and ACR had had significant correlations to the degree of incontinence (P < .001). ACL, ACD and ACR showed statistically significant change with primary repair and gluteus maximus transposition operations. After treatment of fecal incontinence, in good responders' group, the mean resting anal canal resistance increased significantly to 4649.05 ± 1161.49 (postoperative) while in poor responders' group it was 1919.9 ± 1077.73. CONCLUSIONS The Endo-flip can be used to measure the anal canal geometric parameters (ACL and ACD) and then anal canal resistance could be calculated by the flow equation - pre-and post-operatively- which help the adjustment of the surgical repair of sphincter injury in fecal incontinence patients which may improve the surgical outcome.
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Affiliation(s)
- Ahmed Farag
- 63527Cairo University Kasr Alainy Faculty of Medicine, Egypt
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18
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Marcellier G, Dupont A, Bourgeois-Moine A, Le Tohic A, De Carne-Carnavalet C, Poujade O, Girard G, Benbara A, Mandelbrot L, Abramowitz L. Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study. J Clin Med 2023; 12:jcm12041531. [PMID: 36836068 PMCID: PMC9967240 DOI: 10.3390/jcm12041531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22-21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.
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Affiliation(s)
- Gabriel Marcellier
- Proctology and Gastroenterology Department, APHP-Bichat Hospital, 75018 Paris, France
- Correspondence: ; Tel.: +33-6-68-97-79-05
| | - Axelle Dupont
- Biostatistics and Medical IT Department, APHP-Bichat Hospital, 75018 Paris, France
| | | | - Arnaud Le Tohic
- Department of Obstetrics and Gynecology, Versailles Hospital, 78157 Le Chesnay, France
| | | | - Olivier Poujade
- Department of Obstetrics and Gynecology, APHP-Beaujon Hospital, 92110 Clichy, France
| | - Guillaume Girard
- Department of Obstetrics and Gynecology, APHP-Armand Trousseau Hospital, 75012 Paris, France
| | - Amélie Benbara
- Department of Obstetrics and Gynecology, APHP-Jean Verdier Hospital, 93140 Bondy, France
| | - Laurent Mandelbrot
- Department of Obstetrics and Gynecology, APHP-Louis Mourier Hospital, 92700 Colombes, France
| | - Laurent Abramowitz
- Proctology and Gastroenterology Department, APHP-Bichat Hospital, 75018 Paris, France
- Proctology and Gastroenterology Department, Blomet Clinic (Ramsay GDS Group), 75015 Paris, France
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Sun G, de Haas RJ, Trzpis M, Broens PMA. A possible physiological mechanism of rectocele formation in women. Abdom Radiol (NY) 2023; 48:1203-1214. [PMID: 36745205 PMCID: PMC10115871 DOI: 10.1007/s00261-023-03807-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to determine the anorectal physiological factors associated with rectocele formation. METHODS Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected. RESULTS Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011). CONCLUSION Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.
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Affiliation(s)
- Ge Sun
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Robbert J de Haas
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Monika Trzpis
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
| | - Paul M A Broens
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.,Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
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Badri H, Fowler G, Lane S. The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI). Int Urogynecol J 2023; 34:399-404. [PMID: 36278987 DOI: 10.1007/s00192-022-05380-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/17/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Mode of birth (MOB) following OASI is determined by choice, symptoms and anorectal study results in asymptomatic women. Endoanal ultrasound (EAUS) is the gold-standard imaging modality. EAUS use in MOB counselling is supported by strong evidence. Less is understood about how anal manometry (AM) influences MOB counselling. METHODS A retrospective observational study was conducted from 2007 to 2020. Women underwent symptom assessment using validated ePAQ and St Mark's incontinence score (SMIS). Anorectal studies using EAUS and AM were performed. The case group was the normal ultrasound group and the control group was the abnormal ultrasound group. Both groups were compared with normal and abnormal AM result groups. RESULTS A total of 1348 women were included over 13 years. Among these, 454 women were symptomatic, 894 were asymptomatic; 274 (31%) asymptomatic women had isolated abnormal AM results, 313 (35%) had two abnormal anorectal results and 221 (24.7%) had normal anorectal results. Eighty-six asymptomatic women (10.4%) had isolated abnormal EAUS results, 138 (30.4%) symptomatic women had isolated abnormal AM, 221 (48.7%) had two abnormal anorectal results and 57 (12.6%) had normal anorectal results. Thirty-eight symptomatic women (8.4%) had an isolated abnormal EAUS result. CONCLUSIONS AM identifies more women with sphincter function impairment than EAUS alone. Without AM, almost one third of asymptomatic women would not have been identified and could have been inadequately counselled. Performing AM and EAUS together captured most women with compromised anal sphincter function. We conclude that AM should be performed in all women with OASI alongside EAUS to enable accurate MOB counselling.
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Affiliation(s)
- Hawra Badri
- Liverpool Women's NHS Foundation Trust, Liverpool, UK.
| | | | - Steven Lane
- Department of Biostatistics, University of Liverpool, Liverpool, UK
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Quiroz LH, Galliano DE, da Silva G, Carmichael JC, Pan LC, Bromley ER, Hinahara JG, Goss TF. Efficacy and Safety of a Nonanimal Stabilized Hyaluronic Acid/Dextranomer in Improving Fecal Incontinence: A Prospective, Single-Arm, Multicenter, Clinical Study With 36-Month Follow-up. Dis Colon Rectum 2023; 66:278-287. [PMID: 35001051 PMCID: PMC9829037 DOI: 10.1097/dcr.0000000000002348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Fecal incontinence affects 7% to 12% of the US adult population, causing social, financial, and quality of life burdens. OBJECTIVE The primary aim of this study was to evaluate the efficacy and safety of nonanimal stabilized hyaluronic acid/dextranomer through 36 months as a condition of postmarket approval application. DESIGN This was a prospective, single-arm, multicenter, observational Food and Drug Administration-mandated postapproval clinical study. SETTINGS This study was designed and executed by participating centers in 18 hospitals and colorectal health clinics in coordination with the Food and Drug Administration and the study sponsor. PATIENTS A total of 283 subjects who previously failed conservative therapy were enrolled across 18 US sites. INTERVENTIONS Participants received 1 to 2 nonanimal stabilized hyaluronic acid/dextranomer treatments. The first treatment occurred within 30 days of baseline, and a second treatment was administered 1 to 3 months after initial treatment if determined necessary by the physician. Subjects were followed through 7 visits over 36 months after last treatment. MAIN OUTCOME MEASURES Efficacy (as specified by the Food and Drug Administration) was measured as a fecal incontinence reintervention rate of <50% at 36 months. Reintervention included nonanimal stabilized hyaluronic acid/dextranomer re-treatment, surgical interventions, and physical therapy. Safety was measured by device-related adverse events. Secondary end points included Fecal Incontinence Quality of Life Scale and Cleveland Clinic Florida Fecal Incontinence Score. RESULTS Using a Bayesian estimate, the reintervention rate of the intention-to-treat population (n = 283) was 18.9% (95% CI, 14.0-24.4) at 36 months. At 36 months, the reintervention rate for subjects with complete data (n = 192) was 20.8% (95% CI, 15.1-26.6). Significant improvement ( p < 0.0001) was noted across the Cleveland Clinic Florida Fecal Incontinence Score and Fecal Incontinence Quality of Life subscales at 36 months. Ninety-two device-related adverse events were reported by 15.2% of enrolled patients; most were GI disorders and resolved quickly. There were no serious adverse events. LIMITATIONS Limitations of the study included a 32% attrition rate and homogeneous patient population (91.8% white; 85.5% female), possibly limiting generalizability. CONCLUSIONS Nonanimal stabilized hyaluronic acid/dextranomer demonstrated clinically significant, sustained improvement in symptoms and quality of life for fecal incontinence patients without the occurrence of any serious adverse events. See Video Abstract at http://links.lww.com/DCR/B890 . REGISTRATION ClinicalTrials.gov ; Unique identifier: NCT01647906. EFICACIA Y SEGURIDAD DE UN CIDO HIALURNICO/ DEXTRANMERO ESTABILIZADO DE ORGEN NO ANIMAL PARA MEJORAR LA INCONTINENCIA FECAL UN ESTUDIO CLNICO PROSPECTIVO, MULTICNTRICO Y DE UN SOLO BRAZO CON SEGUIMIENTO DE MESES ANTECEDENTES:La incontinencia fecal afecta entre el 7 y el 12% de la población adulta de los EE. UU. Y genera cargas sociales, económicas y de calidad de vida.OBJETIVO:Los objetivos principales de este estudio fueron evaluar la eficacia y seguridad del ácido hialurónico/ dextranómero estabilizado de origen no animal durante 36 meses como condición para la solicitud de aprobación posterior a la comercialización.DISEÑO:Este fue un estudio clínico prospectivo, observacional, de un solo brazo, multicéntrico, ordenado por la FDA después de la aprobación.AJUSTES:Este estudio fue diseñado por los investigadores participantes, la FDA y el patrocinador del estudio que gestionó la recopilación de datos.PACIENTES:Un total de 283 sujetos en quienes previamente falló la terapia conservadora se inscribieron en el estudio prospectivo de un solo brazo en 18 sedes de EE. UU. (NCT01647906).INTERVENCIONES:Los participantes recibieron 1-2 tratamientos con ácido hialurónico/ dextranómero estabilizado no animal. El primer tratamiento se dio dentro de los 30 días posteriores al inicio, mientras que un segundo tratamiento se administró 1-3 meses después del tratamiento inicial si el médico lo determinaba necesario. Los sujetos fueron seguidos durante 7 visitas durante 36 meses después del último tratamiento.PRINCIPALES MEDIDAS DE RESULTADO:La eficacia (según especificado por la FDA) se midió como una tasa de reintervención de incontinencia fecal de <50% a los 36 meses. La reintervención incluyó retratamiento con ácido hialurónico/ dextranómero estabilizado no animal, intervenciones quirúrgicas y fisioterapia. La seguridad se midió mediante los eventos adversos relacionados con tratamiento. Los criterios de valoración secundarios incluyeron la escala de calidad de vida de incontinencia fecal y la puntuación de incontinencia fecal de Cleveland Clinic Florida.RESULTADOS:Utilizando una estimación bayesiana, la tasa de reintervención de la población por intención de tratar (n = 283) fue del 18.9% (IC del 95%: 14.0%, 24.4%) a los 36 meses. A los 36 meses, la tasa de reintervención para los sujetos con datos completos (n = 192) fue del 20.8% (IC del 95%: 15.1%, 26.6%). Se observó una mejora significativa (p <0.0001) en las subescalas de la puntuación de incontinencia fecal de la Cleveland Clinic Florida y de la calidad de vida de la incontinencia fecal a los 36 meses. El 15.2% de los pacientes inscritos informaron 92 eventos adversos relacionados con el tratmiento; la mayoría eran trastornos gastrointestinales y se resolvieron rápidamente. No hubo eventos adversos graves.LIMITACIONES:Las limitaciones incluyen una tasa de deserción del 32% y una población de pacientes homogénea (91.8% blancos, 85.5% mujeres), lo que posiblemente limite la generalización.CONCLUSIÓNES:El ácido hialurónico/ dextranómero estabilizado de origen no animal demostró una mejora sostenida y clínicamente significativa de los síntomas y la calidad de vida de los pacientes con incontinencia fecal, sin que se produjeran efectos adversos graves. Consulte el Video Resumen en http://links.lww.com/DCR/B890 . ( Traducción-Dr. Jorge Silva Velazco )Registro: ClinicalTrials.gov número NCT01647906.
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Affiliation(s)
- Lieschen H. Quiroz
- Female Pelvic Medicine and Reconstructive Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Giovanna da Silva
- Department of Colorectal Surgery, Cleveland Clinic Florida-Weston, Weston, Florida
| | - Joseph C. Carmichael
- Division of Colon & Rectal Surgery, Department of Surgery, UCI Health, Orange, California
| | - Li-Chen Pan
- Boston Healthcare Associates, Boston, Massachusetts
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22
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Trzpis M, Sun G, Chen JH, Huizinga JD, Broens P. Novel insights into physiological mechanisms underlying fecal continence. Am J Physiol Gastrointest Liver Physiol 2023; 324:G1-G9. [PMID: 36283962 DOI: 10.1152/ajpgi.00313.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The machinery maintaining fecal continence prevents involuntary loss of stool and is based on the synchronized interplay of multiple voluntary and involuntary mechanisms, dependent on cooperation between motor responses of the musculature of the colon, pelvic floor, and anorectum, and sensory and motor neural pathways. Knowledge of the physiology of fecal continence is key toward understanding the pathophysiology of fecal incontinence. The idea that involuntary contraction of the internal anal sphincter is the primary mechanism of continence and that the external anal sphincter supports continence only by voluntary contraction is outdated. Other mechanisms have come to the forefront, and they have significantly changed viewpoints on the mechanisms of continence and incontinence. For instance, involuntary contractions of the external anal sphincter, the puborectal muscle, and the sphincter of O'Beirne have been proven to play a role in fecal continence. Also, retrograde propagating cyclic motor patterns in the sigmoid and rectum promote retrograde transit to prevent the continuous flow of content into the anal canal. With this review, we aim to give an overview of primary and secondary mechanisms controlling fecal continence and evaluate the strength of evidence.
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Affiliation(s)
- Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Ge Sun
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Ji-Hong Chen
- Department of Medicine, Farncombe Family Digestive Research Institute, McMaster University, Hamilton, Canada
| | - Jan D Huizinga
- Department of Medicine, Farncombe Family Digestive Research Institute, McMaster University, Hamilton, Canada
| | - Paul Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center, Groningen, The Netherlands.,Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center, Groningen, The Netherlands
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23
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Chen W, He Z, Li S, Wu Z, Tan J, Yang W, Li G, Pan X, Liu Y, Lyu FJ, Li W. The Effect of Tissue Stromal Vascular Fraction as Compared to Cellular Stromal Vascular Fraction to Treat Anal Sphincter Incontinence. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 10:bioengineering10010032. [PMID: 36671604 PMCID: PMC9854502 DOI: 10.3390/bioengineering10010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND The long-term prognosis of current treatments for anal sphincter incontinence (ASI) is poor. Here, we explored the efficacy of tissue adipose stromal vascular fraction SVF (tSVF) on ASI and compared it to that of cellular SVF (cSVF). We then investigated possible mechanisms. METHODS Rat cSVF and tSVF were isolated and labeled with DIL. One day after modeling, three groups received phosphate-buffered saline (PBS), cSVF, tSVF, respectively. The control group received nil modeling nor any treatments. The effect was assessed by function test for anal pressure and electromyography, and staining for fiber content, proliferation and differentiation at day 5 and day 10. RESULTS cSVF injection resulted in faster healing than tSVF. The cSVF group showed significant improvement on anal pressure on day 10. For the electromyography test, cSVF showed significant improvement for the frequencies on day 10, and for the peak values on both time points, while tSVF showed significant improvement for the peak values on day 10. The two SVF both alleviated fibrosis. Immunofluorescence tracing identified differentiation of some injected cells towards myosatellite cells and smooth muscle cells in both SVF groups. For all the tests, the tSVF group tends to have similar or lower effects than the cSVF group with no significant difference. CONCLUSION cSVF and tSVF are both safe and effective in treating ASI, while the effect of cSVF is slighter higher than tSVF.
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Affiliation(s)
- Wenbin Chen
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Zijian He
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Shuyu Li
- School of Biology and Biological Engineering, South China University of Technology, Guangzhou 510641, China
| | - Zixin Wu
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Jin Tan
- The Sixth Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Weifeng Yang
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Guanwei Li
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Xiaoling Pan
- The Sixth Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Yuying Liu
- The Sixth Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
| | - Feng-Juan Lyu
- The Sixth Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
- Correspondence: (F.-J.L.); (W.L.)
| | - Wanglin Li
- Department of Colorectal and Anal Surgery, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou 510641, China
- Correspondence: (F.-J.L.); (W.L.)
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24
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Lin AY, Varghese C, Paskaranandavadivel N, Seo S, Du P, Dinning P, Bissett IP, O'Grady G. Faecal incontinence is associated with an impaired rectosigmoid brake and improved by sacral neuromodulation. Colorectal Dis 2022; 24:1556-1566. [PMID: 35793162 PMCID: PMC10084032 DOI: 10.1111/codi.16249] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/04/2022] [Accepted: 05/20/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The rectosigmoid brake, characterised by retrograde cyclic motor patterns on high-resolution colonic manometry, has been postulated as a contributor to the maintenance of bowel continence. Sacral neuromodulation (SNM) is an effective therapy for faecal incontinence, but its mechanism of action is unclear. This study aims to investigate the colonic motility patterns in the distal colon of patients with faecal incontinence, and how these are modulated by SNM. METHODS A high-resolution fibreoptic colonic manometry catheter, containing 36 sensors spaced at 1-cm intervals, was positioned in patients with faecal incontinence undergoing stage 1 SNM. One hour of pre- and post meal recordings were obtained followed by pre- and post meal recordings with suprasensory SNM. A 700-kcal meal was given. Data were analysed to identify propagating contractions. RESULTS Fifteen patients with faecal incontinence were analysed. Patients had an abnormal meal response (fewer retrograde propagating contractions compared to controls; p = 0.027) and failed to show a post meal increase in propagating contractions (mean 17 ± 6/h premeal vs. 22 ± 9/h post meal, p = 0.438). Compared to baseline, SNM significantly increased the number of retrograde propagating contractions in the distal colon (8 ± 3/h premeal vs. 14 ± 3/h premeal with SNM, p = 0.028). Consuming a meal did not further increase the number of propagating contractions beyond the baseline upregulating effect of SNM. CONCLUSION The rectosigmoid brake was suppressed in this cohort of patients with faecal incontinence. SNM may exert a therapeutic effect by modulating this rectosigmoid brake.
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Affiliation(s)
- Anthony Y Lin
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Sean Seo
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Peng Du
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Phil Dinning
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Discipline of Human Physiology, Flinders University, Adelaide, South Australia, Australia
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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25
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The Effect of Mesenchymal Stem Cells, Adipose Tissue Derived Stem Cells, and Cellular Stromal Vascular Fraction on the Repair of Acute Anal Sphincter Injury in Rats. Bioengineering (Basel) 2022; 9:bioengineering9070318. [PMID: 35877369 PMCID: PMC9311655 DOI: 10.3390/bioengineering9070318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Anal sphincter incontinence (ASI) can cause a serious decline in the quality of life and can cause a socioeconomic burden. Studies have shown that bone marrow mesenchymal stem cells (MSC) have significant therapeutic effects on ASI, but the cost and risk of MSC harvest limit their further application. In contrast, adipose tissue derived stem cells (ADSC) and cellular stromal vascular fraction (CSVF) as stem cell sources have multipotency and the advantage of easy harvest. Objective: Here we aim to investigate the effects of ADSC and CSVF on treating ASI and compare them to that of bone marrow MSC. Methods: Bone marrow MSC, ADSC, and CSVF were obtained and labeled with green fluorescent protein (GFP), and CSVF was labeled with DIL. Sprague Dawley (SD) rats were divided into 5 groups. Four groups were injected with 0.2 mL phosphate buffer saline (PBS), 1 × 107/0.2 mL of MSC, ADSC, or CSVF, respectively, after model establishment. The control group received no treatment. The repair was assessed by anal functional tests and immunostaining on day 5 and day 10 after injection. Results: MSC, ADSC, and CSVF significantly promoted tissue repair and the recovery of muscle contraction and electromyographic activity in ASI. The generation of myosatellite cells by injected MSC, ADSC, and CSVF was found in the wounded area. On day 5, CSVF showed highest therapeutic effect, while on day 10, MSC and ADSC showed higher therapeutic effects than CSVF. When comparing the effects of MSC and ADSC, ADSC was slightly better than MSC in the indexes of anal pressure, etc. Conclusion: ADSC and CVSF are alternative stem cell sources for ASI repair.
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26
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Al-Mukhtar Othman J, Åkervall S, Nilsson IEK, Molin M, Milsom I, Gyhagen M. Fecal incontinence in nonpregnant nulliparous women aged 25 to 64 years-a randomly selected national cohort prevalence study. Am J Obstet Gynecol 2022; 226:706.e1-706.e23. [PMID: 34774822 DOI: 10.1016/j.ajog.2021.11.032] [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: 06/16/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The extent to which fecal incontinence is associated with obstetrical history or pelvic floor injuries is still a controversial and unresolved issue. One crucial first step toward answering this question is the need to study fecal incontinence in nonpregnant, nulliparous women. OBJECTIVE The aim of this study was to present detailed, descriptive measures of the accidental leakage of liquid or solid stool and gas in a randomly selected, large national cohort of nonpregnant, nulliparous women aged 25 to 64 years. STUDY DESIGN The Swedish Total Population Register identified the source population. Four independent, age-stratified, simple random samples in a total of 20,000 nulliparous women aged 25 to 64 years were drawn from 625,810 eligible women. Information was collected in 2014 using postal and web-based questionnaires. The 40-item questionnaire included questions about the presence and frequency of the leakage of solid and liquid stool and gas, which provided the basis for the generic terms fecal and anal incontinence. Statistical analyses of the differences between the groups were performed using the Fisher's exact test for dichotomous variables and the Mann-Whitney U-test for continuous variables. The trend between >2 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. When analyzing the trend between multiple ordered vs nonordered categorical variables, the Kruskal-Wallis test was used. The age-related probability and risk increase per 10 years for incontinence parameters was calculated from logistic regression models adjusted for body mass index. RESULTS The study population was 9197 women, and the response rate was 52.2%, ranging from 44.7% in women aged 25 to 34 years to 62.4% among those from 55 to 64 years. All the types of incontinence, except severe isolated gas incontinence, increased with age up to 64 years. The estimated probability of fecal incontinence was 8.8% at age 25 years and 17.6% at age 64. The leakage of liquid stool was dominant, occurring in 93.1% (95% confidence interval, 91.4-94.5) of the women with fecal incontinence, whereas leakage of solid stool occurred in 33.9% (95% confidence interval, 31.1-36.7), of which approximately 80% also had concomitant leakage of liquid stool. The leakage of liquid stool increased markedly up to age 65, whereas the increase in the isolated leakage of solid stool was negligible across all ages (overall <0.4%). Liquid and solid stool, separate or in combination, co-occurred with gas in approximately 80%. The distribution pattern of the different types of leakage, single or combined, was similar in all the age groups. Both age and body mass index (kg/m2) were risk factors for fecal incontinence (P<.0001), with an interaction effect of P=.16. CONCLUSION Abnormal stool consistency has been identified as the strongest risk factor for accidental bowel leakage. The same pattern characterized by a dominance of liquid stool and gas leakage, prevalent concomitant leakage of solid and liquid stool, and a negligible rate of isolated leakage of solid feces was observed across all ages. The low rates of isolated leakage of solid stool support the impression that dysfunction of the continence mechanism of the pelvic floor had a negligible role for bowel incontinence, which is essential information for comparison with women with birth-related injuries.
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Affiliation(s)
- Jwan Al-Mukhtar Othman
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Ida E K Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | | | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
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27
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Wong KW, Thakar R, Andrews V, Sultan AH. Is there a role for transperineal ultrasound imaging of the anal sphincter immediately after primary repair of third degree tears? Eur J Obstet Gynecol Reprod Biol 2022; 271:260-264. [PMID: 35255362 DOI: 10.1016/j.ejogrb.2022.02.182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/23/2022] [Accepted: 02/28/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE When obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs). STUDY DESIGN This is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair. RESULTS 21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear. 8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair. Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant. CONCLUSIONS Women who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair.
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Affiliation(s)
- Ka Woon Wong
- University Hospital Lewisham, London, UK; Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Surrey, UK
| | - Ranee Thakar
- Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Surrey, UK; St George's University of London, UK
| | | | - Abdul H Sultan
- Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Surrey, UK; St George's University of London, UK.
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28
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Roper JC, Thakar R, Sultan AH. Under-classified obstetric anal sphincter injuries. Int Urogynecol J 2022; 33:1473-1479. [PMID: 35150290 DOI: 10.1007/s00192-021-05051-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOSTHESIS Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time. METHODS Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified. RESULTS A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears. CONCLUSION Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.
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Affiliation(s)
- Joanna C Roper
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK.,Honorary Senior Lecturer, St George's University of London, London, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK. .,Honorary Reader, St George's University of London, London, UK.
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29
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Matsumoto M, Misawa N, Tsuda M, Manabe N, Kessoku T, Tamai N, Kawamoto A, Sugama J, Tanaka H, Kato M, Haruma K, Sanada H, Nakajima A. Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography. Diagnostics (Basel) 2022; 12:300. [PMID: 35204390 PMCID: PMC8871156 DOI: 10.3390/diagnostics12020300] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/15/2022] [Indexed: 12/12/2022] Open
Abstract
Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient's colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.
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Affiliation(s)
- Masaru Matsumoto
- School of Nursing, Ishikawa Prefectural Nursing University, 1-1 Gakuendai, Kahoku 929-1210, Japan;
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
| | - Noboru Misawa
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
| | - Momoko Tsuda
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, 18-16 Kawahara-cho, Hakodate 041-8512, Japan; (M.T.); (M.K.)
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan; (N.M.); (K.H.)
| | - Takaomi Kessoku
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
- Department of Palliative Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Nao Tamai
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsuo Kawamoto
- Division of Ultrasound and Department of Diagnostic Imaging, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan;
| | - Junko Sugama
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan;
| | - Hideko Tanaka
- School of Nursing, College of Nursing and Nutrition, Shukutoku University, 673 Nitona-cho, Chuo-ku, Chiba City 260-8703, Japan;
| | - Mototsugu Kato
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, 18-16 Kawahara-cho, Hakodate 041-8512, Japan; (M.T.); (M.K.)
| | - Ken Haruma
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan; (N.M.); (K.H.)
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
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Weinstein MM, Pulliam SJ, Keyser L, Richter HE. Use of a motion-based digital therapeutic in women with fecal incontinence: A pilot study. Neurourol Urodyn 2021; 41:475-481. [PMID: 34897780 PMCID: PMC9300000 DOI: 10.1002/nau.24854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/23/2021] [Accepted: 11/08/2021] [Indexed: 11/06/2022]
Abstract
AIMS There is limited data addressing the value of vaginal biofeedback (VBF) on fecal incontinence (FI) symptoms. The objective of this pilot study was to evaluate whether use of a motion-based VBF device and app was effective for at-home treatment of women with FI. We hypothesized that VBF would result in improvement in FI symptoms. METHODS A single-arm 10-week prospective pilot trial in women with FI was conducted using the VBF device. The primary outcome was change in St. Mark's score from baseline to week 10. Secondary outcomes included change in 2-week bowel diary and FI quality of life (FIQoL). Statistical analysis included paired t test and Wilcoxon's signed-rank test. RESULTS Of 29 enrolled women, 27 had data available for analysis. Mean (±SD) age was 60.9 (±14.4). 63% (17) subjects were White, 33% (9) were Black. Mean St. Mark's score was 14.6 (±4.4) at baseline and 11.6 (±5.1) at 10-weeks (p = 0.005). Changes in the total FIQol, and three of four subsets of the FIQoL scores were also significantly improved (p < 0.001). Bowel diary showed decrease in FI episodes, baseline 8.4 (±8.73) to 10 weeks 4.8 (±3.79), (p = 0.052). CONCLUSIONS In this pilot study, there was significant improvement in FI symptom-specific severity and quality of life using a vaginal, motion-based device for biofeedback. A larger study is needed to better understand the value of this device, which may be useful for women who prefer a vaginal device, which can be utilized at home compared with standard anal biofeedback for treatment of FI in the clinical setting.
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Affiliation(s)
- Milena M Weinstein
- Department of Obstetrics, Gynecology and Reproductive Biology, Division of Female Pelvic Medicine and Reconstructive Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Samantha J Pulliam
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Tufts University School of Medicine, Renovia Inc., Boston, Massachusetts, USA
| | - Laura Keyser
- Renovia Inc., Boston, MA, USA.,Department of Physical Therapy, Andrews University, Berrien Spring, Michigan, USA
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Xiang X, Sharma A, Patcharatrakul T, Yan Y, Karunaratne T, Parr R, Ayyala DN, Hall P, Rao SSC. Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence. Neurogastroenterol Motil 2021; 33:e14168. [PMID: 34051120 DOI: 10.1111/nmo.14168] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/04/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT). METHODS Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis. KEY RESULTS Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences. CONCLUSIONS & INFERENCES Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.
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Affiliation(s)
- Xuelian Xiang
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amol Sharma
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tanisa Patcharatrakul
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tennekoon Karunaratne
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Rachel Parr
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Deepak Nag Ayyala
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Patricia Hall
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Satish S C Rao
- Division of Gastroenterology & Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Understanding the physiology of human defaecation and disorders of continence and evacuation. Nat Rev Gastroenterol Hepatol 2021; 18:751-769. [PMID: 34373626 DOI: 10.1038/s41575-021-00487-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.
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Rao SSC, Yan Y, Xiang X, Sharma A, Ayyala D, Hamdy S. Effects of Translumbosacral Neuromodulation Therapy on Gut and Brain Interactions and Anorectal Neuropathy in Fecal Incontinence: A Randomized Study. Neuromodulation 2021; 24:1269-1277. [PMID: 34156730 PMCID: PMC8542581 DOI: 10.1111/ner.13485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Translumbosacral neuromodulation therapy (TNT) improves symptoms of fecal incontinence (FI), but its mechanism of action is unknown. We tested the hypothesis that TNT at one or more frequency will significantly improve underlying pathophysiology of FI through modulation of ascending and/or descending signaling pathways in the gut and brain axis and anorectal sensorimotor function. MATERIALS AND METHODS We assessed afferent anorectal-cortical evoked potentials (CEP) following electrical stimulation of anorectum, efferent cortico-anorectal and lumbo-anorectal and sacro-anorectal motor evoked potentials (MEP) after transcranial and lumbosacral magnetic stimulations, and anorectal manometry before and after six weekly TNT sessions in FI subjects, randomized to 1, 5, or 15 Hz repetitive magnetic stimulations. Neurophysiology, anorectal sensorimotor function, and symptoms were compared to examine mechanistic effects. Co-primary measures were ano-cortical CEPs, cortico-anal MEPs, and lumbosacral-anal MEPs. Baseline and post-treatment data were compared with Wilcoxon signed-rank test and changes between the three frequencies with one-way ANOVA. RESULTS Thirty-three FI patients participated. After TNT, the afferent anal CEP latencies significantly decreased in the 1 Hz group compared to baseline (p = 0.0029) and 5 Hz or 15 Hz groups (p = 0.032). Cortico-anal MEPs were unchanged in all three groups. Bilateral lumbo-anal and sacro-anal MEP latencies significantly decreased with 1 Hz, lumbo-anal with 15 Hz, and sacro-anal with 5 Hz compared to baseline but without group differences. The 1 Hz group showed significant increase in anal squeeze sphincter pressure (p < 0.005) and maximum tolerable volume (p < 0.019) and demonstrated higher FI responder rate (p < 0.04) compared to the other two groups. The MEP responders were significantly correlated with FI responders (p = 0.006) in 1 Hz group. CONCLUSIONS TNT significantly improves afferent ano-cortical signaling, efferent lumbo-anal and sacro-anal neuropathy and anorectal sensorimotor function. These neurobiologic effects were most prominent with 1 Hz frequency. TNT improves FI by modifying the underlying pathophysiology possibly through neuromodulation.
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Affiliation(s)
- Satish S C Rao
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Yun Yan
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Xuelian Xiang
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Amol Sharma
- Division of Neurogastroenterology/Motility, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Deepak Ayyala
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Shaheen Hamdy
- GI Sciences, School of Medical Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Comparison of Patient Impact and Clinical Characteristics Between Urgency and Passive Fecal Incontinence Phenotypes. Female Pelvic Med Reconstr Surg 2021; 26:570-574. [PMID: 29979355 DOI: 10.1097/spv.0000000000000603] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine if categorizing fecal incontinence (FI) as urgency or passive FI is clinically meaningful, we compared clinical severity, quality of life, physical examination findings, and functional and anatomic deficits between women with urgency and passive FI. METHODS This study is a prospective cross-sectional study of women with at least monthly FI. All women completed the St Mark's Vaizey and the Fecal Incontinence Quality of Life questionnaires and underwent anorectal manometry and endoanal ultrasound. We compared women with urgency FI to women with passive FI. RESULTS Forty-six women were enrolled, 21 (46%) with urgency FI and 25 (54%) with passive FI. Clinical severity by Vaizey score did not differ between groups (urgency 11.7 ± 1.6 vs passive 11.0 ± 1.0, P = 0.51). Women with urgency FI had worse median (range) lifestyle and coping scores than passive FI (Fecal Incontinence Quality of Life: lifestyle domain 2.5 [1, 4] vs 3.8 [1, 4], P = 0.04; coping domain 1.7 [1, 3] vs 2.4 [0.9, 4], P < 0.01). Women with urgency FI had higher anal resting and squeeze pressure than passive FI (60 ± 4 mm Hg vs 49 ± 3 mm Hg, P = 0.03; 78 [48, 150] mm Hg vs 60 [40, 103], P = 0.05). Internal anal sphincter defects were more common in women with passive FI (41.7% vs 30.0%, P = 0.53) and external anal sphincter defects more common in women with urgency FI (25% vs 16.7%, P = 0.71), but this did not reach statistical significance. CONCLUSIONS We identified functional and anatomic differences between women with urgency FI and passive FI. Pheonotyping women with FI into these subtypes is clinically meaningful.
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Balaphas A, Meyer J, Meier RPH, Liot E, Buchs NC, Roche B, Toso C, Bühler LH, Gonelle-Gispert C, Ris F. Cell Therapy for Anal Sphincter Incontinence: Where Do We Stand? Cells 2021; 10:2086. [PMID: 34440855 PMCID: PMC8394955 DOI: 10.3390/cells10082086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/12/2022] Open
Abstract
Anal sphincter incontinence is a chronic disease, which dramatically impairs quality of life and induces high costs for the society. Surgery, considered as the best curative option, shows a disappointing success rate. Stem/progenitor cell therapy is pledging, for anal sphincter incontinence, a substitute to surgery with higher efficacy. However, the published literature is disparate. Our aim was to perform a review on the development of cell therapy for anal sphincter incontinence with critical analyses of its pitfalls. Animal models for anal sphincter incontinence were varied and tried to reproduce distinct clinical situations (acute injury or healed injury with or without surgical reconstruction) but were limited by anatomical considerations. Cell preparations used for treatment, originated, in order of frequency, from skeletal muscle, bone marrow or fat tissue. The characterization of these preparations was often incomplete and stemness not always addressed. Despite a lack of understanding of sphincter healing processes and the exact mechanism of action of cell preparations, this treatment was evaluated in 83 incontinent patients, reporting encouraging results. However, further development is necessary to establish the correct indications, to determine the most-suited cell type, to standardize the cell preparation method and to validate the route and number of cell delivery.
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Affiliation(s)
- Alexandre Balaphas
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
- Department of Surgery, Geneva Medical School, University of Geneva, 1205 Geneva, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Raphael P. H. Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Nicolas C. Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Bruno Roche
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Leo H. Bühler
- Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland; (L.H.B.); (C.G.-G.)
| | - Carmen Gonelle-Gispert
- Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland; (L.H.B.); (C.G.-G.)
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
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Alketbi MSG, Meyer J, Robert-Yap J, Scarpa R, Gialamas E, Abbassi Z, Balaphas A, Buchs N, Roche B, Ris F. Levator ani and puborectalis muscle rupture: diagnosis and repair for perineal instability. Tech Coloproctol 2021; 25:923-933. [PMID: 33745102 DOI: 10.1007/s10151-020-02392-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/20/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Puborectalis muscle rupture usually arises from peri-partum perineal trauma and may result in anterior, middle compartment prolapses, posterior compartment prolapse which includes rectocele and rectal prolapse, with or without associated anal sphincter damage. Patients with puborectalis muscle and levator ani rupture may present some form of incontinence or evacuation disorder, sexual dysfunction or pelvic organ descent. However, the literature on this subject is scarce. The aim of our study was to evaluate management and treatment of functional disorders associated with puborectalis and/or pubococcygei rupture at the level of the insertion in the pubis in a cohort of patients referred to a tertiary care coloproctology center. METHODS We conducted a prospective cohort study of patients with levator ani and puborectalis muscle avulsion in the Proctology and Pelvic Floor Unit, Division of Digestive Surgery of the University Hospitals of Geneva from January 2001 to November 2018. Clinical examination, anoscopy and ultrasound were performed on a routine basis. Rupture of the levator ani muscle was diagnosed by clinical examination and ultrasound. A Wexner incontinence score was completed before and 6 months after surgery. Levator ani muscle repair was performed using a transvaginal approach. RESULTS Fifty-two female patients (median age 56 ± 11.69 SD years, range 38-86 years) were included in the study. Thirty-one patients (59.6%) had anal incontinence, 25 (48.1%) urinary incontinence, 28 (53.9%) dyschezia (obstructive defecation or excessive straining to defecate), 20 (38.5%) dyspareunia, 17 (32.7%) colpophony, and 13 (25.0%) impaired sensation during sexual intercourse. Deviation of the anus on the side opposite the lesion was observed in 50 patients (96.2%), confirmed with clinical examination and both endoanal and perineal ultrasound. Out of these 52 patients, levator ani rupture (including puborectalis rupture) were categorized into right sided, 43 (82.69%), left sided, 7 (13.46%) and bilateral, 2 (3.85%). Levator ani muscle repair was performed in all patients, associated with posterior repair and levatorplasty in 26 patients (50%) and with sphincteroplasty in 34 patients (63.4%). Four patients (7.7%) experienced postoperative complications: significant postoperative pain (n = 3; 5.77%), urinary retention (n = 2; 3.85%), hematoma (n = 1; 1.92%), and perineal abscess (n = 1; 1.92%). Forty-one patients (78.8%) had full restoration of normal puborectalis muscle function (Wexner score: 0/20) after surgery, and overall, all patients had an improvement in the Wexner score and in sexual function. Dyschezia was reported by 28 patients (53.9%) preoperatively, resolved in 18 (64.3%) and improved by 50% or more in 10 (35.71%). CONCLUSIONS Diagnosis of levator ani and puborectalis muscle rupture requires careful history taking, clinical examination, endoanal and perineal ultrasound. Surgical repair improved anal continence as well as sexual function in all patients. Transvaginal levator ani repair seems to be well tolerated with good short-term results.
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Affiliation(s)
- M S Gh Alketbi
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.
| | - J Meyer
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - J Robert-Yap
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - R Scarpa
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - E Gialamas
- Division of Digestive Surgery, Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Z Abbassi
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - A Balaphas
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - N Buchs
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - B Roche
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - F Ris
- Proctology Unit and Pelvic Floor Unit, Division of Digestive Surgery, Department of Surgery, Geneva University Hospitals and Medical School, 4 rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
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Hill AJ, Balgobin S, Mishra K, Jeppson PC, Wheeler T, Mazloomdoost D, Anand M, Ninivaggio C, Hamner J, Bochenska K, Mama ST, Balk EM, Corton MM, Delancey J. Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review. Am J Obstet Gynecol 2021; 225:169.e1-169.e16. [PMID: 33705749 DOI: 10.1016/j.ajog.2021.02.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise. OBJECTIVE Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to "Terminologia Anatomica," the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding. STUDY DESIGN From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review. RESULTS Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. "Terminologia Anatomica" has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication. CONCLUSION This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.
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Lu P, Chen J, Zhang C, Saur D, Baer CE, Lifshitz LM, Fogarty KE, ZhuGe R. Oscillating calcium signals in smooth muscle cells underlie the persistent basal tone of internal anal sphincter. J Cell Physiol 2021; 236:5937-5952. [PMID: 33452672 PMCID: PMC8132622 DOI: 10.1002/jcp.30279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 02/05/2023]
Abstract
A persistent basal tone in the internal anal sphincter (IAS) is essential for keeping the anal canal closed and fecal continence; its inhibition via the rectoanal inhibitory reflex (RAIR) is required for successful defecation. However, cellular signals underlying the IAS basal tone remain enigmatic. Here we report the origin and molecular mechanisms of calcium signals that control the IAS basal tone, using a combination approach including a novel IAS slice preparation that retains cell arrangement and architecture as in vivo, 2-photon imaging, and cell-specific gene-modified mice. We found that IAS smooth muscle cells generate two forms of contractions (i.e., phasic and sustained contraction) and Ca2+ signals (i.e., synchronized Ca2+ oscillations [SCaOs] and asynchronized Ca2+ oscillations [ACaOs]) that last for hours. RyRs, TMEM16A, L-type Ca2+ channels, and gap junctions are required for SCaOs, which account for phasic contraction and 75% of sustained contraction. Nevertheless, only RyRs are required for ACaOs, which contribute 25% of sustained contraction. Nitric oxide, the primary neurotransmitter mediating the RAIR, blocks both types of Ca2+ signals, leading to IAS's full relaxation. Our results show that the oscillating nature of Ca2+ signals generates and maintains the basal tone without causing cytotoxicity to IAS. Our study provides insight into fecal continence and normal defecation.
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Affiliation(s)
- Ping Lu
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jun Chen
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Chenghai Zhang
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute at Harvard Medical School, Boston, MA, USA
| | - Dieter Saur
- Department of Internal Medicine II, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Christina E Baer
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
- Sanderson Center for Optical Experimentation, University of Massachusetts Medical School, Worcester, MA, USA
| | - Lawrence M Lifshitz
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kevin E Fogarty
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ronghua ZhuGe
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
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Pincus JB, Moss NP, Chang C, Goldberg RP, Rostaminia G. Pelvic floor architectural defects in female patients with urge fecal incontinence versus passive fecal leakage: a dynamic ultrasound study. Int Urogynecol J 2021; 33:2133-2141. [PMID: 34292342 DOI: 10.1007/s00192-021-04919-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/10/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Fecal incontinence (FI) has two primary subtypes: urgency fecal incontinence (UFI) and passive fecal leakage (PFL). The pathophysiology underlying the subtypes is incompletely understood. OBJECTIVES To compare the bowel habits, physical examinations and pelvic floor anatomical defects in patients with UFI-dominant FI versus patients with PFL-dominant FI. STUDY DESIGN This is a retrospective cross-sectional study of female patients who presented with fecal incontinence symptoms to our tertiary urogynecology center. All subjects underwent a comprehensive history, physical examination, 3D-static pelvic floor ultrasound, and 2D-dynamic ultrasound of the posterior compartment. Patients with UFI-dominant FI were compared to patients with PFL-dominant FI. RESULTS One hundred forty-five patients were included in the analysis; 57 categorized as UFI-dominant FI, 69 PFL-dominant FI and 19 categorized as having "both" leakage patterns. In comparing bowel habits, patient with UFI-dominant FI had more frequent bowel movements (15.5 ± SD 13.0/week vs. 10.9 ± SD 7.6 /week, p = 0.022) and were more likely to have loose stools (48.2% vs. 26.1%, p = 0.01). No statistically significant differences were observed in the prevalence of external anal sphincter defect (11.3% vs. 17.2%, p = 0.38) or internal anal sphincter defect (11.3% vs. 19%, p = 0.26) between groups. Finally, patients with UFI-dominant FI had a higher incidence of rectal hypermobility (loss of rectal support on Valsalva) (58% vs. 36.9%, p = 0.025). CONCLUSION Patients with urge-predominant FI have increased frequency of bowel movements, looser stools, and increased rectal folding diagnosed via dynamic ultrasound as compared to patients with passive-dominant FI.
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Affiliation(s)
- Joseph B Pincus
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA. .,Division of Urogynecology, NorthShore University HealthSystem, 9650 Gross Point Road, Suite 3900, Skokie, IL, 60076, USA.
| | - Nani P Moss
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA
| | - Cecilia Chang
- NorthShore University HealthSystem Research Institute, Evanston, IL, USA
| | - Roger P Goldberg
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA
| | - Ghazaleh Rostaminia
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA
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Cuong LM, Van Quyet H, Hung TM, Anh NN, Ha TT, Van Du V, Van Loi D, Khai HHH, Kien VD. Normal values for high-resolution anorectal manometry in healthy young adults: evidence from Vietnam. BMC Gastroenterol 2021; 21:295. [PMID: 34266417 PMCID: PMC8281378 DOI: 10.1186/s12876-021-01865-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/21/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-resolution anorectal manometry (HRAM) has been developed to improve measurement of anorectal functions. This study aims to identify normal HRAM values in healthy young Vietnamese adults. METHODS We conducted a cross-sectional study at the National Hospital of Traditional Medicine (Hanoi, Vietnam) from July through December 2014. Healthy young adults were invited to participate in the study. All anorectal measurement values were performed using the ISOLAB high-resolution manometry system. Differences between groups were analyzed using Student's t-tests. RESULTS Thirty healthy young adults, including 15 males and 15 females aged 19-26 years, were recruited. Mean functional anal canal length was 3.4 ± 0.5 cm (range: 2.4-4.8 mm). Mean maximum resting pressure, mean maximum squeezing pressure, mean maximum coughing pressure, and mean maximum strain pressure were 65.5, 168.0, 125.9, and 84.2 mm Hg, respectively. All anal pressure values were significantly different between males and females. For rectal sensation measurements, only the volume at first sensation was significantly higher in males than in females. CONCLUSIONS This study provides normal HRAM value for healthy young adults in Vietnam. Sex may influence anal pressure and first rectal sensation values in this cohort. Further studies should be conducted in order to improve the quality of HRAM normal values and to confirm the effects of sex.
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Affiliation(s)
- Le Manh Cuong
- National Hospital of Traditional Medicine, No. 29 Nguyen Binh Khiem Street, Hanoi, Vietnam.
| | - Ha Van Quyet
- Hanoi Medical University, No. 1 Ton That Tung Street, Hanoi, Vietnam
| | - Tran Manh Hung
- Bach Mai Hospital, No. 78 Giai Phong Street, Hanoi, Vietnam
| | - Nguyen Ngoc Anh
- Hanoi Medical University, No. 1 Ton That Tung Street, Hanoi, Vietnam
| | - Tran Thu Ha
- National Hospital of Traditional Medicine, No. 29 Nguyen Binh Khiem Street, Hanoi, Vietnam
| | - Vu Van Du
- National Hospital of Obstetrics and Gynecology, No. 43 Trang Thi Street, Hanoi, Vietnam
| | - Do Van Loi
- National Hospital of Obstetrics and Gynecology, No. 43 Trang Thi Street, Hanoi, Vietnam
| | - Ha Huu Hoang Khai
- Hanoi Medical University, No. 1 Ton That Tung Street, Hanoi, Vietnam
| | - Vu Duy Kien
- OnCare Medical Technology Company Limited, No. 77/508 Lang Street, Hanoi, Vietnam
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Singh A, Rattan S. BDNF rescues aging-associated internal anal sphincter dysfunction. Am J Physiol Gastrointest Liver Physiol 2021; 321:G87-G97. [PMID: 34075793 PMCID: PMC8321795 DOI: 10.1152/ajpgi.00090.2021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Aging can lead to rectoanal incontinence due to internal anal sphincter (IAS) dysfunction, which is characterized by a decrease in IAS tone and contractility and an increase in nonadrenergic noncholinergic (NANC) relaxation. We aimed to determine whether brain-derived neurotropic factor (BDNF) rescues this aging-associated IAS dysfunction (AAID). To do so, we studied the effects of BDNF on the basal and G protein-coupled receptors (GPCR)-stimulated IAS smooth muscle tone and on NANC relaxation in Fischer 344 rats representing different age groups [26-mo-old (aging) vs. 6-mo-old (young)], before and after tyrosine kinase receptor B (TrkB) antagonist K252a. We also used isolated smooth muscle cells (SMCs) to determine the effects of BDNF before and after different agonists. For some studies, we monitored NO release using smooth muscle perfusates. BDNF reversed AAID by rescuing the basal IAS tone and agonists [thromboxane A2 analog (U46619) and angiotensin II (ANG II)]-induced contractility, and NANC relaxation. These rescue effects of BDNF were selective as K252a attenuated the changes in the IAS without modifying the effects of K+depolarization. Because of the direct association between the basal and GPCR-stimulated IAS tone and RhoA/ROCK activation, we speculate that this pathway in the rescue effects of BDNF. Conversely, our data suggest that aging-associated increased NANC relaxation is reversed by decreased release of NO and decrease in the sensitivity of the released inhibitory neurotransmitter. In summary, BDNF rescue of AAID involves RhoA/ROCK and inhibitory neurotransmission. These data have direct implications for the role of BDNF in the pathophysiology and therapeutic targeting of aging-associated rectoanal motility disorders.NEW & NOTEWORTHY These studies demonstrate that brain-derived neurotropic factor (BDNF) rescues the aging-associated internal anal sphincter (IAS) dysfunction, characterized by a decrease in IAS tone, and increase in non-adrenergic noncholinergic relaxation. We determined the effects of BDNF on the basal and GPCR (TXA2 and ANG II)-stimulated IAS tone, and on NANC relaxation, before and after TrkB inhibitor K252a. BDNF may have an important role in the pathophysiology and therapeutic targeting of certain rectoanal motility disorders.
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Affiliation(s)
- Arjun Singh
- Department of Medicine, Division of Gastroenterology & Hepatology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology & Hepatology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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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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Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation. Neurogastroenterol Motil 2021; 33:e14050. [PMID: 33263938 DOI: 10.1111/nmo.14050] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting. PURPOSE This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.
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Affiliation(s)
- S Mark Scott
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam D Farmer
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Institute of Applied Clinical Science, University of Keele, Keele, UK
| | - Philip G Dinning
- College of Medicine and Public Health, Flinders Medical Centre, Flinders University & Discipline of Gastroenterology, Adelaide, SA, Australia
| | - Emma V Carrington
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca E Burgell
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | - Asma Fikree
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Gastroenterology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Karen Nugent
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Jose Maria Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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Mengistu Z, Gillor M, Dietz HP. Is pelvic floor muscle contractility an important factor in anal incontinence? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:995-998. [PMID: 32959435 DOI: 10.1002/uog.23128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/06/2020] [Accepted: 09/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma. METHODS This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data. RESULTS Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m2 . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis. CONCLUSION Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Z Mengistu
- Department of Gynecology and Obstetrics, University of Gondar, Gondar, Ethiopia
| | - M Gillor
- University of Sydney, Sydney, NSW, Australia
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
| | - H P Dietz
- University of Sydney, Sydney, NSW, Australia
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Affiliation(s)
- P Iovino
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - M Bellini
- Gastrointestinal Unit-Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
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Does Bariatric Surgery Improve Faecal Incontinence? A Systematic Review and Meta-analysis. Obes Surg 2021; 31:2942-2953. [PMID: 33852150 PMCID: PMC8175321 DOI: 10.1007/s11695-021-05360-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/08/2021] [Accepted: 03/16/2021] [Indexed: 12/14/2022]
Abstract
Introduction Obesity increases the risk of pelvic floor disorders in individuals with obesity, including faecal incontinence. Faecal incontinence (FI) is a condition with important clinical and psychosocial consequences. Though it is associated with obesity, the effect of bariatric surgery on the prevalence and severity of FI is not well reported. Objective To assess the effect of bariatric surgery on the prevalence and severity of FI in adult patients with obesity. Methods This systematic review was conducted in accordance with the PRISMA statement. Two independent reviewers performed a literature search in MEDLINE, PubMed, Cochrane and Embase from 1 January 1980 to 12 January 2019. We included published English-language randomized control trials and observational studies assessing pre- and post-bariatric surgery prevalence or severity of FI. Random-effects models with DerSimonian and Laird’s variance estimator were used for meta-analysis. Results Thirteen studies were included, eight assessing prevalence (678 patients) and 11 assessing severity of FI (992 patients). There was no significant difference in prevalence post-operatively overall, though it trended towards a reduction [pooled OR=0.55; =0.075]. There was a significant reduction of FI prevalence in women post-bariatric surgery [95% CI 0.22 to 0.94, p=0.034]. There was a statistically significant reduction in FI prevalence following Roux-en-Y gastric bypass and one anastomosis gastric bypass [0.46, 95% CI 0.26 to 0.81; p=0.007]. There was no significant reduction of incontinence episodes post-operatively [pooled mean difference =−0.17, 95% CI −0.90 to 0.56; p=0.65]. Quality of life (QOL) was not significantly improved post-bariatric surgery [mean differences for the following facets of QOL: behaviour −0.35, 95% CI −0.94 to 0.24; depression 0.04, 95% CI −0.12 to 0.2; lifestyle −0.33, 95% CI −0.98 to 0.33; p values of 0.25, 0.61 and 0.33, respectively]. Discussion There was a significant reduction in FI prevalence in women and those who underwent Roux-en-Y or one anastomosis gastric bypass. Our results for FI prevalence overall, FI severity and impact on quality of life were not statistically significant. Larger studies are needed in this under-researched area to determine the true effect of bariatric surgery on FI. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s11695-021-05360-7.
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Kim H, Shim J, Seo Y, Lee C, Chang Y. What Is Fecal Incontinence That Urologists Need to Know? Int Neurourol J 2021; 25:23-33. [PMID: 33504128 PMCID: PMC8022170 DOI: 10.5213/inj.2040240.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/26/2020] [Indexed: 12/13/2022] Open
Abstract
Fecal incontinence (FI) undoubtedly reduces quality of life and adversely affects the social life of the affected individual. FI has a higher prevalence with age and has an equivalent prevalence to urinary incontinence in patients with genitourinary disease, but is often not confirmed in these cases. A thorough investigation is needed to diagnose FI, with the common etiology of this condition in mind, and several questionnaires can be used to identify symptoms. The physical examination contains digital rectal examination carries out to identify the patient's condition. Ultrasound, colonoscopy, and rectum pressure test can be performed. Patients educated in diet-related issues, bowel movements, and defecation mechanism. Nonoperative options such as diet control and Kegel exercise should be performed at first. Surgical treatment of FI is considered when conservative management and oral medications produce no improvement. Surgical options include less invasive procedures like bulking agent injections, and more involved approaches from sacral nerve stimulation to invasive direct sphincter repair and artificial bowel sphincter insertion. Good outcomes in FI cases have also recently been reported for barrier devices.
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Affiliation(s)
- HongWook Kim
- Department of Urology, Konyang University College of Medicine, Daejeon, Korea
- Konyang University Myunggok Medical Research Institute, Daejeon, Korea
| | - Jisung Shim
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Yumi Seo
- Department of Urology, Dankook University College of Medicine, Cheonan, Korea
| | - Changho Lee
- Department of Urology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Youngseop Chang
- Department of Urology, Konyang University College of Medicine, Daejeon, Korea
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Translumbosacral Neuromodulation Therapy for Fecal Incontinence: A Randomized Frequency Response Trial. Am J Gastroenterol 2021; 116:162-170. [PMID: 32740081 PMCID: PMC9455260 DOI: 10.14309/ajg.0000000000000766] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for fecal incontinence (FI) remain unsatisfactory because they do not remedy the underlying multifactorial dysfunction(s) including anorectal neuropathy. The aim of this study was to investigate the optimal dose frequency, clinical effects, and safety of a novel treatment, translumbosacral neuromodulation therapy (TNT), aimed at improving neuropathy. METHODS Patients with FI were randomized to receive 6 sessions of weekly TNT treatments consisting of 600 repetitive magnetic stimulations over each of 2 lumbar and 2 sacral sites with either 1, 5, or 15 Hz frequency. Stool diaries, FI severity indices, anorectal neurophysiology and sensorimotor function, and quality of life were compared. Primary outcome measure was the change in FI episodes/week. Responders were patients with ≥50% decrease in weekly FI episodes. RESULTS Thirty-three patients with FI participated. FI episodes decreased significantly (∆ ±95% confidence interval, 4.2 ± 2.8 (1 Hz); 2 ± 1.7 (5 Hz); 3.4 ± 2.5 (15 Hz); P < 0.02) in all 3 groups when compared with baseline. The 1 Hz group showed a significantly higher (P = 0.04) responder rate (91 ± 9.1%) when compared with the 5 Hz group (36 ± 18.2%) or 15 Hz (55 ± 18.2%); no difference was found between the 5 and 15 Hz groups (P = 0.667). Anal neuropathy, squeeze pressure, and rectal capacity improved significantly only in the 1 Hz (P < 0.05) group compared with baseline, but not in other groups. Quality of life domains improved significantly (P < 0.05) with 1 and 5 Hz groups. No device-related serious adverse events were noted. DISCUSSION TNT significantly improves FI symptoms in the short term, and the 1 Hz frequency was overall better than 5 and 15 Hz. Both anorectal neuropathy and physiology significantly improved, demonstrating mechanistic improvement. TNT is a promising, novel, safe, efficacious, and noninvasive treatment for FI (see Visual Abstract, Supplementary Digital Content 3, http://links.lww.com/AJG/B598).
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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: 0.2] [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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Siri S, Zhao Y, Maier F, Pierce DM, Feng B. The Macro- and Micro-Mechanics of the Colon and Rectum I: Experimental Evidence. Bioengineering (Basel) 2020; 7:E130. [PMID: 33086503 PMCID: PMC7712174 DOI: 10.3390/bioengineering7040130] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022] Open
Abstract
Many lower gastrointestinal diseases are associated with altered mechanical movement and deformation of the large intestine, i.e., the colon and rectum. The leading reason for patients' visits to gastrointestinal clinics is visceral pain, which is reliably evoked by mechanical distension rather than non-mechanical stimuli such as inflammation or heating. The macroscopic biomechanics of the large intestine were characterized by mechanical tests and the microscopic by imaging the load-bearing constituents, i.e., intestinal collagen and muscle fibers. Regions with high mechanical stresses in the large intestine (submucosa and muscularis propria) coincide with locations of submucosal and myenteric neural plexuses, indicating a functional interaction between intestinal structural biomechanics and enteric neurons. In this review, we systematically summarized experimental evidence on the macro- and micro-scale biomechanics of the colon and rectum in both health and disease. We reviewed the heterogeneous mechanical properties of the colon and rectum and surveyed the imaging methods applied to characterize collagen fibers in the intestinal wall. We also discussed the presence of extrinsic and intrinsic neural tissues within different layers of the colon and rectum. This review provides a foundation for further advancements in intestinal biomechanics by synergistically studying the interplay between tissue biomechanics and enteric neurons.
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Affiliation(s)
- Saeed Siri
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA; (S.S.); (Y.Z.); (D.M.P.)
| | - Yunmei Zhao
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA; (S.S.); (Y.Z.); (D.M.P.)
| | - Franz Maier
- Lightweight Design and Composite Materials, University of Applied Sciences Upper Austria, 4600 Wels, Austria;
| | - David M. Pierce
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA; (S.S.); (Y.Z.); (D.M.P.)
- Department of Mechanical Engineering, University of Connecticut, Storrs, CT 06269, USA
| | - Bin Feng
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA; (S.S.); (Y.Z.); (D.M.P.)
- Department of Physiology and Neurobiology, University of Connecticut, Storrs, CT 06269, USA
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