Detection of anal sphincter defects in female patients with fecal incontinence: a comparison of 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound

Functional Assessment of Anal Sphincter with Transperineal Ultrasound and Its Relationship to Anal Continence

BACKGROUND/OBJECTIVES

Anal incontinence is linked to pelvic floor dysfunction. Diagnosis involves assessing both the function and structure of the anorectal unit. Although transperineal ultrasound has gained attention as a less invasive option, its effectiveness as a diagnostic tool for evaluating the relationship between structure and function is still debated. This study aimed to explore the relationship between quantitative measurements of anal sphincter and pelvic floor structures as well as the subjective symptoms and objective assessments of sphincter function regarding anal incontinence.

METHODS

50 women with pelvic floor dysfunction were recruited for the study. The severity of anal incontinence was assessed using the CACP score. Ultrasound imaging was employed to measure anal sphincter area, while sphincter pressures were evaluated through manometry. The relationships between variables were analyzed using Pearson's and Spearman's correlation tests.

RESULTS

The mean anal sphincter area was 5.51 cm2 at rest and 4.06 cm2 during maximal contraction. Resting anal sphincter pressure had an average of 46.29 mmHg, and contraction pressure averaged 103.25 mmHg. No significant correlation was found between the anal sphincter area and pressure at rest (r = 0.018) or during contraction (r = -0.210). However, a moderate correlation was observed between the change in sphincter pressure and area during contraction (r = 0.312). The CACP score showed no significant correlation with the sphincter area at rest (r = -0.084) but was weakly correlated during contraction (r = -0.270).

CONCLUSIONS

Conventional diagnostic tools for evaluating anal incontinence can be uncomfortable and are not always readily available. Perineal sonography presents a promising, less invasive alternative for dynamic assessment of the anal sphincter.

Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study

OBJECTIVES

To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein.

METHODS

Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings.

RESULTS

Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts.

CONCLUSION

TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.

METHODS

This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.

RESULTS

Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).

CONCLUSION

In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnosis of maternal birth trauma by pelvic floor ultrasound

BRIEF SUMMARY

Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.

Combined 3D Endoanal Ultrasound and Transperineal Ultrasound Improves the Detection of Anal Sphincter Defects

INTRODUCTION

Anal sphincter injury, mainly due to obstetric or iatrogenic etiology, is the most common cause of fecal incontinence (FI). Three-dimensional endoanal ultrasound (3D EAUS) is used for assessment of the integrity and the degree of anal muscle injury. However, 3D EAUS accuracy may be hampered by regional acoustic effects, such as intravaginal air. Therefore, our aim was to examine whether a combination of transperineal ultrasound (TPUS) and 3D EAUS would improve the accuracy of detection of anal sphincter injury.

METHODS

We prospectively performed 3D EAUS followed by TPUS in every patient evaluated for FI in our clinic between January 2020 and January 2021. The diagnosis of anal muscle defects was assessed in each ultrasound technique by two experienced observers that were blinded to each other's assessments. Interobserver agreement for the results of the 3D EAUS and the TPUS exams was examined. A final diagnosis of anal sphincter defect was based on the results of both ultrasound methods. Discordant results were re-analyzed by the two ultrasonographers for a final consensus on the presence or absence of defects.

RESULTS

A total of 108 patients underwent ultrasonographic assessment due to FI (mean age 69 ± 13). Interobserver agreement for the diagnosis of tear on EAUS and TPUS was high (83%) with Cohen's kappa of 0.62. EAUS confirmed anal muscle defects in 56 patients (52%), while TPUS confirmed them in 62 patients (57%). The final consensus agreed on the diagnosis of 63 (58%) muscular defects and 45 (42%) normal exams. The Cohen's kappa coefficient of agreement between the results of the 3D EAUS and the final consensus was 0.63.

CONCLUSIONS

The combination of 3D EAUS and TPUS improved the detection of anal muscular defects. The application of both techniques for the assessment of the anal integrity should be considered in every patient going through ultrasonographic assessment for anal muscular injury.

Morphological differences in the female anal sphincter complex between endoanal and exoanal ultrasound

INTRODUCTION AND HYPOTHESIS

This study was aimed at describing the morphological characteristics of the normal female anal sphincter complex (ASC) by high-resolution transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS).

METHODS

Thirty volunteers, including 19 nulliparous and 11 women who had only given birth by Cesarean section, were recruited. The ASC was shown in a set of five slices by EAUS and 8 slices by TPUS. EAUS slices 1 and 5 matched TPUS slices 1 and 8; EAUS slices 2, 3, and 4 were approximately at the levels of TPUS slices 3, 5, and 7. The anterior and lateral EAS and IAS thicknesses were measured and the two methods were compared.

RESULTS

The median age was 29 years. The mean body mass index (BMI) was 20.6 kg/m². All measured values obtained by TPUS were normally distributed. The EAS thickness on EAUS slice 2 and the IAS thickness on EAUS slices 2 and 3 were not normally distributed. The mean anterior EAS thickness was 2.51 mm, 2.96 mm, and 3.53 mm in slices 3, 5, and 7 on TPUS and was significantly thinner than that in slices 2 (2.62 mm), 3 (3.77 mm), and 4 (4.62 mm) on EAUS. In contrast, the IAS was markedly thicker on TPUS. The ratio of sphincter thickness anteriorly to laterally was similar using the two methods.

CONCLUSIONS

The morphological characteristics of EAS shown by TPUS and EAUS were similar. EAS was thinner, and IAS was thicker on TPUS. The IAS seems to be distorted on endoanal imaging.

Diagnostic capabilities of transperineal ultrasound (TPUS) to evaluate anal sphincter defect post obstetric anal sphincter injury (OASIS)? A systematic review

INTRODUCTION

Endoanal ultrasound (3D-EAUS) is the gold standard imaging investigation for evaluating the anal sphincter; unfortunately, it is not universally available in most obstetric units. This study aims to appraise the ability of transperineal ultrasound (TPUS) compared with 3D-EAUS as the gold standard to identify anal sphincter defects after primary repair of OASIS.

METHODS

A systematic search of major databases to identify diagnostic accuracy of 3D-TPUS in evaluating anal sphincter defects. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were designed for this systematic review. The risk of bias and applicability concerns were assessed using the QUADAS-2 tool. Our eligibility criteria are patients with a history of primary repair of anal sphincter injuries (OASIS). They were followed up after the primary repair to detect the anal sphincter defect using 3D-TPUS vs. 3D-EAUS as a gold standard.

RESULTS

Two eligible observational studies were included and assessed for risk of bias using the QUADAS-2 tool and showed a low risk of bias and a low risk of concerns. 3D-TPUS had various sensitivity to detect external anal sphincter defects in two studies; meanwhile, the specificity was around 67-70%. For detecting the internal anal sphincter defects, 3D-TPUS had low sensitivity but high specificity (93-94%).

CONCLUSION

3D-TPUS had various sensitivity to detect external anal sphincter defects and low sensitivity to detect internal anal sphincter defects. On the other hand, 3D-TPUS had low specificity for detecting external anal sphincter defects and high specificity for detecting internal anal sphincter defects.

Validation of new ultrasound algorithm for estimating prevalence of anal sphincter trauma in a urogynecological population

OBJECTIVES

To estimate the prevalence of major perineal trauma in a urogynecological population, to test the predictive value of sonographic tear grading (Gillor algorithm) for anal incontinence (AI), AI bother score and St Mark's score, and to compare the predictive power of the Gillor algorithm with that of the residual-defect method.

METHODS

This was a retrospective study of 721 women attending a tertiary urogynecology unit between February 2019 and May 2021. All women underwent a standardized interview, including determination of St Mark's score and visual analog scale (VAS) bother score for AI, as well as exoanal (translabial) ultrasound with later offline analysis. Results were reported as the presence of a residual defect of the external anal sphincter (EAS), i.e. a discontinuity of ≥ 30° in ≥ 4/6 tomographic slices, and according to the Gillor algorithm (normal, Grade 3a, Grade 3b or Grade 3c/4).

RESULTS

Mean age at assessment was 57 (range, 19-93) years and mean body mass index was 30 (range, 17-57) kg/m² . Six hundred and thirty-six (88.2%) women were vaginally parous and 161 (22.3%) had undergone at least one forceps delivery. AI was reported by 186/721 (25.8%) women, with a median St Mark's score of 10 (interquartile range (IQR), 6-14) and a median VAS score of 6.3 (IQR, 3.9-10). EAS defects were detected in 261 (36.2%) women, with a residual defect diagnosed in 88 (12.2%). On sonographic grading according to the Gillor algorithm, we identified 532 (73.8%) women with a normal sphincter, 66 (9.2%) with Grade-3a tear, 87 (12.1%) with Grade-3b tear and 36 (5.0%) with Grade-3c/4 tear. In total, the Gillor algorithm classified 189 (26.2%) women as having suffered a major perineal tear. The two grading systems were in moderate agreement (κ, 0.537 (95% CI, 0.49-0.56); P < 0.001). There were weak, albeit significant, associations between EAS defects and measures of AI (P = 0.009 to P = 0.047), both for residual defect as well as the Gillor algorithm.

CONCLUSION

Neither the Gillor algorithm nor the residual-defect method of quantifying sphincter trauma on imaging is clearly superior in terms of predicting AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

When to assess residual anal sphincter defect after OASI by ultrasound

OBJECTIVES

Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months.

STUDY DESIGN

This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation.

RESULTS

Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination.

CONCLUSIONS

In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

Location of obstetric anal sphincter injury scars on translabial tomographic ultrasound

OBJECTIVE

Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing to the absence of effective clinical audit. The aim of this study was to evaluate the location of scars or defects of the external anal sphincter (EAS), diagnosed by translabial ultrasound (TLUS), following primary OASI repair.

METHODS

This was a retrospective analysis of 309 women who were seen at a tertiary obstetric unit after primary repair of OASI between June 2012 and May 2019. All women underwent a standardized interview, including St Mark's incontinence score, followed by clinical examination and TLUS assessment within 2-9 months after OASI repair. Postprocessing of TLUS volume datasets was performed by an investigator who was blinded to all other information. Tomographic ultrasound imaging was used to evaluate the presence of a scar or defect in the proximal and distal parts of the EAS. Women were classified into four groups according to the imaging findings: (1) no visible defect or distortion (likely false positive); (2) only proximal OASI; (3) only distal OASI; and (4) both proximal and distal OASI.

RESULTS

Of the 309 women seen during the study period, 34 were excluded because they were referred for reasons other than recent (< 1 year) OASI, 16 owing to missing data and four owing to poor image quality, leaving 255 patients for analysis. Women were seen on average 0.25 ± 0.1 years after the index birth, and their mean age at delivery was 29.1 ± 4.6 years. Anal incontinence was reported by 97 (38.0%) women. A scar or defect was seen only in the proximal part of the EAS in 64 (25.1%) women and only in the distal part in 19 (7.5%) (P < 0.001). In 165 (64.7%) women, the damage affected both the proximal and distal EAS.

CONCLUSIONS

EAS scars after primary OASI repair commonly affect the entire length of the EAS; however, partial tears seem to be more likely to occur proximally. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

OBJECTIVES

Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI.

METHODS

In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter.

RESULTS

In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001).

CONCLUSIONS

Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Establishing a peripartum perineal trauma clinic: a narrative review

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI. Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the mode of delivery for subsequent pregnancies after an OASI.

METHODS

This narrative review covers information from patients' questionnaires specific to anal incontinence, anal physiology assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI.

RESULTS

This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national professional organizations and experienced perineal clinics.

CONCLUSION

This review summarizes the different choices in developing a perineal clinic to facilitate their development in promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for obstetrician-gynaecologists, family doctors, and residents.

Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique?

OBJECTIVES

"Significant" obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS.

METHODS

Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck's and the Norderval's systems. Intraobserver and inter-techniques correlations were calculated.

RESULTS

From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, "button hole" tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck's Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval's classification.

CONCLUSIONS

OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.

Obstetric anal sphincter injuries: strategies for prevention, diagnosis, and management

Obstetric anal sphincter injuries (OASIS) are one of the most common causes of anal incontinence (AI) in women of reproductive age and can have a significant impact on quality of life. However, many women do not report symptoms to their physicians because of embarrassment and shame. Therefore, prevention and diagnosis of the tear is essential. Diagnostic strategies have evolved considerably in recent years, with an increase in prevalence of OASIS as a consequence. The use of 3D endoanal (3D-EAUS) and 4D transperineal ultrasound (4D-TPUS), in addition to standard clinical examination have enhanced the detection of OASIS. Once identified, adequate repair by a skilled practitioner and optimal postpartum management should be ensured in order to reduce the risk of anal incontinence. This review presents the available evidence on strategies for prevention, diagnosis, and management of OASIS.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Correlations of obstetric anal sphincter injury (OASIS) grade, specific symptoms of anal incontinence, and measurements by endoanal and transperineal ultrasound

Purpose

The aim of the study was to investigate the association between the initial grade of obstetrical anal sphincter injury (OASIS), and Wexner score parameters, with ultrasonographic findings by endoanal ultrasound (EAUS, golden standard) and transperineal ultrasound (TPUS) 6 months post-partum.

Methods

Fifty-nine women after primary repair of OASIS were included at Helsingborg Hospital, Sweden, 2016–2017. Six months post-partum the women filled in a questionnaire regarding symptoms of anal incontinence by the Wexner score and were scanned with EAUS and TPUS (resting state and contracting state) for classification of the residual defect by a modified Starck score.

Results

Correlations were found between the OASIS grade and residual defects; length (r_s = 0.41, P = 0.003), depth (r_s = 0.38, P = 0.006) and angle (r_s = 0.40, P = 0.004) of the external anal sphincter (EAS) measured with TPUS in resting state. Using EAUS, correlation between OASIS grade and EAS depth (r_s = 0.35, P = 0.007) and angle (r_s = 0.37, P = 0.004) were similar, but there was no correlation with length (r_s = 0.20, P = 0.14). Between incontinence to gas and the angle of the residual defect in the IAS using TPUS in resting state, correlation was moderate (r_s = 0.42, P = 0.003). Regarding incontinence to liquid stool, measurements by TPUS in resting state of EAS residual defect depth (r_s = 0.46, P < 0.001) and angle (r_s = 0.44, P = 0.001) also correlated moderately. Both corresponding correlations using EAUS were weaker.

Conclusion

Defects measured with EAUS and TPUS six months post-partum correlated to initial OASIS grade and symptoms of anal incontinence. Specific symptoms correlated with specific anatomical defects, and TPUS was not an inferior method to EAUS.

Does exclusion of subcutaneous external anal sphincter on exoanal imaging matter?

OBJECTIVE

There is some speculation that an intact distal anal sphincter complex is of decisive importance for continence, although the external anal sphincter (EAS) is considered to be a single functional and anatomical entity. On tomographic translabial ultrasound (TLUS), the caudal slice at the level of the subcutaneous EAS is currently omitted from the diagnostic algorithm due to the prevalence of artifact at that level. The aim of this study was to determine the predictive value of assessment of the subcutaneous EAS on tomographic TLUS for anal incontinence (AI).

METHODS

This was a retrospective study of 463 women seen at our urogynecological service in 2015. All underwent a standardized questionnaire, including determination of St Mark's incontinence score (SMIS), clinical examination and three-/four-dimensional TLUS. On tomographic TLUS, EAS defect angles in slices one to seven were measured on maximum pelvic floor muscle contraction. A slice was defined as positive for a defect if the defect angle was ≥ 30°. The association between significant subcutaneous EAS trauma (i.e. defect angle of ≥ 30° in slice seven) and symptoms of AI, symptom bother score and SMIS was assessed. The performances of the standard six-slice model and the seven-slice model, including the subcutaneous EAS, in the prediction of AI were compared.

RESULTS

While there was a highly significant association between all measures of AI and significant EAS trauma in slice seven, addition of the seventh slice to the existing six-slice model did not improve the predictive value for AI.

CONCLUSION

As inclusion of the subcutaneous slice of the EAS on tomographic TLUS does not seem to improve the predictive value for AI, the current methodology for assessment of EAS trauma on tomographic TLUS can remain unchanged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Accuracy of clinical diagnosis of anal sphincter defect: clinical evaluation versus 3D-transperineal ultrasound

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are common and an important factor in the etiology of anal incontinence. The objective of this study was to evaluate, classify and compare the agreement of clinically diagnosed third-degree sphincter tears with 3D-transperineal ultrasound (3D-TPUS) realized within 3-7 days post-delivery.

METHODS

This is a retrospective observational study were 119 patients with third-degree obstetric anal sphincter tears were diagnosed and treated, 85 of those underwent a 3D-TPUS examination 3-7 days postpartum. We compared the proportion of third-degree perineal tears, classified with the clinical examination as grade 3a+b and grade 3c, with the 3D-TPUS.

RESULTS

In 16 patients with clinically diagnosed third-degree perineal tears grade a and b, the ultrasound examination confirmed the lesion of the external anal sphincter (EAS) muscle, but in nine patients (56% of the cases) we found a lesion of the internal anal sphincter (IAS) muscle, missed by clinical examination. In the remaining 69 patients with the third-degree perineal tears grade c, the ultrasound examination confirmed both lesions (EAS and IAS muscles) in 56 women, but in 13 patients (19% of the cases) defects of the IAS muscle could not be confirmed by the ultrasound.

CONCLUSIONS

There was moderate agreement regarding diagnosis of grade 3a+b and grade c perineal tears between ultrasound and clinical examination, so a combined use of clinical and ultrasound knowledge can improve the possibility to find a gold standard in the diagnosis of OASIS.

What is a significant defect of the anal sphincter on translabial ultrasound?

OBJECTIVE

The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two-thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound.

METHODS

This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed.

RESULTS

There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single-slice defect angle on TUI was low, and areas under the receiver-operating-characteristics curves were too low to determine a distinct cut-off value for defect angle.

CONCLUSIONS

Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single-slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut-off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Parturition mode recommendation and symptoms of pelvic floor disorders after obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

Our primary objective was to evaluate parturition mode (PM) recommendations following obstetric anal sphincter injuries (OASIs) and adherence to these recommendations and to evaluate recurrence of OASIs in women who had a subsequent vaginal delivery (VD). The hypothesis was that adherence to the PM recommendations leads to a reasonable OASI recurrence rate.

METHODS

This was a retrospective observational cohort study of patients with previous OASIs between 2010 and 2016. After an outpatient visit including 3D transperineal ultrasound to screen for pelvic floor and anal sphincter injuries, all patients received recommendations for a subsequent PM. Patients were invited to complete validated questionnaires 2 to 5 years post-OASIs.

RESULTS

The majority of invited patients (265/320) attended follow-up, with 264 receiving a recommendation for PM. Only 5.6% did not adhere to the received recommendation. One hundred sixty-one patients delivered again, 58% had a VD, and 42% had a cesarean section (CS). Recurrence of OASIs was observed in 4.3% of the patients that had a VD. Fecal incontinence occurred in 4.9%, however any form of anal incontinence in 48% of patients. While dyspareunia was common in patients with residual external anal sphincter (EAS) injuries and levator ani muscle (LAM) avulsions, anal pain occurred more frequently in EAS injuries and fecal incontinence in LAM avulsions.

CONCLUSIONS

This study showed that the vast majority of patients followed PM recommendations, and this resulted in a low recurrence of OASIs with a high CS rate. Fecal incontinence after OASIs was correlated with the degree of OASIs.

Anal sphincter imaging: better done at rest or on pelvic floor muscle contraction?

INTRODUCTION AND HYPOTHESIS

Exo-anal ultrasound imaging of the anal sphincter is usually undertaken on pelvic floor muscle contraction (PFMC) as this seems to enhance tissue discrimination. Some women are unable to achieve a satisfactory PFMC, and in this situation, the sphincter is assessed at rest. We aimed to determine whether sphincter imaging at rest is inferior to imaging on PFMC.

METHODS

We analysed 441 women in this retrospective study. All underwent a standardised interview, including St Mark's incontinence score, clinical examination and 4D trans-labial ultrasound (TLUS). On analysing volume data, tomographic imaging was used to obtain a standardised set of slices at rest and on PFMC to evaluate external anal sphincter (EAS) and internal anal sphincter (IAS) trauma as described previously.

RESULTS

When assessments obtained from volumes acquired at rest and on PFMC were tested against measures of anal incontinence (AI), all associations between the diagnosis of significant anal sphincter defects and AI were no stronger when imaging was performed on PFMC. On cross-tabulation, the percentage agreement for significant defects of the EAS and IAS at rest and on PFMC was 96.5% and 98.9% respectively, if discrepancy by one slice was allowed.

CONCLUSIONS

Exo-anal tomographic imaging of sphincter defects at rest seems sufficiently valid for clinical use and may not be inferior to sphincter assessment on pelvic floor muscle contraction.

Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury

INTRODUCTION

Endoanal ultrasound is considered the gold standard when assessing the obstetric anal sphincter complex. Due to its relative intrusiveness and economic cost, other ultrasound modalities are on the rise, such as transperineal ultrasound with a convex probe. The aim of our study was to evaluate the agreement between endoanal ultrasound scores (EAUS score) and transperineal ultrasound scores (TPUS score) in assessing residual obstetric anal sphincter defects.

MATERIAL AND METHODS

Fifty-nine women were examined 6 months after primary suturing of obstetric anal sphincter injury with two ultrasound modalities. A standardized scoring system analyzing the length, depth and radial extent of both the external (EAS) and internal (IAS) sphincter was used. Wexner fecal incontinence score was used to assess the patients' symptoms.

RESULTS

Transperineal ultrasound scores score showed a strong significant correlation with EAUS score during both pelvic floor relaxation and contraction: Spearman's rho [r_s ] = 0.74, P < 0.001, and r_s  = 0.77, P < 0.001, respectively. For both EAS and IAS, significant correlations were found for all parameters, that is, length, depth and angle between both EAUS and TPUS. A statistically significant correlation was found between EAUS score and Wexner score (r_s  = 0.36, P = 0.005). A significant correlation between the EAS-EAUS score (r_s  = 0.36, P = 0.005) and Wexner score was found, but no significance was found between IAS-EAUS score and Wexner score (r_s  = 0.22, P = 0.097). Significant correlations were found for Wexner score and TPUS score in resting state (r_s  = 0.36, P = 0.01) and contracting state (r_s  = 0.28, P < 0.05), and between Wexner score and EAS-TPUS score in resting state (r_s  = 0.32, P = 0.02).

CONCLUSIONS

The results indicated a strong agreement between endoanal and transperineal ultrasound in assessing residual obstetric anal sphincter defects 6 months after primary suturing. Furthermore, a weak significant correlation was found between the ultrasound scores and the patients' Wexner fecal incontinence score.

Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries

BACKGROUND

The optimal imaging modality of obstetric anal sphincter injuries needs to take into consideration convenience, availability, and ability to assess the sphincter morphologic condition. Endoanal ultrasound imaging currently is regarded as the reference standard, but it is not widely available in obstetric units. Exoanal alternatives exist, such as 3-dimensional introital or transperineal ultrasound imaging, which are already readily available in most obstetrics and gynecology units.

OBJECTIVE

The primary objective was to evaluate the diagnostic accuracy of 3-dimensional introital and 3-dimensional transperineal ultrasound imaging compared with 3-dimensional endoanal ultrasound imaging as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate a diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort that is experienced for each imaging modality.

STUDY DESIGN

A cross-sectional study was conducted of 250 women who sustained obstetric anal sphincter injuries, all of whom underwent 3-dimensional introital, transperineal, and endoanal ultrasound imaging. Introital and transperineal ultrasound imaging were assessed with tomographic ultrasound imaging. All of the women completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on receiver operating characteristic curves with endoanal ultrasound imaging as the reference standard. Diagnostic test characteristics of introital and transperineal ultrasound imaging were calculated with the use of these optimal cut-offs.

RESULTS

Optimal cut-off for a significant external anal sphincter defect was ≥3 of 7 slices; sensitivity and specificity were 0.65 and 0.75 on introital imaging and 0.70 and 0.69 on transperineal ultrasound imaging. Optimal cut-off for a significant internal anal sphincter defect was ≥2 of 5 slices; sensitivity and specificity were 0.59 and 0.84 on introital imaging and 0.43 and 0.97 on transperineal ultrasound imaging. The area under the curve for the diagnosis of external and internal anal sphincter defects ranged from 0.70-0.74 (P<.001) for introital and transperineal imaging. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63, and negative predictive value ranged from 0.85-0.93 for introital and transperineal ultrasound imaging. Endoanal ultrasound imaging was the only modality for a defect to correlate with symptoms; mean modified St. Mark's score for a defect sphincter was 2.4 (standard deviation, 4.1) and for an intact sphincter was 0.9 (standard deviation, 2.7; P<.01). Introital and transperineal ultrasound imaging were associated with less discomfort than endoanal ultrasound imaging.

CONCLUSION

Endoanal ultrasound imaging remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound imaging are not suitable for the identification of sphincter defects; however, high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardization of a significant defect. In women with a history of obstetric anal sphincter injuries, introital and transperineal ultrasound imagings are suitable to screen for an intact sphincter if endoanal ultrasound imaging is not available. When defects are found, women should then have endoanal ultrasound imaging to verify the diagnosis.

How repeatable is assessment of external anal sphincter trauma by exoanal 4D ultrasound?

OBJECTIVE

Three-/four-dimensional translabial ultrasound (TLUS) is gaining popularity for the assessment of anal sphincter trauma, although repeatability data are lacking. This study aimed to determine the repeatability of tomographic ultrasound imaging (TUI) on TLUS for the diagnosis of external anal sphincter (EAS) trauma and compare the performance of a novice with that of an experienced investigator.

METHODS

This was a retrospective study of archived ultrasound datasets of patients who presented with symptoms of pelvic floor dysfunction and were examined twice between 2012 and 2016 at an average interval of 260 (range, 1-1100) days. All volumes were obtained using a GE Medical Systems Voluson 730 Expert or E8 ultrasound system. Post-processing of volumes was performed independently by two investigators, one with over 1 year's experience and another with no prior experience in using TUI, who were blinded to clinical data, each other's results and the results obtained at the first timepoint. Significant trauma on EAS was diagnosed if four of the six TUI slices showed a defect of ≥ 30°. Intra- and interobserver agreement were determined using Cohen's kappa (κ) and intraclass correlation coefficients.

RESULTS

During the study period, 105 women underwent two TLUS assessments of the anal sphincter. Of these, 103 patients with ultrasound volumes available for both timepoints were included in the analysis. The novice investigator demonstrated average repeatability for assessment of significant EAS trauma and single-slice defect (κ, 0.30 and 0.22, respectively) despite relatively high agreement between measurements obtained at the two timepoints (84.5% and 79.3%, respectively). The experienced investigator demonstrated good to very good repeatability for significant EAS trauma and single-slice defect (κ, 0.91 and 0.78, respectively) between the two assessments, which equates to 98.1% and 94.7% agreement, respectively.

CONCLUSION

The repeatability of TLUS measurements for diagnosis of EAS trauma seems to be very good when imaging is undertaken with state-of-the-art equipment and the analysis is performed by an experienced observer; however, the performance of a novice investigator is much poorer. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Non-invasive obstetric anal sphincter injury diagnostics using impedance spectroscopy

Obstetric anal sphincter injuries are the most common cause of fecal incontinence in women yet remain under-diagnosed. The aim of this study was to assess the suitability of impedance spectroscopy for diagnosing sphincter injuries arising during delivery. This was a prospective single-center study. 22 female patients were included: 10 with symptoms of sphincter dysfunction, in the early postpartum period, and 12 unaffected, in the distant period of more than 2 years after natural delivery. The presence, extent and severity of anal sphincters injury was assessed by measuring the sphincter parameters in physical examination, the degree of sphincter damage in endoanal ultrasound imaging and the sphincters function parameters in anorectal manometry. All measurements were used as references and compared with the outcomes from the impedance spectroscopy models. Impedance spectroscopy showed the highest precision (with mean accuracy of 83.9%) in relation to transanal ultrasonography. 74.1% of its results corresponded to the results of rectal physical examination and 76.7% - to those of anorectal manometry. The method showed the highest accuracy in the assessment of the sphincter's parameters, both anatomically and functionally. New impedance spectroscopy techniques hold promise for detecting obstetric anal sphincter injuries.

Medium- to Long-term Follow-up of Obstetric Anal Sphincter Injury

BACKGROUND

Obstetric anal sphincter injury is the primary modifiable risk factor for anal incontinence in women. Currently, endoanal ultrasound is most commonly used to detect residual anal sphincter defects after childbirth. Translabial ultrasound has recently been introduced as a noninvasive alternative.

OBJECTIVES

This study aimed to determine medium- to long-term outcomes in women after obstetric anal sphincter injuries diagnosed and repaired at delivery.

DESIGN

This is a cross-sectional study.

SETTINGS

This study was performed in a tertiary obstetric unit.

PATIENTS

Between 2005 and 2015, 707 women were diagnosed with obstetric anal sphincter injuries; 146 followed an invitation for follow-up.

INTERVENTIONS

Clinical examination, anal manometry, and translabial ultrasound were performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were the St Mark incontinence score and the evidence of sphincter disruption on translabial ultrasound.

RESULTS

Of 372 contactable patients, 146 attended at a mean follow-up of 6.6 years (1.7-11.9), of which 75 (51%) reported symptoms of anal incontinence with a median "bother score" of 6 (interquartile range, 3-8). Median St Mark score was 3 (interquartile range, 2-5). Twenty-four (16%) had a score of ≥5. Women who had been diagnosed with a 3c/4th degree tear had more symptoms (58% vs 44%), significantly lower mean maximal resting pressure (p < 0.001), maximal squeeze pressure (p < 0.001), and more residual external (p < 0.001) and internal (p = 0.012) sphincter defects in comparison with those who had a 3a/3b tear. Women with residual external sphincter defects had lower mean maximal squeeze pressure (p = 0.02). Residual internal sphincter defects (p = 0.001) and levator avulsion (p = 0.048) are independent risk factors for anal incontinence on multivariate modeling.

LIMITATIONS

This study was limited by the lack of predelivery data of bowel symptoms and BMI and incomplete intrapartum documentation of tear grade.

CONCLUSIONS

Symptoms of anal incontinence were highly prevalent (51%), with a high bother score of 6. St Mark scores were associated with residual internal anal sphincter defects and levator avulsion. Women who had a higher tear grade showed a higher incidence of residual sphincter defects and lower manometry pressures. See Video Abstract at http://links.lww.com/DCR/A824.

Delivery mode, levator avulsion and obstetric anal sphincter injury: A cross-sectional study 20 years after childbirth

BACKGROUND

Levator ani muscle (LAM) and anal sphincter injuries are common after vaginal birth and are associated with pelvic organ prolapse and anal incontinence.

AIMS

Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.

METHODS

All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ² test and results are expressed as odds ratios (OR).

RESULTS

Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.

CONCLUSIONS

Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.

EFSUMB Recommendations for Gastrointestinal Ultrasound Part 3: Endorectal, Endoanal and Perineal Ultrasound

This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.

[Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVES

The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors.

METHODS

A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice.

RESULTS

To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C).

CONCLUSION

It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.

Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study

OBJECTIVES

To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later.

METHODS

This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects.

RESULTS

Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries.

CONCLUSIONS

Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Expert consensus document: Advances in the evaluation of anorectal function

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Exoanal Imaging of the Anal Sphincters

Since its introduction in the early 1990s, endoanal sonography has become the mainstay of morphologic assessment of the anal canal and sphincter, especially for obstetric anal sphincter trauma. Lack of availability of suitable systems and the invasive nature of the method have limited uptake and clinical utility. More recently, exoanal or transperineal/translabial tomographic imaging has been developed as a noninvasive alternative. This pictorial overview aims to introduce the reader to this new diagnostic modality and to demonstrate common findings in asymptomatic and symptomatic women.

Postpartum two- and three-dimensional ultrasound evaluation of anal sphincter complex in women with obstetric anal sphincter injury

OBJECTIVE

To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS).

METHODS

External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated.

RESULTS

Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (κ = 0.01), fair for 2D-TPUS (κ = 0.30) and good for 3D-TPUS (κ = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (κ = 0.41) and 2D-TPUS (κ = 0.52) and good for 3D-TPUS (κ = 0.66). Good intraobserver (3D-EAUS, κ = 0.73; 3D-TPUS, κ = 0.78) and interobserver (3D-EAUS, κ = 0.68; 3D-TPUS, κ = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04).

CONCLUSIONS

2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Current applications of transperineal ultrasound in gastroenterology

Transperineal ultrasound is an inexpensive, safe and painless technique that dynamically and non-invasively evaluates the anorectal area. It has multiple indications, mainly in urology, gynaecology, surgery and gastroenterology, with increased use in the last decade. It is performed with conventional probes, positioned directly above the anus, and may capture images of the anal canal, rectum, puborectalis muscle (posterior compartment), vagina, uterus, (central compartment), urethra and urinary bladder (anterior compartment). Evacuatory disorders and pelvic floor dysfunction, like rectoceles, enteroceles, rectoanal intussusception, pelvic floor dyssynergy can be diagnosed using this technique. It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature, with images obtained at rest, straining and sustained squeezing. This technique is an accurate examination for detecting, classifying and following of perianal inflammatory disease. It can also be used to sonographically guide drainage of deep pelvic abscesses, mainly in patients who cannot undergo conventional drainage. Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence, postpartum and also following surgical repair of obstetric tears. There are also some studies referring to its role in anal stenosis, for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.

Anal sphincter trauma and anal incontinence in urogynecological patients

OBJECTIVES

To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma.

METHODS

This was a retrospective analysis of ultrasound volume datasets of 501 patients attending a tertiary urogynecological unit. All patients underwent a standardized interview including determination of St Mark's score for those presenting with AI. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS and the internal anal sphincter (IAS).

RESULTS

Among a total of 501 women, significant EAS and IAS defects were found in 88 and 59, respectively, and AI was reported by 69 (14%). Optimal prediction of AI was achieved using a model that included four abnormal slices of the EAS on TUI. IAS defects were found to be less likely to be associated with AI. In a multivariable model controlling for age and IAS trauma, the presence of at least four abnormal slices gave an 18-fold (95% CI, 9-36; P < 0.0001) increase in the likelihood of AI, compared with those with fewer than four abnormal slices. Using receiver-operating characteristics curve statistics, this model yielded an area under the curve of 0.86 (95% CI, 0.80-0.92).

CONCLUSIONS

Both AI and significant EAS trauma are common in patients attending urogynecological units, and are strongly associated with each other. Abnormalities of the IAS seem to be less important in predicting AI. Our data support the practice of using, as a minimal criterion, defects present in four of the six slices on TUI for the diagnosis of significant EAS trauma.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound

OBJECTIVES

Obstetric anal sphincter tears are common and an important factor in the etiology of anal incontinence. The objective of the study was to evaluate the prevalence of residual defects of the external anal sphincter (EAS) after primary repair of obstetric anal sphincter injury using four-dimensional (4D) transperineal ultrasound and to correlate sonographic findings of residual defects and levator avulsion with significant symptoms of anal incontinence, defined as St Mark's fecal incontinence score (SMIS) of ≥ 5.

METHODS

This was a retrospective observational study. One-hundred and forty women were seen after primary repair of obstetric anal sphincter tears in a dedicated perineal clinic at a tertiary hospital in Australia. They all underwent a standardized interview, and physical and 4D transperineal ultrasound examination.

RESULTS

Mean follow-up interval was 1.9 months after delivery. Eighty-nine (64%) women had a 3a/3b tear, 28 (20%) a 3c/4(th) degree tear and 23 (16%) an unclassified 3(rd) degree tear. Thirty-five (25%) patients reported symptoms of anal incontinence. Nine had an SMIS of ≥ 5. A residual defect was found in 56 (40%) cases and levator avulsion in 27 (19%). On multivariate logistic regression, residual defects (P = 0.03; odds ratio (OR) = 6.38; 95% CI, 1.23-33.0) and levator avulsion (P = 0.047; OR = 4.38; 95% CI, 1.02-18.77) were found to be independent risk factors for anal incontinence.

CONCLUSIONS

Residual defects of the EAS were found on transperineal ultrasound in 40% of women after primary repair of obstetric anal sphincter injuries. Although most were asymptomatic, residual anal sphincter defects and levator avulsion were associated with significant symptoms of anal incontinence as quantified using the SMIS.

Transperineal sonographic anal sphincter complex evaluation in chronic anal fissures

OBJECTIVES

The purpose of this study was to assess the role of transperineal sonography in assessment of pathologic changes to the anal sphincter complex in patients with chronic anal fissures.

METHODS

We conducted a prospective case-control study of 100 consecutive patients of any age and both sexes with chronic anal fissures who presented to a colorectal clinic between January 2012 and August 2013 (group A) and 50 healthy volunteers (group B).

RESULTS

The most common patterns of radiologic changes to anal sphincters associated with chronic anal fissures were circumferential thickening of the anal sphincter complex in 5 patients (5%), circumferential thickening of the internal anal sphincter in 3 patients (3%), preferential thickening of the internal anal sphincter at the 6-o'clock position in 80 patients (80%) and the 12-o'clock position in 7 patients (7%), preferential thickening of the internal and external anal sphincters in 3 patients (3%), and thinning of the internal anal sphincter in 2 patients (2%).

CONCLUSIONS

Chronic anal fissures cause differential thickening of both internal and external anal sphincters, with a trend toward increased thickness in relation to the site of the fissure. Routine preoperative transperineal sonography for patients with chronic anal fissures is recommended, and it is mandatory in high-risk patients.

Obstetrics and fecal incontinence

Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.

Obstetrics and fecal incontinence

Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.

Diagnostic testing for fecal incontinence

Many tests are available to assist in the diagnosis and management of fecal incontinence. Imaging studies such as endoanal ultrasonography and defecography provide an anatomic and functional picture of the anal canal which can be useful, especially in the setting of planned sphincter repair. Physiologic tests including anal manometry and anal acoustic reflexometry provide objective data regarding functional values of the anal canal. The value of this information is of some debate; however, as we learn more about these methods, they may prove useful in the future. Finally, nerve studies, such as pudendal motor nerve terminal latency, evaluate the function of the innervation of the anal canal. This has been shown to have significant prognostic value and can help guide clinical decision making. Significant advances have also happened in the field, with the relatively recent advent of magnetic resonance defecography and high-resolution anal manometry, which provide even greater objective anatomic and physiologic information about the anal canal and its function.

Usefulness of 3D transperineal ultrasound in severe stenosis of the anal canal: preliminary experience in four cases

BACKGROUND

Organic or functional anal canal stenoses are uncommon conditions that occur in the majority of cases as a consequence of anal diseases. A proper assessment is fundamental for decision making; however, proctological examination and endoanal ultrasound are often unfeasible or very difficult to perform even under local or general anesthesia. We therefore began to use 3D transperineal ultrasound to assess patients. The aim of this study was to compare the results of evacuation proctography and 3D transperineal ultrasound in patients with severe anal canal stenosis.

METHODS

Four consecutive patients with high-grade anal canal stenosis were evaluated using both proctography and 3D transperineal ultrasound with a micro-convex transducer between March and June 2011.

RESULTS

In all cases, 3D transperineal ultrasound provided detailed information on the length and level of stenosis and on the integrity of the anal sphincters.

CONCLUSIONS

Our preliminary experience suggests that 3D transperineal ultrasound makes it possible to plan optimal surgical treatment.