Autologous skeletal-muscle-derived cell injection for anal incontinence due to obstetric trauma: a 5-year follow-up of an initial study of 10 patients

AIM

Our aim was to determine whether the benefits of autologous skeletal-muscle-derived cell injection to treat obstetric anal incontinence are sustained at 5 years.

METHOD

An observational study was performed of 10 women suffering from obstetric anal incontinence refractory to non-surgical therapy. Autologous skeletal-muscle-derived cells were injected into the external sphincter defect under ultrasound guidance. Incontinence diaries and quality of life questionnaires were obtained pre-implantation and annually after implantation for 5 years. Anal physiology testing was performed before implantation and at 1, 2 and 5 years after implantation. The end-points included were adverse events, Wexner incontinence scores, incontinence episodes, anal squeeze pressures and quality of life over 5 years. An independent statistician used multilevel linear regression to analyse changes in repeated measures over time. Any skewed distributions were log transformed prior to analysis.

RESULTS

No procedure-related adverse events occurred and haematological and biochemical parameters were normal during the 5-year period. There were sustained significant improvements in the Wexner incontinence score and reduced frequency of defaecation and number of incontinence episodes (all comparisons P < 0.001). Anal resting and squeeze pressures showed sustained improvement (all P < 0.001) and quality of life improved overall (P < 0.001), including all submeasures studied (P < 0.001).

CONCLUSION

Autologous skeletal-muscle-derived cells to treat obstetric anal incontinence resulted in sustained improvement in incontinence episodes, physiological measurements of anal function and quality of life at 5 years.

Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group

The purpose of this guideline is to provide a decision aid for diagnosis, treatment, and follow-up of patients with major perineal tears and thus minimize the risk of persistent symptoms. In 2007, the "Guideline for the management of third and fourth degree perineal tears after vaginal birth" was established by members of the Austrian Urogynecologic Working Group (AUB). The guideline was updated in 2011, including literature published up to 30 November 2011. The DELPHI method was used to reach consensus. Evidence-based and consensus-based statements were defined for epidemiology, risk factors, classification, diagnosis, surgery, and follow-up of major perineal lacerations at vaginal birth.

Muscle-derived cell injection to treat anal incontinence due to obstetric trauma: pilot study with 1 year follow-up

OBJECTIVE

To treat anal incontinence due to obstetric external anal sphincter disruption via injection of autologous myoblast cells.

DESIGN

Observational pilot study.

SETTING

University hospital and district hospital

PATIENTS

10 women suffering from anal incontinence due to obstetric anal sphincter injury, refractory to conventional non-surgical therapy.

INTERVENTIONS

Autologous myoblasts were cultured from a pectoralis muscle biopsy, harvested, and injected into the external anal sphincter defect using direct ultrasound guidance.

MAIN OUTCOME MEASURES

Wexner incontinence score, anal squeeze pressures, and quality of life 12 months after injection. Safety and technical feasibility.

RESULTS

The procedure was well tolerated and no adverse events were observed. At 12 months the Wexner incontince score had decreased by a mean of 13.7 units (95% CI, -16.3 to -11.2), anal squeeze pressures were unchanged, and overall quality of life scores improved by a median of 30 points (95% CI, 25 to 42). Anal squeeze pressures did rise significantly at 1 month and 6 months post-injection (p = 0.03).

CONCLUSIONS

Injection of autologous myoblasts is safe, well tolerated, and significantly improves symptoms of anal incontinence due to obstetric anal sphincter trauma.

[Endoanal MR imaging: diagnostic assessment]

Endoanal MR imaging is an alternative to anal endosonography for the acquisition of high-resolution images of the external and internal anal sphincter. A dedicated anal receiver coil is placed in the anus so that it spans the sphincter complex. Highly detailed images of the sphincters can be obtained in any plane and the morphological abnormalities found in various types of anal incontinence can be demonstrated. Whilst MR demonstrates external sphincter disruption with an efficacy similar to that of endosonography, it is better able to demonstrate external sphincter atrophy that is presumed secondary to neuropathy. The finding of coexisting muscular atrophy on MR may prejudice the effects of anal sphincter repair for obstetric disruption.

[Anal incontinence]

Anal incontinence, i.e. the loss of the voluntary control of intestinal contents, covers the spectrum from slight traces of stool in the underwear via the loss of wind to marked episodes of uncontrollable evacuation of soft or hard faeces. These are humiliating symptoms the causes of which can be multiple and complex. In women, the most frequent aetiological factor is injury to the pelvic floor due to birth trauma. Specialists and general practitioners do often not realize that anal incontinence can be treated, which may significantly improve the quality of life of the patients after the appropriate diagnostic tests and subsequent individual therapy.

Changes in anal anatomy following vaginal delivery revealed by anal endosonography

OBJECTIVE

To investigate changes in anal canal anatomy following vaginal delivery in women without apparent sphincter injury.

DESIGN

Prospective controlled observational study.

SETTING

District general hospital.

POPULATION

Consecutive parous and nulliparous women attending a gynaecology outpatient clinic.

METHODS

All women were examined using anal endosonography, and parous subjects without apparent sphincter injury compared with age-matched nulliparous controls to determine any differences in general anal canal morphology.

MAIN OUTCOME MEASURES

Individual anal canal components were measured at defined levels and subjects compared with controls.

RESULTS

Twenty-one of 54 parous women had no anal sphincter scar. Compared with nulliparous women, they had significant anterior sphincter thinning (mean 3.7 mm vs 4.6 mm, P< 0.01) in association with lateral external sphincter thickening (mean 7.0 mm vs 4.4 mm, P<0.01), and longitudinal muscle thickening (mean 2.8 mm vs 2.1 mm, P< 001).

CONCLUSIONS

Specific changes in anal morphology have been demonstrated following vaginal delivery in women without apparent sphincter injury.

Examination techniques for endosonography of the anal canal

BACKGROUND

To determine whether patient position or sphincter contraction influences sphincter thickness or defect assessment.

METHODS

Anal endosonography was performed on 35 consecutive patients (30 women, five men). Twenty-five were scanned in the left lateral and prone positions, and the internal sphincter thickness was measured. In 10 patients, the internal sphincter, longitudinal muscle, external sphincter, and length of any defect were measured at rest and during anal squeeze.

RESULTS

There was no significant difference in internal sphincter thickness measured in the prone and left lateral positions (95% limits of agreement, -0.12 to 0.06). The thickness of the internal sphincter, longitudinal muscle, and external sphincter at rest did not change significantly during straining (95% limits of agreement, -0.44 to 0.3, -0.28 to 0.24, and 0.33 to 0.71, respectively). The squeeze maneuver did not influence defect appearance or length (95% limits of agreement, -2.845 to 2. 379). Greater symmetry of the anterior part of the external sphincter and improved visualization of perineum was achieved in the prone position.

CONCLUSION

Examination in the prone position is preferred. Squeeze maneuvers are of no diagnostic benefit.

Perineal examination as a predictor of underlying external anal sphincter damage

OBJECTIVE

To assess the relation between perineal inspection and sphincter integrity in parous women.

DESIGN

Prospective observational study.

SETTING

District general hospital.

POPULATION

Fifty-seven consecutive parous women attending a gynaecology clinic for problems unrelated to the pelvic floor.

METHODS

A detailed history of bowel function and mode of delivery obtained; the perineum inspected to determine the presence and position of scarring, and anal endosonography performed.

RESULTS

In 19 women with an intact perineum on inspection, endosonography showed perineal scarring in five, with both perineal and sphincter scarring in three. Four had urge faecal incontinence. Three patients had a perineal tear only on inspection, but this group was too small for analysis and was discounted. Nine had an episiotomy scar only. Endosonography demonstrated perineal scarring in four, and combined perineal and sphincter scarring in two; one woman in this group had urge faecal incontinence. Twenty-six women had episiotomy and perineal tears on inspection. Endosonography revealed underlying perineal scarring in five women, with combined perineal and sphincter scarring in 14; six women in this group had urge faecal incontinence and one passive incontinence for flatus. Sonographically the scarring was anterior and circumferential rather than radial, and mostly left-sided, whereas on inspection episiotomy and perineal scarring were right sided.

CONCLUSIONS

A normal perineum on clinical examination does not exclude underlying sphincter damage. The incidence of sphincter damage increases significantly when an episiotomy scar is associated with a perineal tear.

Transvaginal versus anal endosonography for detecting damage to the anal sphincter

OBJECTIVE

We undertook this study to establish the accuracy of transvaginal endosonography for detecting damage to the anal sphincter.

SUBJECTS AND METHODS

Anal endosonography was performed in 47 parous patients and one nulliparous patient using a sonographic scanner, an 1850 endoprobe, and a 10-MHz transducer protected by a water-filled hard plastic cone. This procedure was followed by transvaginal sonography using the same system but with a water-filled balloon in 43 and a dedicated vaginal probe Type 8551 of 10-MHz frequency in five. Axial images were obtained as low in the perineum as possible. The transvaginal images were reviewed with the observer unaware of the findings from anal endosonography and were then compared with the anal endosonograms.

RESULTS

The transvaginal images were inadequate for review in three patients. In the remaining 45 patients, anal endosonography showed internal sphincter defects in 18 and external sphincter tears in 21. Transvaginal endosonography showed eight internal and 10 external sphincter defects only, giving a sensitivity of 44% and a specificity of 96% for the detection of internal sphincter defects and a sensitivity of 48% and a specificity of 88% for external sphincter tears.

CONCLUSION

Transvaginal examination is not accurate for assessing the anal sphincter because of the anatomic limitations this approach imposes on axial imaging of the anal canal.