Objective methods cannot predict anal incontinence after primary repair of extensive anal tears

BACKGROUND

An increased awareness of anal incontinence after delivery tears has developed during the last years. The aim of this study was to compare complaints with the results of physiological methods in women with complete sphincter ruptures primarily repaired at delivery.

METHODS

Twenty-seven women, 16 with total rupture of the external anal sphincter and 11 who also had a ruptured internal anal sphincter were studied. Interviews on pelvic floor function, investigation with recto-anal manometry, single fiber EMG and anal endosonography were performed at 11.9 (2.5) months after delivery. Fifteen women vaginally delivered without sphincter rupture served as controls.

RESULTS

Pelvic floor dysfunction was admitted in 74%, in particular gas incontinence (59%). Maximum squeeze pressure was significantly reduced (p<0.01) compared to controls, while resting anal pressure was unaffected. Fiber density was increased in 81% of patients and 91% had detectable defects on endosonography. Neither the degree of rupture nor the presence of complaints significantly correlated to the objective methods.

CONCLUSIONS

A majority of women with primarily repaired anal sphincter ruptures at delivery were incontinent. Sphincter defects and signs of neuropathy could not precisely predict symptoms.

[Abdominal rectopexy in the treatment of rectal prolapse: how to foresee the functional result]

21 patients (19 women) who underwent rectal prolapse repair were prospectively studied. At the one year follow-up, 6 of the eleven incontinent patients (54 per cent) regained full continence and while three of the remaining 5 patients improved they still referred occasional imperfection of continence. Resting anal pressure and maximal squeeze pressure were both significantly lower in the five patients who remained incontinent, 23 (17-31) mm Hg vs 50 (31-52) mm Hg (p < = 0.02) and 52 (17-75) mm Hg vs 108 (89-110) mm Hg (p < = 0.02), respectively. Moreover the manometric results showed evidence that in patients who remained incontinent, the anal pressure in response to rectal distention, was significantly lower than patients who regained continence (p < = 0.05) both before and after operation. We conclude that incontinent patients with rectal prolapse who exhibit a markedly low minimal residual anal pressure on recto-anal reflex inhibition are less likely to improve after rectopexy and that this preoperative test may be a useful predictor.

[The impact of conventional proctocolectomy on sexual function]

Seventy-one women who had a proctocolectomy for ulcerative colitis (n. 41) or Crohn's disease (n. 30) were interviewed in the follow-up clinic for gynaecological problems and fertility. Forty-nine per cent (35/71) of the women had a distressing vaginal discharge after proctocolectomy, compared with 9% before surgery. At the gynaecological examination 45% (32/71) had a heavy vaginal secretion without any signs of an acute vaginal infection. In 68% (30/44) fluid retention in the vagina was associated with a caudally firmly-fixed and dilated posterior vaginal fornix. Twelve per cent (8/66) of the women reported dyspareunia before surgery. After surgery, 27% (18/66) complained of this symptom. Fertility was significantly reduced after surgery since only 37% (10/27) of the women who attempted to become pregnant succeeded within five years follow-up. The corresponding figure before surgery was 72% (39/54). Those who conceived went through pregnancy and parturition without any incident, 6 of 24 delivered by cesarean section. Fifty-seven men who had a proctocolectomy for ulcerative colitis (n.41) or Crohn's disease (n. 30) were interviewed in the follow-up clinic for the presence of sexual disturbances and their incidence was studied. Fifty-seven per cent of elderly patients (above 40 years old) complained of reduced libido and sexual satisfaction. In younger patients (below 40 years old) 33% complained of an impaired quality of sexual life and 22% complained of an impaired sexual satisfaction. However, despite some sexual dysfunction, 56% reported improved sexual life and 67% improved sexual satisfaction. This may be explained by improved general health and increased libido after removal of diseased bowel.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of the pelvic nerves on anorectal motility in the cat

The influence of the parasympathetic pelvic nerves on anorectal motility was studied in anaesthetized cats. Anal pressure and rectal motility were recorded by a manometric and a volumetric method, respectively. Severing of the pelvic nerves did not cause any pressure change in the anus, indicating that these nerves are not significantly tonically active. Efferent low intensity (0.05-0.5 ms, 8 V at 5 Hz) electrical stimulation of the pelvic nerves (PNS) elicited a contraction of the internal anal sphincter (IAS), while high intensity stimulation (greater than 1 ms, 8 V at 5 Hz) caused a sphincter relaxation. A rectal contraction was noted on both low and high intensity stimulation. After sectioning of the sympathetic nerves, PNS elicited a contraction in both the anus and the rectum irrespective of stimulation intensity. PNS inhibited the anal contraction elicited by simultaneous stimulation of the sympathetic nerves or noradrenaline infusion. The inhibitory anal responses to PNS were unaffected or augmented by atropine, unaffected by propranolol and abolished by hexamethonium. The excitatory anal effects of PNS were reduced or abolished by atropine and abolished by phentolamine. The rectal contraction induced by low intensity PNS was abolished by atropine or converted to a relaxation. In half of the experiments an atropine resistant rectal contraction was observed in response to high intensity PNS. The results are consistent with a pelvic nerve influence on IAS pressure through several mechanisms, including modulation of the activity in the sympathetic nerves and activation of inhibitory non-adrenergic, non-cholinergic neurons. The pelvic nerves convey both cholinergic and non-cholinergic excitatory, as well as non-adrenergic, non-cholinergic inhibitory fibres to the rectum.

Mobilization of colonic kallikrein following pelvic nerve stimulation in the atropinized cat

1. Pelvic nerve stimulation (p.n.s.) in cats induces atropine-resistant colonic vasodilatation and colonic contraction. The effects of this on cat colon are mimicked by synthetic bradykinin infusions. The present study examines the effect of p.n.s. on the activation of kallikrein, the kinin-forming enzyme present in colonic tissue and its effects on the plasma kinin system in the atropinized cat.2. Mean level (+/- S.D.) of mucosal kallikrein was found to be about 37 times higher in unstimulated colonic mucosa (300 +/- 100 ng bradykinin equivalents min(-1)g(-1)) than in the underlying muscle (8.2 +/- 6.3 ng bradykinin equiv min(-1)g(-1)).3. After a p.n.s. of 5 min, mean kallikrein level in colonic muscle was 7.3 +/- 3.5 ng bradykinin equiv min(-1)g(-1), which was not significantly different from the control muscle kallikrein. However, there was an 86% fall in mucosal kallikrein to 41.3 +/- 34.7 ng bradykinin equiv min(-1)g(-1) after 5 min p.n.s., indicating a rapid activation and secretion of mucosal kallikrein.4. Secretion of mucosal kallikrein was paralleled by specific depletion of plasma kininogen, the precursor of active kinin in blood draining the colon. The mean plasma kininogen level fell to 79 and 68% of the prestimulated value (3.1 +/- 1.1 S.D. mug bradykinin equiv per ml. plasma) after 5 and 10 min p.n.s. respectively. Total plasma protein and haematocrit remained unaltered excluding non-specific changes due to protein extravasation or haemodilution and indicating utilization of the plasma kinin precursor.5. Following 2 hr p.n.s., raised levels of kallikrein were detected in both colonic muscle (28 +/- 2.0 bradykinin equiv min(-1)g(-1)) and mucosa 434 +/- 118 ng bradykinin equiv min(-1)g(-1)). Preliminary studies using a kallikrein inhibitor indicated that the increased kallikrein levels originated from plasma.6. Direct stimulation of the parasympathetic pelvic nerve in the atropinized cat thus produced activation of the plasma kinin system in the colon and formation of free kinins may be responsible for the mucosal vasodilatation and strong motor contraction which is not blocked by large doses of atropine. The observation that prolonged stimulation causes extravasation of plasma kallikrein, a potential inflammatory mediator, into the tissues may be of clinical significance.

Blood flow in the small intestine of cat and man as analyzed by an inert gas washout technique

Using a recently developed 85Kr-elimination technique, blood flow and flow distribution of the human small intestine have been investigated in patients during abdominal surgery. Total intestinal blood flow was estimated to be 38 +/- 4 ml per min and 100 g of intestinal tissue (mean +/- SE: n = 19), jejunal blood flow being slightly higher than ileal. In 14 of these patients muscularis blood flow was determined to be 21 +/- 2 ml per min and 100 g of muscularis tissue and mucosal-submucosal blood flow was calculated to be 51 +/- 6 ml per min and 100 g of mucosal-submucosal tissue. Seventy-five +/- 3% of total blood flow was distributed to the mucosa-submucosa and the remaining 25 +/- 3% to the muscularis. It was demonstrated that an increasing fraction of flow was diverted to the mucosa-submucosa with enhanced total intestinal blood flow. The human gut exhibited great qualitative and quantitative circulatory similarities with the feline small intestine.

Colonic blood flow in cat and man as analyzed by an inert gas washout technique

An inert gas elimination technique for studying blood flow and flow distribution in the colon was developed on the cat and applied to patients during abdominal surgery. The method involves recording of the elimination of intra-arterially injected 85Kr from a colonic segment whereby the gamma- and beta-radiation of the tracer is registered simultaneously by a scintillation detector and Geiger-Muller tube, respectively. Total blood flow was determined from the recording of gamma-radioactivity using a modification of Zierler's formula, and muscularis blood flow as calculated according to Kety from the mono-exponential elimination recorded by the Geiger-Muller tube. The relative weights of the muscularis and mucosa-submucosa were determined from dissections or histological sections. With these weights and total and muscularis blood flows, flow in the mucosa-submucosa was calculated. Total colonic blood flow was 18 +/- 2 ml per min and 100 g of colonic tissue (mean +/- SE; n = 21). In the muscularis layer blood flow amounted to 11 +/- 1 ml per min and 100 g of muscularis tissue (n = 12), and flow in the mucosa-submucosa was calculated to be 28 +/- 5 ml per min and 100 g of mucosal-submucosal tissue. A major fraction (66 +/- 6%) of total blood flow was distributed to the mucosa-submucosa. As total colonic blood flow was enhanced the increase in flow was diverted only to the mucosa-submucosa. The feline and human large bowel exhibited great qualitative and quantitative circulatory similarities.