Anal sphincteric neurogenic injury in asymptomatic nulliparous women and fecal incontinence

While anal sphincter neurogenic injury documented by needle electromyography (EMG) has been implicated to cause fecal incontinence (FI), most studies have been uncontrolled. Normal values and the effects of age on anal sphincter motor unit potentials (MUP) are ill defined. The functional significance of anal sphincter neurogenic injury in FI is unclear. Anal pressures and EMG were assessed in 20 asymptomatic nulliparous women (age, 38 ± 5 yr; mean ± SE) and 20 women with FI (54 ± 3 yr). A computerized program quantified MUP duration and phases. These parameters and MUP recruitment were also semiquantitatively assessed by experienced electromyographers in real time. Increasing age was associated with longer and more polyphasic MUP in nulliparous women by quantitative analysis. A higher proportion of FI patients had prolonged (1 control, 7 patients, P = 0.04) and polyphasic MUP (2 controls, 9 patients, P = 0.03) at rest but not during squeeze. Semiquantitative analyses identified neurogenic or muscle injury in the anal sphincter (11 patients) and other lumbosacral muscles (4 patients). There was substantial agreement between quantitative and semiquantitative analyses (κ statistic 0.63 ± 95% CI: 0.32-0.96). Anal resting and squeeze pressures were lower (P ≤ 0.01) in FI than controls. Anal sphincter neurogenic or muscle injury assessed by needle EMG was associated (P = 0.01) with weaker squeeze pressures (83 ± 10 mmHg vs. 154 ± 30 mmHg) and explained 19% (P = 0.01) of the variation in squeeze pressure. Anal sphincter MUP are longer and more polyphasic in older than younger nulliparous women. Women with FI have more severe neurogenic or muscle anal sphincter injury, which is associated with lower squeeze pressures.     

Dilatation and closing anal reflexes. Description and clinical significance of new reflexes: preliminary report.

The present communication describes new reflexes which are called 'dilatation and closing anal reflexes', and discusses their clinical significance. The study comprised 21 healthy volunteers and 15 incontinent patients (7 with partial fecal incontinence and 8 with urinary stress incontinence). The technique comprised the introduction into the rectal neck of a balloon-tipped catheter. The balloon was inflated with air in increments of 10 ml up to 50 ml, and the EMG response of the external and urethral sphincters to balloon inflation and deflation was recorded. A new device called 'switch inflation' apparatus was used to inflate the balloon simultaneously with switching of the EMG apparatus. Rapid rectal neck inflation and deflation evoked external anal and urethral sphincter contraction. Slow and gradual inflation or deflation did not initiate the response. The anesthetized external anal sphincter did not respond to the stimulus, while the saline-infiltrated sphincter responded. The latency of the reflexes was recorded. In fecal incontinent patients, the external anal sphincter, on rapid rectal neck inflation or deflation, showed lower EMG activity and longer latency than in normal volunteers; the external urethral sphincter responded as in normal volunteers. In urinary stress incontinent patients, the external anal sphincter responded normally for both rectal neck inflation and deflation. The external urethral sphincter showed lower EMG activity and prolonged latency than normal on rectal neck inflation; it did not respond to deflation. The dilatation and closing reflexes seem to play a role in fecal and urinary continence as well as in fecal sampling. Detectable changes in latency or amplitude of the evoked response indicate a defect in the reflex pathway.(ABSTRACT TRUNCATED AT 250 WORDS)     

Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.     

Urodynamic biofeedback treatment of urinary incontinence in children with myelomeningocele

Eight children with myelomeningocele and chronic neurogenic urinary incontinence were provided urodynamic biofeedback training. During urodynamic biofeedback, six of the eight children demonstrated improved self-regulation of detrusor and/or sphincter functioning. However, substantial improvements in clinical symptomatology (i.e., urinary incontinence) were clearly shown by only one child. Unexpectedly, chronic neurogenic fecal incontinence was reduced in four children. Several methodological modifications are discussed which may improve clinical symptomatology and which may facilitate further urodynamic biofeedback research for these children with congenital neurogenic urinary incontinence.This work was supported by a grant from The Crippled Children's Guild through the Behavioral Pediatrics Program at Orthopaedic Hospital.     

Results of Parks operation for faecal incontinence after anal sphincter injury.

Parks operation for faecal incontinence was performed on 97 patients with total loss of anorectal control due to injury. All had sustained complete division of the anal sphincters as a result of trauma, anal surgery, or obstetric tears and either were incontinent or had been given a colostomy. In all patients the divided sphincters were repaired using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There was no operative mortality. Continence was completely restored in 65 (78%) and improved in a further 11 (13%) of the 83 patients assessed from four to 116 months postoperatively. Minor complications which did not affect the eventual clinical outcome occurred in 23 patients. Factors associated with failure of the operation included breakdown of the repair in the early postoperative period, fistula, and pelvic floor neuropathy. The results show that even after severe injury to the sphincters surgical reconstruction can restore continence in most patients.     

Bowel Dysfunction in Spinal Cord Injury: Current Perspectives

Permanent disruptions of gastrointestinal function are very common sequel of spinal cord injury (SCI). When motor and sensory nervous integrity are severely affected, neurogenic gastrointestinal dysfunction is an inevitable consequence. Autonomic nervous system miss function has significantly diminished or lost sensory sensations followed with incomplete evacuation of stool from the rectal vault, immobility, and reduced anal sphincter tone all of those predisposing to increased risk of fecal incontinence (FI). The FI is, beside paralysis of extremities, one of the symptoms most profoundly affecting quality of life (QOL) in patients with SCI. We are reviewing current perspectives in management of SCI, discussing some pathophysiology mechanisms which could be addressed and pointing toward actual practical concepts in use for evaluation and improvements necessary to sustain SCI patients QOL.     

Sphincter incontinence: Is regenerative medicine the best alternative to restore urinary or anal sphincter function?

Incontinence is a major public health concern in aging societies. It is caused by age-dependent spontaneous apoptosis of muscle cells in the urinary and fecal sphincters, and is aggravated in women due to birth trauma. Compared to other currently employed invasive surgical management techniques associated with morbidity and recurrence, replacement or regeneration of dysfunctional sphincter through stem cell therapy and tissue engineering techniques hold great promise. This review focuses on the pathophysiological analysis of urinary incontinence and the possible application of muscle-derived-stem cells, satellite cells, chondrocytes and adipose-derived-stem cells in restoring sphincter functions.     

Mesenchymal stem cells can improve anal pressures after anal sphincter injury

Objective.Fecal incontinence reduces the quality of life of many women but has no long-term cure. Research on mesenchymal stem cell (MSC)-based therapies has shown promising results. The primary aim of this study was to evaluate functional recovery after treatment with MSCs in two animal models of anal sphincter injury.Methods.Seventy virgin female rats received a sphincterotomy (SP) to model episiotomy, a pudendal nerve crush (PNC) to model the nerve injuries of childbirth, a sham SP, or a sham PNC. Anal sphincter pressures and electromyography (EMG) were recorded after injury but before treatment and 10 days after injury. Twenty-four hours after injury, each animal received either 0.2 ml saline or 2 million MSCs labelled with green fluorescing protein (GFP) suspended in 0.2 ml saline, either intravenously (IV) into the tail vein or intramuscularly (IM) into the anal sphincter.Results.MSCs delivered IV after SP resulted in a significant increase in resting anal sphincter pressure and peak pressure, as well as anal sphincter EMG amplitude and frequency 10 days after injury. MSCs delivered IM after SP resulted in a significant increase in resting anal sphincter pressure and anal sphincter EMG frequency but not amplitude. There was no improvement in anal sphincter pressure or EMG with in animals receiving MSCs after PNC. GFP-labelled cells were not found near the external anal sphincter in MSC-treated animals after SP.Conclusion.MSC treatment resulted in significant improvement in anal pressures after SP but not after PNC, suggesting that MSCs could be utilized to facilitate recovery after anal sphincter injury.     

Midline episiotomy and anal incontinence: retrospective cohort study

ObjectiveTo evaluate the relation between midline episiotomy and postpartum anal incontinence.DesignRetrospective cohort study with three study arms and six months of follow up.SettingUniversity teaching hospital.ParticipantsPrimiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration.ResultsWomen who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour. ConclusionsMidline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.     

Rectoanal reflex in healthy subject

The present work was performed in order to examine the rectoanal reflex in healthy subject. Our findings suggest that the fecal continence is sustained by both the anal sphincters. The maximal anal pressure at rest is governed by activity of the internal sphincter while the external anal sphincter promptly contracts when the rectum is distended.     

Motor unit number estimation and quantitative needle electromyography in stroke patients

ObjectiveTo evaluate the effect of upper motor neuron damage upon motor units’ function by means of two separate and supplementary electrophysiological methods.MethodsThe abductor digiti minimi muscle of the non-paretic and the paretic side was studied in forty-six stroke patients with (a) motor unit number estimation (MUNE) – adapted multiple point stimulation method and (b) computerized quantitative needle electromyography (EMG) assessing the configuration of voluntary recruited motor unit potentials. Main outcome comparisons were focused on differences between non-paretic and paretic side.ResultsOn the affected hands mean MUNE value was significantly lower and mean area of the surface recorded single motor unit potentials was significantly larger than the corresponding ones on the non-paretic hands. EMG findings did not reveal remarkable differences between the two sides. Neither severity nor chronicity of stroke was related to MUNE or EMG parameters.DiscussionMUNE results, which suggested reduced motor unit numbers in stroke patients, in conjunction with the normal EMG features in these same muscles has given rise to different interpretations. In a clinical setting, reinnervation type changes in the EMG similar to that occurring in neuronopathies or axonal neuropathies should not be expected in muscles with central neurogenic lesion.     

Biofeedback for the treatment of anal incontinence in a child with ureterosigmoidostomy

The case of a 7-year-old boy born with exstrophy of the bladder is presented. Biofeedback and behavioral therapy were employed in the treatment of anal incontinence, which occurred following ureterosigmoidostomy diversion. After 19 treatment and follow-up sessions over a period of 12 months, there was significant decrease in fecal/urinary incontinence. The patient was soiled 29% of waking hours over the first 4 weeks of treatment. This figure dropped to 9.7% over the last three sessions. Subjective satisfaction of parent, child, and teachers was high. These gains were maintained over a 12-month follow-up period. Given the design of the present study, it is not possible to determine whether the biofeedback per se had a specific treatment effect. The case demonstrates the usefulness of a broad-based behavior therapy in the management of fecal/urine soiling, which is a frequent, refractory complication of ureterosigmoidostomy.     

Biofeedback for the treatment of anal incontinence in a child with ureterosigmoidostomy

The case of a 7-year-old boy born with exstrophy of the bladder is presented. Biofeedback and behavioral therapy were employed in the treatment of anal incontinence, which occurred following ureterosigmoidostomy diversion. After 19 treatment and follow-up sessions over a period of 12 months, there was significant decrease in fecal/urinary incontinence. The patient was soiled 29% of waking hours over the first 4 weeks of treatment. This figure dropped to 9.7% over the last three sessions. Subjective satisfaction of parent, child, and teachers was high. These gains were maintained over a 12-month follow-up period. Given the design of the present study, it is not possible to determine whether the biofeedback per se had a specific treatment effect. The case demonstrates the usefulness of a broad-based behavior therapy in the management of fecal/urine soiling, which is a frequent, refractory complication of ureterosigmoidostomy.     

Effect of nifedipine on anorectal sensorimotor functions in health and fecal incontinence

The mechanisms of increased rectal stiffness in women with fecal incontinence (FI) and rectal urgency are not understood. Our hypothesis was that distention-induced activation of mechanosensitive L-type calcium channels in smooth muscle contributes to increased rectal stiffness in FI. Anal pressures, rectal distensibility (compliance, capacity, and contractile response to sinusoidal oscillation), and rectal sensation were assessed before and after oral nifedipine (30 + 10 mg) or placebo in 16 women with FI and 16 asymptomatic women. At baseline, FI patients had a lower anal pressure increment during squeeze (health, 66.9 ± 7.6: FI, 28.6 ± 5.9, mean ± SE, P ≤ 0.01), lower rectal capacity (P = 0.052), and higher rectal pressures during sinusoidal oscillation (health, 13.7 ± 3.2: FI, 21.7 ± 1.4, mean ± SE, P = 0.02) than the healthy women, which suggests an exaggerated rectal contractile response to distention. Nifedipine decreased mean BP, increased heart rate (P = 0.01 vs. placebo), and reduced anal resting pressure (P ≤ 0.01) but did not significantly modify rectal distensibility in health or FI. Plasma nifedipine concentrations (health, 103 ± 21 ng/ml: FI, 162 ± 34 ng/ml) were correlated with increased rectal compliance (r = 0.6, P = 0.02) in all study participants and, in healthy subjects, with decreased rectal pressures during sinusoidal oscillation (r = 0.86, P = 0.01), indicative of reduced stiffness. No consistent effects on rectal perception were observed. These observations confirm that FI is associated with anal weakness and increased rectal stiffness. At therapeutic plasma concentrations, nifedipine reduced anal resting pressure but did not improve rectal distensibility in FI, outcomes that argue against a predominant contribution of myogenic L-type calcium channels to reduced rectal distensibility in FI.     

Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair.

OBJECTIVES--To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. DESIGN--(i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements. SETTING--Antenatal clinic in teaching hospital in inner London. SUBJECTS--(i) All women (n = 8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. MAIN OUTCOME MEASURES--Obstetric risk factors, defecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. RESULTS--(i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001), birth weight > 4 kg (P = 0.00002), and occipito-posterior position at delivery (P = 0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P = 0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. CONCLUSIONS--Vacuum extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.     

Automatic localisation of innervation zones: A simulation study of the external anal sphincter

Traumas of the innervation zone (IZ) of the external anal sphincter (EAS), e.g. during delivery, can promote the development of faecal incontinence. Recently developed probes allow high-resolution detection of EMG signals from the EAS. The analysis of pelvic floor muscles by surface EMG (in particular, the estimation of the location of the IZ) has potential applications in the diagnosis and investigation of the mechanisms of incontinence.An automatic method (based on matched filter approach) for the estimation of the IZ distribution of EAS from surface EMG is discussed and tested using an analytical model of generation of EMG signals from sphincter muscles. Simulations are performed varying length of the fibres, thickness of the mucosa, position of the motor units, and force level. Different distributions of IZs are simulated.The performance of the proposed method in the estimation of the IZ distribution is affected by surface MUAP amplitude (as the estimation made by visual inspection), by mucosa thickness (performance decreases when fibre length is higher) and by different MU distributions. However, in general the method is able to identify the position of two IZ locations and can measure asymmetry of the IZ distribution. This strengthens the potential applications of high density surface EMG in the prevention and investigation of incontinence.     

Rectal sensorimotor dysfunction in women with fecal incontinence

The rate and pattern of rectal distension affect rectal distensibility, perception, and anal relaxation in health. Because rectal urgency is a prominent symptom in fecal incontinence (FI), we assessed rectal distensibility, contractions, perception, and anal pressures during rectal distention in 21 healthy, asymptomatic women (age 61 +/- 2 yr, mean +/- SE) and 51 women with FI (60 +/- 2 yr). Rectal staircases (0-32 mmHg, 4-mm steps) and ramp distensions [0-200 ml at 25, 50, and 100 ml/min with a phase of sustained distension (SD), lasting 1 min, between inflation and deflation]. The rectum was stiffer during rapid than slow ramp distention. This effect was more prominent at a lower volume (50 ml) and was also more pronounced in older subjects and in FI. A rectal contractile response was observed not only during inflation but also during SD and during deflation. During inflation, this contractile response was rate dependent in controls but not in FI. During staircase but not ramp distentions, the threshold for the desire to defecate was lower in FI. During ramp distentions, the duration of perception was significantly longer in FI. The rate of distention did not affect rectal perception (i.e., sensory thresholds or duration of perception) during ramp distentions. Baseline anal pressures and the magnitude of anal relaxation during rectal distention were also reduced in FI. In addition to reduced rectal capacity and compliance, women with FI had an exaggerated rate-dependent reduction in rectal distensibility, lower sensory thresholds, and more prolonged perception, indicative of rectoanal dysfunctions.     

Women with stress urinary incontinence demonstrate motor control differences during coughing

IntroductionThis study compared the patterns of pelvic floor muscle (PFM) activity during coughing between women with stress urinary incontinence (SUI) and continent women, using surface electromyography (EMG) and posterior vaginal wall (PVW) pressure.MethodsTwenty-four women participated: eight continent, eight with mild SUI and eight with severe SUI. Volunteers performed three maximum coughs in supine and standing. Maximum PFM EMG and PVW pressure amplitudes and the timing of the EMG peak relative to the PVW pressure peak were determined. Ensemble average PVW pressure versus EMG curves were created.ResultsThere were no significant differences among the groups in the maximum EMG or PVW pressure amplitudes. The EMG and PVW pressure peaked simultaneously in both positions in the continent group. In the mild SUI group, the EMG and PVW pressure peaked simultaneously in supine, but the EMG peaked before the PVW pressure in standing. In the severe SUI group, the EMG peaked before the PVW pressure in both positions. The shapes of the PVW pressure versus EMG curves were similar among the groups and positions, however the SUI groups displayed higher EMG-intercepts than the continent women. Conclusion: These findings suggest that urine leakage during coughing in women with SUI may be related to delays in force generation rather than PFM weakness.     

个体化生物反馈训练联合早期排便功能训练对低位直肠癌保肛术后患者肠道功能、肛肠动力学和生活质量的影响

摘要 目的：探讨个体化生物反馈训练联合早期排便功能训练对低位直肠癌保肛术后患者肠道功能、肛肠动力学和生活质量的影响。方法：纳入我院2018年4月~2021年9月期间收治的90例行低位直肠癌保肛术患者。按照住院号奇偶数将患者分为对照组（早期排便功能训练,45例）和研究组（对照组基础上结合个体化生物反馈训练,45例）。对比两组肠道功能、肛肠动力学和生活质量、肛门失禁情况及控便满意度。结果：两组干预后排便受饮食影响、便频便急、排便感觉异常评分均下降,但研究组高于对照组（P<0.05）。两组干预后健康调查量表简表（SF-36）各维度评分均升高,且研究组高于对照组（P<0.05）。研究组的肛门失禁例数少于对照组,控便满意度则高于对照组（P<0.05）。两组干预后肛管静息压、肛管最大收缩压、直肠最大耐受容量均下降,但研究组高于对照组（P<0.05）。结论：个体化生物反馈训练联合早期排便功能训练可促进低位直肠癌保肛术后患者肠道功能恢复,改善肛肠动力学和生活质量,减少肛门失禁情况发生,控便满意度较好。