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Anal Sphincter (anal + sphincter)
Kinds of Anal Sphincter Terms modified by Anal Sphincter Selected AbstractsClinical trial: effects of botulinum toxin on levator ani syndrome , a double-blind, placebo-controlled studyALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 9 2009S. S. C. RAO Summary Background, Levator ani syndrome is characterized by anorectal discomfort/pain, treatment of which is unsatisfactory. We hypothesized that Botulinum toxin relieves spasm and improves symptoms. Aim, To perform a randomized, placebo-controlled, crossover study to examine the efficacy and safety of botulinum toxin in patients with levator ani syndrome. Methods, Twelve patients with levator ani syndrome (,1 year) received anal intra sphincteric injections of 100 units of botulinum toxin A and placebo at 90-day intervals using EMG guidance. Daily frequency, severity, duration and intensity of pain (VAS) were recorded. Anorectal manometry, balloon expulsion and pudendal nerve latency tests were performed to examine the physiological changes and adverse effects. Results, Seven patients (male/female = 4/3) completed the study and three had incomplete data, but all 10 underwent in an ITT analysis; two others dropped out. After administration of botulinum toxin, the mean frequency, intensity and duration of pain were unchanged (P = 0.31) compared with baseline. The 90-day mean VAS pain score was 6.79 ± 0.27 vs. baseline score of 7.08 ± 0.29 (P = 0.25). Anal sphincter pressures, rectal sensory thresholds, pudendal nerve latency and balloon expulsion times were unchanged after drug or placebo administration. Conclusions, Injection of botulinum toxin into anal sphincter is safe, but it does not improve anorectal pain in levator ani syndrome. [source] Comparison of the contractile properties, oxidative capacities and fibre type profiles of the voluntary sphincters of continence in the ratJOURNAL OF ANATOMY, Issue 3 2010Maria Buffini Abstract The external urethral sphincter (EUS) and external anal sphincter (EAS) are the principal voluntary striated muscles that sustain continence of urine and faeces. In light of their common embryological origin, shared tonic sphincteric action and synchronized electrical activity in vivo, it was expected that they would exhibit similar physiological and structural properties. However, the findings of this study using paired observations of both sphincters isolated from the rat show clearly that this is not the case. The anal sphincter is much more fatigable than the urethral sphincter. On completion of a fatigue protocol, the amplitude of the last twitch of the EAS had declined to 42 ± 3% of the first twitch, whereas the last twitch of the EUS was almost identical to that of the first (95 ± 3%). Immunocytochemical detection of myosin heavy-chain isoforms showed that this difference was not due to the presence of more slow-twitch oxidative type 1 fibres in the EUS compared with the EAS (areal densities 4 ± 1% and 5 ± 1%, respectively; P = 0.35). In addition, the fatigue difference was not explained by a greater contribution to force production by fast oxidative type 2A fibres in the urethral sphincter. In fact, the anal sphincter contained a higher areal density of type 2A fibres (56 ± 5% vs. 37 ± 4% in the EUS, P = 0.017). The higher oxidative capacity of the EUS, measured histochemically, explained its fatigue resistance. These results were surprising because the fatigue-resistant urethral muscle exhibited faster single-twitch contraction times compared with the anal sphincter (56 ± 0.87 ms vs. 72.5 ± 1.16 ms, P < 0.001). Neither sphincter expressed the type 2X myosin isoform but the fast-twitch isoform type 2B was found exclusively in the EUS (areal density 16 ± 2%). The type 2B fibres of the EUS were small (diameter 19.5 ± 0.4 ,m) in comparison to typical type 2B fibres of other muscles. As a whole the EUS is a more oxidative than glycolytic muscle. In conclusion, analysis of the twitch mechanics and fatigue of two sphincters showed that the EUS contained more fatigue-resistant muscle fibres compared with the EAS. [source] Correlation between gross anatomical topography, sectional sheet plastination, microscopic anatomy and endoanal sonography of the anal sphincter complex in human malesJOURNAL OF ANATOMY, Issue 2 2009S. Al-Ali Abstract This study elucidates the structure of the anal sphincter complex (ASC) and correlates the individual layers, namely the external anal sphincter (EAS), conjoint longitudinal muscle (CLM) and internal anal sphincter (IAS), with their ultrasonographic images. Eighteen male cadavers, with an average age of 72 years (range 62,82 years), were used in this study. Multiple methods were used including gross dissection, coronal and axial sheet plastination, different histological staining techniques and endoanal sonography. The EAS was a continuous layer but with different relations, an upper part (corresponding to the deep and superficial parts in the traditional description) and a lower (subcutaneous) part that was located distal to the IAS, and was the only muscle encircling the anal orifice below the IAS. The CLM was a fibro-fatty-muscular layer occupying the intersphincteric space and was continuous superiorly with the longitudinal muscle layer of the rectum. In its middle and lower parts it consisted of collagen and elastic fibres with fatty tissue filling the spaces between the fibrous septa. The IAS was a markedly thickened extension of the terminal circular smooth muscle layer of the rectum and it terminated proximal to the lower part of the EAS. On endoanal sonography, the EAS appeared as an irregular hyperechoic band; CLM was poorly represented by a thin irregular hyperechoic line and IAS was represented by a hypoechoic band. Data on the measurements of the thickness of the ASC layers are presented and vary between dissection and sonographic imaging. The layers of the ASC were precisely identified in situ, in sections, in isolated dissected specimens and the same structures were correlated with their sonographic appearance. The results of the measurements of ASC components in this study on male cadavers were variable, suggesting that these should be used with caution in diagnostic and management settings. [source] The treatment of faecal incontinence following ileostomy takedown after rectal surgery for cancerJOURNAL OF NURSING AND HEALTHCARE OF CHRONIC ILLNE SS: AN INTERNATIONAL INTERDISCIPLINARY JOURNAL, Issue 3 2009Federico Attene MD Aim., The aim of this study was to assess the effectiveness of rehabilitative treatment of the pelvic floor on faecal incontinence after ileostomy take-down. Background., Several conditions can induce surgeons to fashion an excluding ileostomy. In our experience 40% of patients subjected to ileostomy takedown refer faecal incontinence which becomes a chronic condition if not treated. Design., Between 2006 and 2008 we observed fourteen patients with faecal incontinence after ileostomy takedown. Previous manometric assessment of the pelvic floor functionality they underwent rehabilitative treatment by electrostimulation of the anal sphincter. Methods., The rehabilitation program was organised in 10 sessions each of 15 minutes. In each session a double electrode probe was introduced through the anus which is able to conduct electric impulses at a frequency of 75 Hz with an intensity of 15,50 mA and duration of 150 ,s. Results., All patients showed important clinical and manometric improvement. Three patients needed a second rehabilitative treatment with subsequent clinical resolution of faecal incontinence. Conclusions., Improvement in all patients was found although the data are not statistically significant. Consideration of social and psychological implications of treatments is important. Patients need to acquire full control of their body and its functions. Considering that faecal incontinence is a pathology with high social costs it appears necessary to establish an effective and repeatable method of treatment. Electric stimulation seems to be the most adequate tool for this purpose. Relevance to clinical practice., The standardisation of parameters in the treatment protocol of incontinence could allow to extend this therapy to a lot of colo-proctological units. [source] Anal sphincter preservation in locally advanced low rectal adenocarcinoma after preoperative chemoradiation therapy and coloanal anastomosisJOURNAL OF SURGICAL ONCOLOGY, Issue 1 2003Pedro Luna-Pérez MD Background and Objectives Standard treatment of rectal adenocarcinoma located 3,6 cm above anal verge is abdominoperineal resection. The objective was to evaluate feasibility, morbidity, and functional results of anal sphincter preservation after preoperative chemoradiation therapy and coloanal anastomosis in patients with rectal adenocarcinoma located between 3 and 6 cm above the anal verge. Methods This study included 17 males and 15 females with a mean age of 54.8,± 15.4 years. Tumors were located at a mean of 4.7,±,1.1 cm above the anal verge. The mean tumor size was 4.6,±,1.5 cm. All patients received the scheduled treatment. Twenty-two patients underwent coloanal anastomosis with the J pouch; 10 underwent straight anastomosis. Average surgical time was 328.7,±,43.8 min, and the average intraoperative hemorrhage was 471.5,±,363.6 ml. The mean distal surgical margin was 1.3,±,0.6 cm. Five patients (15.6%) received a blood transfusion. Results Major complications included coloanal anastomotic leakage (three); pelvic abscess (three), and coloanal stenosis (two). Tumor stages were as follows: T0,2,N0,M0,=,12; T3,N0,M0,=,9; T1,3,N+,M0,=,9, and T1,3,N0,3,M+,=,2. Diverting stomas were closed in 30 patients. Median follow-up was 25 months. Recurrences occurred in four patients and were local and distant (n,=,1) and distant (n,=,3). Anal sphincter function was perfect (n,=,20), incontinent to gas (n,=,3), occasional minor leak (n,=,2), frequent major soiling (n,=,3), and colostomy (n,=,2). Conclusions In patients with locally advanced rectal cancer located 3,6 cm from anal verge who are traditionally treated with abdominoperineal resection, preservation of anal sphincter after preoperative chemoradiation therapy plus complete rectal excision with coloanal anastomosis is feasible and is associated with acceptable morbidity and no mortality. J. Surg. Oncol. 2003;82:3,9. © 2002 Wiley-Liss, Inc. [source] Clinical trial: effects of botulinum toxin on levator ani syndrome , a double-blind, placebo-controlled studyALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 9 2009S. S. C. RAO Summary Background, Levator ani syndrome is characterized by anorectal discomfort/pain, treatment of which is unsatisfactory. We hypothesized that Botulinum toxin relieves spasm and improves symptoms. Aim, To perform a randomized, placebo-controlled, crossover study to examine the efficacy and safety of botulinum toxin in patients with levator ani syndrome. Methods, Twelve patients with levator ani syndrome (,1 year) received anal intra sphincteric injections of 100 units of botulinum toxin A and placebo at 90-day intervals using EMG guidance. Daily frequency, severity, duration and intensity of pain (VAS) were recorded. Anorectal manometry, balloon expulsion and pudendal nerve latency tests were performed to examine the physiological changes and adverse effects. Results, Seven patients (male/female = 4/3) completed the study and three had incomplete data, but all 10 underwent in an ITT analysis; two others dropped out. After administration of botulinum toxin, the mean frequency, intensity and duration of pain were unchanged (P = 0.31) compared with baseline. The 90-day mean VAS pain score was 6.79 ± 0.27 vs. baseline score of 7.08 ± 0.29 (P = 0.25). Anal sphincter pressures, rectal sensory thresholds, pudendal nerve latency and balloon expulsion times were unchanged after drug or placebo administration. Conclusions, Injection of botulinum toxin into anal sphincter is safe, but it does not improve anorectal pain in levator ani syndrome. [source] The pharmacology of the internal anal sphincter and new treatments of ano-rectal disordersALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 7 2001T. A. Cook Surgical options for faecal incontinence in the presence of intact sphincters are limited. Furthermore, in patients with fissures, lateral sphincterotomy reduces anal sphincter hypertonia but there has been concern about complications. A greater understanding of the basic pharmacology of the internal anal sphincter has led to the development of novel treatments for both these disorders. A Medline review was undertaken for internal anal sphincter pharmacology, anal fissures and faecal incontinence. This review is based on these articles and those found by further cross-referencing. ,Nitric oxide released from non-adrenergic non-cholinergic nerves is the main inhibitory agent in the internal anal sphincter. Relaxations are also mediated through ,-adrenoceptors and muscarinic receptors. Stimulation of ,-receptors results in contraction. Calcium and its entry through L -type calcium channels is important for the maintenance of tone. Nitric oxide donors produce reductions in resting anal tone and heal fissures but are associated with side-effects. Muscarinic agents and calcium channel antagonists show promise as low side-effect alternatives. Botulinum toxin appears more efficacious than other agents in healing fissures. To date, ,-receptor agonists have been disappointing at improving incontinence. Further understanding of the pharmacology of the internal anal sphincter may permit the development of new agents to selectively target the tissue with greater efficacy and fewer side-effects. [source] Neurophysiological testing in anorectal disordersMUSCLE AND NERVE, Issue 3 2006Jean-Pascal Lefaucheur MD, PhDArticle first published online: 15 JUL 200 Abstract The neurophysiological techniques currently available to evaluate anorectal disorders include concentric needle electromyography (EMG) of the external anal sphincter, anal nerve terminal motor latency (TML) measurement in response to transrectal electrical stimulation or sacral magnetic stimulation, motor evoked potentials (MEPs) of the anal sphincter to transcranial magnetic cortical stimulation, cortical recording of somatosensory evoked potentials (SEPs) to anal nerve stimulation, quantification of electrical or thermal sensory thresholds (QSTs) within the anal canal, sacral anal reflex (SAR) latency measurement in response to pudendal nerve or perianal stimulation, and perianal recording of sympathetic skin responses (SSRs). In most cases, a comprehensive approach using several tests is helpful for diagnosis: needle EMG signs of sphincter denervation or prolonged TML give evidence for anal motor nerve lesion; SEP/QST or SSR abnormalities can suggest sensory or autonomic neuropathy; and in the absence of peripheral nerve disorder, MEPs, SEPs, SSRs, and SARs can assist in demonstrating and localizing spinal or supraspinal disease. Such techniques are complementary to other methods of investigation, such as pelvic floor imaging and anorectal manometry, to establish the diagnosis and guide therapeutic management of neurogenic anorectal disorders. Muscle Nerve, 2005 [source] Standardization of anal sphincter electromyography: Utility of motor unit potential parametersMUSCLE AND NERVE, Issue 7 2001Simon Podnar MD Abstract Advanced electromyography systems offer quantitative analysis of a number of motor unit potential (MUP) parameters. However, only limited data are available on the diagnostic usefulness of these parameters. In the present study, we compared the sensitivities of MUP parameters in revealing "neuropathic" changes in the external anal sphincter (EAS) muscles in 56 patients examined 5,240 months after damage to the cauda equina or conus medullaris. Using multi-MUP analysis, 20 MUPs were obtained from patients' EAS muscles. Their MUP parameters were compared with normative data from 64 controls. The diagnostic sensitivities of mean values/"outliers" of MUP parameters for detecting neuropathic EAS muscles were calculated (area 25%/30%; number of turns 18%/29%; size index 13%/24%; thickness 18%/18%; amplitude 17%/17%; spike duration 20%/9%; duration 15%/12%; number of phases 15%/11%; and their combination 51%/52%). Altogether, the cumulative sensitivity of multi-MUP analysis using both mean values and "outliers" was 62%. The combination of MUP parameters improves the diagnostic yield of MUP analysis, but the influence on specificity remains unknown. © 2001 John Wiley & Sons, Inc. Muscle Nerve 24: 946,951, 2001 [source] Endothelin A receptors mediate relaxation of guinea pig internal anal sphincter through cGMP pathwayNEUROGASTROENTEROLOGY & MOTILITY, Issue 9 2010S.-c. Huang Abstract Background, Endothelin (ET) modulates motility of the internal anal sphincter through unclear receptor subtypes. Methods, We measured relaxation of guinea pig internal anal sphincter strips caused by ET-related peptides and binding of 125I-ET-1 to cell membranes prepared from the internal anal sphincter muscle. Visualization of 125I-ET-1 binding sites in tissue was performed by autoradiography. Key Results , In the guinea pig internal anal sphincter, ET-1 caused a marked relaxation insensitive to tetrodotoxin, atropine, or ,-conotoxin GVIA. ET-2 was as potent as ET-1. ET-3 caused a mild relaxation. The relative potencies for ETs to cause relaxation were ET-1 = ET-2 > ET-3. The ET-1-induced relaxation was inhibited by BQ-123, an ETA antagonist, but not by BQ-788, an ETB antagonist. These indicate that ETA receptors mediate the relaxation. The relaxant response of ET-1 was attenuated by LY 83583, KT 5823, Rp-8CPT-cGMPS, tetraethyl ammonium, 4-aminopyridine and N(omega)-nitro-l-arginine, but not significantly affected by NG -nitro-l-arginine methyl ester, NG -methyl-l-arginine, charybdotoxin, apamin, KT 5720, and Rp-cAMPS. These suggest the involvement of cyclic guanosine 3,,5,-cyclic monophosphate (cGMP), and potassium channels. Autoradiography localized 125I-ET-1 binding to the internal anal sphincter. Binding of 125I-ET-1 to the cell membranes prepared from the internal anal sphincter revealed the presence of two subtypes of ET receptors, ETA and ETB receptors. Conclusions & Inferences, Taken together, these results demonstrate that ETA receptors mediate relaxation of guinea pig internal anal sphincter through the cGMP pathway. [source] Supraspinal control of external anal sphincter motility: effects of vesical distension in humans and catsNEUROGASTROENTEROLOGY & MOTILITY, Issue 11 2006V. Vitton Abstract, A pontine centre located near the micturition centre controlling external anal sphincter (EAS) motility via noradrenergic neurones has been described in cats. The aim of this study was to determine (i) whether a similar centre controls EAS motility in humans and (ii) whether this centre is involved in vesico-sphincteric reflexes in cats and humans. The effects of an alpha-1-adrenoceptor antagonist (nicergoline) and those of vesical distension on the electrical activity of the EAS were studied in paraplegic and non-paraplegic volunteers. The effects of vesical distension by injecting saline at physiological levels on the responses of the EAS to pudendal nerve stimulation were investigated in intact cats and cats with nerve sections. In non-paraplegic subjects, nicergoline and vesical distension abolished the activity of the EAS. These effects were no longer observed in paraplegic patients. In cats, vesical distension inhibited the reflex response of the EAS to pudendal nerve stimulation. This vesico-sphincteric reflex, which was no longer observed in spinal animals, persisted after nicergoline injection. These findings indicate that in humans, there exists a supra-spinal centre facilitating the tonic activity of the EAS via noradrenergic neurones not involved in the inhibitory vesico-sphincteric reflex. [source] Ano-rectal motility responses to pelvic, hypogastric and pudendal nerve stimulation in the Göttingen minipigNEUROGASTROENTEROLOGY & MOTILITY, Issue 2 2006I. S. Andersen Abstract, We investigated the effect of efferent stimulation of the pelvic (PN), hypogastric (HGN) and pudendal (PuN) nerves on ano-rectal motility in Göttingen minipigs using an impedance planimetry probe. Changes in the rectal cross-sectional area (CSA) at five axial positions and pressures in the rectum and anal canal were investigated simultaneously. Pelvic nerve stimulation elicited a CSA decrease in the proximal part of the rectum and a simultaneous CSA increase in its distal part. Anal pressure also decreased. Hypogastric nerve and PuN stimulation elicited an increase in anal pressure, but no rectal response. Severing the HGN produced a persistent reduction in resting anal pressure, but no change was observed when the PN and the PuN were severed. Stimulation of the distal part of all three nerves produced a persistent response. Administration of phentolamine and pancouronium eliminated the response to stimulation of the HGN and the PuN, respectively. Conclusion:, Rectal responses to PN stimulation vary more than previously suggested. The HGN has an excitatory effect on the internal anal sphincter, and the PuN on the external anal sphincter. However, the PuN plays no major role in maintaining basal anal pressure. [source] Selective block of external anal sphincter activation during electrical stimulation of the sacral anterior roots in a canine modelNEUROGASTROENTEROLOGY & MOTILITY, Issue 5 2005N. Bhadra Abstract, Our aim was to electrically activate small diameter parasympathetic fibres in the sacral anterior roots, without activating the larger somatic fibres to the external anal sphincter (EAS). Electrodes were implanted on selected roots in five adult dogs. Pressures were recorded from the rectum and EAS. Quasitrapezoidal (Qzt) pulses for selective activation of smaller axons and narrow rectangular (Rct) pulses to activate all fibres were applied. Sphincter block was defined as [(Pmax , Pmin)/Pmax] × 100%. Roots were also tested with 20 Hz trains. In three animals, evacuation of bowel contents was recorded with artificial fecal material. Stimulation with Qzt pulses showed decrease in sphincter recruitment with increasing pulse amplitudes, indicating propagation arrest in the large fibres. The average sphincter suppression was 94.1% in 16 roots implanted. With Qzt pulse trains, the average evoked sphincter pressure was significantly lower than Rct pulses. Evoked rectal pressures were not significantly different. The mean mass of expelled bowel contents of 51.1 g by Qzt trains was significantly higher than that of 14.8 g expelled by Rct trains. Our results demonstrate that this selective stimuli can activate small diameter fibres innervating the distal bowel and result in significant evacuation of rectal contents. [source] Pudendal nerve stimulation evokes reflex bladder contractions in persons with chronic spinal cord injury,,NEUROUROLOGY AND URODYNAMICS, Issue 7 2007Paul B. Yoo Abstract Aims Although electrical stimulation of the pudendal nerve has been shown to evoke reflex micturition-like bladder contractions in both intact and spinalized cats, there is little evidence to suggest that an analogous excitatory reflex exists in humans, particularly those with spinal cord injury (SCI). We present two cases where electrical activation of pudendal nerve afferents was used to evoke excitatory bladder responses. Subjects and Methods A percutaneously placed catheter electrode was used to electrically stimulate the pudendal nerve trunk in two males with SCI. The response was quantified with recorded changes in detrusor pressure and EMG activity of the external anal sphincter. Results In both individuals, frequency specific (f,=,20,50 Hz) activation of the pudendal nerve trunk evoked excitatory bladder contractions that also depended on the stimulus amplitude and bladder volume. Conclusion The results suggest that selective activation of the perineal branches of the pudendal nerve may further augment the excitatory reflex evoked by electrical stimulation. Neurourol. Urodynam. 26:1020,1023, 2007. © 2007 Wiley-Liss, Inc. [source] Asymmetric sphincter innervation is associated with fecal incontinence after anal sphincter trauma during childbirthNEUROUROLOGY AND URODYNAMICS, Issue 1 2007Beate M. Wietek Abstract Aims Functional asymmetry of pelvic floor innervation has been shown to exist in healthy subjects, and has been proposed to be a predictor of increased risk for fecal incontinence in case of trauma. However, this remains to be shown for different clinical conditions such as traumatic childbirth. Methods A conventional surface EMG system was used to assess the innervation of the external anal sphincter. A symmetry index was used to define the relative EMG amplitude asymmetry of the external anal sphincter between 0 (symmetric) and 1 (asymmetric). Three cohorts were studied: 40 nulliparous women in the third trimester (Study 1), 15 primiparous women within 6 months following vaginal delivery without clinically apparent anal sphincter trauma (Study 2), and 50 women after childbirth-related third or fourth degree perineal tear 6,12 months postpartum (Study 3). Furthermore, all women underwent conventional anorectal manometry. Results Sixteen or forty nulliparous women reported signs of fecal incontinence; however, relative asymmetry was not correlated to symptom severity (P,=,0.345), and not to manometric measures (Study 1). In Study 2, Women who had suffered clinically apparent anal sphincter trauma (P,=,0.07) tended to have a stronger association between incontinence and asymmetry. In Study 3, 19/50 women reported moderate to severe incontinence. Asymmetry and symptom severity were significantly correlated (P,<,0.001). Patients with incontinence had a significantly higher asymmetry score than their continent counterparts. Conclusion Functional asymmetry of anal sphincter innervation is significantly associated with incontinence symptoms, but only after childbirth-related sphincter injuries and therefore, should be regarded as an additional risk factor. Neurourol. Urodynam. © 2006 Wiley-Liss, Inc. [source] External anal sphincter contraction during cough: Not a simple spinal reflex,NEUROUROLOGY AND URODYNAMICS, Issue 7 2006Xavier Deffieux Abstract Aims: To assess whether the anal contraction during voluntary coughing is a simple spinal reflex-mediated activity or not. To address this question we studied the external intercostal (EIC) muscle activity and external anal sphincter (EAS) response to cough. Materials and Methods: Electromyographic recordings were made from pre-gelled disposable surface electrodes. EAS electromyographic recordings were made from the EAS of the pelvic floor in 15 continent women all suffering from urgency and/or frequency without urge or stress urinary incontinence, and referred for urodynamic investigation. Electromyographic signal was immediately integrated (EMGi). The abdominal pressure was recorded with bladder and rectal pressure. EAS EMGi was recorded during successive voluntary cough. In three women, we have also recorded EIC EMGi activity since it is synchronous with diaphragmatic EMG activity during cough initiation. Results: In all subjects, EAS EMGi activity precedes the onset of the abdominal pressure increase. The mean latency of EAS EMGi was 615 msec (±278). In the three subjects whose EMGi activity was recorded both on EAS and EIC, the onset of EAS EMGi activity occurred before the EIC EMGi activity (latency ranging from 40 to 780 msec) and before the increase in the abdominal pressure. Conclusions: The present study suggests that during coughing, EAS EMG activity increases before external intercostal muscle EMGi activity. The contraction of the EAS preceding the activation of muscles involved in coughing indicates that this response is not a result of a simple spinal reflex, but more likely the result of a more intricate reflex involving complex integrative centers. Neurourol. Urodynam. 25:782,787, 2006. © 2006 Wiley-Liss, Inc. [source] External anal sphincter responses after S3 spinal root surface electrical stimulationNEUROUROLOGY AND URODYNAMICS, Issue 7 2006Giuseppe Pelliccioni Abstract Aims The aim of this study is to present the normative data of direct and reflex motor anal sphincter responses, simultaneously evoked by S3 surface electrical stimulation. By this method, it is possible to test the functional integrity of the nervous pathways activated during sacral neuromodulation (SNM). Methods Twenty healthy subjects were studied. Motor-evoked potentials (MEPs) were recorded by concentric needle electrode from external anal sphincter (EAS). Electrical stimulation was applied by means of a bipolar surface electrode over the S3 right or left sacral foramina. Results Direct (R1) and reflex responses (R2 and R3) were found at latencies of 6.98, 25.12, and 50.31 msec, respectively. The two first responses were recorded in all the cases; the last response is steadily recorded in 17 out of 20 subjects. Conclusions Our data can serve as reference values for future study in patients with pelvic floor dysfunction. EAS responses following S3 percutaneous electrical stimulation can represent a useful aid in the selection of candidates to SNM. Neurourol. Urodynam. 25:788,791, 2006. © 2006 Wiley-Liss, Inc. [source] Protocol for clinical neurophysiologic examination of the pelvic floorNEUROUROLOGY AND URODYNAMICS, Issue 6 2001Simon Podnar Abstract Clinical neurophysiologic examination of the pelvic floor is performed worldwide, but there is no consensus on the choice of tests, nor on technical details of individual methods. Standardized methods are, however, necessary to obtain their valid application in different laboratories for the purpose of collection of normative data, comparison of patient data and organization of multi-center studies. It is proposed that in patients with suspected "lower motor neuron" type lesions concentric needle electromyography (CNEMG) is the most informative test to detect pelvic floor denervation/reinnervation, and the external anal sphincter (EAS) muscle is the most appropriate muscle to be examined (either in isolation,when a selective lesion is suspected,or in addition to examination of other muscles). An algorithm consisting of standardized tests including a standardized approach to CNEMG examination of the EAS is presented. The proposed electrophysiologic assessment consists of a computer-assisted analysis of denervation and reinnervation features of the CNEMG signal, a qualitative assessment of reflex and voluntary activation of EAS motor units, and of electrical (or mechanical) elicitation of the bulbocavernosus reflex in those patients in whom manual anogenital stimulation failed to elicit a robust response in the EAS. The proposed protocol could serve as a basis for further studies on validity, sensitivity and specificity of electrophysiologic assessment in patients with different types of "lower motor neuron" involvement of pelvic floor muscles and sacral dysfunction. Neurourol. Urodynam. 20:669,682, 2001. © 2001 Wiley-Liss, Inc. [source] Implantation of ethylene vinyl alcohol copolymer for faecal incontinence managementANZ JOURNAL OF SURGERY, Issue 5 2010Jacqueline H. Stephens Abstract Purpose:, The primary objectives of this trial were to evaluate the safety and feasibility of treatment and to gain a preliminary indication of the effectiveness of ethylene vinyl alcohol injections into the anal sphincters of faecally incontinent patients. Methods:, Between April 2004 and February 2006, we conducted a prospective, single-arm, procedure optimization study of ethylene vinyl alcohol injections in 21 subjects with well-characterized faecal incontinence and an intact external anal sphincter at two Australian hospitals. Results:, There was a significant decrease in the Cleveland Clinic Florida Faecal Incontinence Score (CCFFIS) (P= 0.0005) and the Faecal Incontinence Severity Index score (P= 0.005) after treatment. At 12 months post-treatment, the mean CCFFIS had decreased by 37% (P= 0.0021), and 47% of subjects had a ,50% improvement in CCFFIS. There were significant improvements in embarrassment (P= 0.0455) and coping/behaviour (P= 0.0056) domains of the Faecal Incontinence Quality of Life. At 12 months, the mean anal canal length had increased by 29% (P= 0.066), with 40% of patients demonstrating increases of 50% or more. There were no further improvements following retreatment. Conclusions:, Ethylene vinyl alcohol injection into the anal intersphincteric plane is feasible and well tolerated. Improvement in faecal incontinence compared with baseline was seen. Retreating initial non-responders was not successful. [source] Faecal incontinence after lateral internal sphincterotomy is often associated with coexisting occult sphincter defects: A study using endoanal ultrasonographyANZ JOURNAL OF SURGERY, Issue 10 2001Joe J. Tjandra Background: Troublesome faecal incontinence following a lateral internal sphincterotomy (LIS) is often attributed to faulty surgical techniques: division of excessive amount of internal sphincter or inadvertent injury to the external sphincter. The aim of the present paper was to assess the anatomic and physiological factors that may contribute to faecal incontinence following a technically satisfactory lateral internal sphincterotomy by a group of colorectal specialists. Methods: Fourteen patients (nine women, five men; median age: 38 years; range: 23,52 years) who developed troublesome postoperative faecal incontinence were evaluated by clinical assessment, endoanal ultrasonography and anorectal physiological studies (manometry, pudendal nerve terminal motor latency) by two independent observers. The Cleveland Clinic continence score (0,20; 0, perfect continence; 20, complete incontinence) was used to quantify the severity of faecal incontinence. Fourteen continent subjects after a LIS (nine female patients, five male patients; median age: 36 years; range: 20,44 years) were also evaluated as ,continent' controls (continence score , 4). Results: In the incontinent group, the median postoperative Cleveland Clinic continence score was 9 (range: 6,13) compared with a preoperative score of 1 (range: 0,3). On assessment by endoanal ultrasonography the site of the internal sphincterotomy was clearly identified. There were additional coexisting defects, on endoanal ultrasonography, of the external anal sphincter in seven female patients, of the internal sphincter in two female and two male patients; and a defect of both the external and internal sphincters in a male patient who had had a prior fistulotomy. The pudendal nerve terminal motor latency (PNTML) was prolonged in two female patients on the side contralateral to the lateral internal sphincterotomy. In two of five male patients there was no evidence of any occult sphincter injuries. In the continent controls a defect of the distal portion of the external sphincter was noted in one female patient. None of the patients had a prolonged PNTML. The maximum voluntary contraction was significantly lower in the female subjects than in the female continent controls (92 mmHg vs 140 mmHg; P < 0.05), while the resting anal canal pressures and length of the high pressure zone were similar between the study subjects and the continent controls. Conclusion: Troublesome faecal incontinence after a satisfactorily performed lateral internal sphincterotomy is often associated with coexisting occult sphincter defects. [source] The anatomy of the perineal membrane: its relationship to injury in childbirth and episiotomyAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 2 2002Christopher N Hudson ABSTRACT Background Episiotomy during childbirth, intended to protect the anal sphincter, may fail to do so. Furthermore damage to the anal sphincter complex may occur without complete perineal tear. We hypothesise that these particular injuries may occur due to posterior displacement of the anus leading to distraction of the anal sphincter complex from an anterior attachment to the perineal membrane. However, the anatomical basis for this has not been well defined. Objective To investigate the relationship between the anal sphincter and the perineal membrane. Materials and methods High-resolution MRI scans of a female cadaver perineum were performed. The imaging findings were correlated with the anatomical structure identified on dissection and histological examination. Results The perineal membrane was easily identified on MR imaging. Fibres from the perineal membrane could be seen to attach to the anal sphincter complex at the apex of the perineal body. This was confirmed on histological examination and was a deeper layer than that of the decussation of the superficial transverse perineal muscle with the superficial part of the external anal sphincter. Conclusion The upper ano-rectal canal and apex of the perineal body have demonstrable attachment to the free margin of the perineal membrane postero-lateral to the lower vagina. This attachment would resist posterior displacement of the anal canal. [source] Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasoundBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 6 2008GE Fowler Objective, To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter. Design, A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed. Methods, To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans. Main outcome measures, Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A,E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations. Conclusions, LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms. [source] A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continenceBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 12 2002Myra Fitzpatrick Objective To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function. Design Prospective, randomised, controlled trial. Setting Tertiary referral maternity teaching hospital. Population One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing. Methods A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound. Main outcome measures Mode of delivery; altered faecal continence. Results Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group (P= 0.005). Eighty-four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty-one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies. Conclusions Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing. [source] Assessment of third degree tears using three-dimensional anal endosonography with combined anal manometry: a novel techniqueBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 7 2002A.B. Williams Three-dimensional anal endosonography has enabled sagittal and coronal reconstructions of the anal canal to be matched with longitudinal pressure data, to present a combined picture of structure and function. This novel technique has been applied to a group of women with a clinical diagnosis of a third degree tear. Endosonography showed that only 68% of women had ultrasound evidence of sphincter damage. Anal canal anatomy and pressure profile did not differ significantly between those with and those without sphincter damage, but the anterior external anal sphincter and the puborectalis tended to be shorter and the pressures were lower in those with sphincter disruption. [source] Anal sphincter EMG in the diagnosis of parkinsonian syndromesACTA NEUROLOGICA SCANDINAVICA, Issue 3 2010K. Winge Winge K, Jennum P, Lokkegaard A, Werdelin L. Anal sphincter EMG in the diagnosis of parkinsonian syndromes. Acta Neurol Scand: 2010: 121: 198,203. © 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Background,,, The role of electromyography (EMG) recorded from the external anal sphincter (EAS) in the diagnosis of atypical parkinsonian syndromes is a matter for continuous debate. Most studies addressing this issue are retrospective. Methods,,, In this study, we prospectively investigated six patients with Parkinson's Disease (IPD), 14 patients with multiple system atrophy (MSA) and eight with progressive supranuclear palsy (PSP) using EMG of the EAS, motor-evoked potential (MEP) to the EAS and EMG of m. gastrocnemius and nerve conduction velocity measured at the sural nerve. Patients were followed up for 2 years to secure correct diagnosis. Results,,, The mean duration of motor unit potentials (MUPs) recorded from the EAS was significantly longer in patients with MSA and PSP compared with MUPs recorded from patients with PD (P < 0.005 for both). There were no signs of diffuse loss of motor neurons or peripheral neuropathy. MEP revealed signs of supranuclear affection in patients with MSA, whereas in patients with PSP the mechanism is a focal loss of motor neurons in Onuf's nucleus. Conclusion,,, Abnormal EMG of the EAS is strongly suggestive of atypical parkinsonism and the pathophysiology may be different in patients with MSA and PSP. [source] Contribution of the pudendal nerve to sensation of the distal rectumBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 7 2005C. L. H. Chan Background: Anal and rectal sensory mechanisms and pudendal nerve function are important in the control of faecal continence. The contribution of the pudendal nerve to sensation of the distal rectum was investigated. Methods: Heat thresholds in the anal canal, distal and mid rectum were measured using a specially designed thermoprobe. Rectal sensory threshold volumes were measured using the balloon distension method. Needle electrodes were inserted into the external anal sphincter. Pudendal nerve block was performed through a perineal approach, and completeness assessed by loss of electromyographic activity. Heat and rectal volume thresholds were measured again following unilateral and bilateral pudendal nerve block. Results: The technique was successful in four of six volunteers. Bilateral pudendal nerve block produced complete anaesthesia to heat in the anal canal (P = 0·029), but had no effect on heat thresholds in the distal or mid rectum. Rectal sensory threshold volumes were also unaffected by pudendal nerve anaesthesia. Conclusion: Anal canal sensation is subserved by the pudendal nerve, but this nerve is not essential to nociceptive sensory mechanisms in the distal or mid rectum. The transition between visceral control mechanisms in the lower rectum and somatic mechanisms in the anal canal may have functional importance in the initiation of defaecation and the maintenance of continence. Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2004G. I. Vorobiev Background: Intersphincteric resection can provide tumour-free margins for rectal tumours located 0,1 cm above the dentate line. However, the internal anal sphincter (IAS) is partially or totally resected and some degree of anal incontinence may develop. A novel technique of smooth muscle plasty of the IAS and colonic pouch construction is described, along with an assessment of morbidity, oncological results and functional outcome. Patients and methods: Between 1997 and 2002, 27 patients (16 men; median age 55 (range 26,75) years) were operated on for T2,3 N0,1 M0 rectal carcinoma located a median of 1·0 (range 0·5,1·5) cm from the dentate line. Resection of the IAS was performed transanally. A smooth muscle cuff, fashioned from the muscular layer of colon, and a colonic pouch were used for anorectal reconstruction. Results: There were no perioperative deaths. Anastomotic leakage developed in two patients. After a median follow-up of 38 (range 14,66) months no local recurrence was detected. Distant metastases occurred in three patients, two of whom died. Perfect functional outcome was achieved in 22 of 26 patients. At 6 months after surgery the mean(s.d.) resting anal pressure was 49(8) mmHg. Conclusion: In selected patients intersphincteric resection does not compromise the oncological result. The suggested anorectal reconstruction may improve the functional outcome. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Complications and functional outcome following artificial anal sphincter implantation,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 7 2002Dr H. Ortiz Background: The postoperative complications and functional outcome following 24 consecutive implantations of an artificial anal sphincter were assessed prospectively. Methods: A total of 24 artificial anal sphincters (Acticon Neosphincter®) were implanted in 22 patients (mean age 47 years). The mean follow-up period was 28 (range 6,48) months. Results were assessed prospectively by two independent observers at 4-month intervals. The cumulative probability of artificial anal sphincter removal was analysed by the Kaplan,Meier method. Results: Five patients were free of complications. During the postoperative period, complications occurred in nine patients, two of whom required reoperation. During follow-up, complications developed in ten patients, nine of whom were reoperated. Definitive device explantation was necessary in seven patients. The cumulative probability of device explantation was 44 per cent at 48 months. The 15 patients with functioning implants were followed up for a mean of 26 (range 7,48) months. Continence grading improved from a mean of 18 (range 14,20) in the preoperative period to 4 (range 0,14) after operation (P < 0·001). Resting anal canal pressure in patients with a functioning implant increased from a mean of 35 (range 8,87) mmHg before operation to 54 (range 34,70) mmHg after implantation (P < 0·01). Conclusion: An artificial anal sphincter is a useful alternative for refractory faecal incontinence but the incidence of late postoperative complications is high. © 2002 British Journal of Surgery Society Ltd [source] Multicentre retrospective analysis of the outcome of artificial anal sphincter implantation for severe faecal incontinenceBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2001Dr D. F. Altomare Background: A new prosthetic device, the ActiconTM artificial anal sphincter, has recently been introduced for treating severe faecal incontinence. The results of this procedure in 28 patients are presented. Methods: The patients underwent operation for severe faecal incontinence in four Italian university hospitals and patients were reviewed after a median follow-up of 19 (range 7,41) months. Results: Early infections occurred in four patients, requiring removal of the device in three. Dehiscence of the perineal wound occurred in nine patients. After activation of the device, the cuff had to be removed in a further four patients (for rectal erosion in two, anal pain in one and late infection in one). The cuff was accidentally broken in one patient. A new anal cuff was repositioned successfully in two patients. Overall, five patients had complete removal of the device and two removal of the cuff only. Twenty-one patients available for long-term evaluation had a major improvement in faecal continence. Median resting anal pressure increased from 27 mmHg before surgery to 32 mmHg after operation. Preoperative squeeze pressure was 42 mmHg while maximum postoperative anal pressure with the activated device was 67 mmHg. The median American Medical System incontinence score decreased significantly from 98·5 to 5·5 (P < 0·001). Similar figures were observed using the Continence Grading Scale (from 14·9 to 2·6; P < 0·001). Twelve patients developed symptoms of obstructed defaecation while two patients complained of anal pain. Conclusion: Improved continence was achieved after neosphincter implantation in three-quarters of the patients. Early infection and rectal erosion, together with difficulty in evacuating, are still major concerns with this technique. © 2001 British Journal of Surgery Society Ltd [source] Long-term effects of stapled haemorrhoidectomy on internal anal function and sensitivity,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2001Dr D. F. Altomare Background: Stapled haemorrhoidectomy is gaining wide acceptance but there is still some concern about the risk of injury to the internal anal sphincter (IAS). IAS function and morphology, and anal canal sensitivity were studied prospectively in patients undergoing this operation. Methods: Twenty patients (11 women; mean age 43 years) with stage III haemorrhoids entered the study. All underwent preoperative anorectal manometry, rectoanal inhibitory reflex (RAIR) testing and three-dimensional transanal ultrasonography. A test of anal sensation was administered to evaluate ability to discriminate between air and warm water. All the investigations were repeated 6 months after the operation. Results: The mean(s.d.) maximal resting pressure was 87(30) mmHg before surgery and 81(20) mmHg afterwards (P not significant). The maximal squeeze pressure did not change after operation (178(43) versus 174(60) mmHg). The RAIR showed the same features in 19 of 20 patients before and 18 of 20 after operation. Three-dimensional ultrasonography demonstrated no changes in the width of the IAS (mean(s.d.) 2·1(4) mm before and 2·1(3) mm after surgery). The ability of the anal mucosa to discriminate air from warm water improved in five patients. Continence scores did not differ significantly after 6 months. Conclusion: Stapled haemorrhoidectomy does not affect the function and morphology of the IAS in the long term. The sensitivity of the anal canal can improve in patients with preoperative sensory impairment. © 2001 British Journal of Surgery Society Ltd [source] | ||||||||||||||||||||||||||||