Relationship between anal functional lumen imaging probe (EndoFLIP®) results and the clinical presentation of faecal incontinence.

AIM: Faecal incontinence (FI) subtypes (urge, passive, mixed) are linked to the physiopathological mechanism of FI. Previous studies have failed to demonstrate a consistent relationship between FI subtype and anal sphincter dysfunction. Our aim was to evaluate the relationship between anal sphincter function, assessed using the new EndoFLIP® technology, and FI subtype. METHOD: Patients referred for FI were prospectively enrolled between October 2015 and May 2021 in a registry, and data were retrospectively examined. Each patient underwent a clinical assessment as well as three-dimensional high-resolution or water-perfused anorectal manometry, anal EndoFLIP®, and anorectal electrophysiological and endoanal ultrasound tests. The results of the investigations were compared across FI subtypes. RESULTS: The cohort included 133 patients, 54 (41%) of whom met the criteria for urge FI, 40 (30%) for passive FI and 39 (29%) for mixed FI. The resting anal distensibility index (DI) at 50 ml of distension was significantly lower in patients with urge FI than in patients with passive FI (p = 0.04). At rest, a DI at 50 ml of distension ≥7.3 mm2  mmHg-1 and a DI at 40 ml of distension <1.3 mm2  mmHg-1 were associated with the passive and urge FI subtypes, respectively, with poor discriminatory power (an accuracy of 0.49 compared with 0.33 for random assignment). There were no differences in anorectal manometry, endoanal ultrasound or electrophysiological test results among the urge, passive and mixed FI subgroups (all p > 0.05). CONCLUSION: The anal sphincter DI using the EndoFLIP® system displayed poor predictive performance in distinguishing among FI subtypes.

Interstitial cells of Cajal and human colon motility in health and disease.

Our understanding of human colonic motility, and autonomic reflexes that generate motor patterns, has increased markedly through high-resolution manometry. Details of the motor patterns are emerging related to frequency and propagation characteristics that allow linkage to interstitial cells of Cajal (ICC) networks. In studies on colonic motor dysfunction requiring surgery, ICC are almost always abnormal or significantly reduced. However, there are still gaps in our knowledge about the role of ICC in the control of colonic motility and there is little understanding of a mechanistic link between ICC abnormalities and colonic motor dysfunction. This review will outline the various ICC networks in the human colon and their proven and likely associations with the enteric and extrinsic autonomic nervous systems. Based on our extensive knowledge of the role of ICC in the control of gastrointestinal motility of animal models and the human stomach and small intestine, we propose how ICC networks are underlying the motor patterns of the human colon. The role of ICC will be reviewed in the autonomic neural reflexes that evoke essential motor patterns for transit and defecation. Mechanisms underlying ICC injury, maintenance, and repair will be discussed. Hypotheses are formulated as to how ICC dysfunction can lead to motor abnormalities in slow transit constipation, chronic idiopathic pseudo-obstruction, Hirschsprung's disease, fecal incontinence, diverticular disease, and inflammatory conditions. Recent studies on ICC repair after injury hold promise for future therapies.

Location of obstetric anal sphincter injury scars on translabial tomographic ultrasound.

OBJECTIVE: Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing to the absence of effective clinical audit. The aim of this study was to evaluate the location of scars or defects of the external anal sphincter (EAS), diagnosed by translabial ultrasound (TLUS), following primary OASI repair. METHODS: This was a retrospective analysis of 309 women who were seen at a tertiary obstetric unit after primary repair of OASI between June 2012 and May 2019. All women underwent a standardized interview, including St Mark's incontinence score, followed by clinical examination and TLUS assessment within 2-9 months after OASI repair. Postprocessing of TLUS volume datasets was performed by an investigator who was blinded to all other information. Tomographic ultrasound imaging was used to evaluate the presence of a scar or defect in the proximal and distal parts of the EAS. Women were classified into four groups according to the imaging findings: (1) no visible defect or distortion (likely false positive); (2) only proximal OASI; (3) only distal OASI; and (4) both proximal and distal OASI. RESULTS: Of the 309 women seen during the study period, 34 were excluded because they were referred for reasons other than recent (< 1 year) OASI, 16 owing to missing data and four owing to poor image quality, leaving 255 patients for analysis. Women were seen on average 0.25 ± 0.1 years after the index birth, and their mean age at delivery was 29.1 ± 4.6 years. Anal incontinence was reported by 97 (38.0%) women. A scar or defect was seen only in the proximal part of the EAS in 64 (25.1%) women and only in the distal part in 19 (7.5%) (P < 0.001). In 165 (64.7%) women, the damage affected both the proximal and distal EAS. CONCLUSIONS: EAS scars after primary OASI repair commonly affect the entire length of the EAS; however, partial tears seem to be more likely to occur proximally. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence of and Factors Associated With Fecal Incontinence: Results From a Population-Based Survey.

BACKGROUND & AIMS: Fecal incontinence (FI) is characterized by uncontrolled passage of solid or liquid stool. We aimed to determine the prevalence and severity of FI in a large sample of US residents. METHODS: We recruited a representative sample of patients in October 2015 to complete the National Gastrointestinal (GI) Survey; a mobile app called MyGiHealth was used to systematically collect data on GI symptoms. FI was defined as accidental leakage of solid or liquid stool. Severity of FI was determined by responses to the National Institutes of Health FI Patient Reported Outcomes Measurement Information System questionnaire. Multivariable regression models were used to identify factors associated with FI prevalence and severity. RESULTS: Among 71,812 individuals who completed the National GI Survey, 14.4% reported FI in the past; of these, 33.3% had FI within the past 7 days. Older age, male sex, and Hispanic ethnicity increased the likelihood of having FI within the past week. Individuals with Crohn's disease, ulcerative colitis, celiac disease, irritable bowel syndrome, or diabetes were more likely to report FI. Non-Hispanic black and Hispanic individuals and individuals with Crohn's disease, celiac disease, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, or chronic idiopathic constipation had more severe symptoms of FI than individuals without these features. CONCLUSIONS: In a large population-based survey, 1 in 7 people reported previous FI. FI is age-related and more prevalent among individuals with inflammatory bowel disease, celiac disease, irritable bowel syndrome, or diabetes than people without these disorders. Proactive screening for FI among these groups is warranted.

Relationships between the results of anorectal investigations and symptom severity in patients with faecal incontinence.

PURPOSE: Anorectal dysfunction is the focus of diagnostic investigations for faecal incontinence. However, severity of incontinence and anorectal investigation results can be discordant. The aim of this study was to define the relationships between anorectal investigation results and incontinence severity to determine which measures, if any, were predictive of incontinence severity. METHODS: Patients presenting for investigation of faecal incontinence completed a symptom questionnaire, anorectal manometry, rectal sensation, pudendal nerve terminal motor latency, and endoanal ultrasound. Bivariate analyses were conducted between the Jorge-Wexner score and investigation results. Subgroup analyses were performed for gender and symptom subtypes (urge, passive, mixed). A multiple regression analysis was performed. RESULTS: Five hundred and thirty-eight patients were included. There were weak correlations between the Jorge-Wexner score and maximal squeeze pressure [r = - 0.24, 95%CI(- 0.31, - 0.16), p < 0.001], and resting pressure [r = - 0.18, (95%CI(- 0.26, - 0.10), p < 0.001]. In men only, there were significant associations between the Jorge-Wexner score and endoanal sonography [IAS defects: t(113) = - 2.26, p = 0.03, d = 0.58, 95%CI(- 4.38, - 0.29)] and rectal sensation (MTV: rs = - 0.24, 95%CI(- 0.41, - 0.06), p = 0.01). No substantial differences were observed in the urge/passive/mixed subgroup analyses. Multiple regression analysis included three variables: age (ß = 0.02, p = 0.17), maximal resting pressure (ß = - 0.01, p = 0.28), and maximal squeeze pressure (ß = - 0.01, p < 0.01). The variance in the Jorge-Wexner score accounted for by this model was < 10%, (R2 = 0.07, p = < 0.01, adjusted R2 = 0.06). CONCLUSION: Anorectal investigations cannot predict the severity of faecal incontinence. This may be due to limitations of diagnostic modalities, the heterogeneity of anorectal dysfunction in these patients, or contributing factors which are extrinsic to the anorectum.

Clinical impact of bowel symptoms in women with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the correlations between the POP-Q Bp point and the perineal body (Pb) and genital hiatus (Gh) measurements and constipation, anal incontinence, severity of symptoms and quality of life. METHODS: The patients were distributed into two groups according to the posterior vaginal wall Bp point: one group with Bp ≤-1 (without posterior vaginal wall prolapse, control group) and the other group with Bp ≥0 (with posterior vaginal wall prolapse, case group). Demographic data, defecatory dysfunction and SF-36 scores were compared between the groups. Correlations between severity of posterior prolapse (Bp, Gh, Pb and Gh + Pb) and severity of bowel symptoms were also calculated. RESULTS: A total of 613 women were evaluated, of whom 174 were included, 69 (39.7%) in the control group and 105 (60.3%) in the case group. The groups were similar in terms of anal incontinence, fecal urgency and/or constipation. There was no correlation between the severity of constipation and anal incontinence according to the Wexner score, and the severity of posterior vaginal wall prolapse measured in terms of point Bp. There were, however, statistically significant differences in Pb, Gh and Gh + Pb between the groups. The Pb and Gh + Pb measurements were positively correlated with symptoms of constipation, as well as with the scores of some SF-36 domains, but were not correlated with anal incontinence. CONCLUSIONS: These results suggest that the severity of posterior vaginal wall prolapse is not correlated with constipation or anal incontinence, but Pb and Gh + Pb measurements are correlated with constipation and SF-36 scores.

Clinical anatomy of fecal incontinence in women.

Fecal incontinence is a devastating condition that has a severe impact on quality of life. This condition disproportionately affects women and its incidence is increasing with the aging United States population. Fecal continence is maintained by coordination of a functioning anal sphincter complex, intact sensation of the anorectum, rectal compliance, and the ability to consciously control defecation. Particularly important are the puborectalis sling of the levator ani muscle complex and intact innervation of the central and peripheral nervous systems. An understanding of the intricate anatomy required to maintain continence and regulate defecation will help clinicians to provide appropriate medical and surgical management and diminish the negative impact of fecal incontinence. In this article, we describe the anatomic and neural basis of fecal continence and normal defecation as well as changes that occur with fecal incontinence in women. Clin. Anat. 30:901-911, 2017. © 2017 Wiley Periodicals, Inc.

[ОPTIMIZATION OF SURGICAL TREATMENT OF HEMORRHOIDAL DISEASE STAGES III-IV].

The treatment results in patients, suffering chronic hemorrhoidal disease stages III- IV, in accordance to the elaborated method of hemorrhoidectomy, using radio-wave scalpel «Surgitron TM¼ with further welding of vascular pedicle, applying high-frequency electrocoagulator ЕК-301М1, are presented. In the patients, оperated on in accordance to the method proposed, the intraoperative complications rate and the blood loss severity were essentially lesser than in a comparison group. Owing an adequate level of surgical skills, the operative treatment method elaborated guarantees the reduction of early and late postoperative morbidity, rapid coming back to routine way of living postoperatively.

Perineal body stretch during labor does not predict perineal laceration, postpartum incontinence, or postpartum sexual function: a cohort study.

INTRODUCTION AND HYPOTHESIS: The perineum stretches naturally during obstetrical labor, but it is unknown whether this stretch has a negative impact on pelvic floor outcomes after a vaginal birth (VB). We aimed to evaluate whether perineal stretch was associated with postpartum pelvic floor dysfunction, and we hypothesized that greater perineal stretch would correlate with worsened outcomes. METHODS: This was a prospective cohort study of primiparous women who had a VB. Perineal body (PB) length was measured antepartum, during labor, and 6 months postpartum. We determined the maximum PB (PBmax) measurements during the second stage of labor and PB change (ΔPB) between time points. Women completed functional questionnaires and had a Pelvic Organ Prolapse Quantification (POP-Q) system exam 6 months postpartum. We analyzed the relationship of PB measurements to perineal lacerations and postpartum outcomes, including urinary, anal, and fecal incontinence, sexual activity and function, and POP-Q measurements. RESULTS: Four hundred and forty-eight women with VB and a mean age of 24 ± 5.0 years with rare (5 %) third- or fourth-degree lacerations were assessed. During the second stage of labor, 270/448 (60 %) had perineal measurements. Mean antepartum PB length was 3.7 ± 0.8 cm, with a maximum mean PB length (PBmax) during the second stage of 6.1 ± 1.5 cm, an increase of 65 %. The change in PB length (ΔPB) from antepartum to 6 months postpartum was a net decrease (-0.39 ± 1.02 cm). PB change and PBmax were not associated with perineal lacerations or outcomes postpartum (all p > 0.05). CONCLUSIONS: PB stretch during labor is unrelated to perineal laceration, postpartum incontinence, sexual activity, or sexual function.

Coadministration of basic fibroblast growth factor-loaded polycaprolactone beads and autologous myoblasts in a dog model of fecal incontinence.

PURPOSE: Basic fibroblastic growth factor (bFGF), a member of the heparin-binding growth factor family, regulates muscle differentiation. We investigated whether coadministration of autologous myoblasts and bFGF-loaded polycaprolactone beads could improve sphincter recovery in a dog model of fecal incontinence (FI). METHODS: FI was induced by resecting 25% of the posterior anal sphincter in ten mongrel dogs. One month later, the dogs were randomized to receive either PKH-26-labeled autologous myoblasts alone (M group, five dogs) or autologous myoblasts and bFGF-loaded polycaprolactone beads (MBG group, five dogs). The outcomes included anal manometry, compound muscle action potentials (CMAPs) of the pudendal nerve, and histology. RESULTS: The increase in anal contractile pressure over 3 months was significantly greater in the MBG group (from 4.85 to 6.83 mmHg) than that in the M group (from 4.94 to 4.25 mmHg), with a coefficient for the difference in recovery rate of 2.672 (95% confidence interval [CI] 0.962 to 4.373, p = 0.002). The change in the CMAP amplitude was also significantly greater in the MBG group (from 0.59 to 1.56 mV) than that in the M group (from 0.81 to 0.67 mV) (coefficient 1.114, 95% CI 0.43 to 1.80, p = 0.001). Labeled cells were detected in 2/5 (40%) and 5/5 (100%) dogs in the M and MBG groups, respectively. CONCLUSION: Coadministration of bFGF-loaded PCL beads and autologous myoblasts improved the recovery of sphincter function in a dog model of FI and had better outcomes than cell-based therapy alone.

Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence--a blinded assessment in an animal model.

AIM: Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro-oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling. METHOD: An experimental FI model was created in 12 female pigs: eight underwent RF 6 weeks following induction of FI (FI+RF) and four were untreated (UFI). Four animals served as controls (CG). Two blinded pathologists examined all haematoxylin and eosin and trichrome stained slides. RESULTS: Compared with the UFI group, histological examination of the IAS in the FI+RF group demonstrated an increased smooth muscle (SM)/connective tissue ratio (77.2 vs 68.1%, P < 0.05) and increased collagen I compared with collagen III content (67.2 vs 54.9%, P < 0.001). The RF+FI group exhibited greater SM bundle thickness compared with the UFI group (SM width 486.93 vs 338.59 µm, P < 0.01; height 4384.4 vs 3321.0 µm, P < 0.05). The EAS of the FI+RF animals showed a significantly higher type I/II fibre ratio (33.5 vs 25.2%, P = 0.023) and fibre type I diameter (67.2 vs 59.7 µm, P < 0.001) compared with the UFI group. Post-RF manometry showed higher basal (18.8 vs 0 mmHg, P < 0.001) and squeeze (76.8 vs 12.4 mmHg, P < 0.05) anal pressures. After RF treatment, the number of interstitial cells of Cajal was significantly reduced compared with the UFI and CG groups [0.9 (FI+RF) vs 6.7 (UFI) vs 0.7 (CG) per mm(2) , P < 0.001]. CONCLUSION: In an animal model nonablative RF appeared to induce morphological changes in the IAS and EAS leading to an anatomical state reminiscent of normal sphincter structure.

Clinical symptoms related to anal sphincter defects and atrophy on external phased-array MR imaging.

INTRODUCTION AND HYPOTHESIS: Defecatory complaints have a severe impact on quality of life. The additional value of pelvic floor MRI in patients with defecatory complaints is unclear. Our aim was to correlate the presence of defects and atrophy of the anal sphincter complex using pelvic floor MRI in women with mixed pelvic floor symptoms and to establish patient characteristics and self reported complaints predictive of pathology. METHODS: This is a retrospective study among women with mixed pelvic floor symptoms who underwent external phased-array MRI and completed a questionnaire on bothersome defecatory complaints. Data on patient characteristics, including obstetrical history and questionnaire scores were correlated with the assessment of anal sphincter defects and atrophy on pelvic floor MRI. RESULTS: One hundred and fifty-eight women were included. A defect of the external anal sphincter (EAS) and internal anal sphincter (IAS) was found in 18 (11%) and 5 (3%) patients respectively. Atrophy of the EAS was present in 72 patients (46%), with more cases of mild (n = 52, 33%) than severe atrophy (n = 20, 13%). The variable "previous third or fourth degree tear" had a significant positive association with an IAS defect on MRI, with an OR of 9.533 (1.425-63.776). Patients with EAS atrophy had higher scores for fecal incontinence (indicating more bother) than patients without EAS atrophy. Higher age and BMI were true predictors of the presence of more severe EAS atrophy. CONCLUSION: Atrophy of the EAS was highly prevalent in this population and was associated with bothersome symptoms of fecal incontinence.

Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial.

PURPOSE: Here we aimed to evaluate the incidence of obstetric anal sphincter injuries in spontaneous primigravid deliveries with mediolateral episiotomy beyond 36 gestational weeks. METHODS: We performed a prospective, randomized controlled study including 201 primigravid women that delivered vaginally. Anal sphincter anatomy and integrity was evaluated before hospital discharge in all cases with transvaginal sonography (5-9 MHz) (Siemens Sonoline G50 and Voluson 730 Expert). The vaginal ultrasound probe is placed in the fourchette of the vaginal introitus to obtain the transverse section of the anal sphincter. RESULTS: In the cases with sphincter defect, mean gestational week and second stage of labor were prolonged significantly (p = 0.039 and p < 0.0001, respectively). The mean perineal body distance in cases with sphincter injury, as detected by sonography, 2.18 ± 0.33 cm, is compared to 2.31 ± 2.43 cm in cases without injury. There was a significant difference between the two groups (p = 0.0142). Shoulder dystocia was significantly higher in cases with sphincter injury, compared to cases without injury (p = 0.011). No clinical findings were reported in 11.5 % of cases (Sonography findings 1A∓, 1B∓) and 3.5 % of cases had clinical and sonographic findings (Sonography findings 2A∓, 2B∓). "Occult tears" were considered as those cases not detected clinically, but detected by sonography (11.5 % of all cases). Two months after examination, a moderate incontinence (Wexner continence scale) was found in 71.5 % of cases with overt sphincter tear, which was significantly different to the non-overt sphincter tear group. Multiple logistic regression analyses for sphincter injuries identified prolonged second stage of labor and shoulder dystocia as two independent risk factors. CONCLUSION: Here, we found that only a portion of anal sphincter injuries can be detected after physical examination, with many of cases of "occult tears" escaping notice. These cases of occult anal sphincter injury are detectable by sonography with transperineal use of a vaginal probe. Based on these findings, we propose that this technique is convenient for obstetric, gynecologic and proctologic evaluation of sphincter anatomy.

The anococcygeal ligaments: Cadaveric study with application to our understanding of incontinence in the elderly.

The term "anococcygeal ligament (ACL)" has been used to refer to two distinct structures: a superficial fibrous band originating from the myosepta of the external anal sphincter (EAS) and running upwards to the coccyx (the superficial ACL); and a deep fibrous band originating from the periosteum of the coccyx, merging with the thick presacral fascia and attaching to the superior end of the EAS (the deep ACL). In the present work, elastic fiber histology and muscle immunohistochemistry of sagittal sections obtained from 15 donated elderly male cadavers showed that superficial ACL, corresponding to a superficial fascia or skin ligament, was composed of very tortuous elastic fibers, with a fine elastic fiber mesh at their coccygeal attachment; whereas the deep ACL was composed of almost straight collagen and elastic fibers, intermingled with the coccygeal periosteum. Due to the weak insertion into the coccyx and the wavy course, the superficial ACL is unlikely to provide, even in association with contraction of the longitudinal anal muscle, a stable mechanical support to maintain the configuration of the EAS. Being similar to the suspensory ligament of breast, tissue repair of the skin ligament would not have a mechanical role. In contrast, the deep ACL, in association with the thick presacral fascia, likely plays a role in maintaining a suitable positioning of the anorectum to the coccyx. However, their relative lack of smooth muscles compared with rich elastic fibers indicates that both ACLs may become permanently overextended under conditions of long-term mechanical stress.

Prevalence of fecal and double fecal and urinary incontinence in hospitalized patients.

PURPOSE: The purpose of this study was to assess the period prevalence of fecal and double incontinence in patients with and without indwelling urinary catheters in Austrian hospitals and to identify factors associated with incontinence in this group. SUBJECTS AND SETTINGS: Austrian hospital patients from 227 Austrian hospitals with more than 50 beds were invited to participate in the study from 2009 to 2012 by means of leaflets and information sessions. The study sample comprised 9861 patients who agreed to participate in the study. METHODS: An internal coordinator was responsible for the measurement within each participating hospital. Researchers trained these coordinators and they, in turn, trained the teams of ward nurses to correctly conduct the survey and collect data on 1 day in April. The instrument used in this study was the Dutch National Prevalence Measurement of Care Problems (Landelijke Prevalentiemeting Zorgproblemen), which includes not only demographic data, questions regarding incontinence occurrence, duration, and nursing interventions, but also questions about nutritional status, level of care dependency, and pressure ulcers. RESULTS: The period prevalence of fecal incontinence was 6.5%, while the period prevalence of double incontinence among patients with an indwelling urinary catheter was 5.2% and 2.8% in patients without a urinary catheter, respectively. A variety of factors, including age, primary diagnosis, pressure ulcers excluding grade (stage) 1, low body mass index, malnutrition, and level of care dependency, were associated with fecal incontinence (P < .000). CONCLUSION: Study findings indicate that the prevalence of fecal and double continence is higher in patients with an indwelling urinary catheter as compared with patients with no urinary catheter. A longitudinal study might yield a more accurate picture regarding fecal/double incontinence.

A novel animal model for external anal sphincter insufficiency.

PURPOSE: Reliable animal models are essential to evaluate future therapeutic options like cell-based therapies for external anal sphincter insufficiency. The goal of our study was to describe the most reliable model for external sphincter muscle insufficiency by comparing three different methods to create sphincter muscle damage. METHODS: In an experimental animal study, female Lewis rats (200-250 g) were randomly assigned to three treatment groups (n = 5, each group). The external sphincter muscle was weakened in the left dorsal quadrant by microsurgical excision, cryosurgery, or electrocoagulation by diathermy. Functional evaluation included in vivo measurements of resting pressure, spontaneous muscle contraction, and contraction in response to electrical stimulation of the afferent nerve at baseline and at 2, 4, and 6 weeks after sphincter injury. Masson's trichrome staining and immunofluorescence for skeletal muscle markers was performed for morphological analysis. RESULTS: Peak contraction after electrical stimulation was significantly decreased after sphincter injury in all groups. Contraction forces recovered partially after cryosurgery and electrocoagulation but not after microsurgical excision. Morphological analysis revealed an incomplete destruction of the external sphincter muscle in the cryosurgery and electrocoagulation groups compared to the microsurgery group. CONCLUSIONS: For the first time, three different models of external sphincter muscle insufficiency were directly compared. The animal model using microsurgical sphincter destruction offers the highest level of consistency regarding tissue damage and sphincter insufficiency, and therefore represents the most reliable model to evaluate future therapeutic options. In addition, this study represents a novel model to specifically test the external sphincter muscle function.

Static and dynamic evaluation of pelvic floor disorders with an open low-field tilting magnet.

AIM: To assess the feasibility of magnetic resonance defaecography (MRD) in pelvic floor disorders using an open tilting magnet with a 0.25 T static field and to compare the results obtained from the same patient both in supine and orthostatic positions. MATERIALS AND METHODS: From May 2010 to November 2011, 49 symptomatic female subjects (mean age 43.5 years) were enrolled. All the patients underwent MRD in the supine and orthostatic positions using three-dimensional (3D) hybrid contrast-enhanced (HYCE) sequences and dynamic gradient echo (GE) T1-weighted sequences. All the patients underwent conventional defaecography (CD) to correlate both results. Two radiologists evaluated the examinations; inter and intra-observer concordance was measured. The results obtained in the two positions were compared between them and with CD. RESULTS: The comparison between CD and MRD found statistically significant differences in the evaluation of anterior and posterior rectocoele during defaecation in both positions and of rectal prolapse under the pubo-coccygeal line (PCL) during evacuation, only in the supine position (versus MRD orthostatic: rectal prolapse p < 0.0001; anterior rectocoele p < 0.001; posterior rectocoele p = 0.008; versus CD: rectal prolapse p < 0.0001; anterior rectocoele p < 0.001; posterior rectocoele p = 0.01). The value of intra-observer intra-class correlation coefficient (ICC) ranged from good to excellent; the interobserver ICC from moderate to excellent. CONCLUSION: MRD is feasible with an open low-field tilting magnet, and it is more accurate in the orthostatic position than in the supine position to evaluate pelvic floor disorders.

MRI findings in patients with defecatory dysfunction after surgical correction of anorectal malformation.

BACKGROUND: Postoperative anorectal malformation patients frequently have defecatory dysfunction. MRI may be useful in the management of these patients. OBJECTIVE: To analyze static and dynamic MRI findings in patients with defecatory dysfunction after correction of anorectal malformation (ARM), and compare differences between patients with constipation and fecal incontinence. MATERIALS AND METHODS: Pelvic MRI studies of 20 constipated and 32 incontinent postoperative ARM patients were analyzed retrospectively to determine the location and morphology of the neorectum, presence of peritoneal fat herniation, presence of scarring, development of the striated muscle complex (SMC) and any other abnormalities. The two groups were then compared using χ(2)-test. Eighteen patients also underwent MRI defecography to evaluate pelvic floor function and abnormalities are reported. RESULTS: The children with incontinence were more likely to have abnormal location of the neorectum (P = 0.031), increased anorectal angle (ARA) (P = 0.031) and peritoneal fat herniation (P = 0.032), and less likely to have dilation of the neorectum (P = 0.027), than the children with constipation. There were no significant differences between the two groups in incidence of focal stenosis of the neorectum (P = 0.797), presence of extensive scarring (P = 0.591) and developmental agenesis of the SMC (P > 0.05). MRI defecography showed 6 anterior rectoceles, 6 cystoceles and 18 pelvic floor descents. CONCLUSIONS: MRI is a helpful imaging modality in postoperative ARM patients with defecatory dysfunction, and it shows distinct differences between the children with constipation and incontinence and provides individualized information to guide further treatment.

Obstetric trauma, pelvic floor injury and fecal incontinence: a population-based case-control study.

OBJECTIVES: Current concepts based on referral center data suggest that pelvic floor injury from obstetric trauma is a major risk factor for fecal incontinence (FI) in women. In contrast, a majority of community women only develop FI decades after vaginal delivery, and obstetric events are not independent risk factors for FI. However, obstetric events are imperfect surrogates for anal and pelvic floor injury, which is often clinically occult. Hence, the objectives of this study were to evaluate the relationship between prior obstetric events, pelvic floor injury, and FI among community women. METHODS: In this nested case-control study of 68 women with FI (cases; mean age 57 years) and 68 age-matched controls from a population-based cohort in Olmsted County, MN, pelvic floor anatomy and motion during voluntary contraction and defecation were assessed by magnetic resonance imaging. Obstetric events and bowel habits were recorded. RESULTS: By multivariable analysis, internal sphincter injury (cases-28%, controls-6%; odds ratio (OR): 8.8; 95% confidence interval (CI): 2.3-34) and reduced perineal descent during defecation (cases-2.6 ± 0.2 cm, controls-3.1 ± 0.2 cm; OR: 1.7; 95% CI: 1.2-2.4) increased FI risk, but external sphincter injury (cases-25%, controls-4%; P<0.005) was not independently predictive. Puborectalis injury was associated (P<0.05) with impaired anorectal motion during squeeze, but was not independently associated with FI. Grades 3-4 episiotomy (OR: 3.9; 95% CI: 1.4-11) but not other obstetric events increased the risk for pelvic floor injury. Heavy smoking (≥ 20 pack-years) was associated (P=0.052) with external sphincter atrophy. CONCLUSIONS: State-of-the-art imaging techniques reveal pelvic floor injury or abnormal anorectal motion in a minority of community women with FI. Internal sphincter injury and reduced perineal descent during defecation are independent risk factors for FI. In addition to grades 3-4 episiotomy, smoking may be a potentially preventable, risk factor for pelvic floor injury.