Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury.

INTRODUCTION: Endoanal ultrasound is considered the gold standard when assessing the obstetric anal sphincter complex. Due to its relative intrusiveness and economic cost, other ultrasound modalities are on the rise, such as transperineal ultrasound with a convex probe. The aim of our study was to evaluate the agreement between endoanal ultrasound scores (EAUS score) and transperineal ultrasound scores (TPUS score) in assessing residual obstetric anal sphincter defects. MATERIAL AND METHODS: Fifty-nine women were examined 6 months after primary suturing of obstetric anal sphincter injury with two ultrasound modalities. A standardized scoring system analyzing the length, depth and radial extent of both the external (EAS) and internal (IAS) sphincter was used. Wexner fecal incontinence score was used to assess the patients' symptoms. RESULTS: Transperineal ultrasound scores score showed a strong significant correlation with EAUS score during both pelvic floor relaxation and contraction: Spearman's rho [rs ] = 0.74, P < 0.001, and rs  = 0.77, P < 0.001, respectively. For both EAS and IAS, significant correlations were found for all parameters, that is, length, depth and angle between both EAUS and TPUS. A statistically significant correlation was found between EAUS score and Wexner score (rs  = 0.36, P = 0.005). A significant correlation between the EAS-EAUS score (rs  = 0.36, P = 0.005) and Wexner score was found, but no significance was found between IAS-EAUS score and Wexner score (rs  = 0.22, P = 0.097). Significant correlations were found for Wexner score and TPUS score in resting state (rs  = 0.36, P = 0.01) and contracting state (rs  = 0.28, P < 0.05), and between Wexner score and EAS-TPUS score in resting state (rs  = 0.32, P = 0.02). CONCLUSIONS: The results indicated a strong agreement between endoanal and transperineal ultrasound in assessing residual obstetric anal sphincter defects 6 months after primary suturing. Furthermore, a weak significant correlation was found between the ultrasound scores and the patients' Wexner fecal incontinence score.

Correlations of obstetric anal sphincter injury (OASIS) grade, specific symptoms of anal incontinence, and measurements by endoanal and transperineal ultrasound.

PURPOSE: The aim of the study was to investigate the association between the initial grade of obstetrical anal sphincter injury (OASIS), and Wexner score parameters, with ultrasonographic findings by endoanal ultrasound (EAUS, golden standard) and transperineal ultrasound (TPUS) 6 months post-partum. METHODS: Fifty-nine women after primary repair of OASIS were included at Helsingborg Hospital, Sweden, 2016-2017. Six months post-partum the women filled in a questionnaire regarding symptoms of anal incontinence by the Wexner score and were scanned with EAUS and TPUS (resting state and contracting state) for classification of the residual defect by a modified Starck score. RESULTS: Correlations were found between the OASIS grade and residual defects; length (rs = 0.41, P = 0.003), depth (rs = 0.38, P = 0.006) and angle (rs = 0.40, P = 0.004) of the external anal sphincter (EAS) measured with TPUS in resting state. Using EAUS, correlation between OASIS grade and EAS depth (rs = 0.35, P = 0.007) and angle (rs = 0.37, P = 0.004) were similar, but there was no correlation with length (rs = 0.20, P = 0.14). Between incontinence to gas and the angle of the residual defect in the IAS using TPUS in resting state, correlation was moderate (rs = 0.42, P = 0.003). Regarding incontinence to liquid stool, measurements by TPUS in resting state of EAS residual defect depth (rs = 0.46, P < 0.001) and angle (rs = 0.44, P = 0.001) also correlated moderately. Both corresponding correlations using EAUS were weaker. CONCLUSION: Defects measured with EAUS and TPUS six months post-partum correlated to initial OASIS grade and symptoms of anal incontinence. Specific symptoms correlated with specific anatomical defects, and TPUS was not an inferior method to EAUS.

Sonographic visualization of the rectoanal inhibitory reflex in children suspected of having Hirschsprung disease: a pilot study.

OBJECTIVE: To date, for detection of the absence of peristalsis in children with chronic constipation and a suspicion of Hirschsprung disease (HD), children have been investigated with a contrast enema. If the radiographic investigation is inconclusive, anometry and a rectal biopsy are performed. A new noninvasive real-time sonographic method for examination of the rectoanal inhibitory reflex (RAIR) was compared with anometry. METHODS: The rectum and anal canal of children were visualized transperineally on sonography. The RAIR was elicited by injecting water into the rectum, and the events in the bowel were recorded on video for offline analysis. RESULTS: Injection of water initiated a peristaltic wave that moved the rectal contents into the proximal part of the anal canal in healthy children. Among 28 children with suspected HD, 3 showed aganglionosis in their biopsy samples. These 3 children lacked the RAIR according to both sonography and anometry. Both methods had a negative predictive value of 100%. In 17 children, the RAIR was present according to both sonography and anometry, and all of these children had normal histologic findings. In 8 children, sonography did not show the reflex despite normal histologic findings; in 2 of these, the quality of the investigation made the evaluation uncertain. CONCLUSIONS: This pilot study indicates that in children with chronic constipation, a transperineal sonographic examination of the RAIR is comparable to anometry and can facilitate the diagnose of HD.

Pelvic floor in females with anorectal malformations--findings on perineal ultrasonography and aspects of delivery mode.

BACKGROUND: Advice on the mode of delivery to females born with anorectal malformation (ARM) is needed. The primary aim was to evaluate the anatomy of the pelvic floor muscles in females with ARM operated with posterior sagittal anorectal plasty (PSARP). The second aim was to correlate the extent of muscle defects to the bowel symptoms. METHODS: This interventional study with perineal 4D/3D ultrasonography describes the smooth muscles in the intestinal wall (neo-IAS), external sphincter, levators and anal canal using a muscle score (0-6 worst). The bowel symptoms were prospectively registered with Krickenbeck criteria score (0-7 worst). RESULTS: Forty females with different subtypes of ARM, median age 13 (4-21), were followed up regarding bowel symptoms. Seventeen were examined with ultrasonography. Bowel symptoms were similar for those examined with ultrasonography and those not, median score 5 and 3 (1-7) respectively, (p=0.223, Fisher's exact test). All the females had at least one muscular defect. There was no significant correlation between muscle defects and bowel symptoms (p=0.094, Spearman's correlation). CONCLUSION: Females with ARM have considerable defects in the pelvic floor without any significant correlation to bowel symptoms. All women with ARM would benefit from individualized predelivery evaluations and caesarian section should be considered.

Sonographic characteristics of rectal sensations in healthy females.

PURPOSE: This study was designed to characterize rectal sensations by visualizing the internal and external anal sphincter and intra-anal transport of bolus during elicited rectal sensations. METHODS: The anal canal was visualized with real-time transperineal ultrasonography in 13 healthy female volunteers. Rectal sensations were elicited by injecting water into the rectum. The ultrasound images were recorded on a videotape and analyzed offline. RESULTS: The median time between an injection of water and the events studied was calculated in 105 rectal sensations. A relaxation in the internal anal sphincter (4 seconds after the injection of water), an antegrade transport of bolus (4 seconds) into the anal canal, and a contraction in the external anal sphincter (5 seconds) were observed before a sensation (6 seconds) was reported. The antegrade flow continued until the distal internal anal sphincter contracted (18 seconds) and the bolus moved in a retrograde transport direction (17 seconds) thereafter the sensation disappeared (18 seconds) and the external anal sphincter relaxed (22 seconds). A significant correlation in time between the end of the sensation, contraction in the internal anal sphincter, reversed flow of anal contents, and relaxation of the external anal sphincter was found (Pearson, P<0.01). CONCLUSIONS: The results verified that the internal anal sphincter contributes to the perception of rectal sensations by a relaxation allowing intra-anal bolus to increase the pressure on the anoderm during rectal contraction. A new observation is presented on the time relation between contraction in the distal internal anal sphincter, reversed flow in the anal canal, and the end of rectal sensations.

Bleeding disorders among young women: a population-based prevalence study.

BACKGROUND: Bleeding problems are prevalent in the general population but may indicate a general bleeding disorder. Our aim was to describe the prevalence of perceived bleeding symptoms, including menorrhagia, in young healthy females. METHODS: By aid of school nurses we distributed a questionnaire to all girls (n =1,410) in the first grade of the upper secondary schools in the town of Malmö, Sweden. We received 1,019 (72%) responses. The questionnaire consisted of 17 main questions addressing general bleeding problems, menses and menstrual bleeding problems, family history, and other health related questions. RESULTS: The mean age of the girls was 16.7 years. Eight girls had a previously diagnosed bleeding disorder and had a higher frequency of most bleeding symptoms. Seventy-three percent of girls experienced at least one bleeding symptom, 43% had more than one symptom, 23% were troubled by more than two symptoms, and 10% more than three symptoms. Thirty-seven percent experienced heavy menstruation and of these 22% had different drugs as treatment for menorrhagia. Thirty-eight percent had a family history of heavy menstruation and half of them suffered from heavy menstruation themselves. CONCLUSIONS: Bleeding symptoms were relatively prevalent in this population and similar to other population-based studies.