Rectocele repair with stapled transvaginal rectal resection.

BACKGROUND: Constipation is a clinical symptom in patients suffering from slow transit and/or obstructed defecation. Proper treatment requires the identification of all associated disorders and the quantification of symptoms. Rectocele can cause the symptoms of obstructed defecation syndrome (ODS). The aim of this study was to evaluate the clinical and functional outcomes of a novel technique of transvaginal stapled rectal resection (TVSRR) using a straight staple line, to treat rectocele. METHODS: The study included 84 females [median age 51 years (range 29-73 years)], with obstructed defecation, grades II-III rectocele, and multiple abnormalities on defecography. The magnitude and degree of ODS were quantified by the Altomare ODS scoring system. Continence status was evaluated using the Pescatori scoring system. The rectal and vaginal manometric study, the index of patient satisfaction using a visual analog score (VAS), and the validated Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire results were recorded. All patients underwent TVSRR. RESULTS: There were no intraoperative complications. Early postoperative complications were defecatory urgency in seven patients (8.3 %), dyspareunia in two (2.4 %), and rectovaginal fistula in one (1.2 %). Five patients (6 %) had recurrence of ODS symptoms. There was no significant change in continence pre- and postoperatively. The ODS score and VAS revealed significant improvement within the first postoperative year in 94 % of patients. The PAC-QOL questionnaire mean total scores indicated an improvement in both the patient satisfaction and the QOL during the 12-month follow-up. The self-reported definitive outcome was excellent in 46 patients (54.7 %), good in 29 (34.5 %), fairly good in 20 (23.8 %), and poor in five (6.0 %). CONCLUSIONS: Vaginal repair carries no risk of fecal incontinence. Large anterior rectocele is considered the main indication for this technique. Using the linear stapler is a cost-effective, simple, and easy technique.

Combined partial fistulectomy and electro-cauterization of the intersphincteric tract as a sphincter-sparing treatment of complex anal fistula: clinical and functional outcome.

BACKGROUND: The aim of this study was to report a simple, effective and safe procedure, associated with minimal risk of incontinence and recurrence, for treating complex anal fistulas. METHODS: This was a prospective study of 53 consecutive patients with complex anal fistulas. The technique used included excision of the distal part of the fistula tract down to the external anal sphincter and electro-cauterization of the intersphincteric part of the tract with simple closure of the internal opening. Data collected included patient characteristics, fistula type determined by magnetic resonance imaging, pre- and postoperative continence status evaluated using the Wexner incontinence score (0-10), previous operations, hospital stay, healing time, recurrence rate and complications. RESULTS: The patients had a mean age of 41.37 ± 7.82 years; the most frequent fistula type was the high transsphincteric fistula; the mean follow-up period was 19 months with a success rate of 92.5 %; the mean wound healing time was 3.6 weeks; the incontinence scores were the same as before the procedure. The recurrence rate was 7.5 %. CONCLUSIONS: Partial fistulectomy combined with electrocauterization of the intersphincteric fistula tract is a simple, and effective procedure for the treatment of complex anal fistulas.

Electromyographic study of ejaculatory mechanism.

Cavernosus muscle (CM), seminal vesicle (SV) and vasal ampullary (VA) contractions at ejaculation are said to be reflex mechanisms (ejaculatory reflex), which have been scarcely dealt with in the literature. We investigated the hypothesis that contraction of the CMs, SVs and VA at ejaculation is a reflex action. The electromyographic (EMG) activity of CM, SV and VA during ejaculation was recorded in 28 healthy men. The test was repeated after separate anaesthetization of the glans penis (GP), CMs, SVs, and VA in the pre-ejaculatory period. Latent ejaculatory time (LET) was calculated. CMs showed no EMG activity until rigid erection phase was reached. SVs and VA exhibited resting EMG activity which increased gradually with different stages of erection. At ejaculation, CMs, SVs and VA showed two to four intermittent contractions. The mean LET was 1.3 +/- 0.2 sec. GP anaesthetization led to the disappearance of CM, SV and VA EMG activity at ejaculation, while bland gel did not affect EMG activity. CMs, SVs and VA when anaesthetized in the pre-ejaculatory period exhibited no EMG activity at ejaculation, while saline did not affect EMG activity. Increased EMG activity of CM, SV and VA apparently denotes increase in their contractile activity. CM, SV and VA contraction on GP stimulation and ejaculation are assumed to be reflex actions and are mediated through the 'glans-cavernosovesicular reflex' (GCVR) which presumably represents the ejaculatory reflex. Changes in LET or evoked response would indicate a defect in the reflex pathway. The GCVR might act as an investigative tool in diagnosing erectile dysfunction, provided further studies are performed in this respect.

Effect of cooling on the rectal tone.

OBJECTIVES: It has been claimed that recognizable organized sensory nerve endings could not be detected in the rectal wall. Hence the identification of cold receptors sensitive to cold temperature in the rectal wall has so far not been reported in the literature. We investigated the hypothesis that rectal cooling effected an increase of the rectal tone. METHODS: Twenty-eight healthy volunteers (18 men, 10 women, age 26-50 years) were studied. The rectal wall tone was assessed by the barostat system during infusion of normal saline at 30 degrees C and at 4 degrees C. The test was repeated after rectal anesthetization with lidocaine. RESULTS: The rectal tone on rectal saline infusion showed no response at a temperature of 30 degrees C, and asignificant increase (p < 0.05) at 4 degrees C. The latency measured by the switch-inflation apparatus recorded a mean of 15.3 +/- 1.2 ms. Iced saline infusion into the anesthetized rectum effected no significant change in the rectal tone. CONCLUSIONS: The current study has demonstrated that rectal infusion of iced saline produced an increase of the rectal tone. This effect is suggested to be a reflex and mediated through the 'rectal cooling reflex'. The reflex is suggested to act as an investigative tool in the diagnosis of rectal motile disorders provided further studies are performed.

A study on the etiology of uterine pressure rise on semen deposition in the vagina or uterus.

PURPOSE OF INVESTIGATION: In a recent study we have demonstrated that semen deposition into the vagina or uterus effects uterine pressure rise which is suggested to assist in "sucking" semen into the uterine cavity. The purpose of this study was to investigate whether the uterine pressure rise is effected by the sperm or the substances contained in the seminal plasma, and to test the response of the vagina and uterus to abnormal semen deposition. METHODS: Semen was obtained from 60 men divided into four groups: A) obstructive azoospermia, B) Sertoli cell-only syndrome, C) oligozoospermia and D), fertile subjects. Before and after semen deposition into the vagina and uterus both vaginal and uterine pressure were recorded. RESULTS: Semen from groups A and B produced no significant vaginal or uterine pressure changes (p > 0.05) when it was deposited into either the vagina or uterus. Group C and D semen when placed in the vagina or uterus separately effected significant intrauterine pressure rise (p < 0.05) but no vaginal pressure changes (p > 0.05). The pressure rise was higher when the semen was deposited in the uterus than in the vagina (p < 0.05) and with the normospermic than oligozoospermic semen (p < 0.05). In groups C and D, the seminal plasma produced no vaginal or uterine pressure changes (p > 0.05), whereas the sperm effected intrauterine pressure rise (p < 0.05) which was more elevated with sperm from normospermic than oligozoospermic semen (p < 0.05). CONCLUSIONS: Aspermic semen did not effect vaginal or uterine pressure rise, while oligozoospermic and normospermic semen produced rise of uterine but not vaginal pressure. Uterine pressure rise was induced by the sperm and not the seminal plasma. Further studies are required to define the sulstances secreted by the sperm which produce this increased uterine pressure.

Response of the internal reproductive organs to clitoral stimulation: the clitorouterine reflex.

We investigated hypothesis that uterine erection, elevation and enlargement during sexual response are reflex and result from penis buffeting the glans clitoris (GC). In 23 healthy women, two recording electrodes were applied to the uterine mucosa and one to cervix uteri (CU). GC was stimulated electrically and mechanically by pencil electrode. The uterine and CU pressures were measured. Tests were repeated after anesthetization of the uterus or GC. Uterine electrodes recorded slow waves, followed by random bursts of action potentials (APs). No waves registered from CU. Electrical or mechanical GC stimulation eliminated uterine electric waves, but anesthetized GC did not, nor did GC stimulation while the uterus anesthetized. Uterine pressure declined on electrical or mechanical stimulation. Results suggest presence of reproducible reflex relationship between GC and the uterus, we call 'clitorouterine reflex'. GC buffeting seems to evoke reflex and initiate uterine responses. Reflex may prove of diagnostic significance in sexual disorders.

Electric activity of the rectosigmoid canal and its relation to rectal and sigmoid electric activity: an evidence of a sphincteric function of the rectosigmoid canal.

We have previously demonstrated that the rectosigmoid junction is more than a junction: it is a segment with a mean length of 2.8 cm which we termed the 'rectosigmoid canal' (RSC). Our data support the existence of a physiologic and anatomic sphincter at the RSC which regulates the passage of stools from the sigmoid colon (SC) to the rectum (R). In view of its sphincteric action we investigated the hypothesis that the RSC has a higher electric activity than that of the SC and R. The tests were performed during repair of huge incisional hernia in 11 subjects (age 46.7(12.5 years; 8 women). The electric activity was recorded by means of 2 monopolar electrodes applied to each of the SC, RSC and R. The RSC was then anesthetized with xylocaine and the electric activity of SC, RSC and R was recorded after 10 minutes and one hour. The test was repeated using saline instead of xylocaine. The SC, RSC and R exhibited electric activity in the form of pacesetter potentials (PPs) and action potentials (APs). The PPs were monophasic in the SC and triphasic in the RSC and R. The frequency, amplitude and conduction velocity of the waves recorded from the RSC and R had higher readings (p<0.05) than those from the SC. The RSC and R showed a similar frequency and conduction velocity, but the RSC had a higher amplitude (p<0.05). Ten minutes after RSC anesthetization, electric waves were recorded from the SC but not from the RSC or R; electric activity returned one hour after anesthetization. Saline injection of the RSC did not affect the electric activity of the RSC, SC or R. The electric wave pattern and parameters of the RSC and R differed from those of the SC, suggesting that they are evoked by 2 different pacemakers. The similarity in pattern, frequency and conduction velocity of electric waves of RSC and R supposedly denotes that the rectal waves are a continuation of those of the RSC and that both are evoked by a single pacemaker located in the RSC. The higher amplitude of the RSC waves may be due to the thicker RSC musculosa in comparison to that of the SC and R and may by itself be an evidence of the sphincteric function of the RSC.

Magnetic stimulation of the cavernous nerve for the treatment of erectile dysfunction in humans.

A recent study in dogs has demonstrated that magnetic stimulation (MS) of the cavernous nerve produced an increase of the intracorporeal pressure and full penile erection. In view of these results, we tested the possible application of this procedure in humans with erectile dysfunction (ED). The study comprised 32 patients with ED (age 38.3 +/- 9.6 y) and 20 healthy volunteers (age 36.8 +/- 8.8 y). Routine erectile function tests suggested that impotence was neurogenic. A magnetic coil was placed over the dorsal aspect of the penis in the vicinity of the symphysis pubis. MS was performed using a stimulation of 40% intensity, 20 Hz frequency, 50 s on and 50 s off for 10 minutes duration. In the healthy volunteers, the coil was placed as aforementioned but was not activated. The intracorporeal pressure was recorded and penile tumescence and rigidity observed during MS in the patients and without stimulation in the controls. MS led to gradual increase in length and diameter of the penis until full erection was achieved; the penis became firm, rigid and pulsatile. The intracorporeal pressure increased significantly (P < 0.0001) at full erection. Mean latency to full erection was 19.3 +/- 3.4 s. Upon off-stimulation, penile erection and intracorporeal pressure returned to baseline after a mean of 22.7 +/- 3.2 s. Penile and pressure response to MS was resumed after an off-time of 50 s. The response was reproducible infinitely if the off-time was observed. The controls showed no penile tumescence or rigidity or increase of the intracorporeal pressure. In conclusion, MS of the cavernous nerve is effective in inducing penile rigidity. It is a simple, easy and non-invasive method which has no adverse effects. It might prove to be suitable for application in patients with ED.

The corporo-glans ligament: description and functional significance of a ligament connecting the corpora cavernosa to the glans penis.

The two corpora cavernosa (CC) end blindly under cover of the glans penis (GP). The method of attachment of the CC to the GP could not be traced in the literature. The current communication investigated the hypothesis of a ligamentous attachment existing between the two corporal ends and the GP. In all, 18 male cadaveric specimens were studied by direct dissection and histologically. Six were neonates and 12 adults (mean age 32.3+/-10.6 s.d. y). After examining and photographing the connection between the CC and GP, sagittal, parasagittal, and coronal sections of the connection were stained and studied microscopically. A triangular fibrous tissue band connected the distal blind ends of the two CC with the GP. The base of this band was attached to the tunica albuginea of the two CC, while the apex was continuous with the fibrous septa between the sinusoids of the cavernous tissue of the GP. Microscopically, the ligament consisted of collagen and elastic fibers; in some sections, the collagen fibers of the tunica albuginea were continuous with those of the band. A band of collagen and elastic fibers could be identified connecting the two CC to the GP; we term it the 'corporo-glans ligament'. This ligament presumably affords the connection with rigidity, flexibility, and tissue strength. We suggest that it firmly connects the GP to the CC during penile thrusting. Further studies are required to assess the possible role of this ligament in erectile dysfunction.

A study of the effect of straining on the cavernosus muscles: identification of 'straining-cavernosus reflex' and its clinical significance.

Bulbo/ischiocavernosus muscles (BCM, ICM) were found to contract on straining. We investigated the hypothesis that straining effects cavernosus muscles' contraction through a reflex action. The response of the BCM and ICM electromyographic (EMG) activity to increased intra-abdominal pressure (straining) as recorded by the intravesical pressure was registered in 32 healthy volunteers (age 39.2 +/- 10.3 years, 20 men, 12 women). The latency of the response was recorded. Responses were registered again in 17 subjects after individual anaesthetisation of urinary bladder, BCM, and ICM. BCM and ICM EMG activity increased progressively with increasing straining. It was not evoked after frequent successive straining. Latency decreased gradually with increase of straining intensity. Cavernosus muscles did not respond to straining after bladder and cavernosus muscles had been individually anaesthetised. Straining appears to effect cavernosus muscles' contraction through the 'straining-cavernosus reflex'. Cavernosus muscles' contraction produces compression of the penile and clitoral cavernous tissue. BCM contraction, furthermore, causes narrowing or closure of the vaginal introitus. The vagina is suggested to become a high pressure closed cavity which counteracts the increased intra-abdominal pressure and uterine tendency to prolapse. Meanwhile, the elevated intravaginal pressure presumably supports the rectovaginal septum against the concomitant high intrarectal pressure.

Rectal cooling test in the differentiation between constipation due to rectal inertia and anismus.

BACKGROUND: The differentiation between constipation due to rectal inertia and that due to outlet obstruction from non-relaxing puborectalis muscle (PRM) is problematic and not easily achieved with one diagnostic test. Therefore, we studied the hypothesis that the rectal cooling test (RCT) can effectively be used to differentiate between those two forms of constipation. METHODS: The study enrolled 28 patients with constipation and abnormal transit study in whom radio-opaque markers accumulated in the rectum; 15 healthy volunteers acted as controls. Electromyographic activity of the external anal sphincter (EAS) and PRM was initially recorded. Subsequently rectal wall tone was assessed by a barostat system during rectal infusion with normal saline at 30 degrees C and at 4 degrees C with simultaneous electromyography (EMG). RESULTS: There was a significant increase in EMG activity of the EAS and PRM on strain- ing (p<0.001), suggestive of anismus, in 10 of 28 patients and 0 of 15 controls. Rectal tone in controls did not respond to saline infusion at 30 degrees C, but it increased at 4 degrees C (p<0.05). Similarly, in constipated patients rectal tone did not respond to rectal saline infusion at 30 degrees C, but infusion at 4 degrees C increased tone in all 10 patients with anismus (p<0.05); EMG activity of the EAS and PRM also increased (p<0.001). In the remaining 18 patients, rectal tone after saline infusion at 4 degrees C remained unchanged. CONCLUSIONS: Rectal infusion with iced saline increased rectal tone in healthy controls and constipated patients with anismus while it had no effect in the remaining patients. Lack of increase of rectal tone may be secondary to rectal inertia. According to these preliminary observations, the rectal cooling test may be useful in differentiating between rectal inertia and anismus.

Identification of a vaginal pacemaker: An immunohistochemical and morphometric study.

Vaginal electric waves spread caudally in the vagina. We investigated the hypothesis that electric waves originate from a centre of interstitial cells of Cajal (ICCs) in the proximal vagina. Specimens (0.75 x 0.75 cm) were obtained from the vaginal walls of 23 cadavers (age 38.2 +/- 10.2 years). Sections were prepared for immunohistochemical investigations using the specific ICC marker, C-kit. Morphometric studies for image analysis using a Leica imaging system were performed. C-kit positive cells were detected in vaginal smooth muscle. Results from image analyser revealed that mean area percent of positive immunoreactivity for C-kit in the upper part of posterior vaginal wall was significantly higher (p < 0.0001) than of areas in other vaginal walls, and also significantly higher (p < 0.05) in circular than in longitudinal muscle layer. Studies have shown that the greatest collection of ICCs occurred in the upper part of the posterior vaginal wall. The vaginal electric waves are suggested to originate from this 'centre' and spread caudally.

Interstitial cells of Cajal in erectile dysfunction.

The corpora cavernosa (CC) evokes electric activity. Slow waves (SWs) appear to originate from interstitial cells of Cajal (ICCs), which seem to control the activity of the smooth muscle cells (SMC). The ICCs were demonstrated to exist in the CC. We investigated the hypothesis that the ICC distribution differs with each of the various ED types. The study comprised 62 men with ED: 16 neurogenic (NGED), 15 arteriogenic (AGED), 11 venogenic (VGED) and 22 psychogenic (PGED). 15 volunteers with normal erections acted as controls. The patients underwent a complete diagnostic evaluation. A biopsy of 3 x 3 mm from the CC was subjected to C-kit immunohistochemistry examination. Specificity control of the antisera consisted of incubation of the tissue with normal rabbit serum substituted for the primary antiserum. C-kit positive stellate-appearing cells resembling those of ICC were detected in the controls. The branches were either laterally located (multipolar) or lying at each pole (bipolar). They were distinguishable from the SMC, which were C-kit negative. ICC were detected in all specimens from patients with NGED and VGED, absent in 13/15 with AGED and scanty in PGED. ICC distribution was different in the various types of ED. It is suggested that this distribution interferes with SW discharge and the control of SMC activity with a resulting ED.

Molecular andrology as related to sperm DNA fragmentation/sperm chromatin biotechnology.

Genetic male infertility occurs throughout the life cycle from genetic traits carried by the sperm, to fertilization and post-fertilization genome alterations, and subsequent developmental changes in the blastocyst and fetus as well as errors in meiosis and abnormalities in spermatogenesis/spermatogenesis. Genes encoding proteins for normal development include SRY, SOX9, INSL3 and LGR8. Genetic abnormalities affect spermatogenesis whereas polymorphisms affect receptor affinity and hormone bioactivity. Transgenic animal models, the human genome project, and other techniques have identified numerous genes related to male fertility. Several techniques have been developed to measure the amount of sperm DNA damage in an effort to identify more objective parameters for evaluation of infertile men. The integrity of sperm DNA influences a couple's fertility and helps predict the chances of pregnancy and its successful outcome. The available tests of sperm DNA damage require additional large-scale clinical trials before their integration into routine clinical practice. The physiological/molecular integrity of sperm DNA is a novel parameter of semen quality and a potential fertility predictor. Although DNA integrity assessment appears to be a logical biomarker of sperm quality, it is not being assessed as a routine part of semen analysis by clinical andrologists. Extensive investigation has been conducted for the comparative evaluation of these techniques. However, some of these techniques require expensive instrumentation for optimal and unbiased analysis, are labor intensive, or require the use of enzymes whose activity and accessibility to DNA breaks may be irregular. Thus, these techniques are recommended for basic research rather than for routine andrology laboratories.

Sperm DNA fragmentation.

Several techniques have been developed to measure the amount of sperm DNA damage in an effort to identify more objective parameters for evaluation of infertile men. The integrity of sperm DNA influences a couple's fertility and helps predict the chances of pregnancy and its successful outcome. The available tests of sperm DNA damage require additional large-scale clinical trails before their integration into routine clinical practice. The physiological/molecular integrity of sperm DNA is a novel parameter of semen quality and a potential fertility predictor. Although DNA integrity assessment appears to be a logical biomarker of sperm quality, it is not being assessed as a routine part of semen analysis by clinical andrologists. Extensive investigation has been conducted for the comparative evolution of these techniques. However, some of these techniques require expensive instrumentation for optimal and unbiased analysis, are labor intensive, or require the use of enzymes whose activity and accessibility to DNA breaks may be irregular. Thus, these techniques are recommended for basic research rather than for routine andrology laboratories. Sperm chromatin structure evaluation is applied to detect male factors that may affect the chance of success with IVF as well as natural fertility. Further research is needed to define the optimal test of sperm chromatin structure. The clinical application of this test will evolve as well.

Urethral sphincters response to cavernosus muscles stimulation with identification of cavernoso-urethral reflex.

The functional activity of the urethral sphincters during cavernosus muscles' contraction at coitus has been poorly addressed in the literature. We investigated the hypothesis that cavernosus muscles' contraction affects reflex contraction of the urethral sphincters to guard against semen reflux into the urinary bladder or urine leakage from the bladder during orgasm and ejaculation. The electromyographic (EMG) response of the external (EUS) and internal (IUS) urethral sphincters to ischio- (ICM) and bulbo- (BCM) cavernosus muscle stimulation was studied in 15 healthy volunteers (9 men, 6 women, age 39.3 +/- 8.2 SD years). An electrode was applied to each of ICM and BCM (stimulating electrodes) and the 2 urethral sphincters (recording electrodes). The test was repeated after individual anesthetization of the urethral sphincters and the 2 cavernosus muscles, and after using saline instead of lidocaine. Upon stimulation of each of the 2 cavernosus muscles, the EUS and IUS recorded increased EMG activity. Repeated cavernosus muscles' stimulation evoked the urethral sphincteric response without fatigue. The urethral sphincters did not respond to stimulation of the anesthetized cavernosus muscles nor did the anesthetized urethral sphincters respond to cavernosus muscle stimulation. Saline infiltration instead of lidocaine did not affect the urethral sphincteric response to cavernosal muscle stimulation. Results were reproducible. Cavernosus muscles' contraction is suggested to effect EUS and IUS contraction. This action seems to be reflex and mediated through the 'cavernoso-urethral reflex.' Urethral sphincters contraction upon cavernosus muscles contraction during sexual intercourse presumably prevents urine leak from the urinary bladder to urethra, prevents retrograde ejaculation, and propels ejaculate from the posterior to the penile urethra. The cavernoso-urethral reflex can act a diagnostic tool in the investigations of patients with ejaculatory disorders.

Tunica albuginea overlapping: a novel technique for the treatment of erectile dysfunction.

Tunica albuginea (TA) in venogenic erectile dysfunction (VED) was found subluxated and flabby because of degeneration and atrophy of its collagen fibres. This had apparently led to derangement of TA veno-occlusive mechanism. We investigated the hypothesis that overlapping of the subluxated and flabby TA would achieve a competent veno-occlusive mechanism during erection. Tunical overlapping was performed in nine VED patients (age 35.6 +/- 1.6 years). Intracorporal pressure (ICP) was measured pre- and postoperatively. After penile degloving, TA on lateral penile aspect was divided along whole length of corpus cavernosum (CC) and tunical double-breasting for 1-1 1/2 cm was performed. A biopsy was taken from TA and stained with haematoxylin and eosin and Masson's trichrome. Clinical efficiency of the operation was evaluated after 6 months. ICP increased (P < 0.01) postoperatively in the nine patients. The increase was maintained during follow-up period in eight patients and decreased to preoperative level in one. Six months after operation, the eight patients had significantly (P < 0.01) improved scores for the erectile function domain over the preoperative scores. Microscopic examination of TA biopsies showed atrophy of the collagen fibres. Tunical overlapping aims at correction of TA flabbiness, corporal tissue support and improving of veno-occlusive mechanism.

Cauterization-plication operation in the treatment of complete rectal prolapse.

The current communication presents a simple technique for treatment of complete rectal prolapse (CRP). The study included 28 patients presenting with CRP (mean age, 36.4 years; 4 children 2-12 years; 17 female and 11 males). Fourteen patients had fecal incontinence. With the patient under general anesthesia in lithotomy position, the prolapsed rectum was pulled outside the anal canal, the mucosa was cauterized in vertical lines and the exposed muscle layer was plicated by 2/0 coated Vicryl sutures. Posterior levatorplasty was done in 14 adult patients in whom the length of prolapsed segment was more than 10 cm and who were incontinent due to a wide levator hiatus. The postoperative follow up was 31.6+/-14.8 months (mean+/-SD). Five had postoperative mucosal prolapse and one had recurrence 3 months of operation. Mucosal plication was performed for the five patients and the operation was redone for the recurrent patient. Fecal impaction, stricture and fistula formation were not encountered. The technique is simple, easy and with minimal complications.

Experimental use of the obturator internus muscle as a functioning pelvic floor muscle in dogs.

OBJECTIVE: To investigate the possibility of using the obturator internus muscle instead of the levator ani as a pelvic floor muscle. DESIGN: Experimental study. SETTING: Teaching hospital, Egypt. ANIMALS: 7 male and 3 female mongrel dogs. INTERVENTIONS: Through a para-anal incision both muscles were exposed; the levator ani was excised and the lower border of the obturator internus was mobilised and sutured to the anorectal junction, the vesical neck, and the vaginal fornix. MAIN OUTCOME MEASURES: Rectal and anal pressures and electromyographic (EMG) activity recorded before and during transposition, and 1, 3, and 6 months later. Histological examination of biopsy specimens taken from the levator ani before, and from the obturator internus before, and 3, 6, and 12 months after, transposition. RESULTS: Stimulation of the levator ani caused anal pressure to decline significantly (p < 0.05). Stimulation of the obturator internus did not change anal pressure before transposition but caused a decline after it. There was EMG activity in the levator ani at rest, but not in the obturator internus before transposition though it was evident by 6 months afterwards. Levator ani consisted of skeletal muscle fibres with smooth muscle fibres in places, whereas the obturator internus consisted of skeletal fibres alone. Six months after operation examination of the obturator internus showed the presence of some smooth muscle fibres. CONCLUSION: These results suggest that the obturator internus might be suitable both anatomically and physiologically to replace the levator ani. However, before it can be suggested as a treatment for levator dysfunction syndrome further experimental studies are necessary.