Pubovisceral muscle and anal sphincter defects in women with fecal or urinary incontinence after vaginal delivery.

BACKGROUND: Vaginal delivery is the most frequent cause of direct anal sphincter trauma as well as pelvic floor muscle defects in women with corresponding signs and symptoms. The aim of the present study was to identify anatomical and functional abnormalities of the anal canal and pelvic floor in women who had had a vaginal delivery and determine the relationship between such abnormalities and the symptoms and severity of fecal incontinence (FI). METHODS: Consecutive female patients with symptoms of fecal and/or urinary incontinence were recruited through the colorectal and gynecological outpatient clinics at two large university hospitals and were eligible if they had had at a vaginal delivery. All women were assessed for symptoms FI by means of the Cleveland Clinic Florida Incontinence Scale (CCFIS) and for urinary incontinence symptoms, including the presence of complaints of any involuntary leakage of urine, leakage on exertion, sneezing, or coughing, and/or leaking or losing urine associated with an urge to urinate. All women underwent anorectal and endovaginal three-dimensional ultrasonography and anal manometry. The extent of the anal sphincter and PVM defects identified by ultrasound was scored from 1 to 6 based on the longitudinal involvement of the external and internal anal sphincter, the radial angle of the anterior external anal sphincter defect and the longitudinal involvement of the PVM. RESULTS: There were 130 women and 89 (68%) had at least one defect of the anal sphincter or the pubovisceral muscle or both (42/32% had a pubovisceral muscle defect with or without sphincter defects, 47/36% women had an intact pubovisceral muscle but sphincter defect); and 41 (32%) had intact anal sphincter and pubovisceral muscles. The mean levator hiatus area at rest in women with anal sphincter and/or pubovisceral muscle defects was 18 (± 4 SD) which was significantly greater than in women with no defects (16 ± 3 SD; p = 0.01). Women with PVM defects had significantly higher ultrasound scores (median ultrasound score = 4/range 1-10 vs Intact = 2/range 2-5), indicating more extensive defects (p = 0.001). Bivariate analysis revealed a positive association (p < 0.05) between increasing FI symptom severity (CCFIS score) and women with PVM defects (ρ = 0.6913). Within the group of women with defects mean maximum anal squeeze pressure was significantly lower in women with PVM defect (mean 73 ± 34 SD mmHg vs mean 93 ± 38 SD; p = 0.04). Women with PVM defects had significantly higher median CCFIS scores (median score, 7/range 0-16) compared to women with intact PVM (4/range 0-10) (p < 0.001). There was a significant positive correlation between the CCFIS and ultrasound scores (ρ = 0.625; p < 0.001). Bivariate analysis revealed a negative correlations between the CCFIS score and the lengths of the anterior EAS (ρ = - 0.5621, p < 0.001), IAS (ρ = - 0.40, p < 0.001) and the area of the levator hiatus (ρ = 0.5211, p = 0.001). However, no significant correlations were observed between CCFIS scores and the gap measurement (ρ = 0.101; p = 0.253) or the resting (ρ = - 0.08, p = 0.54) or squeeze pressure (ρ = - 0.12; p = 0.34) values on anal manometry. The variables associated with worsening FI symptom severity (CCFIS score) that remained significant in multiple linear regression included the shorter lengths of the anterior EAS and/or the lengths of the anterior IAS and increased area of the levator hiatus. CONCLUSIONS: The study data demonstrate that half of the women had combined defects of PVM and sphincter. There were correlations between anatomical abnormalities including the anal sphincter and/or pubovisceral muscle defects with decrease in the anal pressures and increased severity of FI.

Dynamic translabial ultrasound versus echodefecography combined with the endovaginal approach to assess pelvic floor dysfunctions: How effective are these techniques?

BACKGROUND: The aim of this study was to evaluate the role of dynamic translabial ultrasound (TLUS) in the assessment of pelvic floor dysfunction and compare the results with echodefecography (EDF) combined with the endovaginal approach. METHODS: Consecutive female patients with pelvic floor dysfunction were eligible. Each patient was assessed with EDF combined with the endovaginal approach and TLUS. The diagnostic accuracy of the TLUS was evaluated using the results of EDF as the standard for comparison. RESULTS: A total of 42 women were included. Four sphincter defects were identified with both techniques, and EDF clearly showed if the defect was partial or total and additionally identified the pubovisceral muscle defect. There was substantial concordance regarding normal relaxation and anismus. Perfect concordance was found with rectocele and cystocele. The rectocele depth was measured with TLUS and quantified according to the EDF classification. Fair concordance was found for intussusception. There was no correlation between the displacement of the puborectal muscle at maximum straining on EDF with the displacement of the anorectal junction (ARJ), compared at rest with maximal straining on TLUS to determine perineal descent (PD). The mean ARJ displacement was similar in patients with normal and those with excessive PD on TLUS. CONCLUSIONS: Both modalities can be used as a method to assess pelvic floor dysfunction. The EDF using 3D anorectal and endovaginal approaches showed advantages in identification of the anal sphincters and pubodefects (partial or total). There was good correlation between the two techniques, and a TLUS rectocele classification based on size that corresponds to the established classification using EDF was established.

Quality control of food products purchased by the National School-Feeding Programme in Pernambuco, northeast Brazil, from 1985 to 1988.

The effectiveness of the Quality Control System (QCS) implemented by the Fundação de Assistência ao Escolar (FAE) for quality control of food products from different types and origins purchased by the National School-Feeding Programme (NSFP) in Pernambuco, Northeast Brazil, was evaluated. Physicochemical, microbiological, microscopical and organopetical analyses were performed in 4,860 food samples and the main causes of alterations were detected. Perishability was the characteristic used for distribution of food items into 3 main groups: A, B, and C. In accordance with 972 Quality Certificates between 1985 and 1988, 31.89 of the samples were rejected. The main reasons for rejection were innacuracies of net weight and drained weight and high moisture contents. Group B presented the smallest number of altered samples (27%); for Groups A and C these values were 33% and 44%, respectively. Our data lead to the conclusion that the QCS implemented by FAE is of paramount importance for an adequate quality control of foods provided to beneficiaries and for a good cost effectiveness of the school-feeding programme.

PIP: In Brazil, approximately 25 million children from state elementary schools are covered by the National School-Feeding Program (NSFP). Since 1985 a quality control system (QCS) has supervised the foods distributed by the NSFP. The control of 24 accredited laboratories, called Basis Units (BUs), includes collection, inspection, and analysis. The effectiveness of the QCS was investigated after 4 years of implementation in Pernambuco, Brazil. A total of 4860 samples of food (972 lots) was collected, inspected, and analyzed between 1985 and 1988. Foods were distributed into: Group A (the least perishable goods: sugar, beans, rice, oil, salt), Group B (moderately perishable goods: biscuits, chocolate, manioc flour, corn, meal, dried skim milk, macaroni, sugar-cane syrup, canned sardines, ground corn) and Group C (the most perishable goods: dried and salted fish and meat). Physicochemical, organoleptical, microscopical, and microbiological analyses were performed by the Laboratory of Food Sciences, Federal University of Pernambuco. Results were transcribed to the correspondent Quality Certificate and compared with standard values. Rejection occurred when only 1 critical alteration and/or 2 or more acceptable alterations were present in the food. Data from 972 Quality Certificates showed a slight decline in the rejection levels of food samples from 1985 to 1987, with a tendency towards stabilization in 1988. However, in 1988, rejection levels declined for Group B and increased for Groups A and C. About 31.89% of the total samples did not comply with the standards and were rejected. The highest and the lowest values for quality were found in samples of Group B and C, respectively; and intermediate values were detected in Group A. Group B presented the smallest number of altered samples (27%). The main reasons for rejection of foods in Group A were inaccuracies of the net weight, unsatisfactory grain classification, high moisture contents, and the presence of insects. The QCS is of paramount importance for beneficiaries' protection and for cost effectiveness of the school-feeding program.

Quality control of food products purchased by the National School-Feeding Programme in Pernambuco, northeast Brazil, from 1985 to 1988

The effectiveness of the Quality Control System (QCS) implemented by the Fundaçäo de Assistência ao Escolar (FAE) for quality control of food products from different types and origins purchased by the National School-Feeding Programme (NSFP) in Pernambuco, Northeast Brazil, was evaluated. Physicochemical, microbiological, microscopical and organopetical analyses were performed in 4,860 food samples and the main causes of alterations were detected. Perishability was the characteristic used for distribution of food items into 3 main groups: A, B, and C. In accordance with 972 Quality Certificates between 1985 and 1988, 31.89 of the samples were rejected. The main reasons for rejection were innacuracies of net weight and drained weight and high moisture contents. Group B presented the smallest number of altered samples (27%); for Groups A and C these values were 33% and 44%, respectively. Our data lead to the conclusion that the QCS implemented by FAE is of paramount importance for an adequate quality control of foods provided to beneficiaries and for a good cost effectiveness of the school-feeding programme