[Treatment of severe constipation]. / Vaikean ummetuksen hoito.

Commonly used therapeutic products in constipation, i.e. fiber supplements and laxatives, are not sufficiently effective for intractable constipation. Biofeedback therapy is utilized in functional obstructed defecation syndrome. Botulin injections into the levator muscle have been described to be beneficial. For some patients, retrograde rectal lavage is sufficient. Slow-transit constipation can also be treated by applying sacral nerve stimulation as well as antegrade lavage through a colonic stoma made into the proximal part of the large intestine. Surgical treatment can be offered for selected patients having a mechanical defecation block. Resection of the bowel is the most common surgical treatment.

Sacral neuromodulation in urological indications: the Finnish experience.

OBJECTIVE: Sacral neuromodulation is a treatment modality for voiding dysfunction that is resistant to conventional medical and surgical treatments. In Finland, sacral neuromodulation has been used for the treatment of urgency-frequency syndrome, non-obstructive urinary retention and painful bladder/interstitial cystitis since 1996. MATERIAL AND METHODS: The investigation retrospectively evaluated 180 tested patients, 74 of whom underwent permanent implantation of the InterStim device. RESULTS: A positive test result leading to implantation was significantly more frequent among females than males. Among urinary retention patients, the patients with a positive test leading to implantation were significantly younger than those without implantation. The implantation operation time was significantly shorter when using a tined lead device compared with open electrode insertion (76 vs 122 min). The mean follow-up time was 41 months (range 0-143). Significant improvement after implantation was noted in the mean urinated volumes and number of daily urinations, as well as in the number of catheterizations in urgency-frequency syndrome and urinary retention, respectively. The subjective long-term outcome was similar in these indications. Surgical revision was required for 15 patients (20.3% of implanted patients). CONCLUSIONS: The difference in gender distribution compared with earlier published series may be explained by a selection bias due to the limited referrals of female patients from gynaecologists. The results favour the use of a tined lead device because of the shorter operating room time. Furthermore, the outcome seems to be more favourable among patients with a staged implant procedure compared with a one-stage operation with a tined lead device.

[Neuromodulation in urology and proctology]. / Virtaa virtsaamiseen, watteja valumiseen. Neuromodulaatio virtsaamis- ja ulostamisongelmien hoidossa.

Electrical stimulation of sacral nerve roots is called neuromodulation. In urology, neuromodulation has been used for the treatment of frequency syndrome, urinary incontinence and urinary retention. Faecal incontinence and constipation are the most significant indications for the use of neuromodulation in gastroenterology. Carefully selected patients should be evaluated by trial test during which the symptom diary will be filled before implantation. Permanent generator implantation can be done for patients with significant objective relief of symptoms. Generator setting can be adjusted by a remote control. Clinical trials have shown the benefit of neuromodulation in long-term. Implanted patients have to stay under routine follow-up in order to detect device malfunctions.

[Treatment of anal incontinence]. / Anaali-inkontinenssin hoito.

Diagnosis and treatment of anal incontinence in outpatient care are simple and usually quite feasible for the general practitioner. The main single cause of the incontinence is an age-related weakening of the pelvic floor. The basic care invariably involves moderation of the bowel function by medication and diet as well as strengthening of pelvic floor muscles, which is suitable for the treatment of both anal and urinary incontinence. If basic care does not help, the patient is sent into specialized care. Corrective surgical operations of the sphincter yield varying results. Neurostimulation can be tried for nearly all patients suffering from severe fecal incontinence.

Outcome of primary repair of obstetric anal sphincter rupture using the overlap technique.

BACKGROUND: Grade III and IV anal sphincter ruptures after vaginal delivery are an increasing problem. We assessed the outcome of an overlap technique in primary repair. METHODS: In this retrospective observational study, from 2002 to 2004, 61 consecutive women with grade III and IV obstetric tears were included. Of the 61 women, 42 had complete rupture of the external sphincter and underwent sphincter repair using standardised overlap technique. The outcome was assessed by clinical examination, Wexner questionnaire, and endoanal ultrasonography (EAUS), after a median follow-up of 9.4 months. Main outcome measure was continence following primary repair. RESULTS: At follow-up, 64% of the patients had no symptoms of anal incontinence. A total of 29% experienced occasional incontinence to flatus, 1 patient (2%) experienced occasional incontinence to liquid stools, and 1 patient to liquid or normal stools. EAUS revealed intact external sphincter in 29 of the 35 patients (83%). In 6 patients (17%), EAUS showed partial discontinuity of the sphincter muscle. CONCLUSION: The results show that the primary overlap technique in the repair of anal sphincter rupture following vaginal delivery is highly successful.

Cumulative failure rate of ileal pouch-anal anastomosis and quality of life after failure.

PURPOSE: The aim of the study was to calculate the cumulative occurrence of pouch failure among 486 patients who had undergone proctocolectomy and ileoanal anastomosis for ulcerative colitis or familial adenomatous polyposis. The other goal was to compare the quality of life in the failure group of 21 patients, the successful group, and the healthy population. METHODS: Data were collected from patient histories, with the probability of pouch failure being calculated by the Kaplan-Meier method. Patients with pouch failure and controls were sent a Short-Form 36-item quality-of-life questionnaire, and data were analyzed with paired -test. RESULTS: The overall failure rate was 5.3 percent (26), including 24 pouch excisions and 2 early deaths (0.4 percent). Cumulative probabilities of pouch failure were 1, 5, and 7 percent at 1, 5, and 10 years, respectively. Neither pouchitis, gender, nor diagnosis correlated with pouch failure, but fistula formation ( p< 0.001) did. Patients with failure had lower quality-of-life scores for physical function (p < 0.02), social function ( p< 0.04), energy ( p< 0.02), and physical role function ( < 0.03) than the healthy population. Scores for physical function ( p< 0.01), energy ( p< 0.01), and physical role function ( p< 0.05) were also lower than those of control patients. CONCLUSIONS: The most common cause of pouch failure is fistula, whereas pouch excision is rarely caused by pouchitis. The impaired quality of life of patients in the failure group was caused by impairment of physical function and restrictions in social life.

Anal incontinence: diagnosis by endoanal US or endovaginal MRI.

Preoperative evaluation was made of the diagnostic value of endoanal ultrasound (EAUS) and endovaginal magnetic resonance imaging (EVMRI) in diagnosing anal sphincter defects as the cause of anal incontinence. Nineteen female individuals with anal incontinence were examined clinically with EAUS and with EVMRI at 1.5 T using a prostatic coil. The findings were evaluated independently and compared with findings at surgery. In diagnosing external anal sphincter defects, EAUS and EVMRI showed almost similar agreement with surgical findings, 12 (63%) out of 19 vs 11 (58%), respectively. Internal anal sphincter defects were equally detected by EAUS and EVMRI as compared with surgical diagnosis. There was considerable variation between radiologists in diagnosing defects by EVMRI. EAUS and EVMRI are equal in diagnosing anal sphincter defects.

Sphincter rupture and anal incontinence after first vaginal delivery.

BACKGROUND: The aim of this prospective study was to establish the incidence of anal incontinence and sphincter defects after first vaginal delivery. METHODS: A total of 99 nulliparous and pregnant women were examined prospectively 4 weeks (mean) before delivery and 4 months (mean) after delivery. Of the study population, 75 (76%) women had vaginal delivery and 24 (24%) had cesarean section. Vacuum extraction was necessary in 20 (20%) cases. The symptoms of anal incontinence were asked about using a standard questionnaire. Clinical examination, endoanal ultrasound (EAUS) and anal manometry were performed before and after delivery. RESULTS: The symptoms of mild anal incontinence, mainly gas incontinence, increased after vaginal delivery more than after cesarean section (P < 0.032). Occult anal sphincter defects were noted in 17 (23%) of the 75 women after vaginal delivery by using EAUS. After vacuum extraction, anal sphincter defects were noted in nine (45%) out of 20 women. No new sphincter defects were found in the cesarean section group. The maximal squeezing pressures were significantly decreased in the patients with external anal sphincter (EAS) defects (P = 0.0025). Vacuum extraction leads to more sphincter defects but does not significantly increase anal incontinence or decrease mean anal sphincter pressures. CONCLUSIONS: The first vaginal delivery can result in occult sphincter defects and the use of vacuum extraction increases the risk.

Primary sphincter repair: are the results of the operation good enough?

PURPOSE: This study was designed to evaluate the clinical outcome of primary anal sphincter repair caused by obstetric tears and to analyze possible risk factors associated with sphincter rupture during vaginal delivery. METHODS: A total of 52 females with a third-degree or fourth-degree perineal laceration during vaginal delivery were examined. The symptoms of anal incontinence were obtained by a standard questionnaire. In addition to a clinical examination, endoanal ultrasound, anal manometry, and pudendal nerve terminal motor latency examinations were performed. A control group consisted of 51 primiparous females with no clinically detectable perineal laceration after vaginal delivery. RESULTS: After primary sphincter repair, 31 females (61 percent) had symptoms of anal incontinence. Fecal incontinence occurred in 10 females (20 percent). According to Hardcastle and Parks' and Jorge and Wexner's classifications, the study group had more severe symptoms of anal incontinence than the control group (P<0.001 in both classification groups). In endoanal ultrasound examination, a persistent defect of the external anal sphincter was found in 39 females (75 percent) in the rupture group compared with 10 females (20 percent) in the control group (P<0.001). Anal sphincter pressures were significantly lower in the rupture group than in the control group. An abnormal presentation was the only risk factor for anal sphincter rupture during vaginal delivery. CONCLUSIONS: After primary sphincter repair, persistent external anal sphincter defect and symptoms of anal incontinence are common in females who have had a primary sphincter repair after vaginal delivery. The means of improving the results of primary repair should be studied further.