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Sample records for anal sphincter muscle

  1. Bioengineered internal anal sphincter derived from isolated human internal anal sphincter smooth muscle cells.

    PubMed

    Somara, Sita; Gilmont, Robert R; Dennis, Robert G; Bitar, Khalil N

    2009-07-01

    The internal anal sphincter (IAS) is a specialized circular smooth muscle that maintains rectoanal continence. In vitro models are needed to study the pathophysiology of human IAS disorders. We bioengineered sphincteric rings from human IAS smooth muscle cells (SMC) and investigated their response to cholinergic stimulation as well as investigated whether protein kinase C (PKC) and Rho kinase signaling pathways remain functional. 3-Dimensional bioengineered ring (3DBR) model of the human IAS was constructed from isolated human IAS SMC obtained from surgery. Contractile properties and force generation in response to acetylcholine, PKC inhibitor calphostin-C, Rho/ROCK inhibitor Y-27632, permeable Rho/ROCK inhibitor c3-exoenzyme, and PKC activator PdBU was measured. The human IAS 3DBR has the essential characteristics of physiologically functional IAS; it generated a spontaneous myogenic basal tone, and the constructs were able to relax in response to relaxants and contract in response to contractile agents. The constructs generated dose-dependent force in response to acetylcholine. Basal tone was significantly reduced by calphostin-C but not with Y-27632. Acetylcholine-induced force generation was also significantly reduced by calphostin-C but not with Y-27632. PdBU generated force that was equal in magnitude to acetylcholine. Thus, calphostin-C inhibited PdBU-induced force generation, whereas Y-27632 and c3 exoenzyme did not. These data indicate that basal tone and acetylcholine-induced force generation depend on signaling through the PKC pathway in human IAS; PKC-mediated force generation is independent of the Rho/ROCK pathway. This human IAS 3DBR model can be used to study the pathophysiology associated with IAS malfunctions.

  2. Anatomical Disruption & Length-Tension Dysfunction of Anal Sphincter Complex Muscles in Women with Fecal Incontinence

    PubMed Central

    Kim, Young Sun; Weinstein, Milena; Raizada, Varuna; Jiang, Yanfen; Bhargava, Valmik; Rajasekaran, M. Raj; Mittal, Ravinder K.

    2013-01-01

    BACKGROUND Anal sphincter complex muscles; internal anal sphincter, external anal sphincter and puborectalis muscles, play important role in the anal continence mechanism. Patients with symptoms of fecal incontinence have weak anal sphincter complex muscles; however, their length-tension properties and relationship to anatomical disruption have never been studied. OBJECTIVE To assess the anatomy of anal sphincter complex muscles using 3D-ultrasound imaging system and determine the relationship between anatomical defects and length-tension property of external anal sphincter and puborectalis muscles in women with incontinence symptoms and control subjects. DESIGN Severity of anal sphincter muscle damage was determined by static and dynamic 3Dimensional-ultrasound imaging. Length-tension property was determined by anal and vaginal pressure respectively using custom designed probes. PATIENTS 44 asymptomatic controls and 24 incontinent patients participated in this study. MAIN OUTCOME MEAUSURES Anatomical defects and length-tension dysfunction of anal sphincter complex muscles in FI patients were evaluated. RESULT Prevalence of injury to sphincter muscles are significantly higher in the incontinent patients compared to controls. 85% of patients but only 9% controls reveal damage to ≥2 of the 3 muscles of anal sphincter complex. Anal and vaginal squeeze pressure increased with increase in the probe size (length-tension curve) in majority of controls. In patients, the increase in anal and vaginal squeeze pressures was either significantly smaller than controls or it decreased with the increasing probe size (abnormal length-tension). CONCLUSIONS Length-tension property of the external anal sphincter and puborectalis muscles is significantly impaired in incontinent patients. Our findings have therapeutic implication in the treatment of anal incontinence. PMID:24105004

  3. Damage to anal sphincter/levator ani muscles caused by operative procedure in anal sphincter-preserving operation for rectal cancer.

    PubMed

    Hirano, Atsushi; Koda, Keiji; Kosugi, Chihiro; Yamazaki, Masato; Yasuda, Hideki

    2011-04-01

    Details of postoperative damage to anal sphincter tonus following sphincter-preserving operation for rectal cancer remain unclear. Postoperative anal tonus was measured using 3-dimensional (3D) vector manometry in 56 patients. Anal length with pressure from any direction was defined as total length (TL). Length with circular pressure (LCP), which is only measurable using 3D manometry, was also evaluated. In operations associated with low anastomosis, both TL and LCP at rest were significantly shortened when compared with control (high interior resection [HAR]). In particular, degraded LCP at rest was obvious. Anal lengths in squeezing state were preserved except in cases with intersphincteric resection (ISR). Postoperative incontinence score inversely correlated with functional anal length at rest. Although the sphincter muscles are mechanically preserved, function of the internal sphincter and subsequent defecatory function can be degraded in cases with operative procedures including surgical maneuvers at the pelvic floor. Copyright © 2011 Elsevier Inc. All rights reserved.

  4. The male bulbospongiosus muscle and its relation to the external anal sphincter.

    PubMed

    Peikert, Kevin; Platzek, Ivan; Bessède, Thomas; May, Christian Albrecht

    2015-04-01

    The bulbospongiosus muscle is part of the superficial muscular layer of the perineum and pelvic floor. Its morphology remains controversial in the literature. Therefore, we reinvestigated the fascial arrangement and fiber courses of the bulbospongiosus muscle and its topographical relation to the external anal sphincter. The perineum was dissected in 9 male cadavers (mean ± SD age 78.3 ± 10.7 years). Select samples were obtained for histology and immunohistochemistry. In 43 patients (mean age 60.7 ± 12 years) the topographical relation between the bulbospongiosus muscle and the external anal sphincter was determined by magnetic resonance imaging. The perineum contains several fascial layers consisting of elastic and collagen fibers as well as bundles of smooth muscle cells. The bulbospongiosus muscle was subdivided into a ventral and dorsal portion, which developed in 4 variants. The ventral insertion formed a morphological unity with the ischiocavernous muscle while the dorsal origin had a variable relation to the external anal sphincter (5 variants). A muscle-like or connective tissue-like connection was frequently present between the muscles. However, in some cases the muscles were completely separated. We suggest a concept of variations of bulbospongiosus muscle morphology that unifies the conflicting literature. Its ventral fiber group and the ischiocavernosus muscle form a functional and morphological unity. While the bulbospongiosus muscle and the external anal sphincter remain independent muscles, their frequent connection might have clinical implications for perineal surgery and anogenital disorders. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

  5. Internal anal sphincter: Clinical perspective.

    PubMed

    Kumar, Lalit; Emmanuel, Anton

    2017-08-01

    To summarise current knowledge of Internal anal sphincter. The internal anal sphincter (IAS) is the involuntary ring of smooth muscle in the anal canal and is the major contributor to the resting pressure in the anus. Structural injury or functional weakness of the muscle results in passive incontinence of faeces and flatus. With advent of new assessment and treatment modalities IAS has become an important topic for surgeons. This review was undertaken to summarise our current knowledge of internal anal sphincter and highlight the areas that need further research. The PubMed database was used to identify relevant studies relating to internal anal sphincter. The available evidence has been summarised and advantages and limitations highlighted for the different diagnostic and therapeutic techniques. Our understanding of the physiology and pharmacology of IAS has increased greatly in the last three decades. Additionally, there has been a rise in diagnostic and therapeutic techniques specifically targeting the IAS. Although these are promising, future research is required before these can be incorporated into the management algorithm. Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

  6. Electrical stimulation of anal sphincter or pudendal nerve improves anal sphincter pressure.

    PubMed

    Damaser, Margot S; Salcedo, Levilester; Wang, Guangjian; Zaszczurynski, Paul; Cruz, Michelle A; Butler, Robert S; Jiang, Hai-Hong; Zutshi, Massarat

    2012-12-01

    Stimulation of the pudendal nerve or the anal sphincter could provide therapeutic options for fecal incontinence with little involvement of other organs. The goal of this project was to assess the effects of pudendal nerve and anal sphincter stimulation on bladder and anal pressures. Ten virgin female Sprague Dawley rats were randomly allocated to control (n = 2), perianal stimulation (n = 4), and pudendal nerve stimulation (n = 4) groups. A monopolar electrode was hooked to the pudendal nerve or placed on the anal sphincter. Aballoon catheter was inserted into the anus to measure anal pressure, and a catheter was inserted into the bladder via the urethra to measure bladder pressure. Bladder and anal pressures were measured with different electrical stimulation parameters and different timing of electrical stimulation relative to spontaneous anal sphincter contractions. Increasing stimulation current had the most dramatic effect on both anal and bladder pressures. An immediate increase in anal pressure was observed when stimulating either the anal sphincter or the pudendal nerve at stimulation values of 1 mA or 2 mA. No increase in anal pressure was observed for lower current values. Bladder pressure increased at high current during anal sphincter stimulation, but not as much as during pudendal nerve stimulation. Increased bladder pressure during anal sphincter stimulation was due to contraction of the abdominal muscles. Electrical stimulation caused an increase in anal pressures with bladder involvement only at high current. These initial results suggest that electrical stimulation can increase anal sphincter pressure, enhancing continence control.

  7. Wide variation in anal sphincter muscles in cases of high- and intermediate-type male anorectal malformation.

    PubMed

    Watanabe, Yoshio; Takasu, Hidemi; Sumida, Wataru; Mori, Kensaku

    2013-04-01

    The distribution of sphincter muscle complex in anorectal malformation (ARM) needs to be investigated on a case-by-case basis. This study was undertaken to demonstrate the differences in the anal sphincter muscles between patients with the same type of ARM. Computed tomography (CT) data from cases of high- and intermediate-type male patients with ARM were reviewed using three-dimensional (3D) image analysis. Twenty-seven male patients with ARM (18 high and 9 intermediate) before anorectoplasty were assessed using multidetector-row helical CT (MRH-CT). A 3D reconstruction was made using volume rendering method. The multi-dimensional sections of the 3D reconstructed images of the pelvic muscles were then analyzed and compared with schematic drawings from the literature. The sphincters in the high and intermediate types of ARM could be divided into five groups. In 13 out of 18 cases in the high type and 7 out of 9 cases in the intermediate type, images of the sphincter muscles appeared different from schematic drawings appearing in the literature. In both high and intermediate types of ARM, more than 2/3 of cases demonstrated unexpectedly displaced and deformed hypoplastic sphincters. Therefore, we recommend that variations in anal sphincter should be investigated on an individual basis prior to surgery.

  8. Electrical activity from smooth muscle of the anal sphincteric area of the cat.

    PubMed Central

    Bouvier, M; Gonella, J

    1981-01-01

    1. The electrical activities of longitudinal and circular smooth muscle of the anal sphincteric area have been studied in the cat. 2. Electromyographic recordings were achieved with extracellular electrodes, in vivo on acute and chronic animals, and in vitro on the isolated organ. In addition, electrical and mechanical activities were recorded from muscle strips with the sucrose gap technique. 3. Circular muscle coat electrical activity consisted exclusively of slow variations of the membrane potential of the smooth muscle cells. Each slow potential variation was followed by a contraction. 4. The electrical activity and the concomitant contractions were tetrodotoxin resistant (10(-6) g/ml.). Both disappeared in Ca-free solution or in the presence of Mn ions (10(-3) M). 5. On circular muscle, noradrenaline (10(-8)-10(-7) g/ml. in vitro, or 0.1-0.15 mg/kg in vivo) had an excitatory effect consisting in an increase of slow potential frequency. The action of noradrenaline was antagonized by phentolamine (10(-6)-10(-5) g/ml. in vitro, or 0.2 mg/kg in vivo). 6. On circular muscle, acetylcholine (10(-8)-10(-6) g/ml.), used exclusively on muscle strips, did never produce any clear cut effect. 7. Longitudinal muscle coat electrical activity consisted of spike potentials superimposed on slow time course depolarizations which were never observed alone. Each spike was followed by a contraction. This electrical activity was tetrodotoxin resistant (10(-6) g/ml.). 8. Longitudinal muscle activity was abolished by noradrenaline (10(-6) g/ml.) and enhanced by acetylcholine (10(-8)-10(-6) g/ml.). The action of noradrenaline was antagonized by propranolol (0.2 mg/kg I.V.; 10(-6) g/ml.) and that of acetylcholine by atropine (10(-7) g/ml.). 9. Electrophysiological and pharmacological data indicate that electromechanical coupling is achieved (1) in circular muscle, through Ca dependent slow variations in membrane potential of the muscle cells and (2) in longitudinal muscle, through spike

  9. Relationship Among Anal Sphincter Injury, Patulous Anal Canal, and Anal Pressures in Patients with Anorectal Disorders

    PubMed Central

    Prichard, David; Harvey, Doris M.; Fletcher, Joel G.; Zinsmeister, Alan R.; Bharucha, Adil E.

    2015-01-01

    Background & Aims The anal sphincters and puborectalis are routinely imaged with an endoanal magnetic resonance imaging (MRI) coil, which does not assess co-aptation of the anal canal at rest. Using a MRI torso coil, we identified a patulous anal canal in some patients with anorectal disorders. We aimed to evaluate the relationship between anal sphincter and puborectalis injury, a patulous anal canal, and anal pressures. Methods We performed a retrospective analysis of data from 119 patients who underwent MRI and manometry analysis of anal anatomy and pressures, respectively, from February 2011 through March 2013 at the Mayo Clinic. Anal pressures were determined by high-resolution manometry, anal sphincter and puborectalis injury was determined by endoanal MRI, and anal canal integrity was determined by torso MRI. Associations between manometric and anatomical parameters were evaluated with univariate and multivariate analyses. Results Fecal incontinence (55 patients, 46%) and constipation (36 patients. 30%) were the main indications for testing; 49 patients (41%) had a patulous anal canal, which was associated with injury to more than 1 muscle (all P≤.001) and internal sphincter (P<.01), but not puborectalis (P=.09) or external sphincter (P=.06) injury. Internal (P<.01) and external sphincter injury (P=.02) and a patulous canal (P<.001), but not puborectalis injury, predicted anal resting pressure. A patulous anal canal was the only significant predictor (P<.01) of the anal squeeze pressure increment. Conclusions Patients with anorectal disorders commonly have a patulous anal canal, associated with more severe anal injury, anal resting pressure, and squeeze pressure increment. It is therefore important to identify patulous anal canal because it appears to be a marker of not only anal sphincter injury but disturbances beyond sphincter injury, such as damage to the anal cushions or anal denervation. PMID:25869638

  10. Relationship Among Anal Sphincter Injury, Patulous Anal Canal, and Anal Pressures in Patients With Anorectal Disorders.

    PubMed

    Prichard, David; Harvey, Doris M; Fletcher, Joel G; Zinsmeister, Alan R; Bharucha, Adil E

    2015-10-01

    The anal sphincters and puborectalis are imaged routinely with an endoanal magnetic resonance imaging (MRI) coil, which does not assess co-aptation of the anal canal at rest. By using a MRI torso coil, we identified a patulous anal canal in some patients with anorectal disorders. We aimed to evaluate the relationship between anal sphincter and puborectalis injury, a patulous anal canal, and anal pressures. We performed a retrospective analysis of data from 119 patients who underwent MRI and manometry analysis of anal anatomy and pressures, respectively, from February 2011 through March 2013 at the Mayo Clinic. Anal pressures were determined by high-resolution manometry, anal sphincter and puborectalis injury was determined by endoanal MRI, and anal canal integrity was determined by torso MRI. Associations between manometric and anatomic parameters were evaluated with univariate and multivariate analyses. Fecal incontinence (55 patients; 46%) and constipation (36 patients; 30%) were the main indications for testing; 49 patients (41%) had a patulous anal canal, which was associated with injury to more than 1 muscle (all P ≤ .001), and internal sphincter (P < .01), but not puborectalis (P = .09) or external sphincter (P = .06), injury. Internal (P < .01) and external sphincter injury (P = .02) and a patulous canal (P < .001), but not puborectalis injury, predicted anal resting pressure. A patulous anal canal was the only significant predictor (P < .01) of the anal squeeze pressure increment. Patients with anorectal disorders commonly have a patulous anal canal, which is associated with more severe anal injury and independently predicted anal resting pressure and squeeze pressure increment. It therefore is important to identify a patulous anal canal because it appears to be a marker of not only anal sphincter injury but disturbances beyond sphincter injury, such as damage to the anal cushions or anal denervation. Copyright © 2015 AGA Institute. Published by Elsevier

  11. Transperineal three-dimensional ultrasound imaging for detection of anatomic defects in the anal sphincter complex muscles.

    PubMed

    Weinstein, Milena M; Pretorius, Dolores H; Jung, Sung-Ai; Nager, Charles W; Mittal, Ravinder K

    2009-02-01

    Three-dimensional ultrasound (3D-US) imaging is a powerful tool to visualize various components of the anal sphincter complex, that is, the internal anal sphincter (IAS), the external anal sphincter (EAS), and the puborectalis muscle (PRM). Our goal was to determine the reliability of the 3D-US imaging technique in detecting morphologic defects in the IAS, EAS, and PRM. Transperineal 3D-US images were obtained in 3 groups of women: nulliparous (n = 13), asymptomatic parous (n = 20), and patients with fecal incontinence (FI) (n = 25). The IAS and EAS were assessed to determine the craniocaudal length of defects and were scored as follows: 0 = normal, 1 = less than 25%, 2 = 25% to 50%, 3 = 50% to 75%, and 4 = greater than 75%. The 2 PRM hemislings were scored separately as follows: 0 = normal, 1 = less than 50% abnormal, and 2 = greater than 50% length abnormal. Subjects were grouped according to the score as follows: normal (score 0), minor abnormality (scores of 1 and 2), and major abnormality (scores of 3 and 4). Three observers performed the scoring. The 3D-US allowed detailed evaluation of the IAS, EAS, and PRM. The inter-rater reliability for detecting the defects ranged between 0.80 and 0.95. Nullipara women did not show any significant defect but the defects were quite common in asymptomatic parous and FI patients. The prevalence of defects was greater in the FI patients as compared with the asymptomatic parous women. 3D-US yields reliable assessment of morphologic defects in the anal sphincter complex muscles.

  12. Bimodal effect of oxidative stress in internal anal sphincter smooth muscle

    PubMed Central

    Singh, Jagmohan; Kumar, Sumit

    2015-01-01

    Changes in oxidative stress may affect basal tone and relaxation of the internal anal sphincter (IAS) smooth muscle in aging. We examined this issue by investigating the effects of the oxidative stress inducer 6-anilino-5,8-quinolinedione (LY-83583) in basal as well as U-46619-stimulated tone, and nonadrenergic, noncholinergic (NANC) relaxation in rat IAS. LY-83583, which works via generation of reactive oxygen species in living cells, produced a bimodal effect in IAS tone: lower concentrations (0.1 nM to 10 μM) produced a concentration-dependent increase, while higher concentrations (50–100 μM) produced a decrease in IAS tone. An increase in IAS tone by lower concentrations was associated with an increase in RhoA/Rho kinase (ROCK) activity. This was evident by the increase in RhoA/ROCK in the particulate fractions, in ROCK activity, and in the levels of phosphorylated (p) Thr696-myosin phosphatase target subunit 1 and pThr18/Ser19-20-kDa myosin light chain. Conversely, higher concentrations of LY-83583 produced inhibitory effects on RhoA/ROCK. Interestingly, both the excitatory and inhibitory effects of LY-83583 in the IAS were reversed by superoxide dismutase. The excitatory effects of LY-83583 were found to resemble those with neuronal nitric oxide synthase (nNOS) inhibition by l-NNA, since it produced a significant increase in the IAS tone and attenuated NANC relaxation. These effects of LY-83583 and l-NNA were reversible by l-arginine. This suggests the role of nNOS inhibition and RhoA/ROCK activation in the increase in IAS tone by LY-83583. These data have important implications in the pathophysiology and therapeutic targeting of rectoanal disorders, especially associated with IAS dysfunction. PMID:26138467

  13. Effects of pregnancy, parturition, and anal sphincter transection on function of the external anal sphincter in an animal model.

    PubMed

    Rahn, David D; White, Amanda B; Miller, Rodney T; Word, R Ann; Wai, Clifford Y

    2009-04-01

    To estimate the effects of pregnancy, parturition, and anal sphincter laceration (with repair) on external anal sphincter morphology and neurophysiology and to define the time course of these effects after injury. Within 4 hours of vaginal delivery, 80 rats underwent either sham or anal sphincter laceration with repair. After 3 days, 3 weeks, and 3 and 6 months (n=20 for each time point), animals were killed, and the anal sphincter complexes dissected and removed for neurophysiologic studies. Twitch tension, peak tetanic force, fatigue, and maximal electrical field-stimulated force generation were determined. Sphincters were then fixed and serially sectioned (5-micrometer thickness) at 100-micrometer intervals for histologic analysis. Maximal electrical field-stimulated force generation, maximal tetanic contraction, and twitch tension were decreased in the external anal sphincter 3 days after anal sphincter laceration with repair compared with sham-operated parturient rats (3.3 g compared with 11.6 g, 4.5 g compared with 14.5 g, and 0.6 g compared with 2.0 g, respectively, all P<.02). Increased fatigability of the sphincter muscle was observed in all newly parturient rats-sham and anal sphincter laceration with repair; recovery occurred in the shams by 3 months. A gradual recovery occurred in all these neurophysiologic measures, with no significant differences between anal sphincter laceration with repair and shams by 6 months postpartum. Repaired anal sphincter transection in periparturient animals results in short-term severe compromise of neurophysiologic function of the external anal sphincter. Over time, however, force generation recovers and approximates that of postpartum rats with intact anal sphincters.

  14. Topographic Anatomy of the Anal Sphincter Complex and Levator Ani Muscle as It Relates to Intersphincteric Resection for Very Low Rectal Disease.

    PubMed

    Tsukada, Yuichiro; Ito, Masaaki; Watanabe, Kentaro; Yamaguchi, Kumiko; Kojima, Motohiro; Hayashi, Ryuichi; Akita, Keiichi; Saito, Norio

    2016-05-01

    Intersphincteric resection has become a widely used treatment for patients with rectal cancer. However, the detailed anatomy of the anal canal related to this procedure has remained unclear. The purpose of this study was to clarify the detailed anatomy of the anal canal. This is a descriptive study. Histologic evaluations of paraffin-embedded tissue specimens were conducted at a tertiary referral hospital. Tissue specimens were obtained from cadavers of 5 adults and from 13 patients who underwent abdominoperineal resection for rectal cancer. Sagittal sections from 9 circumferential portions of the cadaveric anal canal (histologic staining) and 3 circumferential portions from patients were studied (immunohistochemistry for smooth and skeletal muscle fibers). Longitudinal fibers between the internal and external anal sphincters consisted primarily of smooth muscle fibers that continued from the longitudinal muscle of the rectum. The levator ani muscle attached directly to the lateral surface of the longitudinal smooth muscle of the rectum. The length of the attachment was longer in the anterolateral portion and shorter in the posterior portion of the anal canal. In the lateral and posterior portions, the levator ani muscle partially overlapped the external anal sphincter; however, there was less overlap in the anterolateral portion. In the posterior portion, thick smooth muscle was present on the surface of the levator ani muscle and it continued to the longitudinal muscle of the rectum. We observed only limited portions in some surgical specimens because of obstruction by tumors. The levator ani muscle attaches directly to the longitudinal muscle of the rectum. The spatial relationship between the smooth and skeletal muscles differed in different portions of the anal canal. For intersphincteric resection, dissection must be performed between the longitudinal muscle of the rectum and the levator ani muscle/external anal sphincter, and the appropriate surgical lines

  15. Internal anal sphincter augmentation and substitution

    PubMed Central

    de la Portilla, Fernando

    2014-01-01

    There is an increasing recognition of the importance of internal anal sphincter (IAS) dysfunction presenting as passive faecal incontinence. This problem may manifest after anal sphincterotomy or following the more minimally invasive operations for haemorrhoids, as well as with advancing age. Because of the poor results of IAS plication and the beneficial outcomes with peri-urethral bulking agents in urology, these materials have been developed for use in IAS dysfunction. This review outlines the basic purported mechanisms of action, defining the materials in clinical use, their methods of deployment, complications and reported outcomes. There is still much that is unknown concerning the ideal agent or the volume and the technique of deployment, which will only be answered by powerful, prospective, randomized, controlled trials. The specific role of autologous stem cells designed to regenerate the sphincters in cases of functional impairment or muscle loss is yet to be seen. PMID:24759338

  16. Transperineal sonographic anal sphincter complex evaluation in chronic anal fissures.

    PubMed

    Bedair, Elsaid M; El Hennawy, Hany M; Moustafa, Ahmed Abdu; Meki, Gad Youssef; Bosat, Bosat Elwany

    2014-11-01

    The purpose of this study was to assess the role of transperineal sonography in assessment of pathologic changes to the anal sphincter complex in patients with chronic anal fissures. We conducted a prospective case-control study of 100 consecutive patients of any age and both sexes with chronic anal fissures who presented to a colorectal clinic between January 2012 and August 2013 (group A) and 50 healthy volunteers (group B). The most common patterns of radiologic changes to anal sphincters associated with chronic anal fissures were circumferential thickening of the anal sphincter complex in 5 patients (5%), circumferential thickening of the internal anal sphincter in 3 patients (3%), preferential thickening of the internal anal sphincter at the 6-o'clock position in 80 patients (80%) and the 12-o'clock position in 7 patients (7%), preferential thickening of the internal and external anal sphincters in 3 patients (3%), and thinning of the internal anal sphincter in 2 patients (2%). Chronic anal fissures cause differential thickening of both internal and external anal sphincters, with a trend toward increased thickness in relation to the site of the fissure. Routine preoperative transperineal sonography for patients with chronic anal fissures is recommended, and it is mandatory in high-risk patients. © 2014 by the American Institute of Ultrasound in Medicine.

  17. Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures.

    PubMed

    Bhardwaj, R; Vaizey, C J; Boulos, P B; Hoyle, C H

    2000-06-01

    Lateral sphincterotomy diminishes internal anal sphincter hypertonia and thereby reduces anal canal pressure. This improves anal mucosal blood flow and promotes the healing of anal fissures. However, sphincterotomy can be associated with long term disturbances of sphincter function. The optimal treatment for an anal fissure is to induce a temporary reduction of anal canal resting pressure to allow healing of the fissure without permanently disrupting normal sphincter function. Broader understanding of the intrinsic mechanisms controlling smooth muscle contraction has allowed pharmacological manipulation of anal sphincter tone. We performed an initial Medline literature search to identify all articles concerning "internal anal sphincter" and "anal fissures". This review is based on these articles and on additional publications obtained by manual cross referencing. Internal anal smooth muscle relaxation can be inhibited by stimulation of non-adrenergic non-cholinergic enteric neurones, parasympathetic muscarinic receptors, or sympathetic beta adrenoceptors, and by inhibition of calcium entry into the cell. Sphincter contraction depends on an increase in cytoplasmic calcium and is enhanced by sympathetic adrenergic stimulation. Currently, the most commonly used pharmacological agent in the treatment of anal fissures is topical glyceryl trinitrate, a nitric oxide donor. Alternative agents that exhibit a similar effect via membrane Ca2+ channels, muscarinic receptors, and alpha or beta adrenoceptors are also likely to have a therapeutic potential in treating anal fissures.

  18. Fetal growth of the anal sinus and sphincters, especially in relation to anal anomalies.

    PubMed

    Arakawa, Takashi; Hwang, Si Eun; Kim, Ji Hyun; Wilting, Joerg; Rodríguez-Vázquez, José Francisco; Murakami, Gen; Hwang, Hong Pil; Cho, Baik Hwan

    2016-03-01

    The anal sinuses, small furrows above the pectinate line, sometimes form perianal abscesses in adults. We examined the pattern of fetal growth of the anal sinus and sphincters using 22 mid-term (8-18 weeks) and 6 late-stage (30-38 weeks) fetuses. In mid-term fetuses, the external and internal sphincters gradually increased in thickness, depending on specimen size (from 0.2 to 1.5 mm), whereas the anteroposterior diameter of the anal canal at the epithelial junction was relatively stable (0.5-1.0 mm) irrespective of specimen size. Anal canal diameter increased less than twofold between mid-term and late-stage fetuses, from 0.5-1.0 to almost 2 mm, whereas sphincter thickness increased over tenfold, from 0.2-1.5 to almost 3.5 mm. The anal sinus often showed balloon-like enlargement when the sphincter muscle bundles were tightly packed in mid-term, but not in late-stage fetuses. Large concentric mechanical stress from the sphincters in late-stage fetuses apparently prevented the anal sinus from expanding in a balloon-like manner. Conversely, to avoid anal stenosis, the growing sinuses maintained a luminal space of the anal canal in response to stress from rapidly growing sphincters. The inferiorly extending sinus usually provided temporal double canals separated by a thick column. In the presence of double lumens, anal canal duplication is likely to develop without any abnormalities of the anal epithelium and sphincters.

  19. Ultrasound anal sphincter defects and 3D anal pressure defects.

    PubMed

    Mion, F; Garros, A; Damon, H; Roman, S

    2017-04-13

    We read with interest the paper by Rezaie et al. on the use of 3D high definition anorectal manometry (3DARM) to detect anal sphincter defects in patients with faecal incontinence [1]. In their series of 39 patients, they described a new metrics to define anal pressure defect (defect of at least 18° of the 25 mmHg isobaric contour on anal resting pressures), and then compared the results of pressure defects determined by 3DARM and 3D anal ultrasound results. They found a rather good negative predictive value of manometry to eliminate the presence of ultrasound anal sphincter defects (92%), and suggested the possibility to use 3DARM to rule out anal sphincter defects and avoid the need of anal ultrasound in selected patients. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

  20. Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function.

    PubMed

    Jenkins, J T; Urie, A; Molloy, R G

    2008-03-01

    The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity. Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano-rectal pathology were prospectively assessed by manometry and anal endosonography. Anterior anal fissures were identified in a younger age group [33 years (IQR 26-37) vs 41 years (IQR 36-52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4-35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH2O (IQR 126-196) vs 205 cmH2O (IQR 174-262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4-55.7)]. Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.

  1. Do hot baths promote anal sphincter relaxation?

    PubMed

    Pinho, M; Correa, J C; Furtado, A; Ramos, J R

    1993-03-01

    Hot perineal baths have been prescribed for the treatment of painful anorectal conditions such as anal fissures and perianal hematomas or for the postoperative care of hemorrhoidectomy. Despite this widely accepted benefit, no studies have been performed to determine whether there is a rational explanation for this procedure. Anorectal manometry was performed in 40 control subjects with no anorectal complaints before and after a hot perineal bath. No significant difference was found between anal pressures at rest or during voluntary contraction before and after the bath. We conclude from this study that no relaxation of anal sphincters can be obtained by hot perineal baths in normal subjects.

  2. Regenerating the Anal Sphincter: Cytokines, Stem Cells, or Both?

    PubMed

    Sun, Li; Xie, Zhuojun; Kuang, Mei; Penn, Marc; Damaser, Margot S; Zutshi, Massarat

    2017-04-01

    Healing of an anal sphincter defect at a time distant from injury is a challenge. We aimed to investigate whether re-establishing stem cell homing at the site of an anal sphincter defect when cytokine expression has declined using a plasmid engineered to express stromal derived factor 1 with or without mesenchymal stem cells can improve anatomic and functional outcome. This was a randomized animal study. Thirty-two female age- and weight-matched Sprague Dawley rats underwent 50% excision of the anal sphincter complex. Three weeks after injury, 4 interventions were randomly allocated (n = 8), including no intervention, 100-μg plasmid, plasmid and 800,000 cells, and plasmid with a gelatin scaffold mixed with cells. The differences in anal sphincter resting pressures just before and 4 weeks after intervention were used for functional analysis. Histology was analyzed using Masson staining. One-way ANOVA followed by the Tukey post hoc test was used for pressure and histological analysis. All 3 of the intervention groups had a significantly greater change in resting pressure (plasmid p = 0.009; plasmid + cells p = 0.047; plasmid + cells in scaffold p = 0.009) compared with the control group. The plasmid-with-cells group showed increased organization of muscle architecture and increased muscle percentage, whereas the control group showed disorganized architecture at the site of the defect. Histological quantification revealed significantly more muscle at the site of defect in the plasmid-plus-cells group compared with the control group, which had the least muscle. Quantification of connective tissue revealed significantly less fibrosis at the site of defect in the plasmid and plasmid-plus-cells groups compared with the control group. Midterm evaluation and muscle morphology were not defined. At this midterm follow-up, local delivery of a stromal derived factor 1 plasmid with or without local mesenchymal stem cells enhanced anal sphincter muscle regeneration long after an

  3. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation: mass contraction of the pelvic floor muscles.

    PubMed

    Shafik, A

    1998-01-01

    We have previously demonstrated both anatomically and physiologically that the external anal (EAS) and urethral (EUS) sphincters and the bulbocavernosus muscle (BC) originate from the puborectalis muscle (PR). It is hypothesized that stimulation of any of these muscles would lead to contraction of all the others. Because the levator ani (pubococcygeus) muscle (LA) also has the same innervation as the above-mentioned muscles, it is further suggested that it, too, contracts reflexly upon stimulation of any of those muscles. The purpose of this study was to test this hypothesis. The study comprised 18 healthy volunteers (mean age 36.6 +/- 8.4 years; 10 men, 8 women). The EAS was stimulated and the response of the EUS, PR, LA and BC was determined. Each muscle was thereafter stimulated separately and the response of the other pelvic floor muscles registered. Stimulation of any of the pelvic floor muscles effected an increased EMG activity of the rest of the muscles. The muscle contraction was instantaneous with no latency in all the muscles except the LA EMG activity, which showed a mean latency of 21.3 +/- 6.6 ms. The pelvic floor muscles' response seems to be attributable to muscle stimulation both directly and indirectly through activation of pudendal nerve fibers in the muscles. The study demonstrated that the pelvic floor muscles behave as one muscle: they contract or relax en masse. This 'mass contraction' might explain some of the physiologic phenomena that occur during pelvic organ evacuation. However, besides this mass contraction, a voluntary 'selective' individual muscle activity exists by which each individual muscle acts independently of the others.

  4. Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex.

    PubMed

    van Meegdenburg, Maxime M; Trzpis, Monika; Heineman, Erik; Broens, Paul M A

    2016-09-01

    Chronic anal fissure is a painful disorder caused by linear ulcers in the distal anal mucosa. Even though it counts as one of the most common benign anorectal disorders, its precise etiology and pathophysiology remains unclear. Current thinking is that anal fissures are caused by anal trauma and pain, which leads to internal anal sphincter hypertonia. Increased anal basal pressure leads to diminished anodermal blood flow and local ischemia, which delays healing and leads to chronic anal fissure. The current treatment of choice for chronic anal fissure is either lateral internal sphincterotomy or botulinum toxin injections. In contrast to current thinking, we hypothesize that the external, rather than the internal, anal sphincter is responsible for increased anal basal pressure in patients suffering from chronic anal fissure. We think that damage to the anal mucosa leads to hypersensitivity of the contact receptors of the anal-external sphincter continence reflex, resulting in overreaction of the reflex. Overreaction causes spasm of the external anal sphincter. This in turn leads to increased anal basal pressure, diminished anodermal blood flow, and ischemia. Ischemia, finally, prevents the anal fissure from healing. Our hypothesis is supported by two findings. The first concerned a chronic anal fissure patient with increased anal basal pressure (170mmHg) who had undergone lateral sphincterotomy. Directly after the operation, while the submucosal anesthetic was still active, basal anal pressure decreased to 80mmHg. Seven hours after the operation, when the anesthetic had completely worn off, basal anal pressure increased again to 125mmHg, even though the internal anal sphincter could no longer be responsible for the increase. Second, in contrast to previous studies, recent studies demonstrated that botulinum toxin influences external anal sphincter activity and, because it is a striated muscle relaxant, it seems reasonable to presume that it affects the striated

  5. Obstetric anal sphincter injury: incidence, risk factors, and management.

    PubMed

    Dudding, Thomas C; Vaizey, Carolynne J; Kamm, Michael A

    2008-02-01

    Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management. This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists. A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality. Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive

  6. [Predictive factors of 2-month postpartum anal incontinence among patients with an obstetrical anal sphincter injury].

    PubMed

    Ménard, S; Poupon, C; Bourguignon, J; Théau, A; Goffinet, F; Le Ray, C

    2016-10-01

    To determine prevalence of short-term postpartum anal incontinence after obstetrical anal sphincter injury and prognostic factors. Retrospective study including every patient with an obstetrical anal sphincter injury between January 2006 and December 2012 in one tertiary maternity unit. Patients were interviewed and examined at 2-month postpartum. Anal incontinence was defined by the presence of at least one of the following symptoms: flatus incontinence, faecal incontinence and faecal urgency. Among 17,110 patients who delivered vaginally during period study, 134 (0.8%) presented an anal sphincter injury. Postpartum obstetrical data were available for 110 of them. Among those patients, 50 women (45.5%) had at least one symptom of anal incontinence at 2-month postpartum and 8 (7.3%) had faecal incontinence. Only maternal age and second stage duration were significantly associated with anal incontinence after obstetrical anal sphincter injury. The degree of sphincter damage at delivery (IIIa, b, c, IV) was not associated with the risk of anal incontinence at 2-month postpartum. Maternal age and second stage duration were the only risk factor for anal incontinence after obstetrical anal sphincter injury in this study. High prevalence of anal incontinence at 2-month postpartum of obstetrical anal sphincter injury is observed no matter what is the degree of anal sphincter damage. Our results highlight the importance to diagnose all obstetrical anal sphincter injuries whatever the degree of damage. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

  7. Anal sphincter trauma and anal incontinence in urogynecological patients.

    PubMed

    Guzmán Rojas, R A; Kamisan Atan, I; Shek, K L; Dietz, H P

    2015-09-01

    To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma. This was a retrospective analysis of ultrasound volume datasets of 501 patients attending a tertiary urogynecological unit. All patients underwent a standardized interview including determination of St Mark's score for those presenting with AI. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS and the internal anal sphincter (IAS). Among a total of 501 women, significant EAS and IAS defects were found in 88 and 59, respectively, and AI was reported by 69 (14%). Optimal prediction of AI was achieved using a model that included four abnormal slices of the EAS on TUI. IAS defects were found to be less likely to be associated with AI. In a multivariable model controlling for age and IAS trauma, the presence of at least four abnormal slices gave an 18-fold (95% CI, 9-36; P < 0.0001) increase in the likelihood of AI, compared with those with fewer than four abnormal slices. Using receiver-operating characteristics curve statistics, this model yielded an area under the curve of 0.86 (95% CI, 0.80-0.92). Both AI and significant EAS trauma are common in patients attending urogynecological units, and are strongly associated with each other. Abnormalities of the IAS seem to be less important in predicting AI. Our data support the practice of using, as a minimal criterion, defects present in four of the six slices on TUI for the diagnosis of significant EAS trauma. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

  8. Functional morphology of anal sphincter complex unveiled by high definition anal manometery and three dimensional ultrasound imaging.

    PubMed

    Raizada, V; Bhargava, V; Karsten, A; Mittal, R K

    2011-11-01

    Anal sphincter complex consists of anatomically overlapping internal anal sphincter (IAS), external anal sphincter (EAS) and puborectalis muscle (PRM). We determined the functional morphology of anal sphincter muscles using high definition anal manometery (HDAM), three dimensional (3D)-ultrasound (US) and Magnetic resonance (MR) imaging. We studied 15 nulliparous women. High definition anal manometery probe equipped with 256 pressure transducers was used to measure the anal canal pressures at rest and squeeze. Lengths of IAS, PRM, and EAS were determined from the 3D-US images and superimposed on the HDAM plots. Movements of anorectal angle with squeeze were determined from the dynamic MR images. High definition anal manometery plots reveal that anal canal pressures are highly asymmetric in the axial and circumferential direction. Anal canal length determined by the 3D-US images is slightly smaller than that measured by HDAM. The EAS (1.9 ± 0.5 cm long) and PRM (1.7 ± 0.4 cm long) surround distal and proximal parts of the anal canal, respectively. With voluntary contraction, anal canal pressures increase in the proximal (PRM) and distal (EAS zone) parts of anal canal. Posterior peak pressure in the anal canal moves cranially in relation to the anterior peak pressure, with squeeze. Similar to the movement of peak posterior pressure, MR images show cranial movement of anorectal angle with squeeze. Our study proves that the PRM is responsible for the closure of the cranial part of anal canal. HDAM, in addition to measuring constrictor function can also record the elevator function of levator ani/pelvic floor muscles. © 2011 Blackwell Publishing Ltd.

  9. Anal sphincteric neurogenic injury in asymptomatic nulliparous women and fecal incontinence.

    PubMed

    Bharucha, Adil E; Daube, Jasper; Litchy, William; Traue, Julia; Edge, Jessica; Enck, Paul; Zinsmeister, Alan R

    2012-07-15

    While anal sphincter neurogenic injury documented by needle electromyography (EMG) has been implicated to cause fecal incontinence (FI), most studies have been uncontrolled. Normal values and the effects of age on anal sphincter motor unit potentials (MUP) are ill defined. The functional significance of anal sphincter neurogenic injury in FI is unclear. Anal pressures and EMG were assessed in 20 asymptomatic nulliparous women (age, 38 ± 5 yr; mean ± SE) and 20 women with FI (54 ± 3 yr). A computerized program quantified MUP duration and phases. These parameters and MUP recruitment were also semiquantitatively assessed by experienced electromyographers in real time. Increasing age was associated with longer and more polyphasic MUP in nulliparous women by quantitative analysis. A higher proportion of FI patients had prolonged (1 control, 7 patients, P = 0.04) and polyphasic MUP (2 controls, 9 patients, P = 0.03) at rest but not during squeeze. Semiquantitative analyses identified neurogenic or muscle injury in the anal sphincter (11 patients) and other lumbosacral muscles (4 patients). There was substantial agreement between quantitative and semiquantitative analyses (κ statistic 0.63 ± 95% CI: 0.32-0.96). Anal resting and squeeze pressures were lower (P ≤ 0.01) in FI than controls. Anal sphincter neurogenic or muscle injury assessed by needle EMG was associated (P = 0.01) with weaker squeeze pressures (83 ± 10 mmHg vs. 154 ± 30 mmHg) and explained 19% (P = 0.01) of the variation in squeeze pressure. Anal sphincter MUP are longer and more polyphasic in older than younger nulliparous women. Women with FI have more severe neurogenic or muscle anal sphincter injury, which is associated with lower squeeze pressures.

  10. Anal sphincteric neurogenic injury in asymptomatic nulliparous women and fecal incontinence

    PubMed Central

    Daube, Jasper; Litchy, William; Traue, Julia; Edge, Jessica; Enck, Paul; Zinsmeister, Alan R.

    2012-01-01

    While anal sphincter neurogenic injury documented by needle electromyography (EMG) has been implicated to cause fecal incontinence (FI), most studies have been uncontrolled. Normal values and the effects of age on anal sphincter motor unit potentials (MUP) are ill defined. The functional significance of anal sphincter neurogenic injury in FI is unclear. Anal pressures and EMG were assessed in 20 asymptomatic nulliparous women (age, 38 ± 5 yr; mean ± SE) and 20 women with FI (54 ± 3 yr). A computerized program quantified MUP duration and phases. These parameters and MUP recruitment were also semiquantitatively assessed by experienced electromyographers in real time. Increasing age was associated with longer and more polyphasic MUP in nulliparous women by quantitative analysis. A higher proportion of FI patients had prolonged (1 control, 7 patients, P = 0.04) and polyphasic MUP (2 controls, 9 patients, P = 0.03) at rest but not during squeeze. Semiquantitative analyses identified neurogenic or muscle injury in the anal sphincter (11 patients) and other lumbosacral muscles (4 patients). There was substantial agreement between quantitative and semiquantitative analyses (κ statistic 0.63 ± 95% CI: 0.32–0.96). Anal resting and squeeze pressures were lower (P ≤ 0.01) in FI than controls. Anal sphincter neurogenic or muscle injury assessed by needle EMG was associated (P = 0.01) with weaker squeeze pressures (83 ± 10 mmHg vs. 154 ± 30 mmHg) and explained 19% (P = 0.01) of the variation in squeeze pressure. Anal sphincter MUP are longer and more polyphasic in older than younger nulliparous women. Women with FI have more severe neurogenic or muscle anal sphincter injury, which is associated with lower squeeze pressures. PMID:22575218

  11. Recurrent obstetric anal sphincter injury and the risk of long-term anal incontinence.

    PubMed

    Jangö, Hanna; Langhoff-Roos, Jens; Rosthøj, Susanne; Sakse, Abelone

    2017-06-01

    Women with an obstetric anal sphincter injury are concerned about the risk of recurrent obstetric anal sphincter injury in their second pregnancy. Existing studies have failed to clarify whether the recurrence of obstetric anal sphincter injury affects the risk of anal and fecal incontinence at long-term follow-up. The objective of the study was to evaluate whether recurrent obstetric anal sphincter injury influenced the risk of anal and fecal incontinence more than 5 years after the second vaginal delivery. We performed a secondary analysis of data from a postal questionnaire study in women with obstetric anal sphincter injury in the first delivery and 1 subsequent vaginal delivery. The questionnaire was sent to all Danish women who fulfilled inclusion criteria and had 2 vaginal deliveries 1997-2005. We performed uni- and multivariable analyses to assess how recurrent obstetric anal sphincter injury affects the risk of anal incontinence. In 1490 women with a second vaginal delivery after a first delivery with obstetric anal sphincter injury, 106 had a recurrent obstetric anal sphincter injury. Of these, 50.0% (n = 53) reported anal incontinence compared with 37.9% (n = 525) of women without recurrent obstetric anal sphincter injury. Fecal incontinence was present in 23.6% (n = 25) of women with recurrent obstetric anal sphincter injury and in 13.2% (n = 182) of women without recurrent obstetric anal sphincter injury. After adjustment for third- or fourth-degree obstetric anal sphincter injury in the first delivery, maternal age at answering the questionnaire, birthweight of the first and second child, years since first and second delivery, and whether anal incontinence was present before the second pregnancy, the risk of flatal and fecal incontinence was still increased in patients with recurrent obstetric anal sphincter injury (adjusted odds ratio, 1.68 [95% confidence interval, 1.05-2.70), P = .03, and adjusted odds ratio, 1.98 [95% confidence interval, 1

  12. Synchronized functional anal sphincter assessment: maximizing the potential of anal vector manometry and 3-D anal endosonography.

    PubMed

    Schizas, A M P; Ahmad, A N; Emmanuel, A V; Williams, A B

    2016-07-01

    Understanding the association between structure and function is vital before considering surgery involving anal sphincter division. By correlating three-dimensional anal endosonography (AES) and three-dimensional anal canal vector volume manometry (VVM), this study details a method to produce measurements of both sphincter length and pressure leading to identification of the functionally important areas of the anal canal. The aim of this study was to provide combined detailed information on anal canal anatomy and physiology. Twelve males and 12 nulliparous females with no bowel symptoms underwent VVM (using a water-perfused, eight-channel radially arranged catheter) and AES. The synchronization of AES and VVM identified that the majority of rest and squeeze anal pressure is present in the portion of the anal canal covered by both anal sphincters. Nearly, 20% of overall resting anal pressure is produced distal to the caudal termination of the internal anal sphincter. Puborectalis accounts for a significantly greater percentage volume of pressure in females both at rest and when squeezing, though the total volume of pressure is not significantly greater. The majority of resting and squeezing pressure and the least asymmetry, in both sexes, is in the portion of the anal canal covered by external anal sphincter. In females, the external anal sphincter is shorter and a proportionately longer puborectalis accounts for a greater percentage of pressure. Sphincter targeted fistula surgery in females must be performed with special caution. A protective role for puborectalis following obstetric anal sphincter injury is suggested. © 2016 John Wiley & Sons Ltd.

  13. Successful implantation of physiologically functional bioengineered mouse internal anal sphincter

    PubMed Central

    Raghavan, Shreya; Miyasaka, Eiichi A.; Hashish, Mohamed; Somara, Sita; Gilmont, Robert R.; Teitelbaum, Daniel H.

    2010-01-01

    We have previously developed bioengineered three-dimensional internal anal sphincter (IAS) rings from circular smooth muscle cells isolated from rabbit and human IAS. We provide proof of concept that bioengineered mouse IAS rings are neovascularized upon implantation into mice of the same strain and maintain concentric smooth muscle alignment, phenotype, and IAS functionality. Rings were bioengineered by using smooth muscle cells from the IAS of C57BL/6J mice. Bioengineered mouse IAS rings were implanted subcutaneously on the dorsum of C57BL/6J mice along with a microosmotic pump delivering fibroblast growth factor-2. The mice remained healthy during the period of implantation, showing no external signs of rejection. Mice were killed 28 days postsurgery and implanted IAS rings were harvested. IAS rings showed muscle attachment, neovascularization, healthy color, and no external signs of infection or inflammation. Assessment of force generation on harvested IAS rings showed the following: 1) spontaneous basal tone was generated in the absence of external stimulation; 2) basal tone was relaxed by vasoactive intestinal peptide, nitric oxide donor, and nifedipine; 3) acetylcholine and phorbol dibutyrate elicited rapid-rising, dose-dependent, sustained contractions repeatedly over 30 min without signs of muscle fatigue; and 4) magnitudes of potassium chloride-induced contractions were 100% of peak maximal agonist-induced contractions. Our preliminary results confirm the proof of concept that bioengineered rings are neovascularized upon implantation. Harvested rings maintain smooth muscle alignment and phenotype. Our physiological studies confirm that implanted rings maintain 1) overall IAS physiology and develop basal tone, 2) integrity of membrane ionic characteristics, and 3) integrity of membrane associated intracellular signaling transduction pathways for contraction and relaxation by responding to cholinergic, nitrergic, and VIP-ergic stimulation. IAS smooth muscle

  14. Anal sphincter injury in vaginal deliveries complicated by shoulder dystocia.

    PubMed

    Hehir, Mark P; Rubeo, Zachary; Flood, Karen; Mardy, Anne H; O'Herlihy, Colm; Boylan, Peter C; D'Alton, Mary E

    2017-05-18

    Shoulder dystocia is an obstetric emergency that occurs in 0.2-3% of all cephalic vaginal deliveries. We hypothesized that because of the difficult nature of deliveries complicated by shoulder dystocia, the condition may be associated with anal sphincter injury. We sought to identify risk factors for obstetric anal sphincter injury in women with shoulder dystocia. This retrospective analysis included all cases of shoulder dystocia from 2007 to 2011 at two large tertiary referral centers, in the USA and Ireland. Details of maternal demographics, intrapartum characteristics, and delivery outcomes in cases of shoulder dystocia were analyzed. Univariate and multivariate analyses were used to describe the association between shoulder dystocia and anal sphincter injury. There were 685 cases of shoulder dystocia, and the rate of shoulder dystocia was similar at both institutions. The incidence of anal sphincter injury was 8.8% (60 out of 685). The rate was 14% (45 out of 324) in nulliparas and 4.2% (15 out of 361) in multiparas. Women with sphincter injury were more likely to be nulliparous (75% [45 out of 60] vs 45% [279 out of 625]; p < 0.0001), have had an operative vaginal delivery (50% [30 out of 60] vs 36% [226 out of 625]; p = 0.03) and require internal maneuvers (50% [30 out of 60] vs 32% [198 out of 625], p = 0.004) than those with an intact sphincter. On multivariate regression analysis, these predictors of sphincter injury remained significant when adjusted for other risk factors. Episiotomy was negatively associated with sphincter injury on multivariate regression analysis. In a retrospective cohort of 685 women with shoulder dystocia, the risk of anal sphincter injury is 9%. Risk factors include nulliparity, operative vaginal delivery, and use of internal maneuvers, whereas episiotomy was found to have a protective effect against anal sphincter injury during cases of shoulder dystocia.

  15. Can Anal Sphincter Defects Be Identified by Palpation?

    PubMed

    Shek, Ka Lai; Atan, Ixora Kamisan; Dietz, Hans Peter

    The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects. This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging. Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small. Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.

  16. Functional Morphology of Anal Sphincter Complex Unveiled by High Definition Manometery & 3-Dimensional Ultrasound Imaging

    PubMed Central

    Raizada, Varuna; Bhargava, Valmik; Karsten, Anna; Mittal, Ravinder K.

    2011-01-01

    Objective Anal sphincter complex consists of anatomically overlapping internal anal sphincter (IAS), external anal sphincter (EAS) & puborectalis muscle (PRM). We determined the functional morphology of anal sphincter muscles using high definition manometery (HDAM), 3D-ultrasound (US) and Magnetic resonance (MR) imaging. Patients We studied 15 nulliparous women. Interventions HDAM probe equipped with 256 pressure transducers was used to measure the anal canal pressures at rest and squeeze. Lengths of IAS, PRM and EAS were determined from the 3D-US images and superimposed on the HDAM plots. Movements of anorectal angle with squeeze were determined from the dynamic MR images. Results HDAM plots reveal that anal canal pressures are highly asymmetric in the axial and circumferential direction. Anal canal length determined by the 3D-US images is slightly smaller than measured by HDAM. The EAS (1.9 ± 0.5 cm long) and PRM (1.7 ± 0.4 cm long) surround distal and proximal parts of the anal canal respectively. With voluntary contraction, anal canal pressures increase in the proximal (PRM) and distal (EAS zone) parts of anal canal. Posterior peak pressure in the anal canal moves cranially in relationship to the anterior peak pressure, with squeeze. Similar to the movement of peak posterior pressure, MR images show cranial movement of anorectal angle with squeeze. Conclusion Our study proves that the PRM is responsible for the closure of the cranial part of anal canal. HDAM, in addition to measuring constrictor function can also record the elevator function of levator ani/pelvic floor muscles. PMID:21951657

  17. A rare case of leiomyoma of the internal anal sphincter

    PubMed Central

    Sturiale, Alessandro; Fabiani, Bernardina; Naldini, Gabriele

    2016-01-01

    Introduction Leiomyoma is a benign tumour which derives from the smooth muscle fibres and it may occurs in every site in which this type of muscle is present. Among all benign soft tissue tumours it represents almost 3.8% and its pathogenesis remains still unknown. Presentation of case The present case is about a 62 year old woman referred to our centre complaining anal and perineal pain which increase after defecation in association with the appearance of a nodule in the perianal region fixed to the anal sphincter. A 360° tridimensional transanal ultrasound was performed and it showed an anterior nodular thickening of the internal anal sphincter. After an inconclusive preoperative biopsy and a counselling with the patient, the surgeons decided to proceed with the surgical excision. The immunohistochemical examination confirmed the preoperative suspicion of leiomyoma. At 1 year follow-up the patient had not tumour-related symptoms or fecal incontinence and any signs of local recurrence at ultrasound imaging were demonstrated. Discussion Leiomyomas are relatively insensitive to chemotherapy whereby surgery is the treatment of choice and it should be adequate to the site and dimension of the lesion achieving a complete resection with free margins. A further close follow-up is needed too. Conclusion Nowadays there is not a gold standard technique to treat such kind of lesions and the decision of the best surgical approach should depend on the dimension and site. In fact, surgery aims to the oncological outcome trying also to minimize the possible post-operative functional complications. PMID:27078867

  18. Mesenchymal stem cells can improve anal pressures after anal sphincter injury☆

    PubMed Central

    Salcedo, Levilester; Mayorga, Maritza; Damaser, Margot; Balog, Brian; Butler, Robert; Penn, Marc; Zutshi, Massarat

    2016-01-01

    Objective Fecal incontinence reduces the quality of life of many women but has no long-term cure. Research on mesenchymal stem cell (MSC)-based therapies has shown promising results. The primary aim of this study was to evaluate functional recovery after treatment with MSCs in two animal models of anal sphincter injury. Methods Seventy virgin female rats received a sphincterotomy (SP) to model episiotomy, a pudendal nerve crush (PNC) to model the nerve injuries of childbirth, a sham SP, or a sham PNC. Anal sphincter pressures and electromyography (EMG) were recorded after injury but before treatment and 10 days after injury. Twenty-four hours after injury, each animal received either 0.2 ml saline or 2 million MSCs labelled with green fluorescing protein (GFP) suspended in 0.2 ml saline, either intravenously (IV) into the tail vein or intramuscularly (IM) into the anal sphincter. Results MSCs delivered IV after SP resulted in a significant increase in resting anal sphincter pressure and peak pressure, as well as anal sphincter EMG amplitude and frequency 10 days after injury. MSCs delivered IM after SP resulted in a significant increase in resting anal sphincter pressure and anal sphincter EMG frequency but not amplitude. There was no improvement in anal sphincter pressure or EMG with in animals receiving MSCs after PNC. GFP-labelled cells were not found near the external anal sphincter in MSC-treated animals after SP. Conclusion MSC treatment resulted in significant improvement in anal pressures after SP but not after PNC, suggesting that MSCs could be utilized to facilitate recovery after anal sphincter injury. PMID:23147650

  19. Endoanal MRI of the anal sphincter complex: correlation with cross-sectional anatomy and histology.

    PubMed Central

    Hussain, S M; Stoker, J; Zwamborn, A W; Den Hollander, J C; Kuiper, J W; Entius, C A; Laméris, J S

    1996-01-01

    The purpose of this study was to correlate the in vivo endoanal MRI findings of the anal sphincter with the cross-sectional anatomy and histology. Fourteen patients with rectal tumours were examined with a rigid endoanal MR coil before undergoing abdominoperineal resection. In addition, 12 cadavers were used to obtain cross-sectional anatomical sections. The images were correlated with the histology and anatomy of the resected rectal specimens as well as with the cross-sectional anatomical sections of the 12 cadavers. The findings in 8 patients, 11 rectal preparations, and 10 cadavers, could be compared. In these cases, there was an excellent correlation between endoanal MRI and the cross-sectional cadaver anatomy and histology. With endoanal MRI, all muscle layers of the anal canal wall, comprising the internal anal sphincter, longitudinal muscle, the external anal sphincter and the puborectalis muscle were clearly visible. The levator ani muscle and ligamentous attachments were also well demonstrated. The perianal anatomical spaces, containing multiple septae, were clearly visible. In conclusion, endoanal MRI is excellent for visualising the anal sphincter complex and the findings show a good correlation with the cross-sectional anatomy and histology. Images Fig. 1 Fig. 2 PMID:8982844

  20. Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth.

    PubMed

    Evers, Emily C; Blomquist, Joan L; McDermott, Kelly C; Handa, Victoria L

    2012-11-01

    The purpose of this study was to investigate the long-term impact of anal sphincter laceration on anal incontinence. Five to 10 years after first delivery, anal incontinence and other bowel symptoms were measured with the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetric exposures were assessed with review of hospital records. Symptoms and quality-of-life impact were compared among 90 women with at least 1 anal sphincter laceration, 320 women who delivered vaginally without sphincter laceration, and 527 women who delivered by cesarean delivery. Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio, 2.32; 95% confidence interval, 1.27-4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality-of-life scores were similar between women who delivered by cesarean section and those who delivered vaginally without sphincter laceration. Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery. Copyright © 2012 Mosby, Inc. All rights reserved.

  1. Predicting obstetric anal sphincter injuries in a modern obstetric population.

    PubMed

    Meister, Melanie R L; Cahill, Alison G; Conner, Shayna N; Woolfolk, Candice L; Lowder, Jerry L

    2016-09-01

    Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal

  2. Successful Implantation of Bioengineered, Intrinsically Innervated, Human Internal Anal Sphincter

    PubMed Central

    Raghavan, Shreya; Gilmont, Robert R.; Miyasaka, Eiichi A.; Somara, Sita; Srinivasan, Shanthi; Teitelbaum, Daniel H; Bitar, Khalil N.

    2011-01-01

    Background & Aims To restore fecal continence, the weakened pressure of the internal anal sphincter (IAS) must be increased. We bioengineered intrinsically innervated human IAS, to emulate sphincteric physiology, in vitro. Methods We co-cultured human IAS circular smooth muscle with immortomouse fetal enteric neurons. We investigated the ability of bioengineered innervated human IAS, implanted in RAG1−/− mice, to undergo neovascularization and preserve the physiology of the constituent myogenic and neuronal components. Results The implanted IAS was neovascularized in vivo; numerous blood vessels were observed with no signs of inflammation or infection. Real-time force acquisition from implanted and pre-implant IAS showed distinct characteristics of IAS physiology. Features included the development of spontaneous myogenic basal tone; relaxation of 100% of basal tone in response to inhibitory neurotransmitter vasoactive intestinal peptide (VIP) and direct electrical field stimulation of the intrinsic innervation; inhibition of nitrergic and VIPergic EFS-induced relaxation (by antagonizing nitric oxide synthesis or receptor interaction); contraction in response to cholinergic stimulation with acetylcholine; and intact electromechanical coupling (evidenced by direct response to potassium chloride). Implanted, intrinsically innervated bioengineered human IAS tissue preserved the integrity and physiology of myogenic and neuronal components. Conclusion Intrinsically innervated human IAS bioengineered tissue can be successfully implanted in mice. This approach might be used to treat patients with fecal incontinence. PMID:21463628

  3. Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy.

    PubMed

    Ho, Y H; Seow-Choen, F; Tsang, C; Eu, K W

    2001-11-01

    Conventional stapled haemorrhoidectomy involves the use of a large circular anal dilator (DL technique), which may cause anal sphincter injuries. This study compared whether the procedure can be effectively performed without this dilator (ND technique), with better sphincter preservation. Fifty-eight patients with symptomatic prolapsed irreducible haemorrhoids were randomized to DL (n = 29) and ND (n = 29) groups. Preoperative continence scoring, anorectal manometry and endoanal ultrasonography were performed. These were repeated at up to 14 weeks after operation, with additional pain scores, analgesic requirements and quality of life assessments. DL haemorrhoidectomy took significantly longer to perform (P = 0.02). However, there were fewer residual skin tags (P = 0.044) and less perianal pruritus (P = 0.007) at 2 weeks, although such symptoms subsided to an equivalent level in both groups afterwards. Internal anal sphincter fragmentation persisting to at least 14 weeks was found in four patients after DL, but not after ND haemorrhoidectomy (P = 0.038). However, these were asymptomatic and no differences were found in continence scores and anal pressures. The pain scores, satisfaction scores, quality of life assessments and time off work were similar. The large circular anal dilator used for stapled haemorrhoidectomy increased the risk of anal sphincter injuries, which may become problematic with ageing.

  4. Challenges faced in the clinical application of artificial anal sphincters*

    PubMed Central

    Wang, Ming-hui; Zhou, Ying; Zhao, Shuang; Luo, Yun

    2015-01-01

    Fecal incontinence is an unresolved problem, which has a serious effect on patients, both physically and psychologically. For patients with severe symptoms, treatment with an artificial anal sphincter could be a potential option to restore continence. Currently, the Acticon Neosphincter is the only device certified by the US Food and Drug Administration. In this paper, the clinical safety and efficacy of the Acticon Neosphincter are evaluated and discussed. Furthermore, some other key studies on artificial anal sphincters are presented and summarized. In particular, this paper highlights that the crucial problem in this technology is to maintain long-term biomechanical compatibility between implants and surrounding tissues. Compatibility is affected by changes in both the morphology and mechanical properties of the tissues surrounding the implants. A new approach for enhancing the long-term biomechanical compatibility of implantable artificial sphincters is proposed based on the use of smart materials. PMID:26365115

  5. Risk of obstetric anal sphincter lacerations among obese women.

    PubMed

    Lindholm, E S; Altman, D

    2013-08-01

    To assess the risk for obstetric anal sphincter lacerations in relation to maternal obesity among primiparous women in Sweden. A population-based study. Sweden. All women with vaginal delivery and singleton pregnancy in Sweden in the years 2003-2008 (n = 210,678). The Medical Birth Registry, the National Board of Health and Welfare, was used to identify cases of rupture and body mass index (BMI) classes. The population was categorised into four classes with BMI of <25, 25 to <30, 30 to <35 and >35 kg/m². Odds ratios were estimated with 95% confidence intervals. In order to estimate the effect of BMI on obstetric anal sphincter lacerations, with possible confounders accounted for, uni- and multivariate logistic regressions were performed. In total, 8958 (4.25%) cases of anal sphincter lacerations (grade III-IV) occurred; increasing BMI showed a significant near-dose-response type of protective effect against grade III-IV lacerations when compared with women with BMI <25 kg/m²: BMI 25 to <30 kg/m², 0.89; BMI 30 to <35 kg/m², 0.84; BMI > 35 kg/m², 0.70. Overweight and obesity were associated with a decreased risk for obstetric anal sphincter lacerations. © 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.

  6. Role of internal anal sphincter damage in the causation of idiopathic faecal incontinence: a prospective study.

    PubMed

    Petros, Peter; Anderson, Jim

    2005-02-01

    This prospective study aimed to examine the relationship between internal anal sphincter (IAS) damage and 'idiopathic' faecal incontinence (FI) in 50 consecutive patients, using endoanal ultrasound examination. The external anal sphincter (EAS) was intact on direct and ultrasonic assessment in all patients. IAS damage was defined as complete rupture or attenuation, less than 2 mm thickness in some part of the sphincter. Complete rupture was found in one patient and damage in a further 17 (total 36%). All three nulliparous patients had normal IAS and EAS. IAS damage was only minimally associated with 'idiopathic' FI, suggesting IAS per se is unlikely to be a direct cause of FI in the 'idiopathic' group of FI patients. Its role might be analogous to the periurethral striated horse-shoe shape muscle in the urethra, which is thought to act as a mucosal sealant.

  7. Thermal responses of shape memory alloy artificial anal sphincters

    NASA Astrophysics Data System (ADS)

    Luo, Yun; Takagi, Toshiyuki; Matsuzawa, Kenichi

    2003-08-01

    This paper presents a numerical investigation of the thermal behavior of an artificial anal sphincter using shape memory alloys (SMAs) proposed by the authors. The SMA artificial anal sphincter has the function of occlusion at body temperature and can be opened with a thermal transformation induced deformation of SMAs to solve the problem of severe fecal incontinence. The investigation of its thermal behavior is of great importance in terms of practical use in living bodies as a prosthesis. In this work, a previously proposed phenomenological model was applied to simulate the thermal responses of SMA plates that had undergone thermally induced transformation. The numerical approach for considering the thermal interaction between the prosthesis and surrounding tissues was discussed based on the classical bio-heat equation. Numerical predictions on both in vitro and in vivo cases were verified by experiments with acceptable agreements. The thermal responses of the SMA artificial anal sphincter were discussed based on the simulation results, with the values of the applied power and the geometric configuration of thermal insulation as parameters. The results obtained in the present work provided a framework for the further design of SMA artificial sphincters to meet demands from the viewpoint of thermal compatibility as prostheses.

  8. Biomechanical modeling of the rectum for the design of a novel artificial anal sphincter.

    PubMed

    Zan, Peng; Yan, Guozheng; Liu, Hua; Yang, Banghua; Zhao, Yujuan; Luo, Nianting

    2010-01-01

    This paper discusses biomechanical issues that are related to the option of a novel artificial anal sphincter around the human rectum. The prosthesis consists of a compression cuff system inside and a reservoir cuff system outside, which is placed around the debilitated sphincter muscle. The micropump shifts fluid between the cuffs and thus takes over the expansion and compression function of the sphincter muscle. However, the human rectum is not a rigid pipe, and motion in it is further complicated by the fact that the bowel is susceptible to damage. With the goal of engineering a safe and reliable machine, the biomechanical properties of the in-vivo porcine rectum are studied and the tissue ischemia is analyzed.

  9. Systemic glyceryl trinitrate reduces anal sphincter tone: is there a therapeutic indication?

    PubMed

    Connolly, C; Tierney, S; Grace, P

    2017-09-13

    Nitric oxide (NO) has diverse roles as a biological messenger. [1] Topically applied nitrate donors cause relaxation of the internal anal sphincter (IAS) and facilitate healing of anal fissures [2,3]. Systemic nitrates are commonly used for the treatment of ischaemic heart disease, yet the effects of systemically administered nitrates on the smooth muscle of the IAS are unknown. Our aim was to test the hypothesis that systemically administered nitrates at a normal dose, cause inhibition of anal sphincter activity. With fully informed consent, anal manometry was performed on nine volunteers. Maximum and mean anal resting pressure (representing the IAS), maximum squeeze pressure (representing the external anal sphincter), heart rate and blood pressure were measured, before and after administration of a normal 400 μg dose of sublingual glyceryl trinitrate spray. Data are expressed as mean (± standard error of the mean (SEM)). In four females and five males ranging from 19 to 50 years of age, administration of GTN resulted in a significant reduction in systolic blood pressure from 138 ± 5 to 127 ± 4 mmHg, P < 0.01. Mean resting pressure, over 5 min, was significantly reduced from 70 ± 10 to 62 ± 10 mmHg P < 0.05. The maximum resting pressure was also significantly reduced from 109 ± 12 to 86 ± 10 mmHg P = 0.04. Maximum squeeze pressure, heart rate and diastolic blood pressure were not significantly reduced. Systemic nitrates significantly inhibit internal anal sphincter function.

  10. Pruritus ani: is anal sphincter dysfunction important in aetiology?

    PubMed

    Eyers, A A; Thomson, J P

    1979-12-15

    Forty-three patients whose principal symptom was pruritus ani were studied. Twenty-eight had anal disease, while in 15 no such disease could be shown. Maximum resting pressures and transient and sustained pressures of the anal canal in response to rectal distension were measured by manometry. Although the maximum resting pressure in the patients with no disease was about the same as that in the group with disease, the pressures recorded in response to rectal distension were significantly lower. These results show that the anal sphincter relaxes in response to rectal distension more readily in patients with no anal disease. Hence soiling may occur, which may be a factor in the genesis of pruritus ani.

  11. Pruritus ani: is anal sphincter dysfunction important in aetiology?

    PubMed Central

    Eyers, A A; Thomson, J P

    1979-01-01

    Forty-three patients whose principal symptom was pruritus ani were studied. Twenty-eight had anal disease, while in 15 no such disease could be shown. Maximum resting pressures and transient and sustained pressures of the anal canal in response to rectal distension were measured by manometry. Although the maximum resting pressure in the patients with no disease was about the same as that in the group with disease, the pressures recorded in response to rectal distension were significantly lower. These results show that the anal sphincter relaxes in response to rectal distension more readily in patients with no anal disease. Hence soiling may occur, which may be a factor in the genesis of pruritus ani. PMID:534862

  12. Internal anal sphincter atrophy in patients with systemic sclerosis.

    PubMed

    Thoua, Nora M; Schizas, Alexis; Forbes, Alastair; Denton, Christopher P; Emmanuel, Anton V

    2011-09-01

    SSc is a connective tissue, multisystem disorder of unknown aetiology. The gastrointestinal tract (GIT) is affected in up to 90% of patients. The exact pathophysiology of GIT involvement is not known, but it is related to both neurogenic and myogenic abnormalities as well as possible vascular and ischaemic changes. Thinning of the internal anal sphincter (IAS) has been demonstrated in SSc with faecal incontinence. We aimed to investigate anal sphincter structure in patients with SSc. Forty-four SSc patients [24 symptomatic (Sx) and 20 asymptomatic (ASx)] and 20 incontinent controls (ICs) were studied. Patients underwent anorectal manometry and endoanal US. In the ICs, external anal sphincter defects were more common, but the IAS was less atrophic, evident by both atrophy scores and IAS thickness. There was no significant difference in atrophy scores [Sx: 2 (1.5-3) vs ASx: 2 (1-2)] or IAS thickness [Sx: 1.85 (1.5-2.3) vs ASx: 1.8 (1.7-2.25)] between the Sx and ASx SSc patients. Patients with SSc (both Sx and ASx) have thin and atrophic IAS, suggesting that IAS atrophy develops even in ASx patients and this may be amenable to treatment with sacral neuromodulation.

  13. Risk factors for sonographic internal anal sphincter gaps 6-12 months after delivery complicated by anal sphincter tear.

    PubMed

    Bradley, Catherine S; Richter, Holly E; Gutman, Robert E; Brown, Morton B; Whitehead, William E; Fine, Paul M; Hakim, Christiane; Harford, Frank; Weber, Anne M

    2007-09-01

    The objective of the study was to identify risk factors for internal anal sphincter (IAS) gaps on postpartum endoanal ultrasound in women with obstetric anal sphincter tear. This prospective study included 106 women from the Childbirth and Pelvic Symptoms Imaging Supplementary Study who had third- or fourth-degree perineal laceration at delivery and endoanal ultrasound 6-12 months postpartum. Data were analyzed using Fisher's exact and t tests and logistic regression. Mean (+/- SD) age was 27.7 (+/- 6.2) years. Seventy-nine women (76%) were white and 22 (21%) black. Thirty-seven (35%) had sonographic IAS gaps. Risk factors for gaps included fourth- vs third-degree perineal laceration (odds ratio [OR] 15.4, 95% confidence interval [CI] 4.8, 50) and episiotomy (OR 3.3, 95% CI 1.2, 9.1). Black race (OR 0.23, 95% CI 0.05, 0.96) was protective. In women with obstetric anal sphincter repairs, fourth-degree tears and episiotomy are associated with more frequent sonographic IAS gaps.

  14. Electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter system.

    PubMed

    Zan, Peng; Yang, Bang-hua; Shao, Yong; Yan, Guo-zheng; Liu, Hua

    2010-12-01

    This paper reports on the electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter. The coupling coils and human tissues, including the skin, fat, muscle, liver, and blood, were considered. Specific absorption rate (SAR) and current density were analyzed by a finite-length solenoid model. First, SAR and current density as a function of frequency (10-10(7) Hz) for an emission current of 1.5 A were calculated under different tissue thickness. Then relations between SAR, current density, and five types of tissues under each frequency were deduced. As a result, both the SAR and current density were below the basic restrictions of the International Commission on Non-Ionizing Radiation Protection (ICNIRP). The results show that the analysis of these data is very important for developing the artificial anal sphincter system.

  15. Electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter system*

    PubMed Central

    Zan, Peng; Yang, Bang-hua; Shao, Yong; Yan, Guo-zheng; Liu, Hua

    2010-01-01

    This paper reports on the electromagnetic effects on the biological tissue surrounding a transcutaneous transformer for an artificial anal sphincter. The coupling coils and human tissues, including the skin, fat, muscle, liver, and blood, were considered. Specific absorption rate (SAR) and current density were analyzed by a finite-length solenoid model. First, SAR and current density as a function of frequency (10–107 Hz) for an emission current of 1.5 A were calculated under different tissue thickness. Then relations between SAR, current density, and five types of tissues under each frequency were deduced. As a result, both the SAR and current density were below the basic restrictions of the International Commission on Non-Ionizing Radiation Protection (ICNIRP). The results show that the analysis of these data is very important for developing the artificial anal sphincter system. PMID:21121071

  16. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study

    PubMed Central

    Marola, Silvia; Gibin, Enrico; Capobianco, Marco; Bertolotto, Antonio; Enrico, Stefano; Solej, Mario; Martino, Valter; Destefano, Ines; Nano, Mario

    2016-01-01

    Abstract Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient. Results Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively). Conclusions The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy. PMID:28352843

  17. The impact of anal sphincter injury on perceived body image.

    PubMed

    Iles, David; Khan, Rabia; Naidoo, Kristina; Kearney, Rohna; Myers, Jenny; Reid, Fiona

    2017-05-01

    Obstetric anal sphincter injury is common but the effect on body image is unreported. The aim of this study was to explore patient perceived changes in body image and other psychological aspects in women attending a perineal follow-up clinic. This retrospective study analysed women's responses to a self-reported questionnaire. Consecutive women with anal sphincter injury who attended a United Kingdom Maternity Hospital perineal follow-up clinic between January 1999 and January 2012 were identified and the records obtained and reviewed. Multivariate regression analyses were performed to examine variables influencing self-reported change in body image. Questionnaires and operation notes were analysed from 422 women who attended at a median of four months after delivery. 222 (53%) reported a change in body image with 80 (19%) reporting lower self-esteem and 75 (18%) a change in their personality due to the change in body image. 248 (59%) perceived an anatomical change due to the delivery. Factors associated with increased likelihood of reporting a change in body image were reporting a perceived change in anatomy due to the delivery, adjusted OR 6.11 (3.56-10.49), anal incontinence, OR 1.97 (1.16-3.36), and delivery by forceps, OR 2.59 (1.23-5.43). This is the first study to quantify body image changes in women after anal sphincter injury sustained in childbirth. These were found to be very common, affecting up to 50% of women. The study has several limitations but it does highlight the significant psychosocial problems of negative self-esteem and personality changes associated with a perceived change in body image that has not previously been reported. It also outlines the further research questions that need to be addressed. Copyright © 2017 Elsevier B.V. All rights reserved.

  18. Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair.

    PubMed

    Harvey, Marie-Andrée; Pierce, Marianne; Alter, Jens-Erik W; Chou, Queena; Diamond, Phaedra; Epp, Annette; Geoffrion, Roxana; Harvey, Marie-Andrée; Larochelle, Annick; Maslow, Kenny; Neustaedter, Grace; Pascali, Dante; Pierce, Marianne; Schulz, Jane; Wilkie, David; Sultan, Abdul; Thakar, Ranee

    2015-12-01

    Objectif : Analyser les données probantes traitant des lésions obstétricales du sphincter anal (LOSA) en ce qui concerne leur diagnostic, les techniques visant leur réparation et les résultats de l’intervention. Formuler des recommandations permettant d’éclairer les conseils offerts aux patientes ayant connu des LOSA en ce qui a trait à la voie d’accouchement à privilégier dans le cadre des grossesses subséquentes. Options : Les fournisseurs de soins obstétricaux qui comptent des patientes ayant connu des LOSA disposent de l’option de réparer le sphincter anal en faisant appel à la méthode de suture « bout à bout » (end-to-end) ou à la méthode « en paletot » (overlapping). Ils pourraient également être appelés à conseiller des femmes ayant déjà connu des LOSA en ce qui a trait à la voie d’accouchement à privilégier pour les grossesses subséquentes. Issues : Le critère d’évaluation était la continence anale à la suite d’une réparation primaire de LOSA et à la suite d’un accouchement subséquent. Résultats : La littérature publiée a été récupérée par l’intermédiaire de recherches menées dans Medline, EMBASE et The Cochrane Library en mai 2011 au moyen d’un vocabulaire contrôlé (p. ex. anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) et de mots clés (p. ex. obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Aucune restriction n’a été imposée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu’en septembre 2014. La littérature grise (non

  19. Obstetric sphincter tears and anal incontinence: an observational follow-up study.

    PubMed

    Zetterström, Jan; López, Annika; Holmström, Bo; Nilsson, Bengt Y; Tisell, Ake; Anzén, Bo; Mellgren, Anders

    2003-10-01

    Persistent defects after primary sphincter repair and occult sphincter tears are common after vaginal deliveries. Anal incontinence may be associated with these morphological defects. Forty-six primiparous women were evaluated with ultrasonography, manometry and electrophysiology. Twenty-four women had undergone primary repair of obstetric sphincter tears (sphincter group), 16 women had no clinical sphincter tear but developed anal incontinence postpartum (symptom group), and six were delivered by elective cesarean section (cesarean group). In the sphincter group, 50% had anal incontinence at follow-up. At ultrasonography, 70% had injuries anteriorly in the midanal canal. At manometry, 4% had decreased resting pressure and 50% decreased squeeze pressure. At electrophysiology, 19% had pathologic pudendal latency and 25% pathologic fiber density. In the symptom group, 44% had injuries anteriorly in the midanal canal at ultrasonography. At manometry, all women had normal resting pressure and 19% had a decreased squeeze pressure. At electrophysiology, 46% had pathologic pudendal latency and 29% pathologic fiber density. In the cesarean group, 33% had mild anal incontinence at follow-up. Ultrasonography and manometry were normal in all women. At electrophysiology, 33% had pathologic pudendal latency and 17% pathologic fiber density. Anal sphincter injuries at childbirth are often inadequately diagnosed and primary repair frequently results in persisting defects in the anal sphincter. Anatomic injuries to the anal sphincter play an important role in the development of anal incontinence after delivery, but a significant proportion of symptomatic women also demonstrate neurologic impairment at electrophysiologic testing.

  20. Evaluation of the development of the fetal anal sphincter with tomography ultrasonography imaging.

    PubMed

    Guang, Yang; Wang, Xi; Cai, Ai-Lu; Xie, Li-Mei; Ding, Hai-Long; Meng, Xin-Yue

    2015-01-01

    The aim of the study described here was to examine the potential of tomography ultrasonography imaging (TUI) in evaluation of the fetal anal sphincter. In this prospective cross-sectional study of the fetal anal sphincter with TUI, 326 singleton pregnancies (mean age = 28 y, range: 22-38 y) were scanned at 19-40 wk of gestation. The fetal anal region and ischium were revealed in 320 of 326 patients (98.2%). The normal fetal anal sphincter diameter and ischial space reached maximums of 15 and 39 mm, respectively. The normal fetal anal sphincter diameter and the ischial space were plotted as a function of gestational age (GA) on a linear curve, and the regression equations for normal fetal anal sphincter diameter and ischial space as a function of GA in weeks were obtained. A scatterplot was also created that revealed a significant positive relationship between normal fetal anal sphincter diameter and ischial space. On the basis of these criteria, imperforate anus was diagnosed in one fetus. Ultrasonographic assessment of the fetal anal sphincter and the ischium with TUI is feasible. The reference values reported in this article may be useful in prenatal diagnosis of fetal anal sphincter abnormalities. Copyright © 2015. Published by Elsevier Inc.

  1. Structure-function relationship of the human external anal sphincter.

    PubMed

    Stewart, Amanda M; Cook, Mark S; Dyer, Keisha Y; Alperin, Marianna

    2017-07-08

    Obstetrical external anal sphincter (EAS) injury and subsequent dysfunction are leading risk factors for female fecal incontinence (FI). Limited knowledge of the EAS structure-function relationship hinders treatment optimization. We directly measured functionally relevant intrinsic parameters of human EAS and tested whether vaginal delivery alters the EAS structure-function relationship. Major predictors of in vivo EAS function were compared between specimens procured from vaginally nulliparous (VN, n = 5) and vaginally parous (VP, n = 7) cadaveric donors: operational sarcomere length (Ls), which dictates force-length relationship; physiological cross-sectional area (PCSA), which determines isometric force-generating capacity; fiber length (Lfn), responsible for muscle excursion and contractile velocity; and muscle stiffness. Data were analyzed using unpaired and paired t tests, α < 0.05. Results are presented as mean ± SEM. The VN and VP (median parity 3) groups were similar in age and BMI. No gross anatomical defects were identified. EAS Ls (2.36 ± 0.05 μm) was shorter than the optimal Lso (2.7 μm), at which contractile force is maximal, P = 0.0001. Stiffness was lower at Ls than Lso (5.4 ± 14 kPa/μm vs 35.3 ± 12 kPa/μm, P < 0.0001). This structural design allows active and passive tension to increase with EAS stretching. EAS relatively long Lfn (106 ± 24.8 mm) permits rapid contraction without decreased force, whereas intermediate PCSA (1.3 ± 0.3 cm(2)) is conducive to maintaining resting tone. All parameters were similar between groups. This first direct examination of human EAS underscores how EAS intrinsic design matches its intended function. Knowledge of the EAS structure-function relationship is important for understanding the pathogenesis of FI and the optimization of treatments for EAS dysfunction.

  2. The magnetic anal sphincter versus the artificial bowel sphincter: a comparison of 2 treatments for fecal incontinence.

    PubMed

    Wong, Mark T C; Meurette, Guillaume; Stangherlin, Pierre; Lehur, Paul-Antoine

    2011-07-01

    Fecal incontinence is a debilitating ailment, and surgery offers the only recourse for the patients in whom conservative treatment fails. This study aims to report the first matched comparison between patients implanted with the magnetic anal sphincter and the artificial bowel sphincter. From December 2008 to June 2010, 10 female patients, median age 64.5 years (range, 42-76), with severe fecal incontinence for a median of 7.5 years (range, 1-40), were implanted with the magnetic anal sphincter. Ten female patients implanted with the artificial bowel sphincter were identified. Both groups were matched for age, etiology, duration of incontinence, and preoperative functional scores. Outcomes measures included length of hospitalization, complications, and changes in functional scores (anorectal physiology, incontinence, and quality of life). Patients with the magnetic anal sphincter had a shorter median operative time (62 vs 97.5 min, P = .0273), length of hospitalization(4.5 vs 10 days, P < .001), and follow-up duration (8 vs 22.5 mo, P = .0068), without a statistically significant difference in 30-day complications (4 vs 2, P = .628) and revision/explantation (1 vs 4, P = .830). Both groups achieved significant improvements in preoperative incontinence (P < .0002) and quality-of-life scores (P < .009). In a comparison of baseline resting anal pressures, patients with the artificial bowel sphincter had significantly higher pressures with the cuff inflated (P = .0082), and those with the magnetic anal sphincter had a significant increase as well (P = .0469). At the latest review, both groups had similar quality-of-life scores (P = .374); patients with the artificial bowel sphincter had higher (median) closed-cuff anal pressures compared with the anal resting pressure of those with a magnetic anal sphincter (89 vs 58.5 cmH2O, P = .0147), together with more constipation (4 vs 1, P = .830) and a trend toward better incontinence scores (P = .0625). This was a

  3. Internal Anal Sphincter Function Following Lateral Internal Sphincterotomy for Anal Fissure

    PubMed Central

    Ram, Edward; Alper, Dan; Stein, Gideon Y.; Bramnik, Zachar; Dreznik, Zeev

    2005-01-01

    Background: Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy. Objective: The aim of this study was to evaluate long-term manometric results of sphincter healing following lateral internal sphincterotomy. Patients and Methods: Between 2000 and 2003, 50 patients with anal fissure were included in this study and underwent sphincterotomy; 12 healthy patients served as controls. All patients with anal fissure underwent manometric evaluation using a 6-channel perfusion catheter. All patients were examined 1 month before surgery and 1, 3, 6, and 12 months following surgery. The control group had 3 manometric evaluations 6 months apart. Results: The mean basal resting pressure before surgery was 138 ± 28 mm Hg. One month after surgery, the pressure dropped to 86 ± 15 mm Hg (P < 0.0001) and gradually rose to a plateau at 12 months (110 ± 18 mm Hg, P < 0.0001). At 12 months, the manometric pressure was significantly lower than the baseline (P < 0.0001). However, manometric measurements in the fissure group were still significantly higher than in the control group (110 ± 18 versus 73 ± 4.8 mm Hg, P < 0.0001). All patients were free of symptoms at the 12-month follow-up. Conclusion: Lateral internal sphincterotomy caused a significant decline in the resting anal pressure. During the first year following surgery, the tone of the internal anal sphincter gradually increased, indicating recovery, but still remained significantly lower than before surgery. However, postoperative resting pressures were higher than those in the control, and no patient suffered any permanent problems with incontinence, so this decrease may not be clinically significant. PMID:16041211

  4. Prevalence of anal sphincter injury in primiparous women.

    PubMed

    Guzmán Rojas, R A; Shek, K L; Langer, S M; Dietz, H P

    2013-10-01

    To determine the prevalence of obstetric anal sphincter injuries (OASIS) in a cohort of primiparous women and to evaluate their association with demographic, obstetric and ultrasound parameters. This was a retrospective analysis of the ultrasound volume datasets of 320 primiparous women, acquired at 5 months postpartum. Tomographic ultrasound imaging (TUI) was used to evaluate the external anal sphincter (EAS). A significant EAS defect was diagnosed if a defect of > 30° was seen in four or more of six TUI slices bracketing the EAS. Significant EAS defects were found in 69 women (27.9% of those delivered vaginally). In nine of those a third-degree tear was diagnosed intrapartum and was sutured. In 60 women with significant defects there was no documentation of sphincter damage at birth, implying unidentified or occult defects (60/69, 87.0%). Among them, 29 had had a second-degree tear, two a first-degree tear and three an intact perineum. In 31 cases an episiotomy had been performed, with five extensions to a third-degree tear. On multivariate analysis only forceps delivery was significantly associated with OASIS. In this cohort of primiparous women we found OASIS in 27.9% of vaginally parous women, most of which had not been diagnosed in the delivery suite. There seems to be a need for better education of labor-ward staff in the recognition of OASIS. On the other hand, it is conceivable that some defects may be masked by intact tissue. The significance of such defects remains doubtful. Forceps delivery was the only identifiable risk factor. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

  5. Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery.

    PubMed

    Baud, David; Meyer, Sylvain; Vial, Yvan; Hohlfeld, Patrick; Achtari, Chahin

    2011-09-01

    This study aims to estimate fecal, urinary incontinence, and sexual function 6 years after an obstetrical anal sphincter tear. Among 13,213 women who had a vaginal delivery of a cephalic singleton at term, 196 women sustained an anal sphincter tear. They were matched to 588 controls. Validated questionnaires grading fecal and urinary incontinence, and sexual dysfunction were completed by the participants. Severe fecal incontinence was more frequently reported by women who had sustained an anal sphincter tear compared to the controls. Women with an anal sphincter tear had no increased risk of urinary incontinence, but reported significantly more pain, difficulty with vaginal lubrication, and difficulty achieving orgasm compared to the controls. A fetal occiput posterior position during childbirth was an independent risk factor for both severe urinary incontinence and severe sexual dysfunction. Fecal incontinence is strongly associated with an anal sphincter tear. A fetal occiput posterior position represents a risk factor for urinary incontinence and sexual dysfunction.

  6. Modified Plug Repair with Limited Sphincter Sparing Fistulectomy in the Treatment of Complex Anal Fistulas

    PubMed Central

    Köckerling, Ferdinand; von Rosen, Thomas; Jacob, Dietmar

    2014-01-01

    Purpose: New technical approaches involving biologically derived products have been used to treat complex anal fistulas in order to avoid the risk of fecal incontinence. The least invasive methods involve filling out the fistula tract with fibrin glue or introduction of an anal fistula plug into the fistula canal following thorough curettage. A review shows that the new techniques involving biologically derived products do not confer any significant advantages. Therefore, the question inevitably arises as to whether the combination of a partial or limited fistulectomy, i.e., of the extrasphincteric portion of the fistula, and preservation of the sphincter muscle by repairing the section of the complex anal fistula running through the sphincter muscle and filling it with a fistula plug produces better results. Methods: A modified plug technique was used, in which the extrasphincteric portion of the complex anal fistula was removed by means of a limited fistulectomy and the remaining section of the fistula in the sphincter muscle was repaired using the fistula plug with fixing button. Results: Of the 52 patients with a complex anal fistula, who had undergone surgery using a modified plug repair with limited fistulectomy of the extrasphincteric part of the fistula and use of the fistula plug with fixing button, there are from 40 patients (follow-up rate: 77%) some kind of follow-up informations, after a mean of 19.32 ± 6.9 months. Thirty-two were men and eight were women, with a mean age of 52.97 ± 12.22 years. Surgery was conducted to treat 36 transsphincteric, 1 intersphincteric, and 3 rectovaginal fistulas. In 36 of 40 patients (90%), the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. None of these patients complained about continence problems. Conclusion: A modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of the

  7. Modified plug repair with limited sphincter sparing fistulectomy in the treatment of complex anal fistulas.

    PubMed

    Köckerling, Ferdinand; von Rosen, Thomas; Jacob, Dietmar

    2014-01-01

    New technical approaches involving biologically derived products have been used to treat complex anal fistulas in order to avoid the risk of fecal incontinence. The least invasive methods involve filling out the fistula tract with fibrin glue or introduction of an anal fistula plug into the fistula canal following thorough curettage. A review shows that the new techniques involving biologically derived products do not confer any significant advantages. Therefore, the question inevitably arises as to whether the combination of a partial or limited fistulectomy, i.e., of the extrasphincteric portion of the fistula, and preservation of the sphincter muscle by repairing the section of the complex anal fistula running through the sphincter muscle and filling it with a fistula plug produces better results. A modified plug technique was used, in which the extrasphincteric portion of the complex anal fistula was removed by means of a limited fistulectomy and the remaining section of the fistula in the sphincter muscle was repaired using the fistula plug with fixing button. Of the 52 patients with a complex anal fistula, who had undergone surgery using a modified plug repair with limited fistulectomy of the extrasphincteric part of the fistula and use of the fistula plug with fixing button, there are from 40 patients (follow-up rate: 77%) some kind of follow-up informations, after a mean of 19.32 ± 6.9 months. Thirty-two were men and eight were women, with a mean age of 52.97 ± 12.22 years. Surgery was conducted to treat 36 transsphincteric, 1 intersphincteric, and 3 rectovaginal fistulas. In 36 of 40 patients (90%), the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. None of these patients complained about continence problems. A modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of the plug with fixing button seems to

  8. 3D Topography of the Young Adult Anal Sphincter Complex Reconstructed from Undeformed Serial Anatomical Sections

    PubMed Central

    Wu, Yi; Dabhoiwala, Noshir F.; Hagoort, Jaco; Shan, Jin-Lu; Tan, Li-Wen; Fang, Bin-Ji; Zhang, Shao-Xiang; Lamers, Wouter H.

    2015-01-01

    Background Pelvic-floor anatomy is usually studied by artifact-prone dissection or imaging, which requires prior anatomical knowledge. We used the serial-section approach to settle contentious issues and an interactive 3D-pdf to make the results widely accessible. Method 3D reconstructions of undeformed thin serial anatomical sections of 4 females and 2 males (21–35y) of the Chinese Visible Human database. Findings Based on tendinous septa and muscle-fiber orientation as segmentation guides, the anal-sphincter complex (ASC) comprised the subcutaneous external anal sphincter (EAS) and the U-shaped puborectal muscle, a part of the levator ani muscle (LAM). The anococcygeal ligament fixed the EAS to the coccygeal bone. The puborectal-muscle loops, which define the levator hiatus, passed around the anorectal junction and inserted anteriorly on the perineal body and pubic bone. The LAM had a common anterior attachment to the pubic bone, but separated posteriorly into puborectal and “pubovisceral” muscles. This pubovisceral muscle was bilayered: its internal layer attached to the conjoint longitudinal muscle of the rectum and the rectococcygeal fascia, while its outer, patchy layer reinforced the inner layer. ASC contraction makes the ano-rectal bend more acute and lifts the pelvic floor. Extensions of the rectal longitudinal smooth muscle to the coccygeal bone (rectococcygeal muscle), perineal body (rectoperineal muscle), and endopelvic fascia (conjoint longitudinal and pubovisceral muscles) formed a “diaphragm” at the inferior boundary of the mesorectum that suspended the anorectal junction. Its contraction should straighten the anorectal bend. Conclusion The serial-section approach settled contentious topographic issues of the pelvic floor. We propose that the ASC is involved in continence and the rectal diaphragm in defecation. PMID:26305117

  9. 3D Topography of the Young Adult Anal Sphincter Complex Reconstructed from Undeformed Serial Anatomical Sections.

    PubMed

    Wu, Yi; Dabhoiwala, Noshir F; Hagoort, Jaco; Shan, Jin-Lu; Tan, Li-Wen; Fang, Bin-Ji; Zhang, Shao-Xiang; Lamers, Wouter H

    2015-01-01

    Pelvic-floor anatomy is usually studied by artifact-prone dissection or imaging, which requires prior anatomical knowledge. We used the serial-section approach to settle contentious issues and an interactive 3D-pdf to make the results widely accessible. 3D reconstructions of undeformed thin serial anatomical sections of 4 females and 2 males (21-35y) of the Chinese Visible Human database. Based on tendinous septa and muscle-fiber orientation as segmentation guides, the anal-sphincter complex (ASC) comprised the subcutaneous external anal sphincter (EAS) and the U-shaped puborectal muscle, a part of the levator ani muscle (LAM). The anococcygeal ligament fixed the EAS to the coccygeal bone. The puborectal-muscle loops, which define the levator hiatus, passed around the anorectal junction and inserted anteriorly on the perineal body and pubic bone. The LAM had a common anterior attachment to the pubic bone, but separated posteriorly into puborectal and "pubovisceral" muscles. This pubovisceral muscle was bilayered: its internal layer attached to the conjoint longitudinal muscle of the rectum and the rectococcygeal fascia, while its outer, patchy layer reinforced the inner layer. ASC contraction makes the ano-rectal bend more acute and lifts the pelvic floor. Extensions of the rectal longitudinal smooth muscle to the coccygeal bone (rectococcygeal muscle), perineal body (rectoperineal muscle), and endopelvic fascia (conjoint longitudinal and pubovisceral muscles) formed a "diaphragm" at the inferior boundary of the mesorectum that suspended the anorectal junction. Its contraction should straighten the anorectal bend. The serial-section approach settled contentious topographic issues of the pelvic floor. We propose that the ASC is involved in continence and the rectal diaphragm in defecation.

  10. Postpartum two- and three-dimensional ultrasound evaluation of anal sphincter complex in women with obstetric anal sphincter injury.

    PubMed

    Ros, C; Martínez-Franco, E; Wozniak, M M; Cassado, J; Santoro, G A; Elías, N; López, M; Palacio, M; Wieczorek, A P; Espuña-Pons, M

    2017-04-01

    To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS). External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated. Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (κ = 0.01), fair for 2D-TPUS (κ = 0.30) and good for 3D-TPUS (κ = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (κ = 0.41) and 2D-TPUS (κ = 0.52) and good for 3D-TPUS (κ = 0.66). Good intraobserver (3D-EAUS, κ = 0.73; 3D-TPUS, κ = 0.78) and interobserver (3D-EAUS, κ = 0.68; 3D-TPUS, κ = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04). 2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2016 ISUOG

  11. Local injection of bone marrow progenitor cells for the treatment of anal sphincter injury: in-vitro expanded versus minimally-manipulated cells.

    PubMed

    Mazzanti, Benedetta; Lorenzi, Bruno; Borghini, Annalisa; Boieri, Margherita; Ballerini, Lara; Saccardi, Riccardo; Weber, Elisabetta; Pessina, Federica

    2016-06-21

    Anal incontinence is a disabling condition that adversely affects the quality of life of a large number of patients, mainly with anal sphincter lesions. In a previous experimental work, in-vitro expanded bone marrow (BM)-derived mesenchymal stem cells (MSC) were demonstrated to enhance sphincter healing after injury and primary repair in a rat preclinical model. In the present article we investigated whether unexpanded BM mononuclear cells (MNC) may also be effective. Thirty-two rats, divided into groups, underwent sphincterotomy and repair (SR) with primary suture of anal sphincters plus intrasphincteric injection of saline (CTR), or of in-vitro expanded MSC, or of minimally manipulated MNC; moreover, the fourth group underwent sham operation. At day 30, histologic, morphometric, in-vitro contractility, and functional analysis were performed. Treatment with both MSC and MNC improved muscle regeneration and increased contractile function of anal sphincters after SR compared with CTR (p < 0.05). No significant difference was observed between the two BM stem cell types used. GFP-positive cells (MSC and MNC) remained in the proximity of the lesion site up to 30 days post injection. In the present study we demonstrated in a preclinical model that minimally manipulated BM-MNC were as effective as in-vitro expanded MSC for the recovery of anal sphincter injury followed by primary sphincter repair. These results may serve as a basis for improving clinical applications of stem cell therapy in human anal incontinence treatment.

  12. Botulinum toxin A injection for chronic anal fissures and anal sphincter spasm improves quality of life in recessive dystrophic epidermolysis bullosa.

    PubMed

    Chaptini, Cassandra; Casey, Genevieve; Harris, Adam G; Wattchow, David; Gordon, Lynne; Murrell, Dedee F

    2015-12-01

    We report a 20-year-old female with generalized, severe, recessive dystrophic epidermolysis bullosa who developed secondary chronic anal fissures. This resulted in anal sphincter spasm and severe, disabling pain. She was treated with five botulinum toxin A injections into the internal anal sphincter over a period of 2 years and gained marked improvement in her symptoms. This case demonstrates the successful use of botulinum toxin A injections to relieve anal sphincter spasm and fissuring, with long-term improvement.

  13. Biomimetic artificial sphincter muscles: status and challenges

    NASA Astrophysics Data System (ADS)

    Leung, Vanessa; Fattorini, Elisa; Karapetkova, Maria; Osmani, Bekim; Töpper, Tino; Weiss, Florian; Müller, Bert

    2016-04-01

    Fecal incontinence is the involuntary loss of bowel content and affects more than 12% of the adult population, including 45% of retirement home residents. Severe fecal incontinence is often treated by implanting an artificial sphincter. Currently available implants, however, have long-term reoperation rates of 95% and definitive explantation rates of 40%. These statistics show that the implants fail to reproduce the capabilities of the natural sphincter and that the development of an adaptive, biologically inspired implant is required. Dielectric elastomer actuators (DEA) are being developed as artificial muscles for a biomimetic sphincter, due to their suitable response time, reaction forces, and energy consumption. However, at present the operation voltage of DEAs is too high for artificial muscles implanted in the human body. To reduce the operating voltage to tens of volts, we are using microfabrication to reduce the thickness of the elastomer layer to the nanometer level. Two microfabrication methods are being investigated: molecular beam deposition and electrospray deposition. This communication covers the current status and a perspective on the way forward, including the long-term prospects of constructing a smart sphincter from low-voltage sensors and actuators based on nanometer-thin dielectric elastomer films. As DEA can also provide sensory feedback, a biomimetic sphincter can be designed in accordance with the geometrical and mechanical parameters of its natural counterpart. The availability of such technology will enable fast pressure adaption comparable to the natural feedback mechanism, so that tissue atrophy and erosion can be avoided while maintaining continence du ring daily activities.

  14. Reinnervation of Urethral and Anal Sphincters With Femoral Motor Nerve to Pudendal Nerve Transfer

    PubMed Central

    Ruggieri, Michael R.; Braverman, Alan S.; Bernal, Raymond M.; Lamarre, Neil S.; Brown, Justin M.; Barbe, Mary F.

    2012-01-01

    Aims Lower motor neuron damage to sacral roots or nerves can result in incontinence and a flaccid urinary bladder. We showed bladder reinnervation after transfer of coccygeal to sacral ventral roots, and genitofemoral nerves (L1, 2 origin) to pelvic nerves. This study assesses the feasibility of urethral and anal sphincter reinnervation using transfer of motor branches of the femoral nerve (L2–4 origin) to pudendal nerves (S1, 2 origin) that innervate the urethral and anal sphincters in a canine model. Methods Sacral ventral roots were selected by their ability to stimulate bladder, urethral sphincter, and anal sphincter contraction and transected. Bilaterally, branches of the femoral nerve, specifically, nervus saphenous pars muscularis [Evans HE. Miller’s anatomy of the dog. Philadelphia: W.B. Saunders; 1993], were transferred and end-to-end anastomosed to transected pudendal nerve branches in the perineum, then enclosed in unipolar nerve cuff electrodes with leads to implanted RF micro-stimulators. Results Nerve stimulation induced increased anal and urethral sphincter pressures in five of six transferred nerves. Retrograde neurotracing from the bladder, urethral sphincter, and anal sphincter using fluorogold, fast blue, and fluororuby, demonstrated urethral and anal sphincter labeled neurons in L2–4 cord segments (but not S1–3) in nerve transfer canines, consistent with rein-nervation by the transferred femoral nerve motor branches. Controls had labeled neurons only in S1–3 segments. Postmortem DiI and DiO labeling confirmed axonal regrowth across the nerve repair site. Conclusions These results show spinal cord reinnervation of urethral and anal sphincter targets after sacral ventral root transection and femoral nerve transfer (NT) to the denervated pudendal nerve. These surgical procedures may allow patients to regain continence. PMID:21953679

  15. Thickening of the internal anal sphincter in idiopathic constipation in children.

    PubMed

    Keshtgar, Alireza S; Ward, Harry C; Clayden, Graham S; Sanei, Ahmad

    2004-12-01

    IAS was 0.9 mm (range 0.3-2.8) and the median resting anal sphincter pressure was 54 mmHg (19-107). The median amplitudes of rectal and anal sphincter contraction were 3 mmHg (1-25) and 9 mmHg (1-35), respectively. The thickness of IAS correlated significantly with total symptom severity score (r=0.31, p=0.0001), soiling score (r=0.28, p=0.001), megarectum score on abdominal palpation (r=0.29, p=0.001), size of megarectum on manometry (r=0.36, p=0.0001), amplitude of rectal contraction (r=0.23, p=0.007), and age of patient (r=0.55, p=0.0001). There was also a significant correlation between the amplitude of rectal and anal sphincter contraction (r=0.32, p=0.0001). There was no correlation between thickness of IAS and resting anal sphincter pressure and amplitude of anal sphincter contraction on anorectal manometry study. A total of 24 children had myectomy of thickened and overactive IAS in addition to the medical treatment of their chronic IC. The histology examination of myectomy specimen with eosin and haematoxylin staining and histochemical acetylcholine esterase staining showed smooth muscle fibres and ganglion cells. Thickening of IAS correlates significantly with duration and severity of symptoms, size of megarectum, and amplitude of rectal contraction. The pathogenesis is secondary to the continuous presence of faeces in the rectum, resulting in chronic abnormal stimulus to the IAS, which leads to hypertrophic changes in the rectum wall and IAS.

  16. Maternal body mass index and risk of obstetric anal sphincter injury.

    PubMed

    Blomberg, Marie

    2014-01-01

    To estimate the association between maternal obesity and risk of three different degrees of severity of obstetric anal sphincter injury. The study population consisted of 436,482 primiparous women with singleton term vaginal cephalic births between 1998 and 2011 identified in the Swedish Medical Birth Registry. Women were grouped into six categories of BMI. BMI 18.5-24.9 was set as reference. Primary outcome was third-degree perineal laceration, partial or total, and fourth-degree perineal laceration. Adjustments were made for year of delivery, maternal age, fetal head position at delivery, infant birth weight and instrumental delivery. The overall prevalence of third- or four-degree anal sphincter injury was 6.6% (partial anal sphincter injury 4.6%, total anal sphincter injury 1.2%, unclassified as either partial and total 0.2%, or fourth degree lacerations 0.6%). The risk for a partial, total, or a fourth-degree anal sphincter injury decreased with increasing maternal BMI most pronounced for total anal sphincter injury where the risk among morbidly obese women was half that of normal weight women, OR 0.47 95% CI 0.28-0.78. Obese women had a favourable outcome compared to normal weight women concerning serious pelvic floor damages at birth.

  17. Maternal Body Mass Index and Risk of Obstetric Anal Sphincter Injury

    PubMed Central

    2014-01-01

    Objective. To estimate the association between maternal obesity and risk of three different degrees of severity of obstetric anal sphincter injury. Methods. The study population consisted of 436,482 primiparous women with singleton term vaginal cephalic births between 1998 and 2011 identified in the Swedish Medical Birth Registry. Women were grouped into six categories of BMI. BMI 18.5–24.9 was set as reference. Primary outcome was third-degree perineal laceration, partial or total, and fourth-degree perineal laceration. Adjustments were made for year of delivery, maternal age, fetal head position at delivery, infant birth weight and instrumental delivery. Results. The overall prevalence of third- or four-degree anal sphincter injury was 6.6% (partial anal sphincter injury 4.6%, total anal sphincter injury 1.2%, unclassified as either partial and total 0.2%, or fourth degree lacerations 0.6%). The risk for a partial, total, or a fourth-degree anal sphincter injury decreased with increasing maternal BMI most pronounced for total anal sphincter injury where the risk among morbidly obese women was half that of normal weight women, OR 0.47 95% CI 0.28–0.78. Conclusion. Obese women had a favourable outcome compared to normal weight women concerning serious pelvic floor damages at birth. PMID:24839604

  18. Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture.

    PubMed

    Persson, Lisa K G; Sakse, Abelone; Langhoff-Roos, Jens; Jangö, Hanna

    2017-06-01

    To evaluate prevalence and risk factors for long-term anal incontinence in women with two prior vaginal deliveries without obstetric anal sphincter injury (OASIS) and to assess the impact of anal incontinence-related symptoms on quality of life. This is a nation-wide cross-sectional survey study. One thousand women who had a first vaginal delivery and a subsequent delivery, both without OASIS, between 1997 and 2008 in Denmark were identified in the Danish Medical Birth Registry. Women with more than two deliveries in total till 2012 were excluded at this stage. Of the 1000 women randomly identified, 763 were eligible and received a questionnaire. Maternal and obstetric data were retrieved from the national registry. The response rate was 58.3%. In total, 394 women were included for analysis after reviewing responses according to previously defined exclusion criteria. Median follow-up time was 9.8 years after the first delivery and 6.4 years after the second. The prevalence of flatal incontinence, fecal incontinence and fecal urgency were 11.7, 4.1, and 12.3%, respectively. Overall, 20.1% had any degree of anal incontinence and/or fecal urgency. In 6.3% these symptoms affected their quality of life. No maternal or obstetric factors including episiotomy and vacuum extraction were consistently associated with altered risk of anal incontinence in the multivariable analyses. Anal incontinence and fecal urgency is reported by one fifth of women with two vaginal deliveries without OASIS at long-term follow-up. Episiotomy or vacuum extraction did not alter the risk of long-term anal incontinence.

  19. The association between late-onset fecal incontinence and obstetric anal sphincter defects.

    PubMed

    Oberwalder, Michael; Dinnewitzer, Adam; Baig, M Khurrum; Thaler, Klaus; Cotman, Kathy; Nogueras, Juan J; Weiss, Eric G; Efron, Jonathan; Vernava, Anthony M; Wexner, Steven D

    2004-04-01

    Endoanal ultrasonographic results have demonstrated that clinically occult anal sphincter damage during vaginal delivery is common. This may or may not be associated with postpartum fecal incontinence (FI). Bayesian meta-analysis of the literature revealed that at least two thirds of obstetric sphincter disruptions are asymptomatic in the postpartum period. Women with postpartum asymptomatic sphincter damage may be at increased risk for FI with aging compared with those without sphincter injury. Case series. Tertiary referral center. After excluding patients with other possible causes of FI, the histories of 124 consecutive women with late-onset FI after vaginal delivery were analyzed. Endoanal ultrasonographic findings, pudendal nerve terminal motor latency assessment, and anal manometric results. Eighty-eight women (71%) with a median of 3 vaginal deliveries had sphincter defects on endoanal ultrasonographic results. The mean incontinence score, squeeze and resting pressures, median age at last delivery, and median duration of FI were not significantly different between patients with and without sphincter defects. Pudendal neuropathy was more frequent in patients without sphincter defects (10 [30.3%], left side; 12 [36.4%], right side) than in patients with sphincter defects (12 [14.3%] and 16 [19.3%], respectively), with the difference nearly reaching statistical significance (P =.054 and P =.059, respectively). The median age at onset of FI in patients with a sphincter defect was 61.5 years vs 68.0 years in those without a sphincter defect, which was not statistically significant (P =.08). Analysis of the current patient population revealed that 88 women (71%) with late-onset FI after vaginal delivery had an anatomical sphincter defect. Thus, FI related to anal sphincter defects is likely to occur even in an elderly population who had experienced vaginal deliveries earlier in life.

  20. Anal sphincter fibrillation: is this a new finding that identifies resistant chronic anal fissures that respond to botulinum toxin?

    PubMed

    Moon, A; Chitsabesan, P; Plusa, S

    2013-08-01

    Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery. It would be useful to identify predictors of poor response to medical therapy. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail botulinum toxin (BT) treatment. A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures, referred to one consultant surgeon between 2007 and 2011, was undertaken. These were correlated with treatment plans and healing rates. Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude 'saw tooth' waveform or anal sphincter fibrillation (ASF) and higher anal sphincter pressures. Nine (82%) of these patients had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only one (7%) had resolution following BT. ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

  1. Intraoperative pelvic nerve stimulation performed under continuous electromyography of the internal anal sphincter.

    PubMed

    Kneist, Werner; Kauff, Daniel W; Rahimi Nedjat, Roman K; Rink, Andreas D; Heimann, Axel; Somerlik, Karin; Koch, Klaus P; Doerge, Thomas; Lang, Hauke

    2010-11-01

    The aim of this animal study was to investigate the effect of intraoperative pelvic nerve stimulation on internal anal sphincter electromyographic signals in order to evaluate its possible use for neuromonitoring during nerve-sparing pelvic surgery. Eight pigs underwent low anterior rectal resection. The intersphincteric space was exposed, and the internal (IAS) and external anal sphincter (EAS) were identified. Electromyography of both sphincters was performed with bipolar needle electrodes. Intermittent bipolar electric stimulation of the inferior hypogastric plexus and the pelvic splanchnic nerves was carried out bilaterally. The recorded signals were analyzed in its frequency spectrum. In all animals, electromyographic recordings of IAS and EAS were successful. Intraoperative nerve stimulation resulted in a sudden amplitude increase in the time-based electromyographic signals of IAS (1.0 (0.5-9.0) μV vs. 4.0 (1.0-113.0) μV) and EAS (p < 0.001). The frequency spectrum of IAS in the resting state ranged from 0.15 to 5 Hz with highest activity in median at 0.77 Hz (46 cycles/min). Pelvic nerve stimulation resulted in an extended spectrum ranging from 0.15 to 20 Hz. EAS signals showed higher frequencies mainly in a range of 50 to 350 Hz. However, after muscle relaxation with pancuronium bromide, only the low frequency spectrum of the IAS signals was still present. Intraoperative verification of IAS function by stimulation of pelvic autonomic nerves is possible. The IAS electromyographic response could be used to monitor pelvic autonomic nerve preservation.

  2. Sacral nerve stimulation for the treatment of faecal incontinence related to dysfunction of the internal anal sphincter.

    PubMed

    Dudding, Thomas C; Parés, David; Vaizey, Carolynne J; Kamm, Michael A

    2010-05-01

    In patients with faecal incontinence related to isolated internal anal sphincter (IAS) disruption, conservative management is the mainstay of treatment. Surgical repair of the internal sphincter is not successful. This study evaluated the use of sacral nerve stimulation (SNS) in those with faecal incontinence and IAS disruption in whom medical and behavioural treatments had failed. Nine patients (seven women, median age 44 years, range 39-62 years), with a history of obstetric or iatrogenic anal sphincter trauma, underwent a trial of SNS. All had passive faecal incontinence, low resting anal sphincter pressure and full thickness IAS muscle disruption of greater than 30 degrees radial extent. The effect of SNS on symptoms was measured by a bowel habit diary and validated questionnaires used to assess impact on quality of life. Eight (89%) patients benefited from temporary stimulation and proceeded to permanent device implantation. Follow-up was at a mean of 46 months (range 2-81). Faecal incontinence decreased from a mean (SD) of 9.9 (10.9) to 1.0 (2.4) episodes per week (p = 0.031), and soiling decreased from 6.1 (1.6) to 1.7 (2.4) episodes per week (p = 0.031), with chronic stimulation. At latest follow-up, three patients had no incontinence, three patients had episodes of minor soiling only, one patient had >75% reduction of incontinent episodes, and two patients remained incontinent. Sacral nerve stimulation is effective in treating faecal incontinence related to a structurally and functionally abnormal internal anal sphincter. Treatment should not be refused on the basis of IAS disruption.

  3. Obstetric anal sphincter injury ten years after: subjective and objective long term effects.

    PubMed

    Fornell, Eva Uustal; Matthiesen, Leif; Sjödahl, Rune; Berg, Göran

    2005-03-01

    To establish the long term effects of obstetric anal sphincter rupture. Prospective observational study. University hospital in Sweden. Eighty-two women from a prospective study from 1990 to compare anorectal function after third degree tear. Women completed a structured questionnaire, underwent a clinical examination and anorectal manometry, endoanal ultrasound (EAUSG) with perineal body measurement. Symptoms of anal incontinence, sexual symptoms, anal manometry scores and evidence of sphincter damage on EAUSG. Five women had undergone secondary repair and three were lost to follow up. Fifty-one women (80%) completed the questionnaire. Twenty-six out of 46 (57%) of the original study group and 6/28 (20%) of the original controls were examined. Incontinence to flatus and liquid stool was more severe in the study group than in controls. Flatus incontinence was significantly more pronounced among women with subsequent vaginal deliveries. Mean maximal anal squeeze pressures were 69 mmHg in the partial rupture group and 42 mmHg in the complete rupture group (P= 0.04). Study group women with signs of internal sphincter injury reported more pronounced faecal incontinence and had lower anal resting pressures (24 mmHg) than those with intact internal sphincters (40 mmHg) (P= 0.01). Perineal body thickness of less than 10 mm was associated with incontinence for flatus and liquid stools, less lubrication during sex and lower anal squeeze pressures (58 mmHg vs 89 mmHg, P= 0.04). Subjective and objective anal function after anal sphincter injury deteriorates further over time and with subsequent vaginal deliveries. Thin perineal body and internal sphincter injury seem to be important for continence and anal pressure.

  4. The molecular basis of the genesis of basal tone in internal anal sphincter.

    PubMed

    Zhang, Cheng-Hai; Wang, Pei; Liu, Dong-Hai; Chen, Cai-Ping; Zhao, Wei; Chen, Xin; Chen, Chen; He, Wei-Qi; Qiao, Yan-Ning; Tao, Tao; Sun, Jie; Peng, Ya-Jing; Lu, Ping; Zheng, Kaizhi; Craige, Siobhan M; Lifshitz, Lawrence M; Keaney, John F; Fogarty, Kevin E; ZhuGe, Ronghua; Zhu, Min-Sheng

    2016-04-22

    Smooth muscle sphincters exhibit basal tone and control passage of contents through organs such as the gastrointestinal tract; loss of this tone leads to disorders such as faecal incontinence. However, the molecular mechanisms underlying this tone remain unknown. Here, we show that deletion of myosin light-chain kinases (MLCK) in the smooth muscle cells from internal anal sphincter (IAS-SMCs) abolishes basal tone, impairing defecation. Pharmacological regulation of ryanodine receptors (RyRs), L-type voltage-dependent Ca(2+) channels (VDCCs) or TMEM16A Ca(2+)-activated Cl(-) channels significantly changes global cytosolic Ca(2+) concentration ([Ca(2+)]i) and the tone. TMEM16A deletion in IAS-SMCs abolishes the effects of modulators for TMEM16A or VDCCs on a RyR-mediated rise in global [Ca(2+)]i and impairs the tone and defecation. Hence, MLCK activation in IAS-SMCs caused by a global rise in [Ca(2+)]i via a RyR-TMEM16A-VDCC signalling module sets the basal tone. Targeting this module may lead to new treatments for diseases like faecal incontinence.

  5. The molecular basis of the genesis of basal tone in internal anal sphincter

    PubMed Central

    Zhang, Cheng-Hai; Wang, Pei; Liu, Dong-Hai; Chen, Cai-Ping; Zhao, Wei; Chen, Xin; Chen, Chen; He, Wei-Qi; Qiao, Yan-Ning; Tao, Tao; Sun, Jie; Peng, Ya-Jing; Lu, Ping; Zheng, Kaizhi; Craige, Siobhan M.; Lifshitz, Lawrence M.; Keaney Jr, John F.; Fogarty, Kevin E.; ZhuGe, Ronghua; Zhu, Min-Sheng

    2016-01-01

    Smooth muscle sphincters exhibit basal tone and control passage of contents through organs such as the gastrointestinal tract; loss of this tone leads to disorders such as faecal incontinence. However, the molecular mechanisms underlying this tone remain unknown. Here, we show that deletion of myosin light-chain kinases (MLCK) in the smooth muscle cells from internal anal sphincter (IAS-SMCs) abolishes basal tone, impairing defecation. Pharmacological regulation of ryanodine receptors (RyRs), L-type voltage-dependent Ca2+ channels (VDCCs) or TMEM16A Ca2+-activated Cl− channels significantly changes global cytosolic Ca2+ concentration ([Ca2+]i) and the tone. TMEM16A deletion in IAS-SMCs abolishes the effects of modulators for TMEM16A or VDCCs on a RyR-mediated rise in global [Ca2+]i and impairs the tone and defecation. Hence, MLCK activation in IAS-SMCs caused by a global rise in [Ca2+]i via a RyR-TMEM16A-VDCC signalling module sets the basal tone. Targeting this module may lead to new treatments for diseases like faecal incontinence. PMID:27101932

  6. Thermal control of shape memory alloy artificial anal sphincters for complete implantation

    NASA Astrophysics Data System (ADS)

    Luo, Yun; Okuyama, Takeshi; Takagi, Toshiyuki; Kamiyama, Takamichi; Nishi, Kotaro; Yambe, Tomoyuki

    2005-02-01

    This paper presents an approach for the thermal control of an artificial anal sphincter using shape memory alloys. An artificial anal sphincter has been proposed by the authors to resolve problems of severe fecal incontinence in patients. The basic design of the artificial sphincter consists of two all-round shape memory alloy plates as the main functional parts, and heaters that are attached to the SMA plates for generating the thermal cycles required for the phase transformation accompanied shape changes of the plates. The SMA artificial sphincter could be fitted around intestines, performing an occlusion function at body temperature and a release function upon heating. Thermal compatibility of such prostheses is most important and is critical for practical use. Since a temperature rise of approximately 20 °C from body temperature is needed to activate a complete transformation of SMA plates, an earlier model of ours allowed only a short period of heating, resulting in incomplete evacuation. In this work, a thermal control approach using a temperature-responsive reed switch has been incorporated into the device to prevent the SMA plates from overheating. Then, with thermal insulation the artificial anal sphincter is expected to allow a long enough opening period for fecal continence; without any thermal impact to the surrounding tissues that would be in contact with the artificial sphincter. Thermal control was confirmed in both in vitro and in vivo experiments, suggesting the effectiveness of the present approach. The modified SMA artificial anal sphincter has been implanted into animal models for chronic experiments of up to 4 weeks, and has exhibited good performance by maintaining occlusion and release functions. At autopsy, no anomaly due to thermal impact was found on the surfaces of intestines that had been in contact with the artificial anal sphincter.

  7. Changes in the innervation of the mouse internal anal sphincter during aging.

    PubMed

    Wang, C; Houghton, M J; Gamage, P P K M; Collins, H E; Patel, B A; Yeoman, M S; Ranson, R N; Saffrey, M J

    2013-07-01

    The innervation of the mouse internal anal sphincter (IAS) has been little studied, and how it changes during aging has not previously been investigated. The aim of this study was therefore to characterize the distribution and density of subtypes of nerve fibers in the IAS and underlying mucosa in 3-, 12- to 13-, 18- and 24- to 25-month-old male C57BL/6 mice. Nerve fibers were immunolabeled with antibodies against protein gene product 9.5 (PGP9.5), neuronal nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP), substance P (SP), calcitonin gene-related peptide (CGRP), and calretinin (CR). Immunoreactivity in nerve fibers in the circular muscle and mucosa was quantified using Image J software. In young adult (3 month) mice, nNOS-immunoreactive (IR) nerve fibers were densely distributed in the circular muscle, but relatively few in the mucosa; VIP-IR nerve fibers were abundant in the circular muscle and common in the mucosa; SP-IR nerve fibers were common in circular muscle and mucosa; CGRP- and CR-IR nerve fibers were dense in mucosa and sparse in circular muscle. The density of PGP9.5 immunoreactivity (IRY) was not significantly reduced with age, but a significant reduction in nNOS-IRY and SP-IRY with age was found in the IAS circular muscle. Neuronal nitric oxide synthase-, VIP-, and SP-IRY in the anal mucosa were significantly reduced with age. CGRP-IRY in both circular muscle and mucosa was increased in 18-month-old animals. The density of immunoreactivity of markers for some types of IAS nerve fibers decreases during aging, which may contribute to age-related ano-rectal dysfunction. © 2013 John Wiley & Sons Ltd.

  8. Mode of delivery after obstetric anal sphincter injury and the risk of long-term anal incontinence.

    PubMed

    Jangö, Hanna; Langhoff-Roos, Jens; Rosthøj, Susanne; Sakse, Abelone

    2016-06-01

    Primiparous women have an increased risk of obstetric anal sphincter injury; because most of these patients deliver again, there are major concerns about mode of delivery: the risk of recurrent obstetric anal sphincter injury and the risk of long-term symptoms of anal incontinence. Although an elective cesarean delivery protects against recurrent obstetric anal sphincter injury, it is uncertain how the second delivery affects the risk of long-term anal incontinence. The purpose of this study was to evaluate whether the mode of delivery for a second pregnancy, after a documented obstetric anal sphincter injury at the time of first delivery, had a significant impact on the prevalence of anal and fecal incontinence in the long term. We performed a population-based questionnaire cohort study that evaluated anal and fecal incontinence, fecal urgency, and affected quality of life caused by anal incontinence in 1978 patients who had obstetric anal sphincter injury in the first delivery and a second vaginal (n = 1472 women; 71.9%) or elective cesarean delivery (n = 506 women; 24.7%) delivery. We performed uni- and multivariable logistic regression analyses to compare groups. Long-term anal incontinence was reported in 38.9% of patients (n = 573) with second vaginal compared with 53.2% (n = 269) with elective cesarean delivery. The corresponding numbers that reported anal incontinence before the second pregnancy was 29.4% for those with vaginal delivery compared with 56.2% of those with elective cesarean delivery (ie, there was a significantly larger change in the risk of anal incontinence in the group with a second vaginal delivery compared with the change in the group with elective cesarean in second delivery). However, adjusted for important maternal and obstetric characteristics, the risk of long-term anal incontinence was nonsignificantly lower in patients with elective cesarean delivery (adjusted odds ratio, 0.77; 95% confidence interval, 0.57-1.05; P = .09

  9. Prolonged-Release Oxycodone/Naloxone Improves Anal Sphincter Relaxation Compared to Oxycodone Plus Macrogol 3350.

    PubMed

    Poulsen, Jakob Lykke; Brock, Christina; Grønlund, Debbie; Liao, Donghua; Gregersen, Hans; Krogh, Klaus; Drewes, Asbjørn Mohr

    2017-10-06

    Opioid analgesics inhibit anal sphincter function and contribute to opioid-induced bowel dysfunction (OIBD). However, it is unknown whether the inhibition can be reduced by opioid antagonism with prolonged-release (PR) naloxone and how this compares to laxative treatment. To compare the effects of combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350 on anal sphincter function and gastrointestinal symptoms. A randomized, double-blind, crossover trial was conducted in 20 healthy men. Participants were treated for 5 days with combined PR oxycodone/naloxone or PR oxycodone plus macrogol 3350. Resting anal pressure, anal canal distensibility, and relaxation of the internal sphincter to rectal distension were evaluated before treatment (baseline) and on day 5. The Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire, stool frequency, and stool consistency were assessed daily. Both PR oxycodone/naloxone and PR oxycodone plus macrogol treatment decreased sphincter relaxation compared to baseline (- 27.5%; P < 0.001 and - 14.7%; P = 0.01). However, sphincter relaxation was increased after PR naloxone/oxycodone treatment compared to macrogol (difference = + 17.6%; P < 0.001). Resting anal pressure and anal canal distensibility did not differ between treatments. PAC-SYM abdominal symptoms score was lower during PR naloxone compared to macrogol (0.2 vs. 3.2; P = 0.002). The number of bowel movements was lower during PR naloxone versus macrogol (4.2 vs. 5.4; P = 0.035). Relaxation of the internal anal sphincter was significantly better after PR oxycodone/naloxone treatment compared to PR oxycodone plus macrogol 3350. These findings highlight that OIBD may require specific therapy against the complex, pan-intestinal effects of opioids.

  10. Preoperative Therapy for Lower Rectal Cancer and Modifications in Distance From Anal Sphincter

    SciTech Connect

    Gavioli, Margherita Losi, Lorena; Luppi, Gabriele; Iacchetta, Francesco; Zironi, Sandra; Bertolini, Federica; Falchi, Anna Maria; Bertoni, Filippo; Natalini, Gianni

    2007-10-01

    Purpose: To assess the frequency and magnitude of changes in lower rectal cancer resulting from preoperative therapy and its impact on sphincter-saving surgery. Preoperative therapy can increase the rate of preserving surgery by shrinking the tumor and enhancing its distance from the anal sphincter. However, reliable data concerning these modifications are not yet available in published reports. Methods and Materials: A total of 98 cases of locally advanced cancer of the lower rectum (90 Stage uT3-T4N0-N+ and 8 uT2N+M0) that had undergone preoperative therapy were studied by endorectal ultrasonography. The maximal size of the tumor and its distance from the anal sphincter were measured in millimeters before and after preoperative therapy. Surgery was performed 6-8 weeks after therapy, and the histopathologic margins were compared with the endorectal ultrasound data. Results: Of the 90 cases, 82.5% showed tumor downsizing, varying from one-third to two-thirds or more of the original tumor mass. The distance between the tumor and the anal sphincter increased in 60.2% of cases. The median increase was 0.73 cm (range, 0.2-2.5). Downsizing was not always associated with an increase in distance. Preserving surgery was performed in 60.6% of cases. It was possible in nearly 30% of patients in whom the cancer had reached the anal sphincter before the preoperative therapy. The distal margin was tumor free in these cases. Conclusion: The results of our study have shown that in very low rectal cancer, preoperative therapy causes tumor downsizing in >80% of cases and in more than one-half enhances the distance between the tumor and anal sphincter. These modifications affect the primary surgical options, facilitating or making sphincter-saving surgery possible.

  11. Bioengineering functional human sphincteric and non-sphincteric gastrointestinal smooth muscle constructs.

    PubMed

    Rego, Stephen L; Zakhem, Elie; Orlando, Giuseppe; Bitar, Khalil N

    2016-04-15

    Digestion and motility of luminal content through the gastrointestinal (GI) tract are achieved by cooperation between distinct cell types. Much of the 3 dimensional (3D) in vitro modeling used to study the GI physiology and disease focus solely on epithelial cells and not smooth muscle cells (SMCs). SMCs of the gut function either to propel and mix luminal contents (phasic; non-sphincteric) or to act as barriers to prevent the movement of luminal materials (tonic; sphincteric). Motility disorders including pyloric stenosis and chronic intestinal pseudoobstruction (CIPO) affect sphincteric and non-sphincteric SMCs, respectively. Bioengineering offers a useful tool to develop functional GI tissue mimics that possess similar characteristics to native tissue. The objective of this study was to bioengineer 3D human pyloric sphincter and small intestinal (SI) constructs in vitro that recapitulate the contractile phenotypes of sphincteric and non-sphincteric human GI SMCs. Bioengineered 3D human pylorus and circular SI SMC constructs were developed and displayed a contractile phenotype. Constructs composed of human pylorus SMCs displayed tonic SMC characteristics, including generation of basal tone, at higher levels than SI SMC constructs which is similar to what is seen in native tissue. Both constructs contracted in response to potassium chloride (KCl) and acetylcholine (ACh) and relaxed in response to vasoactive intestinal peptide (VIP). These studies provide the first bioengineered human pylorus constructs that maintain a sphincteric phenotype. These bioengineered constructs provide appropriate models to study motility disorders of the gut or replacement tissues for various GI organs.

  12. Elective cesarean delivery for women with a previous anal sphincter rupture.

    PubMed

    McKenna, David S; Ester, John B; Fischer, John R

    2003-11-01

    The purpose of this study was to evaluate elective cesarean delivery for women with a history of anal sphincter rupture. The effectiveness of cesarean delivery in parous women with a previous anal sphincter rupture was determined by decision analysis. The outcomes were excess cesarean deliveries and morbidity and mortality rates per prevented case of anal incontinence. We needed 2.3 cesarean deliveries to prevent one case of anal incontinence. A woman who chooses a cesarean delivery has a 11.3% risk of morbidity compared with a 4.2% risk for vaginal delivery (relative risk, 2.7; 95% CI, 2.6-2.8; P<.001). The relative risk for maternal death from a cesarean delivery is 2.6 (95% CI, 1.5-4.5; P<.001). Continent women with a previous anal sphincter rupture who are delivered vaginally are at high risk for permanent anal incontinence. Cesarean delivery will prevent most cases of anal incontinence, although marginally increasing maternal risk. The increased risk may be justified by the potential benefits. Patients should be counseled on these risks and benefits.

  13. One stage operation through modified posterior sagittal approach preserving the sphincter intact for anal agenesis with rectovestibular fistula.

    PubMed

    Liem, Nguyen Thanh; Quynh, Tran Anh

    2015-04-01

    To describe the surgical technique and outcomes of an one stage operation through modified posterior sagittal approach (PSAP) preserving the sphincter intact for anal agenesia with rectovestibula fistula. 57 patients suffering from anal agenesis with rectovestibular fistula were operated by a one-stage operation through a modified PSAP preserving the external sphincter intact from 2002 to 2010. The operation was performed in one-stage through a posterior sagittal approach with three modifications: The external sphincter complex was not opened on the posterior side, the dissection was carried out outside the rectal pouch, the rectal pouch was not tapered and was pulled through the center of the external sphincter identified by muscle stimulator. Patients age varied from 3 days to 30 days (mean: 21±9 days). The mean operative time was 57±8 min (range, 35-90 min). There were no intraoperative complications. There were no intraoperative or postoperative deaths. There were no early postoperative complications. Follow up from 40 months to 140 was obtained in 52 (91.2%) patients. Constipation has seen in 3 patient, 46 patients (88.5%) had 1-2 defecations per day, 2 patients (3.85%) had 3-4 defecations per day, 1 patients (1.9%) had more than 4 defecations, and 3 patients(5.8%) had one defecation every 2-3 days. Rectal mucosal prolapse occurred in 7 patients who required a second operation. One stage operation through modified PSAP is feasible, is safe and provides good continence outcomes for anal agenesis with rectovestibular fistula. Copyright © 2015 Elsevier Inc. All rights reserved.

  14. Functional evaluation of an artificial anal sphincter using shape memory alloys.

    PubMed

    Luo, Yun; Takagi, Toshiyuki; Okuyama, Takeshi; Amae, Shintaro; Wada, Motoshi; Nishi, Kotaro; Kamiyama, Takamichi; Yambe, Tomoyuki; Matsuki, Hidetoshi

    2004-01-01

    This article describes an implantable artificial anal sphincter using shape memory alloys and its in vivo assessment in porcine models. The new design was developed as a low invasive prosthesis with a simple structure to solve the problem of severe fecal incontinence in patients with hypoplastic sphincters or without anal sphincters and especially for ostomates. The artificial anal sphincter consists of two shape memory alloy (SMA) plates as the main functional parts to perform two basic functions when the SMA artificial sphincter is fitted around intestines (i.e., an occlusion at body temperature and an opening function on heating). Our previous assessments with short-term animal experiments revealed promising properties with the occlusion function of the device, although some complications, such as overpressure induced ischemia, heat burn, and infections, remained. This article addresses the concerns related to the practical use of the device, the power supplement to drive the actuator, and overheating protection of the device inside bodies. Results of chronic animal experiments of up to 4 weeks suggested great potential for the improved device.

  15. Over diagnosis and rising rates of Obstetric Anal Sphincter Injuries (OASIS) - time for reappraisal.

    PubMed

    Sioutis, Dimos; Thakar, Ranee; Sultan, Abdul H

    2016-09-19

    To identify the accuracy of clinically diagnosed OASIS using 3D endoanal ultrasound and compare symptoms and anal manometry measurements between those whose anal sphincters were adequately repaired to those who had persistent anal sphincter defects. The endoanal scan images of women who sustained OASIS and attended the perineal clinic over a 10 year period (2003 - 2013) were re-analysed from data entered prospectively of women with clinically diagnosed and repaired OASIS. The St Mark's Incontinence Score (SMIS) as well as anal manometry measurements were included in the analysis. The images of 908 women were re-analysed. We found that there was no evidence of OASIS (Group A) = 64 (7%); external anal sphincter (EAS) scar alone (Group B) = 520 (57.3%); anal sphincter defect (Group C) = 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect and 90 had an internal anal sphincter (IAS) defect and 122 had a combined IAS + EAS defect. The SMIS was significantly higher in women with a defect (p = 0.018) but there was no significant difference in scores between women with an intact sphincter and women with a scar. Compared to the intact group, both the maximum resting (median and range [55 (29-86) vs 43.5 (8-106) mmHg; p < 0.001] and maximum squeeze pressures [103 (44-185) vs 73.5, (23-180); p < 0.001] were significantly lower in women with a defect but less so with a scar. The anal length was significantly shorter in woman with a defect [25 (10-40) vs 20 (10-40) mm]. Seven percent of women who had a clinical diagnosis of OASIS were wrongly diagnosed as they only had a second degree tear. We believe that this rate may differ from other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of anal ultrasound in the immediate post-partum period needs further evaluation as it will be dependent on the expertise of the staff available to accurately interpret the

  16. Nerves supplying the internal anal sphincter: an immunohistochemical study using donated elderly cadavers.

    PubMed

    Ishiyama, Gentaro; Hinata, Nobuyuki; Kinugasa, Yusuke; Murakami, Gen; Fujimiya, Mineko

    2014-12-01

    Nerves serving the internal anal sphincter (NIAS) have been described as the lower rectal branches of the pelvic autonomic nerve plexus. However, their topographical anatomy and fiber components have remained unclear. Using histological sections from ten elderly donated cadavers, we investigated the topographical anatomy and composite fibers of the NIAS using immunohistochemistry for S100 protein, neuronal nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP) and tyrosine hydroxylase (TH). At the 2-3 o'clock position in the lower rectum, the NIAS originated from nerves at the posterolateral corner of the prostate in males or in the lower paracolpium in females. The nerves ran inferiorly along the internal aspect of the levator ani muscle, and joined branches of the myenteric plexus at a level slightly above the epithelial junction. The NIAS contained both nNOS-positive parasympathetic nerve fibers and TH-positive sympathetic fibers, but VIP-positive fibers were few in number. The origin of the NIAS at the posterolateral corner of the prostate as well as in the lower paracolpium might be sacrificed or damaged during radical prostatectomy or tension-free vaginal tape insertion. Low anterior resection of rectal cancer will most likely render damage to the NIAS because of its intersphincteric course. Although the nerve composition of the NIAS is characterized by a higher proportion of sympathetic nerve fibers than the myenteric plexus in the large intestine, their role is unclear. However, evaluation of sphincteric function after surgery would appear to be difficult because of the complex control mechanism independent of nerve supply.

  17. Design of sEMG assembly to detect external anal sphincter activity: a proof of concept.

    PubMed

    Shiraz, Arsam; Leaker, Brian; Mosse, Charles Alexander; Solomon, Eskinder; Craggs, Michael; Demosthenous, Andreas

    2017-09-13

    Conditional trans-rectal stimulation of the pudendal nerve could provide a viable solution to treat hyperreflexive bladder in spinal cord injury. A set threshold of the amplitude estimate of the external anal sphincter surface electromyography (sEMG) may be used as the trigger signal. The efficacy of such a device should be tested in a large scale clinical trial. As such a probe should remain in situ for several hours while patients attend to their daily routine, the recording electrodes should be designed to be large enough to maintain good contact while observing design constraints. The objective of this study was to arrive at a design for intra-anal sEMG recording electrodes for the subsequent clinical trials while deriving the possible recording and processing parameters. Approach: Having in mind existing solutions and based on theoretical and anatomical considerations, a set of four multi-electrode probes were designed and developed. These were tested in a healthy subject and the measured sEMG traces were recorded and appropriately processed. Main results: It was shown that while comparatively large electrodes record sEMG traces that are not sufficiently correlated with the external anal sphincter contractions, smaller electrodes may not maintain a stable electrode tissue contact. It was shown that 3 mm wide and 1 cm long electrodes with 5 mm inter-electrode spacing, in agreement with Nyquist sampling, placed 1 cm from the orifice may intra-anally record a sEMG trace sufficiently correlated with external anal sphincter activity. Significance: The outcome of this study can be used in any biofeedback, treatment or diagnostic application where the activity of the external anal sphincter sEMG should be detected for an extended period of time. . © 2017 Institute of Physics and Engineering in Medicine.

  18. Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth.

    PubMed

    Walsh, Kate A; Grivell, Rosalie M

    2015-10-29

    During childbirth, many women sustain trauma to the perineum, which is the area between the vaginal opening and the anus. These tears can involve the perineal skin, the pelvic floor muscles, the external and internal anal sphincter muscles as well as the rectal mucosa (lining of the bowel). When these tears extend beyond the external anal sphincter they are called 'obstetric anal sphincter injuries' (OASIS). When women sustain an OASIS, they are at increased risk of developing anal incontinence either immediately following birth or later in life. Anal incontinence is associated with significant medical, hygiene and social problems. Endoanal ultrasound (EAUS) can be performed with a bedside scanner by inserting a small probe into the anus and the structures of the anal canal and perineum can be reviewed in real-time. We proposed that by examining the perineum with EAUS after the birth of the baby and before the tear has been repaired, there would be an increase in detection of OASIS. This increased detection could lead to improved primary repair of the external and internal anal sphincter resulting in reduced rates of anal incontinence and improved quality of life for women. EAUS may also have a role after perineal repair in the evaluation of residual injury and may help guide a woman's management in subsequent pregnancies and allow for early referral to specialised units, minimising long-term complications. To evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference list of the one retrieved study. Randomised control trials (RCTs) comparing EAUS versus no ultrasound in women prior to repair of perineal trauma and EAUS performed after perineal repair. RCTs published in abstract form only and trials using a cluster-randomised design were eligible for inclusion

  19. Third- or Fourth-Degree Intrapartum Anal Sphincter Tears Are Associated With Levator Ani Avulsion in Primiparas.

    PubMed

    Valsky, Dan V; Cohen, Sarah M; Lipschuetz, Michal; Hochner-Celnikier, Drorith; Daum, Hagit; Yagel, Itai; Yagel, Simcha

    2016-04-01

    We evaluated primiparous women with clinically diagnosed third- and fourth-degree and anal sphincter tears, to evaluate the rate of levator ani muscle injury compared to primiparous women without sphincter tears. Primiparous women delivering in our maternity ward with intrapartum diagnoses of third- or fourth-degree anal sphincter tears, repaired by the overlapping technique, were recruited to undergo 3-dimensional transperineal sonography of the pelvic floor anatomy, including the anterior and posterior compartments. Primiparas with uncomplicated vaginal deliveries were recruited as a comparison group. Patient files were examined, and maternal backgrounds and delivery and neonatal details were extracted for all patients. Ninety-four women with tears were recruited to the study group, and 464 women with normal vaginal deliveries constituted the comparison group. The groups differed significantly in the rates of levator ani defects: 38 of 94 women (40.4%) in the study group versus 75 of 464 (16.2%) in the comparison group (P < .001; odds ratio, 3.53; 95% confidence interval, 2.18-5.7). Neonatal head circumference differed significantly between the study and comparison groups: (mean ± SD, 34.5 ± 1.3 cm in the study group versus 33.9 ± 1.3 cm in the comparison group; P= .005), as did birth weight (3322 ± 430 g in the study group versus 3169 ± 458 g in the comparison group; P = .007). The groups did not differ in maternal age, gestational age at delivery, length of second stage of labor, and rates of epidural anesthesia, episiotomy, and vacuum extraction. Third- and fourth-degree intrapartum sphincter tears are associated with levator ani avulsion. Knowledge of complex pelvic floor damage may allow for prompt referral to secondary preventive measures for pelvic floor disorders. © 2016 by the American Institute of Ultrasound in Medicine.

  20. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study.

    PubMed

    Marola, Silvia; Ferrarese, Alessia; Gibin, Enrico; Capobianco, Marco; Bertolotto, Antonio; Enrico, Stefano; Solej, Mario; Martino, Valter; Destefano, Ines; Nano, Mario

    2016-01-01

    Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient.

  1. Role of three-dimensional endoanal ultrasound in assessing the anal sphincter morphology of female patients with chronic proctalgia.

    PubMed

    Xue, Ya-Hong; Ding, Shu-Qing; Ding, Yi-Jiang; Pan, Li-Qun

    2017-06-07

    To assess the role of three-dimensional endoanal ultrasound (3D-EAUS) for morphological assessment of the anal sphincter of female patients with chronic proctalgia (CP). In this unmatched case control study, 30 consecutive female patients with CP and 25 normal women (control group) were enrolled. 3D-EAUS was performed in all subjects. Thickness and length of internal anal sphincter (IAS), thickness of puborectalis muscle (PR), length of the external anal sphincter (EAS) plus PR, and puborectalis angle were measured and compared between the two groups. Patients with CP had significantly shorter IAS length and greater PR thickness, as compared to those in normal individuals (26.28 ± 3.59 mm vs 28.87 ± 4.84 mm, P < 0.05 and 9.67 ± 1.57 mm vs 8.85 ± 0.97 mm, P < 0.05, respectively). No significant between-group differences were observed with respect to IAS thickness and the EAS plus PR length (P > 0.05). Puborectalis angle in the CP group was significantly decreased, both in resting (88.23° ± 1.81° vs 89.94° ± 2.07° in control group, P < 0.05) and straining (88.47° ± 3.32° vs 90.72° ± 1.87° in control group, P < 0.05) phases, which suggest the presence of paradoxical contraction of PR in patients with CP. In the CP group, no significant difference in puborectalis angle was observed between the resting and straining phases (88.23° ± 1.81° vs 88.47° ± 3.32° respectively, P > 0.05). The association of greater PR thickness and paradoxical contraction of PR with CP suggest their potential value as markers of CP.

  2. Design and assessment of novel artificial anal sphincter with adaptive transcutaneous energy transfer system.

    PubMed

    Ke, Lei; Yan, Guozheng; Wang, Zhiwu; Yan, Sheng; Liu, Zhiqiang

    2015-02-01

    This paper presents the in vitro assessment of a novel elastic scaling artificial anal sphincter system (ES-AASS) with an adaptive transcutaneous energy transfer system (TETS) for treatment of severe faecal incontinence (FI). The proposed adaptive TETS has a phase control, which can maintain the output voltage at ∼7 V across the full range of the coupling coefficient variation (from 0.09-0.31) during the whole process of charging with a phase shift of 177.5° to 79.1°. A maximum surface temperature of 42.2 °C was measured above the secondary coil during an energy transmission of 3.5 W in air. The specific absorption rate (SAR) and current density analysis of the biological three-layers structure, including the skin, fat and muscle) surrounding the coil pair were analysed and the results of simulation analysis showed that the value of SAR and current density were very small at any given transmission condition compared with the basic restrictions of the International Commission on Non-Ionizing Radiation Protection (ICNIRP). In conclusion, in vitro experimental results showed that the ES-AASS can control simulated faecal behaviour effectively and the performance of TETS was validated.

  3. COX-1 vs. COX-2 as a determinant of basal tone in the internal anal sphincter

    PubMed Central

    de Godoy, Márcio A. F.; Rattan, Neeru; Rattan, Satish

    2009-01-01

    Prostanoids, produced endogenously via cyclooxygenases (COXs), have been implicated in the sustained contraction of different smooth muscles. The two major types of COXs are COX-1 and COX-2. The COX subtype involved in the basal state of the internal anal sphincter (IAS) smooth muscle tone is not known. To identify the COX subtype, we examined the effect of COX-1- and COX-2-selective inhibitors, SC-560 and rofecoxib, respectively, on basal tone in the rat IAS. We also determined the effect of selective deletion of COX-1 and COX-2 genes (COX-1−/− and COX-2−/− mice) on basal tone in murine IAS. Our data show that SC-560 causes significantly more efficacious and potent concentration-dependent decreases in IAS tone than rofecoxib. In support of these data, significantly higher levels of COX-1 than COX-2 mRNA were found in the IAS. In addition, higher levels of COX-1 mRNA and protein were expressed in rat IAS than rectal smooth muscle. In wild-type mice, IAS tone was decreased 41.4 ± 3.4% (mean ± SE) by SC-560 (1 × 10−5 M) and 5.4 ± 2.2% by rofecoxib (P < 0.05, n = 5). Basal tone was 0.172 ± 0.021 mN//mg in the IAS from wild-type mice and significantly less (0.080 ± 0.015 mN/mg) in the IAS from COX-1−/− mice (P < 0.05, n = 5). However, basal tone in COX-2−/− mice was not significantly different from that in wild-type mice. We conclude that COX-1-related products contribute significantly to IAS tone. PMID:19056763

  4. Determining the shape of the turns-amplitude cloud during anal sphincter quantitative EMG.

    PubMed

    Gregory, W Thomas; Clark, Amanda L; Simmons, Kimberly; Lou, Jau-Shin

    2008-07-01

    We aimed to compare our normative data for quantitative interference pattern (IP) analysis of the anal sphincter to previously published data. In 28 nulliparous women, we performed IP analysis during quantitative concentric needle electromyography (QEMG) of the anal sphincter. At each sampling site, a 500-ms epoch was analyzed. The data were log transformed. Linear regression lines (with 95% confidence intervals) were calculated from the log transformed variables "turns-second" and "amplitude-turn." These confidence intervals were then transformed back into the original parameters to yield scatterplots with confidence curves. The mean turns-second were 203 (SD 174). The mean amplitude (mcv)-turn was 266 (SD 87). The regression coefficients for the log-transformed variables are constant = 1.5, slope = 0.3, and resultant cloud of raw data has a convex upper boundary. These appear slightly different than previously published reports, potentially influencing the determination of normal and abnormal studies.

  5. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study

    PubMed Central

    Laine, Katariina; Skjeldestad, Finn Egil; Sandvik, Leiv; Staff, Anne Cathrine

    2012-01-01

    Objective To compare the incidence of obstetric anal sphincter injuries (OASIS) in two time periods, before and after implementing a training programme for improved perineal support aimed at reducing the incidence of obstetric anal sphincter injuries. The secondary aim was to study incidence of obstetric anal sphincter injuries in subgroups defined by risk factors for OASIS. Design Population-based cohort study. Setting University hospital setting in Oslo, Norway. Participants Two cohorts of all delivering women in the largest hospital in Norway during two time periods (2003–2005 and 2008–2010) were studied. After excluding caesarean sections and preterm deliveries (< week 32), the study population consisted of 31 709 deliveries, among which 907 women were identified with obstetric anal sphincter injury. Primary and secondary outcome measures Incidence of OASIS in two time periods. Maternal, obstetrical and foetal risk factors for OASIS were collected from the hospital obstetric database. Univariate analyses and multivariate logistic regression analyses, presenting adjusted ODs for OASIS, were performed. Results The OASIS incidence was significantly reduced by 50%, from 4% (591/14787) in the first time period to 1.9% (316/16 922) in the second. This reduction could not be explained by changes in population characteristics or OASIS risk factors during the study years. The reduction of incidence of OASIS between the two study periods was consistent across subgroups of women; regardless of parity, delivery method and infant birth weight. Conclusions A marked reduction in the incidence of OASIS was observed in all studied subgroups of women after implementing the training programme for perineal protection. Further, this reduction could not be explained by the differences in patient characteristics across the study period. These findings indicate that the training programme with improved perineal protection markedly reduced the risk of OASIS. PMID:23075573

  6. Local thermal stimulation relaxes hypertonic anal sphincter: evidence of somatoanal reflex.

    PubMed

    Jiang, J K; Chiu, J H; Lin, J K

    1999-09-01

    Although it is generally believed that warm perineal baths reduce pain resulting from anal fissure, complicated hemorrhoids, or anal surgery, the exact mechanisms remain unclear. Because hypertonicity of the internal anal sphincter contributes to increasing pain in these conditions, it has been postulated that warm perineal baths could help to relax the anal sphincter, hence reducing pain. It is our purpose to demonstrate response of the anal sphincter to local thermal stimulation via a somatoanal reflex. Continuous anorectal manometry tracings were obtained from 15 healthy volunteers, 22 patients with hemorrhoid, and 20 patients with anal fissure. Local thermal stimulation was achieved by applying a heat pad on the right infragluteal region (local area), and subsequently on the right first interphalangeal region (control area). Obvious response to local thermal stimulation was shown by 13.3 percent of volunteers, 36.4 percent of patients with hemorrhoid, and 60 percent of patients with fissure. Heat-sensitive patients who responded to local thermal stimulation were divided to two groups, those with ultraslow waves and those without ultraslow waves. In patients with ultraslow waves, the amplitude of ultraslow waves decreased significantly after local thermal stimulation, with amplitude before local thermal stimulation, (mean +/- standard deviation) 66.2 +/- 30.6 mmHg, and during local thermal stimulation, 43.2 +/- 22.3 mmHg, respectively, P = 0.003. By contrast, in patients without ultraslow waves, the tonic pressure measured before local thermal stimulation and during local thermal stimulation was 74.2 +/- 23.5 and 60.5 +/- 18.5 mmHg, respectively, P = 0.001. The response began at approximately three minutes after local thermal stimulation when the skin temperature was 42.1 +/- 0.3 degrees C. No anal response was observed when the heat pad was applied to the control area. The maximum resting pressure of the heat-sensitive patients was significantly higher than

  7. Management of complicated chronic anal fissures with high-dose circumferential chemodenervation (HDCC) of the internal anal sphincter.

    PubMed

    Whatley, James Z; Tang, Shou-Jiang; Glover, Porter H; Davis, Eric D; Jex, Kellen T; Wu, Ruonan; Lahr, Christopher J

    2015-12-01

    Botulinum toxin injection into the internal anal sphincter (IAS) is gaining popularity as a second line therapy for chronic anal fissures after patients fail medical therapy. The dosage of Botulinum toxin reported in the literature ranged from 20 to 50 IU. Complicated chronic anal fissure is defined as persistent fissure concurrent with other perianal pathology. We report a new approach involving high-dose circumferential chemodenervation (HDCC) of 100 IU in treating these complicated chronic anal fissures. The aim of this study was to evaluate the fissure healing, complication, and recurrence rates with HDCC. Complicated anal fissure was defined as fissure with other perianal pathologies including skin tag, hypertrophied papilla, fistula, symptomatic hemorrhoids, anal condylomata, and abscess. Between 2008 and 2012, 62 consecutive patients (28 Blacks, 33 Whites, 1 Hispanic) with complete follow-up data were included in this single arm study. These patients underwent HDCC-IAS with addition interventions by a single colorectal surgeon. Follow up data were obtained by chart review and office follow up. Of the 62 patients, the overall success rate was greater than 70% at 3 months follow-up. A few patients developed transient flatus or fecal incontinence, but shortly resolved. There was no major complication following HDCC-IAS. Combination therapy involving HDCC-IAS and local anorectal surgery for associated condition is both safe and effective for fissure healing. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

  8. Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles.

    PubMed

    Dodi, G; Bogoni, F; Infantino, A; Pianon, P; Mortellaro, L M; Lise, M

    1986-04-01

    In 26 volunteers without anorectal complaints, and in 31 patients with anorectal problems such as hemorrhoidal disease, anal fissure, and proctalgia fugax, baseline resting anal canal pressures were recorded manometrically for 5 minutes at room temperature (23 degrees C). In 16 volunteers (Group A) and 21 patients (Group B) anorectal manometry was then performed while the anus was immersed in water at varying temperatures (5 degrees C, 23 degrees C, and 40 degrees C). In ten volunteers (Group A') and ten patients (Group B') resting pressures were recorded for an additional 30 minutes following immersion for 5 minutes at 40 degrees C. In all subjects (at least P less than 0.01), resting anal canal pressures diminished significantly from baseline after immersion at 40 degrees C, but remained unchanged in all subjects after immersion at 5 degrees C and 23 degrees C. In Group A', anal canal pressures remained significantly reduced for 15 minutes (P less than 0.02). In Group B', significant reduction in resting pressure lasted 30 minutes (P less than 0.02). Wet heat applied to the anal sphincter apparatus significantly and reproducibly decreased resting anal canal pressures over time, and therefore was likely to benefit patients after anorectal operations and those with anorectal pain.

  9. Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

    PubMed

    Wickramasinghe, Dakshitha Praneeth; Senaratne, Supun; Senanayake, Hemantha; Samarasekera, Dharmabandhu Nandadeva

    2016-09-01

    The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.

  10. Functional mapping of the pelvic floor and sphincter muscles from high-density surface EMG recordings.

    PubMed

    Peng, Yun; He, Jinbao; Khavari, Rose; Boone, Timothy B; Zhang, Yingchun

    2016-11-01

    Knowledge of the innervation of pelvic floor and sphincter muscles is of great importance to understanding the pathophysiology of female pelvic floor dysfunctions. This report presents our high-density intravaginal and intrarectal electromyography (EMG) probes and a comprehensive innervation zone (IZ) imaging technique based on high-density EMG readings to characterize the IZ distribution. Both intravaginal and intrarectal probes are covered with a high-density surface electromyography electrode grid (8 × 8). Surface EMG signals were acquired in ten healthy women performing maximum voluntary contractions of their pelvic floor. EMG decomposition was performed to separate motor-unit action potentials (MUAPs) and then localize their IZs. High-density surface EMG signals were successfully acquired over the vaginal and rectal surfaces. The propagation patterns of muscle activity were clearly visualized for multiple muscle groups of the pelvic floor and anal sphincter. During each contraction, up to 218 and 456 repetitions of motor units were detected by the vaginal and rectal probes, respectively. MUAPs were separated with their IZs identified at various orientations and depths. The proposed probes are capable of providing a comprehensive mapping of IZs of the pelvic floor and sphincter muscles. They can be employed as diagnostic and preventative tools in clinical practices.

  11. Level of highest mean resting pressure segment in the anal canal. A quantitative assessment of anal sphincter function.

    PubMed

    Goes, R N; Simons, A J; Beart, R W

    1996-03-01

    Even with the development of new technologies, the mechanism of fecal continence is still not completely understood. This study evaluates the relative position of the highest mean resting pressure (HMRP) in the anal canal and its correlation with function in incontinent patients and in controls. Sixteen incontinent patients (mean age, 47.1 +/- 13.9 (range, 18-63) years; 12 female) and 16 controls (mean age, 35.4 +/- 8.7 (range, 24-58) years; 12 female) were studied using a water-perfused eight-port radial catheter computer-assisted vectromanometry. Position of the HMRP was analyzed in relation to the anal verge (D1) and to the proximal functional border of the anal canal (D2). Controls had HMRP located more distally in the anal canal, because D2 was significantly higher than D1 (mean, 3.45 +/- 0.75 vs. 1.81 +/- 0.63 cm; p + 0.001). For incontinent patients, D1 and D2 were similar (mean, 1.86 +/- 0.75 vs. 2.08 +/- 1.11 cm; not significant). Comparison of the relative position of the HMRP between patients and controls showed a more proximal location for incontinent patients than controls (mean, 49.1 +/- 12.1 percent vs. 35.4 +/- 10.2 percent; p = 0.002). Position of the HMRP is significantly more proximal for incontinent patients than for controls, and measurement of the distance from the anal verge to the HMRP in relation to the full length of the anal canal may represent another way to quantitatively assess anal sphincter function.

  12. Evaluation of the intrinsic innervation of the internal anal sphincter using electrical stimulation.

    PubMed Central

    Kamm, M A; Lennard-Jones, J E; Nicholls, R J

    1989-01-01

    Stimulation of the rectal mucosa with a bipolar electrode leads to relaxation of the internal anal sphincter. Intraoperative studies in two subjects showed that transmission of the impulse was independent of extrinsic nerves and was interrupted by circular myotomy. Characteristics of the reflex were studied in 11 healthy women and 19 women with severe idiopathic constipation. One control subject and two patients did not tolerate the test. In the remainder the stimulus caused a clearly defined fall in internal sphincter pressure. The mean resting maximum anal canal pressure before stimulation was the same in both groups (90 (10) v 104 (7) cm H2O, p = 0.3, controls v patients). The threshold stimulus for relaxation (12 (2) v 14 (1) mamps, p = 0.5), the maximum percent fall in resting pressure (43 (7) v 46 (4)%, p = 0.7) and the lowest absolute resting pressure produced by stimulation (48 (13) v 49 (6) cm H2O, p = 0.9) were the same in both groups. The stimulus required to achieve maximum relaxation was significantly higher in the patient group (23 (3) v 32 (2) mamps, p = 0.012) suggesting abnormal intrinsic innervation of the sphincter in these patients. Electrical stimulation should not replace balloon distension for routine testing of the rectoanal reflex but it may be useful in quantitative studies. PMID:2759490

  13. Novel artificial anal sphincter system based on transcutaneous energy transmission system tested in vivo.

    PubMed

    Wang, Yongbing; Liu, Hua; Xu, Qianqian; Yan, Guozheng

    2013-12-01

    This paper proposes a novel artificial anal sphincter system (AASS) for severe fecal incontinence. The AASS is composed of an artificial anal sphincter (AAS), an external transcutaneous energy transmission system (TETS), and an external control device. The AAS is composed of a cuff, a micropump, a reservoir, and a remote control device. It is designed to be implanted into the body of the patient. The function of the AAS is to open and close the patient's natural anus. Patients suffering from loss of their natural sphincter lose rectal sensation and are thus unable to perceive imminent fecal incontinence. In order to restore rectal sensation, a pressure sensor in the AAS cuff is designed to detect pressure in the colon. The pressure reflects the present quantity of colon contents, allowing patients to control the AAS to open or close the anus according to the pressure. The TETS is designed to provide electrical energy to the implanted AAS without wire connections. The external control device is designed to receive the pressure information from the AAS and send the patient's command to the implanted device. This paper provides a thorough discussion of the design of the novel AASS and describes the performance of the AASS when tested in vivo on two Beagle dogs who were chosen to be the subjects for receiving the implant. The experimental results verified that the performance of the AASS met the functional requirements it was designed for; however, the trial also revealed some challenges to be further studied.

  14. [Applicability of 3/4D transperineal ultrasound for the diagnosis of anal sphincter injury during the immediate pospartum].

    PubMed

    García-Mejido, José Antonio; Gutiérrez Palomino, Laura; Fernández Palacín, Ana; Sainz-Bueno, José Antonio

    The most common cause of anal sphincter injuries in women is vaginal birth. Endo-anal ultrasound is currently used for the diagnosis of anal sphincter defect. However, due to the inconvenience caused, it is not an applicable technique during the immediate post-partum. The aim of this study was to determine whether transperineal ultrasound in 3/4D is a useful diagnostic method for the assessment of anal sphincter during the immediate post-partum. A prospective study was conducted on the vaginal deliveries performed between September 2012 and June 2013 in the Valme University Hospital (Seville). Obstetric and foetal parameters that could influence the onset of perineal tears were studied. The patients underwent a transperineal 3/4D ultrasound and a multislice study (48hours after birth). The study included 146 puerperal women. The sphincter complex was assessed in all of them during the immediate post-partum. External anal injuries were observed in 10.3% of the cases. In 8.2% of cases, the primary suture of the external anal sphincter was detected during ultrasound examination, and 2.1% of asymptomatic lesions were diagnosed only with post-partum ultrasound. None of the patients reported discomfort or pain. The 3-dimensional transperineal ultrasound is helpful in determining the primary repair of the anal sphincter during the immediate post-partum, with no discomfort for patients, as well as for establishing those early sphincter injuries that go unnoticed during vaginal delivery. Copyright © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

  15. Impact of mediolateral episiotomy on incidence of obstetrical anal sphincter injury diagnosed by endoanal ultrasound.

    PubMed

    Drusany Staric, Kristina; Lukanovic, Adolf; Petrocnik, Petra; Zacesta, Vita; Cescon, Corrado; Lucovnik, Miha

    2017-08-01

    to examine potential association between mediolateral episiotomy and reduced incidence of obstetrical anal sphincter injuries (OASIS) diagnosed by endoanal ultrasound. prospective cohort study. tertiary referral university hospital. sixty nulliparous women at 28-33 weeks of gestation with singleton pregnancies were included between 2010 and 2012. participants were examined with endoanal ultrasound at 28-33 weeks gestation and at 6-7 weeks post-partum. At both visits, symptoms of anal incontinence were assessed using Cleveland Clinic (Wexner) faecal incontinence scoring system. Mann Whitney U-test and χ(2) test was used to compare groups with vs. without episiotomy and groups with vs. without OASIS diagnosed by ultrasound. χ(2) test was used to assess correlation between OASIS and anal incontinence symptoms (p≤0.05 considered significant). None of the women included had sphincter injury or anal incontinence before childbirth. All delivered vaginally. Mediolateral episiotomy was performed in 33 (55%) cases. Six (10%) had OASIS on endoanal ultrasound (two were also diagnosed clinically), and 11 had symptoms of anal incontinence post-partum. No significant differences were seen in clinical characteristics between groups with vs. without episiotomy. No significant differences were seen in episiotomy rate (p=0.14), angle (p=0.42) and length (p=0.14) between groups with vs. without OASIS on ultrasound. Correlation between anal incontinence symptoms and sonographically diagnosed OASIS was statistically significant (p=0.04). mediolateral episiotomy does not seem to be protective against clinically or sonographically diagnosed OASIS even when episiotomy technique is considered. Endoanal ultrasound allows a significantly better detection of symptomatic OASIS compared to clinical examination alone. mediolateral episiotomy should be considered only when shortening the second stage of labour is indicated due to foetal distress, and not as a means of OASIS prevention

  16. Heme oxygenase-1 upregulation modulates tone and fibroelastic properties of internal anal sphincter

    PubMed Central

    Krishna, Chadalavada Vijay; Singh, Jagmohan; Kumar, Sumit

    2014-01-01

    A compromise in the internal anal sphincter (IAS) tone and fibroelastic properties (FEP) plays an important role in rectoanal incontinence. Herein, we examined the effects of heme oxygenase (HO)-1 upregulation on these IAS characteristics in young rats. We determined the effect of HO-1 upregulator hemin on HO-1 mRNA and protein expressions and on basal IAS tone and its FEP before and after HO-1 inhibitor tin protoporphyrin IX. For FEP, we determined the kinetics of the IAS smooth muscle responses, by the velocities of relaxation, and recovery of the IAS tone following 0 Ca2+ and electrical field stimulation. To characterize the underlying signal transduction for these changes, we determined the effects of hemin on RhoA-associated kinase (RhoA)/Rho kinase (ROCK) II, myosin-binding subunit of myosin light chain phosphatase 1, fibronectin, and elastin expression levels. Hemin increased HO-1 mRNA and protein similar to the increases in the basal tone, and in the FEP of the IAS. Underlying mechanisms in the IAS characteristics are associated with increases in the genetic and translational expressions of RhoA/ROCKII, and elastin. Fibronectin expression levels on the other hand were found to be decreased following HO-1 upregulation. The results of our study show that the hemin/HO-1 system regulates the tone and FEP of IAS. The hemin/HO-1 system thus provides a potential target for the development of new interventions aimed at treatment of gastrointestinal motility disorders, specifically the age-related IAS dysfunction. PMID:25035109

  17. A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe.

    PubMed

    Wilhelm, A

    2011-12-01

    Anal fistula repair still remains challenging. Up to 30% of fistulas persist after surgery despite many improvements in surgical skills and technique. One major reason for surgical failure is a persistent fistula track or remnants of the fistula epithelium which could not be removed during surgery. To overcome this problem, a novel technique was developed using a newly invented radial emitting laser probe ("FiLaC™", Biolitec, Germany) to destroy the fistula epithelium and to simultaneously obliterate the remaining fistula track. In a pilot study, we operated on 11 patients with cryptoglandular anal fistula. All patients underwent previous surgery up to 6 times prior to definitive surgery. In the primary operation, the initial abscess was drained, the internal opening of the fistula identified and seton drainage placed. During fistula repair, we used the flap technique for conventional closure of the internal opening. The remaining fistula track was cleaned mechanically, the laser inserted into the track and energy applied homogeneously at a wavelength of 1,470 nm and 13 watt. While providing continuous retraction of the probe, the remaining epithelium was destroyed and the fistula track obliterated. The median follow-up was 7.4 months. Nine out of 11 fistulas showed primary healing (81.8%). Only one minor form of incontinence (limited soiling) was observed and no complications occurred. The use of a novel diode laser source and a radial emitting laser probe in addition to conventional surgery is a very promising new technique in sphincter-preserving anal fistula repair. The observed healing rate is high. Due to minimized trauma to the sphincter muscle, there are good short-term functional results without observable procedure-related complications.

  18. In vivo growth of a bioengineered internal anal sphincter: comparison of growth factors for optimization of growth and survival.

    PubMed

    Miyasaka, Eiichi A; Raghavan, Shreya; Gilmont, Robert R; Mittal, Krittika; Somara, Sita; Bitar, Khalil N; Teitelbaum, Daniel H

    2011-02-01

    Our laboratory has developed and implanted a novel bioengineered internal anal sphincter (IAS) to treat anal incontinence. Fibroblast growth factor-2 (FGF-2) has been used in mice; however, the optimal growth factor for successful IAS implantation is unclear. This study compares several growth factors in order to optimize IAS viability and functionality. Bioengineered IAS rings were implanted subcutaneously into the dorsum of wildtype C57Bl/6 mice, with an osmotic pump dispensing FGF-2, vascular endothelial growth factor (VEGF), or platelet-derived growth factor (PDGF) (n = 4 per group). Control mice received IAS implants but no growth factor. The IAS was harvested approximately 25 days post-implantation. Tissue was subjected to physiologic testing, then histologically analyzed. Muscle phenotype was confirmed by immunofluorescence. All implants supplemented with growth factors maintained smooth muscle phenotype. Histological scores, blood vessel density and muscle fiber thickness were all markedly better with growth factors. Neovascularization was comparable between the three growth factors. Basal tonic force of the constructs was highest with VEGF or PDGF. All growth factors demonstrated excellent performance. As our ultimate goal is clinical implantation, our strong results with PDGF, a drug approved for use in the United States and the European Union, pave the way for translating bioengineered IAS implantation to the clinical realm.

  19. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery.

    PubMed

    Lowder, Jerry L; Burrows, Lara J; Krohn, Marijane A; Weber, Anne M

    2007-04-01

    This study was performed to assess the effect of pregnancy, route of delivery, and parity on the risk of primary and subsequent anal sphincter laceration in women at first vaginal delivery (1st VD), vaginal birth after cesarean delivery (VBAC), or second vaginal delivery (2nd VD). This retrospective cohort study used data from a perinatal database that included all deliveries at Magee-Womens Hospital from 1995 to 2002. Anal sphincter laceration was the primary outcome, defined as third- and fourth-degree perineal lacerations. The adjusted odds ratio (OR) for primary and subsequent anal sphincter laceration at delivery by risk group was estimated using logistic regression models and reported with 95% confidence intervals (CIs). We assessed 20,674 live, singleton, term deliveries at Magee-Womens Hospital from 1995 to 2002, including 13,183 with 1st VD, 6068 with 2nd VD, and 1423 with VBAC. Anal sphincter laceration occurred in 16% of women with 1st VD, 18% with VBAC, and 3% with 2nd VD. Multivariable logistic regression modeling for primary anal sphincter laceration showed that 1st VD had OR of 5.1 and 95% CI 4.4, 5.9, and VBAC had OR of 5.1, 95% CI 4.2, 6.2 when compared with the reference group with 2nd VD. Shown in order for 1st VD, VBAC, and 2nd VD, the following factors, adjusted for the other listed factors, were significantly related to anal sphincter laceration except as noted: forceps, ORs of 3.0, 2.6, 5.5; midline episiotomy, ORs of 2.7, 2.9, 2.9; infant birth weight 3500 g or more, ORs of 1.9, 1.9, 1.1, not significantly different from OR of 1.0; vacuum delivery, ORs of 1.7, 1.8, 1.5, not significantly different from OR of 1.0, and 2nd stage of labor 2 hours or longer, ORs of 1.8, 0.9, 0.9, last 2 not significantly different from OR of 1.0. Of women who had anal sphincter laceration in their first vaginal delivery, 7.2% (76 of 1054 women who had 2 pregnancies) had recurrent laceration in their second vaginal delivery, compared with 2.3% (123 of 5147) of

  20. Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review.

    PubMed

    Glasgow, Sean C; Lowry, Ann C

    2012-04-01

    Thorough and objective analysis of long-term results following anal sphincter repair for fecal incontinence will permit the correct application of this operation in the context of newer treatment methods. This investigation aimed to comprehensively review outcomes beyond 5 years in patients undergoing anal sphincter repair for fecal incontinence. A systematic review of Embase and MEDLINE articles published between January 1991 and December 2010 was conducted; additional studies were identified by hand-searching bibliographies. A 2-step process was used for screening articles examining sphincter repair or sphincteroplasty in adults with fecal incontinence, with a minimum follow-up of 60 months. Subjective or objective assessment of fecal incontinence in the postoperative period was completed. Data from 16 studies were examined, comprising nearly 900 repairs. There was significant heterogeneity in outcome measures, although most articles utilized at least one established incontinence instrument. In general, most series reported an initial subjectively "good" outcome in the majority of patients, with declines in this proportion over longer follow-up. There was poor correlation between quality of life and the severity of fecal incontinence, with all articles reporting high overall patient satisfaction even if continence declined with time or adaptive measures were needed. No consistent predictive factors for failure were identified. This study was limited by the paucity of level I data with an adequate length of follow-up. Despite worsening results over time, most patients remain satisfied with their surgical outcome postsphincteroplasty. Efforts should be directed at identifying patients who may do poorly following sphincter repair, as well as establishing standardized long-term outcome benchmarks for comparing novel techniques for treating fecal incontinence.

  1. Defecation into clothing without forewarning and mean radiation dose to bowel and anal-sphincter among gynecological cancer survivors.

    PubMed

    Lind, Helena; Alevronta, Eleftheria; Steineck, Gunnar; Waldenström, Ann-Charlotte; Nyberg, Tommy; Olsson, Caroline; Wilderäng, Ulrica; Dunberger, Gail; Al-Abany, Massoud; Åvall-Lundqvist, Elisabeth

    2016-11-01

    To analyze the relationship between mean radiation dose to the bowels and the anal-sphincter and occurrence of 'defecation into clothing without forewarning', a specific and serious fecal incontinence symptom after gynecological radiotherapy. Additional potential risk factors associated with the symptom are explored. Data were collected for 519 eligible gynecological cancer survivors, treated with pelvic radiotherapy, with a median follow-up of 5.8 years, using a study-specific questionnaire and medical records. Correlations between defecation into clothing without forewarning and mean dose to organs at risk; the anal-sphincter region, the rectum, the sigmoid and the small intestines were investigated, also taking other risk factors into account. Twelve percent reported having had the symptom at least once in the preceding six months. Mean doses >50 Gy to the anal-sphincter region, the rectum, the sigmoid and the small intestines were related to the occurrence of the symptom. Significantly associated risk factors were deliveries with high birth weight, heart failure and lactose and/or gluten intolerance. After adjusting for these factors, mean doses >50 Gy to the anal-sphincter region, the sigmoid and the small intestines remained related to the occurrence of the symptom. Mean doses to the bowels and anal-sphincter region are related to the risk of defecation into clothing without forewarning in long-term gynecological cancer survivors treated with pelvic radiotherapy. Further radiobiological modeling may distinguish which organ(s) contribute most to development of the symptom.

  2. Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse.

    PubMed

    Chun, A B; Rose, S; Mitrani, C; Silvestre, A J; Wald, A

    1997-03-01

    To evaluate the structure and function of the internal (IAS) and external (EAS) anal sphincters in anoreceptive homosexual men and to determine whether anoreceptive intercourse (ARI) is associated with a higher risk of incontinence in this population. We studied 14 anoreceptive homosexual males and 10 age-matched non-anoreceptive heterosexual males in a controlled, prospective cohort study. Subjects underwent evaluation of resting and maximum squeeze anal canal pressures (maximum squeeze pressure obtained over resting pressure) by station pull-through technique, using a manometric perfusion catheter followed by endoanal ultrasonography to evaluate the structure of the IAS and EAS. Manometry also was performed in age-matched male controls. All subjects completed a questionnaire that assessed sexual practices and bowel habits, including fecal incontinence. Resting pressures were significantly lower in subjects engaging in ARI (70.7 +/- 3.2 mm Hg vs. 91.4 +/- 5.2 mm Hg; mean +/- SEM, p < 0.003), whereas there was no significant difference in the mean maximum squeeze pressures, compared with controls (177.1 +/- 14.1 mm Hg vs. 151.8 +/- 19.6 mm Hg; mean +/- SEM, p = 0.32). No disruptions of the IAS or EAS were identified in either the anoreceptive or control group. Anoreceptive men tended to have thinner anal sphincters than controls, but the difference was not statistically significant. Furthermore, there were no complaints of fecal incontinence by the study subjects. Passive ARI is associated with decreased resting anal canal pressures, but total pressures are normal. There were no IAS or EAS defects, as well as no fecal incontinence, in our subjects. Better relaxation of the ARI subjects during anal canal manometry may explain the lower resting pressures.

  3. Randomized clinical trial comparing collagen plug and advancement flap for trans-sphincteric anal fistula.

    PubMed

    Bondi, J; Avdagic, J; Karlbom, U; Hallböök, O; Kalman, D; Šaltytė Benth, J; Naimy, N; Øresland, T

    2017-08-01

    The role of a collagen plug for treating anal fistula is not well established. A randomized prospective multicentre non-inferiority study of surgical treatment of trans-sphincteric cryptogenic fistulas was undertaken, comparing the anal fistula plug with the mucosal advancement flap with regard to fistula recurrence rate and functional outcome. Patients with an anal fistula were evaluated for eligibility in three centres, and randomized to either mucosal advancement flap surgery or collagen plug, with clinical follow-up at 3 and 12 months. The primary outcome was the fistula recurrence rate. Anal pain (visual analogue scale), anal incontinence (St Mark's score) and quality of life (Short Form 36 questionnaire) were also reported. Ninety-four patients were included; 48 were allocated to the plug procedure and 46 to advancement flap surgery. The median follow-up was 12 (range 9-24) months. The recurrence rate at 12 months was 66 per cent (27 of 41 patients) in the plug group and 38 per cent (15 of 40) in the flap group (P = 0·006). Anal pain was reduced after operation in both groups. Anal incontinence did not change in the follow-up period. Patients reported an increased quality of life after 3 months. There were no differences between the groups with regard to pain, incontinence or quality of life. There was a considerably higher recurrence rate after the anal fistula plug procedure than following advancement flap repair. Registration number: NCT01021774 (http://www.clinicaltrials.gov). © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

  4. Evaluation of the role of the puborectal part of the levator ani muscle in anal incontinence: a prospective study of 78 female patients with anal incontinence.

    PubMed

    Thomas, Christian; Etienney, Isabelle; Atienza, Patrick

    2011-09-01

    Anal incontinence is most often linked with sphincter rupture and/or stretching the pudendal nerves. The aim of our study was to investigate the involvement of the puborectal part of the levator ani muscle in anal incontinence. Seventy-eight female patients were studied by anorectal manometry, 3-dimensional ultrasound examination, and concentric needle electromyography of the external anal sphincter, puborectal muscle, and bulbocavernous muscles, completing with the evaluation of the pudendal nerve terminal motor latencies. Damage to the puborectal muscle was defined by an abnormal ultrasound and/or abnormal electromyography. Rupture of the anal sphincter apparatus and puborectal muscle was found in 23% and 3.8%. The EMG showed damage to the puborectal part in 39 cases: this was isolated in 4 cases and combined with external anal sphincter damage in 35 patients. Unilateral or bilateral increase in the terminal motor latencies of the pudendal nerves was found in 36% (28/78) of the patients. The frequency of peripheral neurogenic lesions varied from 36% to 90% according to the electromyographic tests used. There was no correlation between puborectal part damage and resting pressure, perception threshold, and maximum tolerable rectal volume. The mean Wexner index score was not increased by the existence of a defect involving the puborectal part found by echography or by damage to the puborectal part shown by the EMG. Investigating puborectal muscle lesions reduced the percentage of idiopathic anal incontinence to 2.5%. Our study confirms the feasibility and usefulness of combined electromyography and 3-dimensional ultrasound examination of the puborectal muscle in anal incontinence.

  5. Anal fissure

    MedlinePlus

    ... bath 2 to 3 times a day. The water should cover only the hips and buttocks. If the anal fissures do not go away with home care methods, treatment may involve: Botox injections into the muscle in the anus (anal sphincter) ...

  6. High ligation of the fistula track by lateral approach: a modified sphincter-saving technique for advanced anal fistulas.

    PubMed

    Chen, T-A; Liu, K-Y; Yeh, C-Y

    2012-09-01

    Ligation of the intersphincteric fistula track is a novel surgical procedure with the advantage of avoiding anal incontinence. We conducted a preliminary investigation of a modified technique for complicated trans-sphincteric anal fistula by high ligation of the track using a lateral approach. From June 2010 to May 2011, 10 patients received high ligation of the fistula track using a lateral approach. Patients selected for the procedure had a mature trans-sphincteric type of anal fistula that involved a significant amount of the external sphincter. Patients with early fistulous abscess or with a history of previous anal surgery were excluded. The surgical technique involved making an incision from the external opening and extending this towards the direction of the internal opening, dissection of the fistula from the underlying soft tissue, high ligation above the internal sphincter and removal of the distal part of the fistula track for pathological examination. Of the 10 patients, eight were men and the mean ± SD age was 40.5 ± 7.23 years. The median (range) duration of follow-up was 7 (6-10) months. In all patients, the wound was completely healed by the sixth postoperative week. Two cases of recurrence were noted later and were successfully managed by traditional fistulotomy. High-ligation surgery of the fistula track for trans-sphincteric anal fistula, aimed at total anal sphincter preservation, has shown encouraging early results. Long-term follow-up and randomized controlled trials are necessary. © 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.

  7. Mean Absorbed Dose to the Anal-Sphincter Region and Fecal Leakage among Irradiated Prostate Cancer Survivors

    SciTech Connect

    Alsadius, David; Hedelin, Maria; Lundstedt, Dan; Pettersson, Niclas; Wilderaeng, Ulrica; Steineck, Gunnar

    2012-10-01

    Purpose: To supplement previous findings that the absorbed dose of ionizing radiation to the anal sphincter or lower rectum affects the occurrence of fecal leakage among irradiated prostate-cancer survivors. We also wanted to determine whether anatomically defining the anal-sphincter region as the organ at risk could increase the degree of evidence underlying clinical guidelines for restriction doses to eliminate this excess risk. Methods and Materials: We identified 985 men irradiated for prostate cancer between 1993 and 2006. In 2008, we assessed long-term gastrointestinal symptoms among these men using a study-specific questionnaire. We restrict the analysis to the 414 men who had been treated with external beam radiation therapy only (no brachytherapy) to a total dose of 70 Gy in 2-Gy daily fractions to the prostate or postoperative prostatic region. On reconstructed original radiation therapy dose plans, we delineated the anal-sphincter region as an organ at risk. Results: We found that the prevalence of long-term fecal leakage at least once per month was strongly correlated with the mean dose to the anal-sphincter region. Examining different dose intervals, we found a large increase at 40 Gy; {>=}40 Gy compared with <40 Gy gave a prevalence ratio of 3.8 (95% confidence interval 1.6-8.6). Conclusions: This long-term study shows that mean absorbed dose to the anal-sphincter region is associated with the occurrence of long-term fecal leakage among irradiated prostate-cancer survivors; delineating the anal-sphincter region separately from the rectum and applying a restriction of a mean dose <40 Gy will, according to our data, reduce the risk considerably.

  8. High-dose circumferential chemodenervation of the internal anal sphincter: A new treatment modality for uncomplicated chronic anal fissure: A retrospective cohort study (with video).

    PubMed

    Glover, Porter H; Tang, Shou-jiang; Whatley, James Z; Davis, Eric D; Jex, Kellen T; Wu, Ruonan; Lahr, Christopher J

    2015-11-01

    Botulinum toxin injection into the internal anal sphincter is gaining popularity as a second line therapy for chronic anal fissures if medical therapy fails. The dosage of botulinum toxin reported ranged from 20 to 50 IU with no more than 3 injection sites and results in a healing rate of 41%-88% at 3 months. We propose a new injection method of high-dose circumferential chemodenervation of 100 IU in treating chronic anal fissure. This was a retrospective review at a single academic center. 75 patients (50 women and 25 men) with uncomplicated chronic anal fissures underwent high-dose circumferential chemodenervation-internal anal sphincter (100 IU). We measured fissure healing, complication, and recurrence rates at 3 and 6 months post injection. Of the 75 patients, healing rate was 90.7% at 3 months follow up with the first injection and 81.3% with the second injection. The recurrence rates were 20.6% and 12.5% at 6 months after the 1st and 2nd injections respectively. Excluding 5 patients who lost follow up, the total healing rate of the study cohort was 100%. At 2 weeks and 3 months, there were no major complications including hematoma, infection, flatus, fecal, and urinary incontinence. High-dose circumferential chemodenervation-internal anal sphincter (100 IU) is a safe and effective method for uncomplicated chronic anal fissure. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

  9. Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula.

    PubMed

    Ratto, C; Litta, F; Parello, A; Donisi, L; Zaccone, G; De Simone, V

    2012-05-01

    The surgical treatment of a complex anal fistula remains controversial, although 'sphincter-saving' operations are desirable. The Gore Bio-A® Fistula Plug is a new bioprosthetic plug that has been proposed for the treatment of complex anal fistula. This study reports preliminary data following implantation of this plug. Eleven patients with a complex anal fistula underwent insertion of Gore Bio-A® Fistula Plugs. The disc diameter and number of tubes in the plug were adapted to the fistula to allow accommodation of the disc into a submucosal pocket, and the excess tubes were trimmed. During the follow-up period, patients underwent clinical and physical examinations and three-dimensional endoanal ultrasound. Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three and four tubes were inserted into the fistula plug in seven, three and one patient, respectively. The median follow-up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Treatment success was noted for eight (72.7%) of 11 patients at the last follow-up appointment. Implanting a Gore Bio-A® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success. © 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.

  10. Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury.

    PubMed

    Aiken, Catherine E; Aiken, Abigail R; Prentice, Andrew

    2015-03-01

    Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. A retrospective 5-year cohort study was conducted in a UK obstetrics center which included a high-risk delivery unit and a low-risk birthing center. The study included 4,831 nulliparous women with vertex-presenting, single, live-born infants at term, stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. Three-hundred twenty-five of 4,831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, no association between duration of the second stage and the likelihood of sphincter injury was recorded. Factors associated with increased likelihood of sphincter injury included older maternal age, higher birthweight, and Southeast Asian ethnicity. In contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6 percent per 15 minutes in the second stage of labor before delivery. For spontaneous vaginal deliveries, duration of the second stage of labor was not an independent risk factor for obstetric anal sphincter injury. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental. © 2014 Wiley Periodicals, Inc.

  11. Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury

    PubMed Central

    AIKEN, Catherine E.; AIKEN, Abigail R.; PRENTICE, Andrew

    2014-01-01

    Background Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women. Methods A retrospective 5-year cohort study in a UK obstetrics center including high-risk delivery unit and low-risk birthing center. 4831 nulliparous women with vertex-presenting, single, live-born infants at term were included. The cohort was stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury. Results 325 of 4831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, there was no association between duration of the second stage and the likelihood of sustaining sphincter injuries. Factors associated with increased likelihood of sustaining sphincter injury included older maternal age, higher birthweight and Southeast Asian ethnicity. By contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6% per 15 minutes in the second stage of labor prior to delivery. Conclusions For spontaneous vaginal deliveries, duration of the second stage of labor is not an independent risk factor for obstetric anal sphincter injuries. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental. PMID:25439012

  12. Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas.

    PubMed

    Hirschburger, Markus; Schwandner, Thilo; Hecker, Andreas; Kierer, Walter; Weinel, Rolf; Padberg, Winfried

    2014-02-01

    The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas. We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively. In our 50 patients, 22 patients (44 %) had a previous proctologic operation and 11 patients (22 %) presented with recurrent fistulas. The fistulas existed for an average of 8 months. The operation time was 28 ± 16 min. Mean follow-up was 22± months. The fistula healed in 44 patients (88 %) who developed no recurrence. In five patients (10 %), the fistula healed, but they developed a recurrence in the observation period. In one patient (2 %), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery. FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.

  13. External anal sphincter defects in patients with fecal incontinence: comparison of endoanal MR imaging and endoanal US.

    PubMed

    Dobben, Annette C; Terra, Maaike P; Slors, J Frederik M; Deutekom, Marije; Gerhards, Michael F; Beets-Tan, Regina G H; Bossuyt, Patrick M M; Stoker, Jaap

    2007-02-01

    To prospectively compare in a multicenter study the agreement between endoanal magnetic resonance (MR) imaging and endoanal ultrasonography (US) in depicting external anal sphincter (EAS) defects in patients with fecal incontinence. The study was approved by the medical ethics committee of all participating centers. A total of 237 consenting patients (214 women, 23 men; mean age, 58.6 years +/- 13 [standard deviation]) with fecal incontinence were examined from 13 different hospitals by using endoanal MR imaging and endoanal US. Patients with an anterior EAS defect depicted on endoanal MR images and/or endoanal US scans underwent anal sphincter repair. Surgical findings were used as the reference standard in the determination of anterior EAS defects. The Cohen kappa statistic and McNemar test were used to calculate agreement and differences between diagnostic techniques. Agreement between endoanal MR imaging and endoanal US was fair for the depiction of sphincter defects (kappa = 0.24 [95% confidence interval: 0.12, 0.36]). At surgery, EAS defects were found in 31 (86%) of 36 patients. There was no significant difference between MR imaging and US in the depiction of sphincter defects (P = .23). Sensitivity and positive predictive value were 81% and 89%, respectively, for endoanal MR imaging and 90% and 85%, respectively, for endoanal US. In the selection of patients for anal sphincter repair, both endoanal MR imaging and endoanal US are sensitive tools for preoperative assessment, and both techniques can be used to depict surgically repairable anterior EAS defects. (c) RSNA, 2007.

  14. Obstetric anal sphincter injury and incontinence 15-23 years after vaginal delivery.

    PubMed

    Halle, Tuva K; Salvesen, Kjell Å; Volløyhaug, Ingrid

    2016-08-01

    The primary aim was to study prevalence of obstetric anal sphincter injuries (OASIS) after normal vaginal deliveries (NVD) and operative vaginal deliveries (OVD) with a subgroup analysis of forceps (FD) vs. vacuum deliveries (VD). The secondary aim was to study the association between OASIS and anal incontinence 15-23 years later. This was a cross-sectional study including 8137 primiparous women in Trondheim, Norway, from 1990 to 1997. The outcome measure was the adjusted odds ratio (aOR) for OASIS between delivery groups. A total of 1122 women responded to a postal questionnaire containing the Colorectal-Anal Distress Inventory (CRADI) in 2013. The aOR for anal incontinence and the difference in CRADI score between women with and without OASIS were calculated. OASIS prevalence was 2% for NVD and 10% for OVD (10% FD, 9% VD). aOR for OASIS was 5.01 (95%CI 3.85-6.51) comparing OVD with NVD. There was no difference between FD and VD (aOR 1.15, 95% CI 0.79-1.67). FD was associated with higher risk of fourth degree perineal tear than VD (aOR 5.08, 95% CI 1.47-17.49). OASIS was associated with increased risk of leakage of well-formed (aOR 8.61, 95% CI 3.08-24.12) and loose stool (aOR 2.75, 95% CI 1.43-5.27) and higher CRADI score (Mann-Whitney U-test, p = 0.01). OVD was associated with increased risk of OASIS. FD was associated with higher risk of fourth degree perineal tear compared with VD. OASIS was associated with increased risk of anal incontinence and higher CRADI score 15-23 years later. © 2016 Nordic Federation of Societies of Obstetrics and Gynecology.

  15. Innervation zones of the external anal sphincter in healthy male and female subjects. Preliminary results.

    PubMed

    Enck, P; Franz, H; Azpiroz, F; Fernandez-Fraga, X; Hinninghofen, H; Kaske-Bretag, K; Bottin, A; Martina, S; Merletti, R

    2004-01-01

    The objective of this work was to investigate the distribution of the innervation zones of the motor units that make up the external anal sphincter (EAS) in healthy males and females. A cylindrical probe carrying a circumferential array of 16 electrodes was used to detect the generation, propagation and extinction of individual motor unit action potentials (MUAPs) at 1, 2, and 3 cm depth from the orifice of the anal canal during maximal voluntary contractions of the EAS. Fifteen healthy males and 37 healthy nulliparous females were investigated. IZs could be detected in all males and in 34 out of 37 females. In the males, the IZs are scattered in the right and left hemisphincter at each of the three levels and their distribution is not affected by depth. In the females, the distribution is also concentrated in the right and left hemisphincter at depth 1 cm but is more uniform at depth 2 cm and more concentrated in the dorsal and ventral regions at depth 3 cm. ANOVA shows a statistically significant dependence of the IZ distribution on depth only in females and not in males. It is concluded that (a) IZs of the EAS can indeed be detected with a circumferential array placed at different depths along the anal canal; (b) large individual variability is observed, and (c) IZs show similar distribution at the three depth levels in males and different distributions in females. Copyright 2004 S. Karger AG, Basel

  16. Laparoscopic total mesorectal excision of low rectal cancer with preservation of anal sphincter: A report of 82 cases

    PubMed Central

    Zhou, Zong-Guang; Wang, Zhao; Yu, Yong-Yang; Shu, Ye; Cheng, Zhong; Li, Li; Lei, Wen-Zhang; Wang, Tian-Cai

    2003-01-01

    AIM: To assess the feasibility and efficacy of laparoscopic total mesorectal excision (LTME) of low rectal cancer with preservation of anal sphincter. METHODS: From June 2001 to June 2003, 82 patients with low rectal cancer underwent laparoscopic total mesorectal excision with preservation of anal sphincter. The lowest edge of tumors was below peritoneal reflection and 1.5-7 cm from the dentate line (1.5-5 cm in 48 cases, 5-7 cm in 34 cases). RESULTS: LTME with anal sphincter preservation was performed on 82 randomized patients with low rectal cancer, and 100% sphincter preservation rate was achieved. There were 30 patients with laparoscopic low anterior resection (LLAR) at the level of the anastomosis below peritoneal reflection and 2 cm above from the dentate line; 27 patients with laparoscopic ultralow anterior resection (LULAR) at the level of anastomoses 2 cm below from the dentate line; and 25 patients with laparoscopic coloanal anastomoses (LCAA) at the level of the anastomoses at or below the dentate line. No defunctioning ileostomy was created in any case. The mean operating time was 120 min (ranged from 110-220 min), and the mean operative blood loss was 20 mL (ranged from 5-120 mL). Bowel function was restored and diet was resumed on day 1 or 2 after operation. The mean hospital stay was 8 d (ranged from 5-14). Postoperative analgesics were used in 45 patients. After surgery, 2 patients had urinary retention, one had anastomotic leakage, and another 2 patients had local recurrence one year later. No interoperative complication was observed. CONCLUSION: LTME with preservation of anal sphincter is a feasible, safe and minimally invasive technique with less postoperative pain and rapid recovery, and importantly, it has preserved the function of the sphincter. PMID:12854145

  17. Factors predicting a failed primary repair of obstetric anal sphincter injury.

    PubMed

    Kirss, Jaan; Pinta, Tarja; Böckelman, Camilla; Victorzon, Mikael

    2016-09-01

    The success of the primary repair of obstetric anal sphincter injury (OASI) is paramount in maintaining adequate fecal continence after childbirth. The factors determining the success or failure of primary repair are unclear. The aim of this study is to investigate modifiable factors determining the success or failure of the primary sphincter repair after OASI. Sixty women with OASI were investigated by endoanal ultrasound or magnetic resonance imaging, and with the Wexner incontinence questionnaire. Based on the findings, the women were divided in two groups; successful primary repair group (n = 41) and failed primary repair group (n = 19). The primary repair failed in 31.7% of the tears. These included more tears repaired by less experienced personnel (p < 0.001) and more repairs performed during on-call hours (p = 0.039) than in the successful primary repair group. Significantly more pain medication was used in the failed group (p = 0.003), and the use of antibiotics and laxatives after the repair was more common in the successful group (p < 0.001). Sphincter injuries were repaired using the overlapping suture technique in 95.1% of the repairs in the successful group compared with 47.4% in the failed group (p = 0.03). The mean (SD) Wexner score was significantly higher in the failed group [5.92 (4.1) vs. 1.88 (4.2), p < 0.001], in agreement with the findings on endoanal ultrasound. Postpartum perineal tears should be evaluated by personnel familiar with the diagnosis and repair of OASI. Delaying the primary repair until next morning is recommended if experienced personnel are unavailable during on-call hours. © 2016 Nordic Federation of Societies of Obstetrics and Gynecology.

  18. Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas.

    PubMed

    Meinero, P; Mori, L

    2011-12-01

    Video-assisted anal fistula treatment (VAAFT) is a novel minimally invasive and sphincter-saving technique for treating complex fistulas. The aim of this report is to describe the procedural steps and preliminary results of VAAFT. Karl Storz Video Equipment is used. Key steps are visualization of the fistula tract using the fistuloscope, correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening using a stapler or cutaneous-mucosal flap. Diagnostic fistuloscopy under irrigation is followed by an operative phase of fulguration of the fistula tract, closure of the internal opening and suture reinforcement with cyanoacrylate. From May 2006 to May 2011, we operated on 136 patients using VAAFT. Ninety-eight patients were followed up for a minimum of 6 months. No major complications occurred. In most cases, both short-term and long-term postoperative pain was acceptable. Primary healing was achieved in 72 patients (73.5%) within 2-3 months of the operation. Sixty-two patients were followed up for more than 1 year. The percentage of the patients healed after 1 year was 87.1%. The main feature of the VAAFT technique is that the procedure is performed entirely under direct endoluminal vision. With this approach, the internal opening can be found in 82.6% of cases. Moreover, fistuloscopy helps to identify any possible secondary tracts or chronic abscesses. The VAAFT technique is sphincter-saving, and the surgical wounds are extremely small. Our preliminary results are very promising.

  19. Pelvic floor and anal sphincter trauma should be key performance indicators of maternity services.

    PubMed

    Dietz, H P; Pardey, J; Murray, H

    2015-01-01

    There is an increasing awareness of maternal somatic birth trauma, which affects many more women than previously thought, primarily in the form of anal sphincter and levator ani tears. Given that such trauma occurs in about one-third of all women giving birth vaginally for the first time, and given that it has serious long-term consequences, it should be audited by all maternity services with a view to providing remedial therapy to delay or prevent subsequent morbidity, and to facilitate practice improvement. The increasing availability of modern imaging equipment and the skills of using it for pelvic floor assessment means that it is now becoming possible to provide such services postnatally.

  20. Effect of an Exercise Protocol on Pelvic Muscle Resting Pressure in Healthy Adult Women.

    DTIC Science & Technology

    1992-01-01

    bulbocavernosi, the superficial transverse perineal muscles, and the external anal sphincter (Mandelstam, 1978). The bulbocavernosi are located on either side...the deep muscles and are absent in some women (Oxorn, 1986). The external anal sphincter is comprised of both superficial (voluntary) and deep...levatores ani and internal anal sphincter to maintain tone and occlude the anal orifice (Oxorn, 1986). The external anal sphincter originates in the

  1. Factors Associated With Timing of Return to Intercourse After Obstetric Anal Sphincter Injuries.

    PubMed

    Leader-Cramer, Alix; Kenton, Kimberly; Davé, Bhumy; Gossett, Dana R; Mueller, Margaret; Lewicky-Gaupp, Christina

    2016-10-01

    The impact of obstetric perineal trauma on timing of return to intercourse is unclear, although sexual desire is clearly decreased in these women. In addition, studies examining timing of return to intercourse are cross-sectional and therefore cannot delineate potential reasons that patients might delay return to intercourse. To identify factors associated with delayed return to intercourse after obstetric anal sphincter injuries. This was a planned secondary analysis of a prospective cohort study of women sustaining obstetric anal sphincter injuries during delivery of a full-term singleton infant. Patients completed the Fecal Incontinence Severity Index at every postpartum visit (1, 2, 6, and 12 weeks) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 once resuming vaginal intercourse. Intercourse was considered "delayed" if patients did not resume intercourse by the 12-week visit. This cutoff was chosen because it was subsequent to the 6-week visit, when patients were instructed to return to normal pelvic activity. Continuous variables were compared using the Student t-test (parametric) or Mann-Whitney U-test (non-parametric). The χ(2) test was used for categorical variables. Statistical significance was assigned with a P value less than .05. Primary outcome measurements were differences in pelvic floor symptoms on validated surveys between the "delayed" and "not-delayed" groups at the first postpartum visit and at the time the subjects returned to intercourse. We used the Patient Health Questionnaire-9 for depression, the Urinary Distress Inventory-6 and Incontinence Impact Questionnaire-7 for urinary symptoms, the visual analog scale for pain, the Fecal Incontinence Severity Index for bowel symptoms, and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 at the return to intercourse visit only. One hundred ninety-nine women were included in this analysis. Most were Caucasian (77%) and primiparous (86%). One hundred nineteen women

  2. Transcutaneous sacral nerve stimulation for intraoperative verification of internal anal sphincter innervation.

    PubMed

    Kauff, D W; Moszkowski, T; Wegner, C; Heimann, A; Hoffmann, K-P; Krüger, T B; Lang, H; Kneist, W

    2017-07-06

    The current standard for pelvic intraoperative neuromonitoring (pIONM) is based on intermittent direct nerve stimulation. This study investigated the potential use of transcutaneous sacral nerve stimulation for non-invasive verification of pelvic autonomic nerves. A consecutive series of six pigs underwent low anterior rectal resection. For transcutaneous sacral nerve stimulation, an array of ten electrodes (cathodes) was placed over the sacral foramina (S2 to S4). Anodes were applied on the back, right and left thigh, lower abdomen, and intra-anally. Stimulation using the novel method and current standard were performed at different phases of the experiments under electromyography of the autonomic innervated internal anal sphincter (IAS). Transcutaneous stimulation induced increase of IAS activity could be observed in each animal under specific cathode-anode configurations. Out of 300 tested configurations, 18 exhibited a change in the IAS activity correlated with intentional autonomic nerve damage. The damage resulted in a significant decrease of the relative area under the curve of the IAS frequency spectrum (P<.001). Comparison of the IAS spectra under transcutaneous and direct stimulation revealed no significant difference (after rectal resection: median 5.99 μV•Hz vs 7.78 μV•Hz, P=.12; after intentional nerve damage: median -0.27 μV•Hz vs 3.35 μV•Hz, P=.29). Non-invasive selective transcutaneous sacral nerve stimulation could be used for verification of IAS innervation. © 2017 John Wiley & Sons Ltd.

  3. A contraction response of the internal anal sphincter to Botulinum toxin: does low-pressure chronic anal fissure have a different pathophysiology?

    PubMed

    Lindsey, I; Jones, O M; Cunningham, C

    2011-09-01

    A subset of low-pressure fissures is not associated with typical internal anal sphincter hypertonia and may involve a different pathophysiological mechanism. We aimed to assess the manometric response of the internal anal sphincter to botulinum toxin in low-pressure fissures compared to high-pressure fissures. Twenty five units of botulinum toxin (Botox(TM)) were injected directly into the internal anal sphincter. Maximum resting pressure (MRP) and maximum squeeze increment (MSI) were documented at baseline and four weeks after injection. Nine (31%) of 29 patients had a low-pressure fissure. Those with an anterior fissure had a significantly lower median baseline MRP than those with a posterior fissure (66 vs 83 mmHg, P = 0.009). Significantly more patients with low-pressure fissures developed a contraction or no response (78%vs 30%, difference 48%, 95% CI 14-82%, P = 0.006). Those developing a contraction response had a lower mean baseline MRP than those developing a relaxation response (56 vs 86 mmHg, difference 30 mmHg, 95% CI 17-43%, P < 0.001). Botulinum toxin appears to have an atypical contraction effect on the internal anal sphincter in low-pressure (usually anterior) fissures. This may be accounted for by blockade of acetylcholine released at parasympathetic nerve terminals and the sympathetic ganglion (relaxation). Low pressure fissures may be physiologically different from high-pressure fissures. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

  4. [Physiology of pharyngeal muscles after surgical restoration of the velopharyngeal sphincter].

    PubMed

    Ysunza, Antonio

    2005-01-01

    Speech velopharyngeal sphincter restoration is generally performed by pharyngeal flap or sphincter pharyngoplasty. Evaluate pharyngeal muscle physiology after pharyngeal flap or sphincter pharyngoplasty using simultaneous electromyography and videonasopharyngoscopy. Forty patients were studied. Twenty patients were operated on with an upper base pharyngeal flap. Twenty patients were operated on with sphincter pharyngoplasty. The following muscles were studied: superior constrictor pharyngeus, palatopharyngeus, and levator veli palatini. None of the patients studied showed electromyographic activity in the lateral flaps of tile pharyngoplasties. None showed electromyographic activity of the upper base pharyngeal flaps. All patients demonstrated strong electromyographic activity on the superior constrictor pharyngeus and the levator veli palatini. Lateral pharyngeal flaps in cases of sphincter pharyngoplasties and the central pharyngeal flap in cases of pharyngeal flaps, do not create new sphincters for velopharyngeal closure. The participation of these structures is passive, increasing tissue volume in specific areas, whereas their movements are caused by the contraction of the superior constrictor pharyngeus and the levator veli palatini.

  5. Effect of age, gender, and parity on anal canal pressures. Contribution of impaired anal sphincter function to fecal incontinence.

    PubMed

    McHugh, S M; Diamant, N E

    1987-07-01

    The contribution of the resting anal canal pressure (RAP) and the maximal squeeze pressure (MSP) to the problem of fecal incontinence was assessed by comparing 143 incontinent patients to a control population of 157 healthy subjects. These parameters were determined using a multilumen continuously perfused catheter and a mechanized rapid pull-through technique. In 10 male volunteers both RAP and MSP were determined using catheters that varied from 3 mm to 18 mm in diameter. In the control population, the RAP was significantly lower in females 40 years of age and over as compared to males. MSP values were significantly lower in females at virtually all ages. In women, parity did not correlate with RAP (coefficient = -0.099, P greater than 0.05) and MSP (coefficient = -0.123, P greater than 0.05) and any decrease in pressures was related to aging. Aging in women was associated with a consistent reduction in RAP (coefficient = -0.614, P less than 0.00005) and MSP (coefficient = -0.372, P = 0.0006). In males, there was a similar but less impressive age-related reduction for the RAP (coefficient = -0.333, P = 0.006) but not for the MSP (coefficient = -0.196, P greater than 0.05). Nine percent of the volunteer population were essentially unable to increase the RAP with maximal squeeze efforts. A linear increase in anal pressures was recorded as catheter diameter increased from 3 to 12 mm. Normative data for the RAP and MSP (mean +/- 2 SD) were constructed for each sex on a decade basis and showed a wide range of pressures for each age grouping. In the group with fecal incontinence (FI) 39% of females and 44% of males fell within the "normal" range for both the RAP and MSP. For all patients with FI, 41% and 17% had impairment of one or both parameters, respectively. It is concluded that: aging affects the RAP in both sexes but to a greater degree in women. The MSP is related to aging in women only; child bearing has no effect upon these parameters; clinical problems of

  6. Surgical treatment of trans-sphincteric anal fistulas with the Fat GRAFT technique: a minimally invasive procedure.

    PubMed

    Stroumza, N; Fuzco, G; Laporte, J; Nail Barthelemy, R; Houry, S; Atlan, M

    2017-08-01

    Anal fistulas are common pathologies with a significant social impact; however, their treatment is often complex and the recurrence rate can be significant. Some surgical treatments for fistula are also associated with the risk of sphincter injury. In this technical note, we aim to evaluate the feasibility and efficacy of the Fat GRAFT technique (Fat Grafting in Anal Fistula Treatment) in the treatment of recurrent anal fistulas. All patients presenting with recurrent trans-sphincteric anal fistulas over an 18-month period were included. After abdominal fat harvesting and fat preparation, fat grafting was performed in the track and peripheral area of the fistula. The internal and external openings of the fistula were closed to maximally preserve the retention of the adipocyte graft in the fistula. Eleven patients underwent the Fat GRAFT procedure (seven men, four women). The average re-injected volume for each fistula was 21 ml (range 10-30 ml). The postoperative course was uneventful. At 6 months three patients developed recurrence (73% healed). There were no postoperative complications. The Fat GRAFT technique appears to be a promising technique with a low risk of anal incontinence, in contrast to other techniques. This method was effective in > 70% of patients in a single session. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

  7. Assessment and in vitro experiment of artificial anal sphincter system based on rebuilding the rectal sensation function.

    PubMed

    Zan, Peng; Liu, Jinding; Jiang, Enyu; Wang, Hua

    2014-05-01

    In this paper, a novel artificial anal sphincter (AAS) system based on rebuilding the rectal sensation function is proposed to treat human fecal incontinence. The executive mechanism of the traditional AAS system was redesigned and integrated for a simpler structure and better durability. The novel executive mechanism uses a sandwich structure to simulate the basic function of the natural human anal sphincter. To rebuild the lost rectal sensation function caused by fecal incontinence, we propose a novel method for rebuilding the rectal sensation function based on an Optimal Wavelet Packet Basis (OWPB) using the Davies-Bouldin (DB) index and a support vector machine (SVM). OWPB using a DB index is used for feature vector extraction, while a SVM is adopted for pattern recognition.Furthermore, an in vitro experiment with the AAS system based on rectal sensation function rebuilding was carried out. Experimental results indicate that the novel executive mechanism can simulate the basic function of the natural human anal sphincter, and the proposed method is quite effective for rebuilding rectal sensation in patients.

  8. Obstetric anal sphincter injury rates among primiparous women with different modes of vaginal delivery.

    PubMed

    Ampt, Amanda J; Patterson, Jillian A; Roberts, Christine L; Ford, Jane B

    2015-12-01

    To determine whether rates of obstetric anal sphincter injuries (OASIS) are continuing to increase and whether risk of OASIS according to mode of delivery is constant over time. In a retrospective population-based study, data were obtained for vaginal singleton vertex deliveries at 37-41 weeks of pregnancy among primiparous women in New South Wales, Australia, between January 2001 and December 2011. Annual OASIS rates were determined among non-instrumental, forceps, and vacuum deliveries with and without episiotomy. Multivariable logistic regression was used to determine adjusted odds ratios for each delivery mode category by year. Trends in adjusted odds ratios over time for each delivery category were compared. OASIS occurred in 955 (4.1%) of 23 081 deliveries in 2001 and 1487 (5.9%) of 25 081 deliveries in 2011. After adjustment for known risk factors, the only delivery categories to show statistically significant increases in OASIS over the study period were non-instrumental deliveries without episiotomy (linear trend P<0.001) and forceps deliveries with episiotomy (linear trend P=0.004). Overall, OASIS rates have continued to increase. Known risk factors do not fully explain the increase in OASIS rates in non-instrumental deliveries without an episiotomy and in forceps deliveries with an episiotomy. Crown Copyright © 2015. Published by Elsevier Ireland Ltd. All rights reserved.

  9. Surgeons’ assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality

    PubMed Central

    Kneist, Werner; Hanke, Laura; Kauff, Daniel W.; Lang, Hauke

    2016-01-01

    Abstract Background: Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve pelvic autonomic nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment. Material and methods: A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the pelvic splanchnic nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME). Results: The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left pelvic side (81% vs. 45%, p = 0.008) as well as the right pelvic side (78% vs. 45%, p = 0.016). The identification rates for PSN did not significantly differ between both groups, respectively (81% vs. 75%, p = 0.420 and 84% vs. 70%, p = 0.187). Conclusions: The transanal approach facilitated visual identification of IAS nerve supply. In combination with electrophysiological nerve assessment the identification rate almost doubled. For further insights functional data are needed. PMID:27333465

  10. Optimal Design of Litz Wire Coils With Sandwich Structure Wirelessly Powering an Artificial Anal Sphincter System.

    PubMed

    Ke, Lei; Yan, Guozheng; Yan, Sheng; Wang, Zhiwu; Li, Xiaoyang

    2015-07-01

    Transcutaneous energy transfer system (TETS) is widely used to energize implantable biomedical devices. As a key part of the TETS, a pair of applicable coils with low losses, high unloaded Q factor, and strong coupling is required to realize an efficient TETS. This article presents an optimal design methodology of planar litz wire coils sandwiched between two ferrite substrates wirelessly powering a novel mechanical artificial anal sphincter system for treating severe fecal incontinence, with focus on the main parameters of the coils such as the wire diameter, number of turns, geometry, and the properties of the ferrite substrate. The theoretical basis of optimal power transfer efficiency in an inductive link was analyzed. A set of analytical expressions are outlined to calculate the winding resistance of a litz wire coil on ferrite substrate, taking into account eddy-current losses, including conduction losses and induction losses. Expressions that describe the geometrical dimension dependence of self- and mutual inductance are derived. The influence of ferrite substrate relative permeability and dimensions is also considered. We have used this foundation to devise an applicable coil design method that starts with a set of realistic constraints and ends with the optimal coil pair geometries. All theoretical predictions are verified with measurements using different types of fabricated coils. The results indicate that the analysis is useful for optimizing the geometry design of windings and the ferrite substrate in a sandwich structure as part of which, in addition to providing design insight, allows speeding up the system efficiency-optimizing design process.

  11. Surgeons' assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality.

    PubMed

    Kneist, Werner; Hanke, Laura; Kauff, Daniel W; Lang, Hauke

    2016-10-01

    Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve pelvic autonomic nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment. A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the pelvic splanchnic nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME). The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left pelvic side (81% vs. 45%, p = 0.008) as well as the right pelvic side (78% vs. 45%, p = 0.016). The identification rates for PSN did not significantly differ between both groups, respectively (81% vs. 75%, p = 0.420 and 84% vs. 70%, p = 0.187). The transanal approach facilitated visual identification of IAS nerve supply. In combination with electrophysiological nerve assessment the identification rate almost doubled. For further insights functional data are needed.

  12. Nature of extracellular signal that triggers RhoA/ROCK activation for the basal internal anal sphincter tone in humans

    PubMed Central

    Singh, Jagmohan; Kumar, Sumit; Phillips, Benjamin

    2015-01-01

    The extracellular signal that triggers activation of rho-associated kinase (RhoA/ROCK), the major molecular determinant of basal internal anal sphincter (IAS) smooth muscle tone, is not known. Using human IAS tissues, we identified the presence of the biosynthetic machineries for angiotensin II (ANG II), thromboxane A2 (TXA2), and prostaglandin F2α (PGF2α). These end products of the renin-angiotensin system (RAS) (ANG II) and arachidonic acid (TXA2 and PGF2α) pathways and their effects in human IAS vs. rectal smooth muscle (RSM) were studied. A multipronged approach utilizing immunocytochemistry, Western blot analyses, and force measurements was implemented. Additionally, in a systematic analysis of the effects of respective inhibitors along different steps of biosynthesis and those of antagonists, their end products were evaluated either individually or in combination. To further describe the molecular mechanism for the IAS tone via these pathways, we monitored RhoA/ROCK activation and its signal transduction cascade. Data showed characteristically higher expression of biosynthetic machineries of RAS and AA pathways in the IAS compared with the RSM. Additionally, specific inhibition of the arachidonic acid (AA) pathway caused ∼80% decrease in the IAS tone, whereas that of RAS lead to ∼20% decrease. Signal transduction studies revealed that the end products of both AA and RAS pathways cause increase in the IAS tone via activation of RhoA/ROCK. Both AA and RAS (via the release of their end products TXA2, PGF2α, and ANG II, respectively), provide extracellular signals which activate RhoA/ROCK for the maintenance of the basal tone in human IAS. PMID:25882611

  13. Comparison of posterior internal anal sphincter myectomy and intrasphincteric botulinum toxin injection for treatment of internal anal sphincter achalasia: a meta-analysis.

    PubMed

    Friedmacher, Florian; Puri, Prem

    2012-08-01

    Internal anal sphincter (IAS) achalasia is a clinical condition with presentation similar to Hirschsprung's disease, but with the presence of ganglion cells on rectal suction biopsy (RSB). The diagnosis is made by anorectal manometry (ARM), which demonstrates the absence of the rectosphincteric reflex on rectal balloon inflation. The recommended treatment of choice is posterior IAS myectomy. Recently, intrasphincteric botulinum toxin (Botox) injection has been effectively used for treatment of IAS achalasia. The aim of this meta-analysis was to compare the efficacy of posterior IAS myectomy with intrasphincteric Botox injection for treatment of IAS achalasia. A systematic literature search for relevant articles was conducted using the following databases: MEDLINE( ® ), EMBASE(®), ISI Web of Science(SM) and the Cochrane Library. A meta-analysis was performed with the studies where IAS achalasia was diagnosed based on the results of ARM and RSB. Odds ratio (OR) with 95 % confidence intervals were calculated. Sixteen prospective and retrospective studies, published from 1973 to 2009, were identified. A total of 395 patients with IAS achalasia were included in this meta-analysis. Fifty-eight percent of patients underwent IAS myectomy and 42 % Botox injection. Regular bowel movements were significantly more frequent after IAS myectomy (OR 0.53, [95 % CI 0.29-0.99]; p = 0.04). There was no significant difference in continued use of laxatives or rectal enemas (OR 0.92, [95 % CI 0.34-2.53], p = 0.89) and in overall complication rates between both procedures (OR 0.68, [95 % CI 0.38-1.21]; p = 0.19). Looking at specific complications, the rate of transient faecal incontinence was significantly higher after Botox injection (OR 0.07, [95 % CI 0.01-0.54]; p < 0.01). Constipation and soiling were not significantly different between both procedures (OR 0.66, [95 % CI 0.30-1.48]; p = 0.31 and OR 0.24, [95 % CI 0.03-2.07]; p = 0.25). The rate of non

  14. Relationship between interstitial cells of Cajal, fibroblast-like cells and inhibitory motor nerves in the internal anal sphincter.

    PubMed

    Cobine, Caroline A; Hennig, Grant W; Kurahashi, Masaaki; Sanders, Kenton M; Ward, Sean M; Keef, Kathleen D

    2011-04-01

    Interstitial cells of Cajal (ICC) have been shown to participate in nitrergic neurotransmission in various regions of the gastrointestinal (GI) tract. Recently, fibroblast-like cells, which are positive for platelet-derived growth factor receptor α (PDGFRα(+)), have been suggested to participate additionally in inhibitory neurotransmission in the GI tract. The distribution of ICC and PDGFRα(+) cell populations and their relationship to inhibitory nerves within the mouse internal anal sphincter (IAS) are unknown. Immunohistochemical techniques and confocal microscopy were therefore used to examine the density and arrangement of ICC, PDGFRα(+) cells and neuronal nitric-oxide-synthase-positive (nNOS(+)) nerve fibers in the IAS of wild-type (WT) and W/W ( v ) mice. Of the total tissue volume within the IAS circular muscle layer, 18% consisted in highly branched PDGFRα(+) cells (PDGFRα(+)-IM). Other populations of PDGFRα(+) cells were observed within the submucosa and along the serosal and myenteric surfaces. Spindle-shaped intramuscular ICC (ICC-IM) were present in the WT mouse IAS but were largely absent from the W/W ( v ) IAS. The ICC-IM volume (5% of tissue volume) in the WT mouse IAS was significantly smaller than that of PDGFRα(+)-IM. Stellate-shaped submucosal ICC (ICC-SM) were observed in the WT and W/W ( v ) IAS. Minimum surface distance analysis revealed that nNOS(+) nerve fibers were closely aligned with both ICC-IM and PDGFRα(+)-IM. An even closer association was seen between ICC-IM and PDGFRα(+)-IM. Thus, a close morphological arrangement exists between inhibitory motor neurons, ICC-IM and PDGFRα(+)-IM suggesting that some functional interaction occurs between them contributing to inhibitory neurotransmission in the IAS.

  15. RhoA/ROCK pathway is the major molecular determinant of basal tone in intact human internal anal sphincter.

    PubMed

    Rattan, Satish; Singh, Jagmohan

    2012-04-01

    The knowledge of molecular control mechanisms underlying the basal tone in the intact human internal anal sphincter (IAS) is critical for the pathophysiology and rational therapy for a number of debilitating rectoanal motility disorders. We determined the role of RhoA/ROCK and PKC pathways by comparing the effects of ROCK- and PKC-selective inhibitors Y 27632 and Gö 6850 (10(-8) to 10(-4) M), respectively, on the basal tone in the IAS vs. the rectal smooth muscle (RSM). Western blot studies were performed to determine the levels of RhoA/ROCK II, PKC-α, MYPT1, CPI-17, and MLC(20) in the unphosphorylated and phosphorylated forms, in the IAS vs. RSM. Confocal microscopic studies validated the membrane distribution of ROCK II. Finally, to confirm a direct relationship, we examined the enzymatic activities and changes in the basal IAS tone and p-MYPT1, p-CPI-17, and p-MLC(20), before and after Y 27632 and Gö 6850. Data show higher levels of RhoA/ROCK II and related downstream signal transduction proteins in the IAS vs. RSM. In addition, data show a significant correlation between the active RhoA/ROCK levels, ROCK enzymatic activity, downstream proteins, and basal IAS tone, before and after ROCK inhibitor. From these data we conclude 1) RhoA/ROCK and downstream signaling are constitutively active in the IAS, and this pathway (in contrast with PKC) is the critical determinant of the basal tone in intact human IAS; and 2) RhoA and ROCK are potential therapeutic targets for a number of rectoanal motility disorders for which currently there is no satisfactory treatment.

  16. RhoA/ROCK pathway is the major molecular determinant of basal tone in intact human internal anal sphincter

    PubMed Central

    Singh, Jagmohan

    2012-01-01

    The knowledge of molecular control mechanisms underlying the basal tone in the intact human internal anal sphincter (IAS) is critical for the pathophysiology and rational therapy for a number of debilitating rectoanal motility disorders. We determined the role of RhoA/ROCK and PKC pathways by comparing the effects of ROCK- and PKC-selective inhibitors Y 27632 and Gö 6850 (10−8 to 10−4 M), respectively, on the basal tone in the IAS vs. the rectal smooth muscle (RSM). Western blot studies were performed to determine the levels of RhoA/ROCK II, PKC-α, MYPT1, CPI-17, and MLC20 in the unphosphorylated and phosphorylated forms, in the IAS vs. RSM. Confocal microscopic studies validated the membrane distribution of ROCK II. Finally, to confirm a direct relationship, we examined the enzymatic activities and changes in the basal IAS tone and p-MYPT1, p-CPI-17, and p-MLC20, before and after Y 27632 and Gö 6850. Data show higher levels of RhoA/ROCK II and related downstream signal transduction proteins in the IAS vs. RSM. In addition, data show a significant correlation between the active RhoA/ROCK levels, ROCK enzymatic activity, downstream proteins, and basal IAS tone, before and after ROCK inhibitor. From these data we conclude 1) RhoA/ROCK and downstream signaling are constitutively active in the IAS, and this pathway (in contrast with PKC) is the critical determinant of the basal tone in intact human IAS; and 2) RhoA and ROCK are potential therapeutic targets for a number of rectoanal motility disorders for which currently there is no satisfactory treatment. PMID:22241857

  17. Nitrergic neuromuscular transmission in the mouse internal anal sphincter is accomplished by multiple pathways and postjunctional effector cells

    PubMed Central

    Sotherton, A. G.; Peri, L. E.; Sanders, K. M.; Ward, S. M.; Keef, K. D.

    2014-01-01

    The effector cells and second messengers participating in nitrergic neuromuscular transmission (NMT) were investigated in the mouse internal anal sphincter (IAS). Protein expression of guanylate cyclase (GCα, GCβ) and cyclic GMP-dependent protein kinase I (cGKI) were examined in cryostat sections with dual-labeling immunohistochemical techniques in PDGFRα+ cells, interstitial cells of Cajal (ICC), and smooth muscle cells (SMC). Gene expression levels were determined with quantitative PCR of dispersed cells from Pdgfrαegfp/+, KitcopGFP/+, and smMHCCre-egfp mice sorted with FACS. The relative gene and protein expression levels of GCα and GCβ were PDGFRα+ cells > ICC ≫ SMC. In contrast, cGKI gene expression sequence was SMC = ICC > PDGFRα+ cells whereas cGKI protein expression sequence was neurons > SMC ≫ ICC = PDGFRα+ cells. The functional role of cGKI was investigated in cGKI−/− mice. Relaxation with 8-bromo (8-Br)-cGMP was greatly reduced in cGKI−/− mice whereas responses to sodium nitroprusside (SNP) were partially reduced and forskolin responses were unchanged. A nitrergic relaxation occurred with nerve stimulation (NS, 5 Hz, 60 s) in cGKI+/+ and cGKI−/− mice although there was a small reduction in the cGKI−/− mouse. Nω-nitro-l-arginine (l-NNA) abolished responses during the first 20–30 s of NS in both animals. The GC inhibitor ODQ greatly reduced or abolished SNP and nitrergic NS responses in both animals. These data confirm an essential role for GC in NO-induced relaxation in the IAS. However, the expression of GC and cGKI by all three cell types suggests that each may participate in coordinating muscular responses to NO. The persistence of nitrergic NMT in the cGKI−/− mouse suggests the presence of a significant GC-dependent, cGKI-independent pathway. PMID:25301187

  18. Obstetric anal sphincter injuries in vaginal delivery of twins: associated risk factors and comparison with singletons.

    PubMed

    Porat, Shay; Baud, David; Farine, Dan

    2013-05-01

    Risk factors related to obstetric anal sphincter injuries (OASIS) are known for singleton deliveries. No study to date has described the rate and risk factors involved in twin deliveries. We conducted a retrospective cohort study (1985-2010) of all vaginal twin and singleton deliveries in a single tertiary center. The adjusted odds ratio (OR) for OASIS at delivery was estimated using the logistic regression model. The study comprised 1,538 and 91,312 patients with vaginal twin and singleton delivery, respectively. Twenty twin (1.27 %) and 2,331 (2.55 %) singleton deliveries were complicated with OASIS. The following OASIS-associated risk factors were shared by both populations: nulliparity [twins adjusted OR 5.9, 95 % confidence interval (CI) 1.7-20.9; singletons adjusted OR 3.9, 95 % CI 3.5-4.4), occipitoposterior (OP) position (twins adjusted OR 3.00, 95 % CI 1.1-8.0; singletons adjusted OR 1.6, 95 % CI 1.3-2.00), birthweight (for each 100 g) (twin adjusted OR 1.1, 95 % CI 1.0-1.2; singletons adjusted OR 1.07, 95 % CI 1.06-1.08), and instrumental delivery (twins adjusted OR 4.3, 95 % CI 1.2-15.4, singletons adjusted OR 2.4, 95 % CI 2.2-2.6). Risk factors of nulliparity, OP position, large fetal size, and instrumental delivery were shared by both twin and singleton deliveries. These data will be useful in counselling women carrying twins who intend to deliver vaginally.

  19. Risk factors for obstetric anal sphincter injury after a successful multicentre interventional programme.

    PubMed

    Stedenfeldt, M; Øian, P; Gissler, M; Blix, E; Pirhonen, J

    2014-01-01

    To evaluate and compare the risk profile of sustaining obstetric anal sphincter injuries (OASIS) and associated risks in five risk groups (low to high), after the OASIS rate was reduced from 4.6% to 2.0% following an interventional programme. The main focus of the intervention was on manual assistance during the final part of second stage of labour. A multicentre interventional cohort study with before and after comparison. Four Norwegian obstetric departments. A total of 40,154 vaginal deliveries in 2003-09. Pre-intervention and postintervention analyses. The associations of OASIS with possible risk factors were estimated using odds ratios obtained by logistic regression. Risk factors of OASIS. The risk of sustaining OASIS decreased by 59% (odds ratio [OR] 0.41; 95% confidence interval [95% CI] 0.36-0.46) after the intervention. Associations with obstetric risks for OASIS were largely unchanged after the intervention, including first vaginal delivery (OR 3.84; 95% CI 2.90-5.07), birthweight ≥ 4500 g (OR 4.42; 95% CI 2.68-7.27), forceps delivery (OR 3.54; 95% CI 1.99-6.29) and mediolateral episiotomy (OR 0.89; 95% CI 0.70-1.12). However, the highest reduction of OASIS, (65%), was observed in group 0 (low-risk) (OR 0.35; 95% CI 0.24-0.51), and a 57% (OR 0.43; 95% CI 0.35-0.52), 61% (OR 0.39; 95% CI 0.31-0.48), and 58% (OR 0.42; 95% CI 0.30-0.60) reduction in groups with one, two and three risk factors, respectively. No change was observed in the group with four risk factors. After the intervention the most significant decrease of OASIS was observed in low-risk births, although the main risk factors for OASIS remained unchanged. © 2013 RCOG.

  20. Risk factors for obstetric anal sphincter injury: To prolong or to vacuum?

    PubMed

    Garmi, Gali; Peretz, Hadar; Braverman, Meirav; Berkovich, Ilanit; Molnar, Robert; Salim, Raed

    2016-03-01

    An awareness of risk factors for obstetric anal sphincter injuries (OASIS) is essential in order to reduce the occurrence of the primary event. These risk factors are demographic, obstetric and intrapartum related. We aimed to identify the risk factors for OASIS and to examine how modifiable risk factors may be used in order to reduce the incidence of OASIS. A retrospective, matched case-control study was conducted in the delivery ward of a single university teaching hospital in Israel, using data from January 2004 to July 2012. All singleton vaginal deliveries at term with OASIS were included. The controls included women matched at a ratio of 1:2 based on gestational age and deliveries that occurred immediately before and after the delivery of the women in the study group. Overall, 113 OASIS were identified. Stepwise conditional logistic regression revealed that the first vaginal birth (OR = 7.6; 95% confidence interval (CI), 3.5-16.3; p < 0.001) particularly after a previous caesarean section (OR = 13.6; 95% CI, 4.7-39.3; p < 0.001) and the length of the second stage (OR 1.5; 95% CI, 1.1-2.1, p = 0.045) were the only risk factors for OASIS. Among 24 primiparous women who already had a prolonged second stage, 15 delivered by vacuum extraction and nine spontaneously; OASIS occurred in eight (53%) and three (33%) women, respectively. Multivariate analysis showed that this difference was not significant (OR = 2.3; 95% CI, 0.4-12.7; p = 0.35). The first vaginal birth particularly after a caesarean delivery and the length of the second stage increased the risk of OASIS. Vacuum extraction performed to shorten a prolonged second stage is not necessarily protective. Copyright © 2015 Elsevier Ltd. All rights reserved.

  1. Increasing incidence of anal sphincter tears among primiparas in Sweden: a population-based register study.

    PubMed

    Ekéus, Cecilia; Nilsson, Emma; Gottvall, Karin

    2008-01-01

    The aim of this study was to examine the incidence and risk factors for anal sphincter tears (ASTs) at delivery. A national population-based study was conducted with data from the Medical Birth Register including all primiparas with singleton pregnancy, who gave birth vaginally in Sweden from 1994 to 2004 (n=365,886). Women with a third and fourth degree AST were compared with those who gave birth during the same period without incurring such tears. The incidence of third degree AST increased by >60%, from 3.4% in 1994 to 5.2% in 2004 in spontaneous births, and from 8.7 to 14.8% in instrumental deliveries during the study period. The proportion of fourth degree AST increased from 0.3 to 0.55% in spontaneous births and from 0.8 to 1.4% in instrumental-assisted deliveries during the same period. Compared with non-instrumental delivery, vacuum extraction (VE) deliveries were related to an increased risk of AST. An infant birth weight of >4,000 g was also associated with an increased risk for both third and fourth degree AST. In addition, women born in Africa and Asia had significantly higher risk for both third and fourth degree AST compared to women born in Sweden. The incidence of third and fourth degree AST increased in both spontaneous births and instrumental deliveries. Instrumental delivery and an infant birth weight >4,000 g are the main risk factors for AST. Women from Africa and Asia have pronounced risks.

  2. Changes in neuromuscular transmission in the W/Wv mouse internal anal sphincter

    PubMed Central

    Duffy, AM; Cobine, CA; Keef, KD

    2011-01-01

    Background Intramuscular interstitial cells of Cajal (ICC-IM) have been shown to participate in nitrergic neuromuscular transmission (NMT) in various regions of the gastrointestinal (GI) tract but their role in the internal anal sphincter (IAS) is still uncertain. Contractile studies of the IAS in the W/Wv mouse (a model in which ICC-IM numbers are markedly reduced) have reported that nitrergic NMT persists and that ICC-IM are not required. However, neither the changes in electrical events underlying NMT nor the contributions of other non-nitrergic neural pathways have been examined in this model. Methods The role of ICC-IM in NMT was examined by recording the contractile and electrical events associated with electrical field stimulation (EFS) of motor neurons in the IAS of wildtype and W/Wv mice. Nitrergic, purinergic and cholinergic components were identified using inhibitors of these pathways. Key Results Under NANC conditions, purinergic, and nitrergic pathways both contribute to EFS induced inhibitory junction potentials (IJPs) and relaxation. Purinergic IJPs and relaxation were intact in the W/Wv mouse IAS whereas nitrergic IJPs were reduced by 50–60% while relaxation persisted. In the presence of L-NNA (NOS inhibitor) and MRS2500 (P2Y1 receptor antagonist), EFS gave rise to cholinergic depolarization and contractions that were abolished by atropine. Cholinergic depolarization was absent in the W/Wv mouse IAS while contraction persisted. Conclusions and Inferences ICC-IM significantly contribute to the electrical events underlying nitrergic and cholinergic NMT whereas contractile events persist in the absence of ICC-IM. The purinergic inhibitory neural pathway appears to be independent of ICC-IM. PMID:22074497

  3. Basal internal anal sphincter tone, inhibitory neurotransmission, and other factors contributing to the maintenance of high pressures in the anal canal.

    PubMed

    Rattan, S; Singh, J

    2011-01-01

    Maintenance of the basal tone in the internal anal sphincter (IAS) is critical for rectoanal continence. Effective evacuation requires a fully functional rectoanal inhibitory reflex (RAIR)-mediated relaxation of the IAS via inhibitory neurotransmission (INT). Systematic studies examining the nature of the INT in different species have identified nitric oxide (NO) as the major inhibitory neurotransmitter. However, other mediators such as vasoactive intestinal polypeptide (VIP), ATP, and carbon monoxide (CO) may also play species-specific role under certain experimental conditions. Measurements of the intraluminal pressures in the IAS along with the force of the isolated IAS tissues are the mainstay in the basic studies for the molecular mechanisms underlying the basal tone and in the nature of the INT. The identification of NO as the inhibitory neurotransmitter has led to major advances in the diagnosis and treatment of a number of rectoanal motility disorders associated with the IAS dysfunction. Besides the IAS, the high pressures in the anal canal are affected by the external anal sphincter (EAS) function, and its malfunction may also lead to rectoanal incontinence. Different approaches including biofeedback have been attempted to improve the EAS function, with variable outcomes. There is a dire need for the innovative ways to improve the week high pressures zone in the anal canal. This viewpoint focuses on two studies that extend the above concept of multiplicity of inhibitory neurotransmitters (Neurogastroenterol Motil 2011 23 e11–25), and that high pressures in the anal canal can be improved by the EAS plication (Neurogastroenterol Motil 2011 23 70–5). © 2010 Blackwell Publishing Ltd.

  4. Assessing the association of oxytocin augmentation with obstetric anal sphincter injury in nulliparous women: a population-based, case-control study.

    PubMed

    Rygh, Astrid B; Skjeldestad, Finn Egil; Körner, Hartwig; Eggebø, Torbjørn M

    2014-07-24

    To assess the association of oxytocin augmentation with obstetric anal sphincter injury among nulliparous women. Population-based, case-control study. Primary and secondary teaching hospital serving a Norwegian region. 15 476 nulliparous women with spontaneous start of labour, single cephalic presentation and gestation ≥37 weeks delivering vaginally between 1999 and 2012. Based on the presence or absence of oxytocin augmentation, episiotomy, operative vaginal delivery and birth weight (<4000 vs ≥4000 g), we modelled in logistic regression the best fit for prediction of anal sphincter injury. Within the modified model of main exposures, we tested for possible confounding, and interactions between maternal age, ethnicity, occiput posterior position and epidural analgaesia. Obstetric anal sphincter injury. Oxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries in women giving spontaneous birth to infants weighing <4000 g (OR 1.8; 95% CI 1.5 to 2.2). Episiotomy was not associated with sphincter injuries in spontaneous births, but with a lower OR in operative vaginal deliveries. Spontaneous delivery of infants weighing ≥4000 g was associated with a threefold higher OR, and epidural analgaesia was associated with a 30% lower OR in comparison to no epidural analgaesia. Oxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries during spontaneous deliveries of normal-size infants. We observed a considerable effect modification between the most important factors predicting anal sphincter injuries in the active second stage of labour. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  5. Assessing the association of oxytocin augmentation with obstetric anal sphincter injury in nulliparous women: a population-based, case–control study

    PubMed Central

    Rygh, Astrid B; Skjeldestad, Finn Egil; Körner, Hartwig; Eggebø, Torbjørn M

    2014-01-01

    Objective To assess the association of oxytocin augmentation with obstetric anal sphincter injury among nulliparous women. Design Population-based, case–control study. Setting Primary and secondary teaching hospital serving a Norwegian region. Population 15 476 nulliparous women with spontaneous start of labour, single cephalic presentation and gestation ≥37 weeks delivering vaginally between 1999 and 2012. Methods Based on the presence or absence of oxytocin augmentation, episiotomy, operative vaginal delivery and birth weight (<4000 vs ≥4000 g), we modelled in logistic regression the best fit for prediction of anal sphincter injury. Within the modified model of main exposures, we tested for possible confounding, and interactions between maternal age, ethnicity, occiput posterior position and epidural analgaesia. Main outcome measure Obstetric anal sphincter injury. Results Oxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries in women giving spontaneous birth to infants weighing <4000 g (OR 1.8; 95% CI 1.5 to 2.2). Episiotomy was not associated with sphincter injuries in spontaneous births, but with a lower OR in operative vaginal deliveries. Spontaneous delivery of infants weighing ≥4000 g was associated with a threefold higher OR, and epidural analgaesia was associated with a 30% lower OR in comparison to no epidural analgaesia. Conclusions Oxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries during spontaneous deliveries of normal-size infants. We observed a considerable effect modification between the most important factors predicting anal sphincter injuries in the active second stage of labour. PMID:25059967

  6. Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries.

    PubMed

    Baghestan, E; Irgens, L M; Børdahl, P E; Rasmussen, S

    2012-01-01

    To investigate the recurrence risk, the likelihood of having further deliveries and mode of delivery after third to fourth degree obstetric anal sphincter injuries (OASIS). Population-based cohort study. The Medical Birth Registry of Norway. A cohort of 828,864 mothers with singleton, vertex-presenting infants, weighing 500 g or more, during the period 1967-2004. Comparison of women with and without a history of OASIS with respect to the occurrence of OASIS, subsequent delivery rate and planned caesarean rate. OASIS in second and third deliveries, subsequent delivery rate and mode of delivery. Adjusted odds ratios of the recurrence of OASIS in women with a history of OASIS in the first, and in both the first and second deliveries, were 4.2 (95% CI 3.9-4.5; 5.6%) and 10.6 (95% CI 6.2-18.1; 9.5%), respectively, relative to women without a history of OASIS. Instrumental deliveries, in particular forceps deliveries, birthweights of 3500 g or more and large maternity units were associated with a recurrence of OASIS. Instrumental delivery did not further increase the excess recurrence risk associated with high birthweight. A man who fathered a child whose delivery was complicated by OASIS was more likely to father another child whose delivery was complicated by OASIS in another woman who gave birth in the same maternity unit (adjusted OR 2.1; 95% CI 1.2-3.7; 5.6%). However, if the deliveries took place in different maternity units, the recurrence risk was not significantly increased (OR 1.3; 95% CI 0.8-2.1; 4.4%). The subsequent delivery rate was not different in women with and without previous OASIS, whereas women with a previous OASIS were more often scheduled to caesarean delivery. Recurrence risks in second and third deliveries were high. A history of OASIS had little or no impact on the rates of subsequent deliveries. Women with previous OASIS were delivered more frequently by planned caesarean delivery. © 2011 The Authors BJOG An International Journal of

  7. Characterization of the motor units of the external anal sphincter in pregnant women with multichannel surface EMG.

    PubMed

    Cescon, Corrado; Raimondi, Eleonora Ester; Začesta, Vita; Drusany-Starič, Kristina; Martsidis, Konstantinos; Merletti, R

    2014-08-01

    Locating the innervation zones (IZs) of the external anal sphincter (EAS) is helpful to obstetricians to identify areas particularly vulnerable to episiotomy in pregnant women. The aim was to investigate the motor unit (MU) properties of the EAS during voluntary contractions. Electromyographic signals were detected, from 478 pregnant women, by means of an intra-anal cylindrical probe carrying a circumferential array of 16 electrodes. The signals were decomposed into the constituent MU action potential trains and 5,947 templates were extracted and analyzed in order to identify the IZ position. MUs innervated at one end are concentrated in the dorsal portion of the sphincter, while MUs innervated in the middle are distributed symmetrically in the left and right portions of the EAS. The angular propagation velocity was estimated for each MU resulting in 260 ± 45 rad/s, corresponding to 1.8 m/s on the probe surface and to about 4 m/s at a radial depth of 10 mm from the probe surface. A novel method for identification and classification of MUs of the EAS is proposed and applied to a large-scale study. It is possible to distinguish MUs of the EAS in a minimally invasive way and identify their IZs. This information should be used to plan episiotomies and minimize risks of EAS denervation.

  8. Midwives' lived experience of a birth where the woman suffers an obstetric anal sphincter injury--a phenomenological study.

    PubMed

    Edqvist, Malin; Lindgren, Helena; Lundgren, Ingela

    2014-08-03

    The occurrence of obstetric anal sphincter injuries (OASIS) has increased in most high-income countries during the past twenty years. The consequences of these injuries can be devastating for women and have an impact on their daily life and quality of health. The aim of this study was to obtain a deeper understanding of midwives' lived experiences of attending a birth in which the woman gets an obstetric anal sphincter injury. A qualitative study using phenomenological lifeworld research design. The data were collected through in-depth interviews with 13 midwives. The essential meaning of the phenomenon was expressed as a deadlock difficult to resolve between a perceived truth among midwives that a skilled midwife can prevent severe perineal trauma and at the same time a coexisting more complex belief. The more complex belief is that sphincter injuries cannot always be avoided. The midwives tried to cope with their feelings of guilt and wanted to find reasons why the injury occurred. A fear of being exposed and judged by others as severely as they judged themselves hindered the midwives from sharing their experience. Ultimately the midwives accepted that the injury had occurred and moved on without any definite answers. Being caught between an accepted truth and a more complex belief evoked various emotions among the midwives. Feelings of guilt, shame and the midwife's own suspicion that she is not being professionally competent were not always easy to share. This study shows the importance of creating a safe working environment in which midwives can reflect on and share their experiences to continue to develop professionally. Further research is needed to implement and evaluate the effect of reflective practices in relation to midwifery care and whether this could benefit women in childbirth.

  9. Effects of substance P on the isolated iris sphincter muscle of the albino rabbit.

    PubMed

    Nishiyama, A; Mochizuki, M; Masuda, K

    1982-01-01

    Effects of substance P on the isolated iris sphincter muscle of the albino rabbit were studied. The muscle was incubated in an organ bath containing Krebs' physiologic solution and the muscle tension was recorded with an isometric transducer. Substance P induced dose-dependent muscle contraction in the concentration range from 3 x 10(-11) to 3 x 10(-7) M and ED50 was estimated to be 3.7 x 10(-9) M. The muscle contraction was not antagonized by tropicamide, phentolamine, propranolol, chlorpheniramine, cimetidine, methysergide or baclofen. Tetrodotoxin (3 x 10(-7) g/ml) pretreatment did not change the muscle contraction induced by substance P. A retrobulbar capsaicin injection did not cause supersensitivity in the muscle response to substance P. These results indicate that the iris sphincter muscle contraction caused by substance P is not mediated by cholinergic-, adrenergic-, histamine- or serotonine-recepters and suggests that its action on the muscle is direct.

  10. Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection for circumferential mixed hemorrhoids.

    PubMed

    Lu, Ming; Shi, Guang-Ying; Wang, Guo-Qiang; Wu, Yan; Liu, Yang; Wen, Hao

    2013-08-14

    To identify a more effective treatment protocol for circumferential mixed hemorrhoids. A total of 192 patients with circumferential mixed hemorrhoids were randomized into the treatment group, where they underwent Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection, or the control group, where traditional external dissection and internal ligation were performed. Postoperative recovery and complications were monitored. The time to wound healing was 12.96 ± 2.25 d in the treatment group shorter than 19.58 ± 2.71 d in the control group. Slight pain rate was 58.3% in the treatment group higher than 22.9% in the control group; moderate pain rate was 33.3% in the treatment group lower than 56.3% in the control group severe pain rate was 8.4% in the treatment group lower than 20.8% in the control group. No edema rate was 70.8% in the treatment group higher than 43.8% in the control group; mild local edema rate was 26% in the treatment group lower than 39.6% in the control group obvious local edema was 3.03% in the treatment group lower than 16.7% in the control group. No stenosis rate was 85.4% in the treatment group higher than 63.5% in the control group; moderate stenosis rate was 14.6% in the treatment group Lower than 27.1% in the control group severe anal stenosis rate was 0% in the treatment group lower than 9.4% in the control group. Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection is the optimal treatment for circumferential mixed hemorrhoids and can be widely applied in clinical settings.

  11. Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection for circumferential mixed hemorrhoids

    PubMed Central

    Lu, Ming; Shi, Guang-Ying; Wang, Guo-Qiang; Wu, Yan; Liu, Yang; Wen, Hao

    2013-01-01

    AIM: To identify a more effective treatment protocol for circumferential mixed hemorrhoids. METHODS: A total of 192 patients with circumferential mixed hemorrhoids were randomized into the treatment group, where they underwent Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection, or the control group, where traditional external dissection and internal ligation were performed. Postoperative recovery and complications were monitored. RESULTS: The time to wound healing was 12.96 ± 2.25 d in the treatment group shorter than 19.58 ± 2.71 d in the control group. Slight pain rate was 58.3% in the treatment group higher than 22.9% in the control group; moderate pain rate was 33.3% in the treatment group lower than 56.3% in the control group severe pain rate was 8.4% in the treatment group lower than 20.8% in the control group. No edema rate was 70.8% in the treatment group higher than 43.8% in the control group; mild local edema rate was 26% in the treatment group lower than 39.6% in the control group obvious local edema was 3.03% in the treatment group lower than 16.7% in the control group. No stenosis rate was 85.4% in the treatment group higher than 63.5% in the control group; moderate stenosis rate was 14.6% in the treatment group Lower than 27.1% in the control group severe anal stenosis rate was 0% in the treatment group lower than 9.4% in the control group. CONCLUSION: Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection is the optimal treatment for circumferential mixed hemorrhoids and can be widely applied in clinical settings. PMID:23946609

  12. Gradient of pressure and time between proximal anal canal and high-pressure zone during internal anal sphincter relaxation. Its role in the fecal continence mechanism.

    PubMed

    Goes, R N; Simons, A J; Masri, L; Beart, R W

    1995-10-01

    The normal response to rectal distention is a relaxation of the proximal anal canal (PAC). We hypothesized that this mechanism would require a gradient of pressure and time to preserve continence. Sixteen volunteers (10 male), mean age, 41.5 (range, 24-60) years, were studied using an eight port axial catheter with a compliant balloon at its tip. Relaxation was induced by a small volume of rectal distention (15-30 ml of air) and was recorded until recovery of resting anal pressure (RAP). Duration of relaxation was measured until recovery of RAP. Amplitude of relaxation was determined between RAP before rectal distention (RAP-BR) and pressure at the point of maximum relaxation (RAP-PMR). Gradient of pressure was determined by comparing RAP-PMR in the high-pressure zone (HPZ) and PAC. Contraction in the distal anal canal was interpreted as external anal sphincter contraction (EASC) and was compared with RAP-PMR in the HPZ. Relaxation was significantly greater in PAC than in HPZ (50 vs. 36 percent; P = 0.001). RAP-PMR was significantly higher in HPZ than in PAC (30.7 vs. 12.6 mmHg; P = 0.001). EASC was observed in six patients and did not show significant difference with RAP-PMR in HPZ (39.7 vs. 36.3 mmHg; not significant). Relaxation began at the same time in all levels but lasted significantly longer in PAC compared with HPZ (13.5 vs. 9.4 sec; P = 0.003). Anal relaxation induced by small volume rectal distention involves a gradient in the pressure and time of relaxation between PAC and the HPZ.

  13. [Value of anal sphincter electromyography, orthostatic hypotension and dizziness in diagnosing multiple system atrophy].

    PubMed

    Wang, Han; Cui, Li-Ying; Du, Hua; Li, Ben-Hong; Liu, Ming-Sheng; Guan, Yu-Zhou

    2008-12-01

    To explore the value of anal sphincter electromyography (ASEMG), orthostatic hypotension (OH), and dizziness in diagnosing multiple system atrophy (MSA). The characteristics of ASEMG and OH were compared among patients with dizziness (MSA and non-MSA), patients without OH (MSA and non-MSA), and patients with probable MSA (OH and non-OH). Totally 476 patients underwent ASEMG examinations. Dizziness was the onset symptom in 69 patients. Between the MSA group and non-MSA group, the mean duration of dizziness [(14.6 +/- 2.1) vs. (12.8 +/- 2.0) ms, P < 0.01] and satellite potential occurrence rate [(22.7 +/- 11.8)% vs. (12.2 +/- 8.9)% , P < 0.01] were significantly different, while the OH rate (84.6% vs. 55.2% ) and the difference of the blood pressure between standing and supine positions were not significantly different. In 162 patients with symptom of dizziness, the mean duration of dizziness [(15.3 +/- 2.7) vs. (12.8 +/- 1.9) ms, P < 0.001], satellite potential occurrence rate [(25.4 +/- 12.8)% vs. (13.5 +/- 10.4)%, P < 0.001] , and difference of the diastolic blood pressure [(18.5 +/- 17.0) vs. (11.7 +/- 12.7) mmHg, P < 0.05] were significantly different between the MSA group and non-MSA group, while the normal rate of blood pressure at standing position (60% vs. 41.9%) and the difference of systolic blood pressure were not significantly different. In 146 patients with abnormal blood pressure at standing and supine positions, the mean duration of dizziness [(15.0 +/- 2.4) vs. (12.8 +/- 1.7) ms, P < 0.001] and satellite potential occurrence rate [(22.0 +/- 12.2)% vs. (10.6 +/- 8.5)%, P < 0.001] were significantly different between the MSA group (n = 61) and non-MSA group (n = 85). In 125 patients with probable MSA, the mean duration of dizziness [(15.5 +/- 2.4) vs. (15.9 +/- 2.2) ms, P > 0.05] and satellite potential occurrence rate [(24.3 +/- 12.6)% vs. (22.7 +/- 12.4)%, P > 0.05] were not significantly different between those with OH and those without OH. The

  14. [Clinical efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter in the treatment of puborectalis syndrome with high anal pressure].

    PubMed

    Ye, Hui; Liu, Weicheng; Qian, Qun; Liu, Zhisu; Jiang, Congqing; Zheng, Keyan; Qin, Qianbo; Ding, Zhao; Gong, Zhilin

    2017-03-25

    To explore the efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter(IAS) in the treatment of puborectalis syndrome with high anal pressure. Twenty-five cases of puborectalis syndrome with high anal resting pressure in the preoperative examination received the operation of partial resection of puborectalis combined with mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o'clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ORB-16007695). Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [(53.56±9.05) mmHg vs. (92.44±7.06) mmHg, (142.80±20.35) mmHg vs. (210.88±20.56) mmHg, respectively, both P=0.000]; anorectal angulation at resting state and forced defecation state increased significantly [(102.32±4.96)degree vs. (95.88±4.01)degree, (117.88±5.95)degree vs. (89.52±3.25)degree, respectively, both P=0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28±3.91, 7.40±3.64 and 8.04

  15. [Improvement of fecal incontinence with silicone implants in patients with internal anal sphincter injury: First report in North America].

    PubMed

    Vergara-Fernández, O; Valdovinos-Díaz, M A; Hagerman-Ruiz Galindo, G; Salinas-Aragón, L E; Ruíz-Campos, M; Castillo-Machado, W

    2011-01-01

    The injection of bulking agents has been described as a useful treatment of urinary and fecal incontinence. Among them, silicone implants have shown benefits in patients with internal anal sphincter (IAS) injury. We describe two patients with a history of hemorrhoidectomy and IAS injuries, which underwent placement of silicone implants. The implants were inserted into the intersphincteric space and the IAS under ultrasound guidance. The Wexner continente score fell from 17 and 19 before treatment, to 6 and 8 at six months follow up, respectively. Patients had no postoperative complications or implants migration. In our patients, injection of silicone implants improved fecal continence score, without postoperative complications or implants migration at six month follow up.

  16. Design and evaluation of an intelligent artificial anal sphincter system powered by an adaptive transcutaneous energy transfer system.

    PubMed

    Ke, Lei; Yan, Guozheng; Wang, Yongbing; Wang, Zhiwu; Liu, Dasheng

    2015-03-01

    The aim of this study was to optimize an intelligent artificial anal sphincter system (AASS) II for patients with severe fecal incontinence. Redesigning and integrating a pressure sensor into the sphincter prosthesis allows us to reduce the sensor volume and makes it suitable for a chronic, ambulatory application. Furthermore, a close-loop frequency control method was designed for the transcutaneous energy transfer system. Finally, a longer working time of the implanted device was obtained by the low-power design of the hardware and software. The new model was implanted in 2 dogs and studied for periods of up to 5 weeks. The output voltage induced on the load of 30 Ω, for a variation range in k of 0.12 ~ 0.42, was maintained at approximately 6.8 V with a frequency control range of the 270 ~ 320 kHz. The minimum and maximum output voltages of the pressure sensor were found to be 1.7 V and 2.34 V, respectively, which corresponded to a pressure range of 90 ~ 120 kPa with maximum change rate of approximately 3.7% caused by the temperature variations. Moreover, compared with AASS I, the low-power design resulting in 94% reduction in power consumption. The efficacy of the device in achieving continence and sensing the need to defecate was assessed in an animal model. The technical concept and the design of the AASS II turned out to be capable of fulfilling the medical requirements.

  17. The evolution of transperineal ultrasound findings of the external anal sphincter during the first years after childbirth.

    PubMed

    Shek, Ka Lai; Zazzera, Vincent Della; Atan, Ixora Kamisan; Rojas, Rodrigo Guzman; Langer, Susanne; Dietz, Hans Peter

    2016-12-01

    Obstetric anal sphincter injuries (OASI) are a major form of maternal birth trauma. Ultrasound imaging is commonly used to evaluate the condition. We undertook a study to compare the sonographic appearance of the external anal sphincter (EAS) 3 to 6 months and 2 to 3 years after a first birth. A retrospective analysis of data of primiparous women obtained in a prospective perinatal imaging study. Women were invited for postnatal assessment 3 - 6 months and 2 - 3 years after a first delivery. All had completed a standardized questionnaire, and had undergone clinical examination and translabial 4D ultrasound imaging. A "significant" EAS defect was diagnosed if four out of six slices on tomographic ultrasound imaging showed a defect of ≥30° circumference. Datasets of 76 women with complete data and no intervening birth were assessed. Their mean age was 30.0 years (range 19.5 - 45.3 years) at the time of antenatal assessment. They were delivered at a mean gestation of 40 weeks (range 37 - 42 weeks), by caesarean section in 19, normal vaginal delivery in 42, vacuum delivery in 14 and forceps delivery in 1. A significant EAS defect on transperineal ultrasound imaging was found in 13 of 57 women (23 %) at an average of 4.7 months and in 12 of 57 (21 %) at a mean 26.4 months after a first vaginal delivery. In this cohort of primiparous women after a term singleton delivery, we found only minor improvement in sonographic appearance of the EAS between 4.7 months and 26.4 months on transperineal ultrasound imaging, arguing against any significant degree of structural recovery during this time period.

  18. Muscle-Derived Cells for Treatment of Iatrogenic Sphincter Damage and Urinary Incontinence in Men

    PubMed Central

    Gerullis, H.; Eimer, C.; Georgas, E.; Homburger, M.; El-Baz, A. G.; Wishahi, M.; Borós, M.; Ecke, T. H.; Otto, T.

    2012-01-01

    Introduction. Aim of this study was to assess the safety and efficacy of injection of autologous muscle-derived cells into the urinary sphincter for treatment of postprostatectomy urinary incontinence in men and to characterize the injected cells prior to transplantation. Methods. 222 male patients with stress urinary incontinence and sphincter damage after uroloical procedures were treated with transurethral injection of autologous muscle-derived cells. The transplanted cells were investigated after cultivation and prior to application by immunocytochemistry using different markers of myogenic differentiation. Feasibility and functionality assessment was achieved with a follow-up of at least 12 months. Results. Follow-up was at least 12 months. Of the 222 treated patients, 120 responded to therapy of whom 26 patients (12%) were continent, and 94 patients (42%) showed improvement. In 102 (46%) patients, the therapy was ineffective. Clinical improvement was observed on average 4.7 months after transplantation and continued in all improved patients. The cells injected into the sphincter were at least ~50% of myogenic origin and representative for early stages of muscle cell differentiation. Conclusions. Transurethral injection of muscle-derived cells into the damaged urethral sphincter of male patients is a safe procedure. Transplanted cells represent different phases of myogenic differentiation. PMID:22919359

  19. Internal anal sphincter relaxation associated with bisacodyl-induced colonic high amplitude propagating contractions in children with constipation: a colo-anal reflex?

    PubMed

    Rodriguez, L; Siddiqui, A; Nurko, S

    2012-11-01

    Describe the association of internal anal sphincter (IAS) relaxation with colonic high- amplitude peristaltic contractions (HAPCs). Retrospective review of colon manometry tracings of children with constipation to determine the IAS relaxation characteristics associated with HAPC's (HAPC-IASR) events and compare them to the those seen during the performance of the anorectal manometry (ARMRAIR) events. A total of 70 HAPC- IASRs were observed in 15 patients, 65 after bisacodyl, two during fasting and three after a meal. In 64% of events, the IAS relaxation started when the HAPC reached left colon and in 36% as proximal as the hepatic flexure. High- amplitude peristaltic contraction propagation seems to be important in HAPC-IASR characteristics; those propagating distal to sigmoid colon demonstrated larger and longer IAS relaxation as well as lower residual pressure, but equivalent resting pressure compared with HAPC's ending proximal to sigmoid colon. Although IAS resting pressure was comparable for ARM-RAIRs and HAPC-IASRs, the duration and magnitude of anal relaxation was higher, and the anal residual pressure was lower in HAPC-IASRs. We demonstrated that IAS relaxation in constipated children is associated with HAPCs migrating in the proximal and distal colon; in most cases, starting when peristalsis is migrating through left colon and in an important proportion while migrating proximally. We also demonstrated that HAPC-IASRs are different from ARM-RAIRs suggesting a neurally mediated reflex. Finally, the IAS relaxation characteristics are highly dependent on the degree of propagation of HAPCs, which could have important implications in the understanding of defecation disorders. © 2012 Blackwell Publishing Ltd.

  20. The social, psychological, emotional morbidity and adjustment techniques for women with anal incontinence following Obstetric Anal Sphincter Injury: use of a word picture to identify a hidden syndrome.

    PubMed

    Keighley, M R B; Perston, Yvette; Bradshaw, Elissa; Hayes, Joanne; Keighley, D Margaret; Webb, Sara

    2016-09-21

    To identify the emotional, social and psychological consequences and recovery process of anal incontinence (AI) following obstetric anal sphincter injuries (OASIS) and explore if this can be identified as a recognisable syndrome with visual representation. A qualitative approach was adopted for this study. Data derived from case studies (n = 81) and interviews (n = 14) with women with AI after OASIS was used to identify the emotional, social and psychological consequences of AI after OASIS. Keywords and synonyms were extracted and the power of these statements displayed as a 'word picture'. The validity and authenticity of the word picture was then assessed by: a questionnaire sent to a group of mothers who had experienced this condition (n = 16); a focus group attended by mothers (n = 14) and supported by health professionals (n = 6) and via interviews with health professionals (n = 12) who were involved with helping mothers with AI following OASIS. Women with AI resulting from OASIS have a specific syndrome - the 'OASIS Syndrome' - which we have uniquely visualised as a 'word picture'. They feel unclean which results in dignity loss, psychosexual morbidity, isolation, embarrassment, guilt, fear, grief, feeling low, anxiety, loss of confidence, a feeling of having been mutilated and a compromised role as a mother. Coping relies on repetitive washing (which may become a ritual), planning daily activities around toiletry needs, sharing, family support, employment if possible and attention to the baby. Recovery and healing is through care of the child and hope generated by love within the family. This study has identified a previously unrecognised 'OASIS Syndrome' and, by way of a new and unique 'word picture', revealed a hidden condition. There should be greater awareness by the public and profession about the 'OASIS Syndrome' and a mechanism for early identification of the condition and referral for management. This, if successful, would

  1. A case-control study of the relationship between a passive second stage of labor and obstetric anal sphincter injuries.

    PubMed

    Gossett, Dana R; Deibel, Philip; Lewicky-Gaupp, Christina

    2016-02-01

    To estimate the relationship between a passive second stage of labor and obstetric anal sphincter injuries (OASIS). A retrospective, case-control study was undertaken of women who delivered at a tertiary-care center in Chicago, IL, USA, between November 2005 and December 2012. Cases had sustained OASIS and were matched on the basis of parity with controls who had no OASIS. Data were obtained from an electronic repository and chart review. Participants with a passive second stage of labor lasting 60 minutes or more were deemed to have "labored down." A logistic regression model to predict OASIS was created. Overall, 1629 cases were compared with 1312 controls. OASIS were recorded among 1452 (57.8%) of 2510 women who did not labor down compared with 169 (40.0%) of 423 women who labored down (P<0.001). However, in binary logistic regression, the addition of laboring down to the model only increased the predictive accuracy from 80.1% to 80.7%. When known risk factors for OASIS are accounted for, the effect of laboring down on perineal outcome is negligible. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  2. Evaluation of the use of PTQ implants for the treatment of incontinent patients due to internal anal sphincter dysfunction.

    PubMed

    de la Portilla, F; Fernández, A; León, E; Rada, R; Cisneros, N; Maldonado, V H; Vega, J; Espinosa, E

    2008-01-01

    This study reports the results of injectable silicone PTQ implants for faecal incontinence due to internal anal sphincter (IAS) dysfunction. Twenty patients (12 women) with partial faecal incontinence aged from 55 to 65 years were treated by a PTQ implant. All patients completed the Cleveland Clinic Continence and Quality of Life questionnaire. Endoluminal ultrasound and anorectal physiological testing were performed in each patient. All implants were inserted into the submucosal plane without ultrasound guidance. Faecal continence was significantly improved up to 1 year. The Wexner continence score fell from a median of 13.05 (range, 5-20) before treatment to 4.5 (range 2-7.7) at 1 month after (P < 0.005). This rose gradually to 6.2 (range, 0-16) at one year (P = 0.02) and 9.4 (range, 1-20) at 2 years (P = 0.127). There were no differences in resting or squeeze pressure before and at 3 months after treatment (P = 0.86 and P = 0.93). Fourteen (70%) patients experienced pruritus ani during the first few weeks after the procedure and one developed infection at the implant site. Silicone implantation is minimally invasive and technically simple. It is effective over 1 year in the treatment of faecal incontinence due to IAS dysfunction.

  3. The incidence of obstetric anal sphincter rupture in primiparous women: a comparison between two European delivery settings.

    PubMed

    Prager, Martina; Andersson, Karin L; Stephansson, Olof; Marchionni, Mauro; Marions, Lena

    2008-01-01

    During the last years, the incidence of obstetric anal sphincter rupture (OASR) has increased markedly in Sweden, and significantly less frequently in Italy. Our objective was to explore if different delivery management may explain the variation in OASR incidences. In a retrospective study, data from 2,000 primiparous women in a Swedish and an Italian delivery unit were compared with respect to OASR, maternal age, gestational length, birth weight, labour induction, use of epidural analgesia (EDA) and oxytocin, vacuum extraction, episiotomy, and duration of the second stage of labour. Incidences of OASR were 9.2 and 0.4% in the Swedish and Italian centres, respectively. Other significant differences were noticed in maternal age, birth weight, gestational length, use of EDA, oxytocin, vacuum extraction, episiotomy, and frequency of induction. Further analysis of the Swedish population revealed a significant association between OASR and birth weight as well as vacuum extraction. The association with gestational age and duration of the second stage of labour approached significance level. However, no association could be found between OASR and maternal age, EDA, episiotomy or induction of labour. Women delivering in the Swedish setting had a 23 times higher risk of OASR. An association between OASR and birth weight, gestational age, instrumental vaginal deliveries and duration of second stage was found. These factors varied between the settings and could possibly explain the differences in OASR incidence. The importance of alternative management, such as constant midwife support and perineal protection during delivery, may be a subject for further studies.

  4. Are there any functional differences of enteric nervous system between the proximal and distal parts from the dentate line in the normal human internal anal sphincter?

    PubMed

    Tomita, Ryouichi; Igarashi, Seigo; Fujisaki, Shigeru; Koshinaga, Tugumichi; Kusafuka, Takeshi

    2008-01-01

    To clarify the functional differences of the enteric nervous system in the human internal anal sphincter (IAS) between the proximal and distal parts from the dentate line, we investigated the enteric nerve responses of normal proximal and distal IAS in vitro. Normal IAS specimens derived from 20 patients with lower rectal cancer (14 men and 6 women aged from 48 to 77 years, average 66.5 years) were used. These IAS muscles were divided into 2 parts [oral site IAS from dentate line; proximal part (PIAS; n=20), anal site IAS from dentate line; distal part (DIAS; n=20)]. A mechanographic technique was used to evaluate in vitro muscle strip responses to electrical field stimulation (EFS) before and after treatment with various autonomic nerve blockers. 1) Response to EFS before blockade of the adrenergic and cholinergic nerves: In PIAS, the incidence of relaxation reactions was greater than that of contraction reactions (p=0.2059). In DIAS, the incidence of contraction reactions was significantly greater than that of relaxation reactions (p=0.0001). The percentage of relaxation responses in the PIAS was significantly greater than that in the DIAS (p=0.0098). 2) Response to EFS after blockade of the adrenergic and cholinergic nerves: In PIAS, the incidence of relaxation reactions via NANC inhibitory nerve was significantly greater than that of contraction reactions via NANC excitatory nerves (p< 0.0001). In DIAS, the incidence of relaxation reactions via NANC inhibitory nerve was greater than that of contraction reactions via NANC excitatory nerves (p=0.2059). The percentage of relaxation responses via NANC inhibitory nerves in the PIAS was significantly greater than that in the DIAS (p=0.00284). 3) EFS responses in the PIAS and DIAS were blocked by tetrodotoxin. There are functional differences in the regulation of the enteric nervous system between the PIAS and DIAS. Contraction reaction via excitatory nerves, especially cholinergic nerves, was mainly involved in the

  5. Female longitudinal anal muscles or conjoint longitudinal coats extend into the subcutaneous tissue along the vaginal vestibule: a histological study using human fetuses.

    PubMed

    Kinugasa, Yusuke; Arakawa, Takashi; Abe, Hiroshi; Rodríguez-Vázquez, Jose Francisco; Murakami, Gen; Sugihara, Kenichi

    2013-05-01

    It is still unclear whether the longitudinal anal muscles or conjoint longitudinal coats (CLCs) are attached to the vagina, although such an attachment, if present, would appear to make an important contribution to the integrated supportive system of the female pelvic floor. Using immunohistochemistry for smooth muscle actin, we examined semiserial frontal sections of 1) eleven female late-stage fetuses at 28-37 weeks of gestation, 2) two female middle-stage fetus (2 specimens at 13 weeks), and, 3) six male fetuses at 12 and 37 weeks as a comparison of the morphology. In late-stage female fetuses, the CLCs consistently (11/11) extended into the subcutaneous tissue along the vaginal vestibule on the anterior side of the external anal sphincter. Lateral to the CLCs, the external anal sphincter also extended anteriorly toward the vaginal side walls. The anterior part of the CLCs originated from the perimysium of the levator ani muscle without any contribution of the rectal longitudinal muscle layer. However, in 2 female middle-stage fetuses, smooth muscles along the vestibulum extended superiorly toward the levetor ani sling. In male fetuses, the CLCs were separated from another subcutaneous smooth muscle along the scrotal raphe (posterior parts of the dartos layer) by fatty tissue. In terms of topographical anatomy, the female anterior CLCs are likely to correspond to the lateral extension of the perineal body (a bulky subcutaneous smooth muscle mass present in adult women), supporting the vaginal vestibule by transmission of force from the levator ani.

  6. Straddle injury with anal sphincter and rectal rupture in a young girl Case report.

    PubMed

    Pietroletti, Renato; Delreno, Federica; D'Orsi, Amalia; Caoci, Stefano; Carlei, Francesco

    2015-07-29

    Negli incidenti stradali o sportivi è possibile l’eventualità di lesioni traumatiche indicate come “straddle injury”, “trauma a cavalcioni”, per caduta o urto del perineo su un corpo solido a gambe divaricate. Per lo più si tratta di traumi chiusi di lieve-moderata entità, esitanti in ematomi ecchimosi o abrasioni. Il caso descritto riguarda una quattordicenne vittima in un incidente stradale di un trauma chiuso “a cavalcioni”. Alla presentazione lamentava dolore e sanguinamento perineale e all’esame obiettivo una ferita lacero contusa in sede perianale anteriore. La TC non risultava diagnostica. L’esame in anestesia documentava la rottura completa dello sfintere esterno a livello della commissura anale anteriore, in continuità con una rottura a tutto spessore del retto per un’estensione prossimale di circa 15 cm. Dopo lavaggio e sutura delle lesioni, la laparoscopia verificava assenza di lesioni nella pelvi e nella cavità addominale, e consentiva il confezionamento di una colostomia su bacchetta mediante allargamento dell’accesso laparoscopico. Decorso post-operatorio regolare e dimissione in VIII giornata. A sei mesi chiusura della colostomia previa verifica di normalità dei parametri di fisiologia anorettale. Al follow up recente assenti incontinenza o soiling. I traumi chiusi “a cavalcioni” coinvolgono per lo più il settore uro genitale, ma il coinvolgimento anorettale si riscontra in quelli di maggiore gravità e/o con meccanismo penetrante. Il caso descritto aveva comportato un’importante lesione anorettale pur trattandosi di un trauma chiuso perineale, verosimilmente per la dinamica dell’incidente e lo stato di sovrappeso. Essenziale è l’esame in anestesia generale, di valore superiore alla diagnostica per immagini, che è utile per escludere lesioni viscerali o ossee. L’approccio laparoscopico è utile anche per l’eventuale confezionamento di una colostomia di protezione.

  7. Incidence and Risk Factors of Obstetric Anal Sphincter Injuries after Various Modes of Vaginal Deliveries in Chinese Women.

    PubMed

    Tung, Chi Wai; Cheon, Willy Cecilia; Tong, Wai Mei Anny; Leung, Hau Yee

    2015-09-20

    Obstetric anal sphincter injuries (OASIS) can cause an adverse impact on women's physical and mental health. There was lack of published data in Chinese population particularly on studying the risk of OASIS for nonrotational outlet forceps. This study was to determine the incidence and risk factors of OASIS. This is a retrospective cohort study carried out in a tertiary referral hospital in Hong Kong. The control group was selected randomly. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. This study reviewed the obstetric records of OASIS women and random control from January 2011 to June 2014. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. Of 15,446 women delivered, 49 had OASIS. The percentage of OASIS increased from 0.3% (2011) to 0.38% (2014). There was an increasing trend of OASIS in attempted spontaneous vaginal delivery without episiotomy (P < 0.01), but it did not increase the OASIS risk (P = 0.46). Univariate analysis of 49 cases and 438 control subjects showed that forceps delivery (odds ratio [OR] =8.73, P < 0.01), prolong second stage of labor (OR = 1.43, P < 0.01) increased the risk for OASIS. In multivariate regression models, only forceps delivery (OR = 6.28, P < 0.01) proved to be independent risk factor. The incidence of OASIS in Chinese women was increased after 2012, but still lower than the reported figures in the literature. Outlet forceps delivery could be a possible associated risk factor.

  8. Incidence and Risk Factors of Obstetric Anal Sphincter Injuries after Various Modes of Vaginal Deliveries in Chinese Women

    PubMed Central

    Chi Wai, Tung; Cecilia, Cheon Willy; Anny, Tong Wai Mei; Hau Yee, Leung

    2015-01-01

    Background: Obstetric anal sphincter injuries (OASIS) can cause an adverse impact on women's physical and mental health. There was lack of published data in Chinese population particularly on studying the risk of OASIS for nonrotational outlet forceps. This study was to determine the incidence and risk factors of OASIS. Methods: This is a retrospective cohort study carried out in a tertiary referral hospital in Hong Kong. The control group was selected randomly. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. This study reviewed the obstetric records of OASIS women and random control from January 2011 to June 2014. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. Results: Of 15,446 women delivered, 49 had OASIS. The percentage of OASIS increased from 0.3% (2011) to 0.38% (2014). There was an increasing trend of OASIS in attempted spontaneous vaginal delivery without episiotomy (P < 0.01), but it did not increase the OASIS risk (P = 0.46). Univariate analysis of 49 cases and 438 control subjects showed that forceps delivery (odds ratio [OR] =8.73, P < 0.01), prolong second stage of labor (OR = 1.43, P < 0.01) increased the risk for OASIS. In multivariate regression models, only forceps delivery (OR = 6.28, P < 0.01) proved to be independent risk factor. Conclusions: The incidence of OASIS in Chinese women was increased after 2012, but still lower than the reported figures in the literature. Outlet forceps delivery could be a possible associated risk factor. PMID:26365956

  9. Fistulotomy or seton in anal fistula: a decisional algorithm.

    PubMed

    Cariati, Andrea

    2013-09-01

    Fistula in ano is a common proctological disease. Several authors stated that internal and external anal sphincters preservation is in the interest of continence maintenance. The aim of the present study is to report our experience using a decisional algorithm on sphincter saving procedures that achieved us to obtain good results with low rate of complications. From 2008 to 2011, 206 patients underwent surgical treatment for anal fistula; 28 patients underwent perianal abscess drainage plus seton placement of trans-sphincteric or supra-sphincteric fistula (13.6 %), 41 patients underwent fistulotomy for submucosal or low inter-sphincteric or low trans-sphincteric anal fistula (19.9 %) and 137 patients underwent partial fistulectomy or partial fistulotomy (from cutaneous plan to external sphincter muscle plan) and cutting seton placement without internal sphincterotomy for trans-sphincteric anal fistula (66.50 %). Healing rates have been of 100 % and healing times ranged from 1 to 6 months in 97 % of patients treated by setons. Transient fecal soiling was reported by 19 patients affected by trans-sphincteric fistula (11.5 %) for 4-6 months and then disappeared or evolved in a milder form of flatus occasional incontinence. No major incontinence has been reported also after fistulotomy. Fistula recurred in five cases of trans-sphincteric fistula treated by seton placement (one with abscess) (1/28) (3.5 %) and four with trans-sphincteric fistula (4/137) (3 %). Our algorithm permitted us to reduce to 20 % sphincter cutting procedures without reporting postoperative major anal incontinence; it seems to open an interesting way in the treatment of anal fistula.

  10. Predicting the activation states of the muscles governing upper esophageal sphincter relaxation and opening

    PubMed Central

    Jones, Corinne A.; Hammer, Michael J.; Cock, Charles; Dinning, Philip; Wiklendt, Lukasz; Costa, Marcello; McCulloch, Timothy M.

    2016-01-01

    The swallowing muscles that influence upper esophageal sphincter (UES) opening are centrally controlled and modulated by sensory information. Activation and deactivation of neural inputs to these muscles, including the intrinsic cricopharyngeus (CP) and extrinsic submental (SM) muscles, results in their mechanical activation or deactivation, which changes the diameter of the lumen, alters the intraluminal pressure, and ultimately reduces or promotes flow of content. By measuring the changes in diameter, using intraluminal impedance, and the concurrent changes in intraluminal pressure, it is possible to determine when the muscles are passively or actively relaxing or contracting. From these “mechanical states” of the muscle, the neural inputs driving the specific motor behaviors of the UES can be inferred. In this study we compared predictions of UES mechanical states directly with the activity measured by electromyography (EMG). In eight subjects, pharyngeal pressure and impedance were recorded in parallel with CP- and SM-EMG activity. UES pressure and impedance swallow profiles correlated with the CP-EMG and SM-EMG recordings, respectively. Eight UES muscle states were determined by using the gradient of pressure and impedance with respect to time. Guided by the level and gradient change of EMG activity, mechanical states successfully predicted the activity of the CP muscle and SM muscle independently. Mechanical state predictions revealed patterns consistent with the known neural inputs activating the different muscles during swallowing. Derivation of “activation state” maps may allow better physiological and pathophysiological interpretations of UES function. PMID:26767985

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

    PubMed

    Shafik, A A; El Sibai, O; Shafik, I A

    2014-11-01

    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. 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. 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 %. Partial fistulectomy combined with electrocauterization of the intersphincteric fistula tract is a simple, and effective procedure for the treatment of complex anal fistulas.

  12. Towards a Treatment of Stress Urinary Incontinence: Application of Mesenchymal Stromal Cells for Regeneration of the Sphincter Muscle

    PubMed Central

    Aicher, Wilhelm K.; Hart, Melanie L.; Stallkamp, Jan; Klünder, Mario; Ederer, Michael; Sawodny, Oliver; Vaegler, Martin; Amend, Bastian; Sievert, Karl D.; Stenzl, Arnulf

    2014-01-01

    Stress urinary incontinence is a significant social, medical, and economic problem. It is caused, at least in part, by degeneration of the sphincter muscle controlling the tightness of the urinary bladder. This muscular degeneration is characterized by a loss of muscle cells and a surplus of a fibrous connective tissue. In Western countries approximately 15% of all females and 10% of males are affected. The incidence is significantly higher among senior citizens, and more than 25% of the elderly suffer from incontinence. When other therapies, such as physical exercise, pharmacological intervention, or electrophysiological stimulation of the sphincter fail to improve the patient’s conditions, a cell-based therapy may improve the function of the sphincter muscle. Here, we briefly summarize current knowledge on stem cells suitable for therapy of urinary incontinence: mesenchymal stromal cells, urine-derived stem cells, and muscle-derived satellite cells. In addition, we report on ways to improve techniques for surgical navigation, injection of cells in the sphincter muscle, sensors for evaluation of post-treatment therapeutic outcome, and perspectives derived from recent pre-clinical studies. PMID:26237258

  13. Synthesis of Facial Image with Expression Based on Muscular Contraction Parameters Using Linear Muscle and Sphincter Muscle

    NASA Astrophysics Data System (ADS)

    Ahn, Seonju; Ozawa, Shinji

    We aim to synthesize individual facial image with expression based on muscular contraction parameters. We have proposed a method of calculating the muscular contraction parameters from arbitrary face image without using learning for each individual. As a result, we could generate not only individual facial expression, but also the facial expressions of various persons. In this paper, we propose the muscle-based facial model; the facial muscles define both the linear and the novel sphincter. Additionally, we propose a method of synthesizing individual facial image with expression based on muscular contraction parameters. First, the individual facial model with expression is generated by fitting using the arbitrary face image. Next, the muscular contraction parameters are calculated that correspond to the expression displacement of the input face image. Finally, the facial expression is synthesized by the vertex displacements of a neutral facial model based on calculated muscular contraction parameters. Experimental results reveal that the novel sphincter muscle can synthesize facial expressions of the facial image, which corresponds to the actual face image with arbitrary and mouth or eyes expression.

  14. Evaluation of anatomical and functional results of overlapping anal sphincter repair with or without the injection of bone marrow aspirate concentrate: a case-control study.

    PubMed

    Khafagy, W W; El-Said, M M; Thabet, W M; Aref, S E-S; Omar, W; Emile, S H; Elfeki, H; El-Ghonemy, M S; El-Shobaky, M T

    2017-01-01

    Overlapping anal sphincter repair (OASR) is used for treatment of faecal incontinence due to an external anal sphincter (EAS) defect; however, it is not the optimal treatment as its functional results tend to deteriorate significantly with time. The present study aimed to evaluate the effect of local injection of bone marrow aspirate concentrate (BMAC) on the outcome of OASR. We compared a prospective group of 20 patients with EAS defect who were managed with OASR and BMAC injection (group I) with a historical control group of an equal number of patients managed with OASR alone (group II). Patients were assessed preoperatively and during follow-up by the Wexner continence score and endoanal ultrasound. The primary end-points were the improvement of the continence level measured by the Wexner score and the residual EAS defect size measured by endoanal ultrasound. At the end of follow-up, group I had significantly lower mean postoperative Wexner score (5.4 ± 7.6 vs 10.6 ± 7.4; P = 0.03) and smaller EAS defect percentage (12.2 ± 17.5 vs 18.3 ± 18.9). These findings were statistically significant in patients with a small preoperative EAS defect equal to or less than one-third of the anal circumference. Patients with larger preoperative EAS did not show a significant improvement of the continence level after repair in either group. Augmenting OASR with local injection of BMAC in patients with faecal incontinence caused by an EAS defect, particularly a smaller defect, can improve both functional and anatomical outcomes of OASR. Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.

  15. Prospective cohort study of phenotypic variation based on an anal sphincter function in adults with fecal incontinence.

    PubMed

    Brochard, C; Bouguen, G; Bodère, A; Ropert, A; Mallet, A-L; Morcet, J; Bretagne, J-F; Siproudhis, L

    2016-10-01

    One-third of patients with fecal incontinence (FI) do not have any anal dysfunction. The aim was to characterize patients with FI with normal anal function compared with patients with anal weakness. The general characteristics and data of anal manometry, endosonography, and defecography of patients who were evaluated for FI at a single institution from 2005 to 2015 were prospectively assessed. Fecal incontinence was defined by the Cleveland Clinic Incontinence Score (CCIS) >4. Anal weakness was defined by one or more of the three following parameters: <25 mmHg at the upper part of the anal canal, <26 mmHg at the lower part of the anal canal, and <60 mmHg for the mean squeeze pressure. A total of 439 patients with FI were included (152 with normal anal function/287 with anal weakness). Severe constipation (Kess score ≥21) was predominant in patients with normal anal function (44/151 vs 50/284, respectively; p = 0.0054). Fecal incontinence with normal anal function was significantly associated with lower age (>63 years; odds ratio [OR] = 0.29), higher weight (>65 kg; OR = 1.69), fecal urgency (OR = 1.58), less severe FI score (CCIS score >10; OR = 0.52), higher abdominal pressure (>36 mmHg; OR = 2.15), and paradoxical puborectal contraction (OR = 2.07) in a multivariate analysis model. Fecal incontinence with normal anal function is a specific phenotype that involves distal constipation and may be an early stage of FI with anal weakness. Physicians should adapt their management to focus on the treatment of constipation. © 2016 John Wiley & Sons Ltd.

  16. Chronic anal fissure: morphometric analysis of the anal canal at 3.0 Tesla MR imaging.

    PubMed

    Erden, Ayşe; Peker, Elif; Gençtürk, Zeynep Bıyıklı

    2017-02-01

    OBJECTıVE: To compare the morphometric data relating to the muscular structures of the anal canal, in patients with chronic anal fissure and in control group, examined at a 3.0 Tesla MR system. Forty-seven consecutive patients with chronic anal fissure and randomly selected 40 patients who had no claims for perianal disease during their life time were included in the study. T2-weighted sagittal, high-resolution (HR) T2-weighted, and contrast-enhanced fat-suppressed T1-weighted oblique axial and oblique coronal images were retrospectively analyzed by two observers in consensus. Thickness of sphincteric muscles, anal canal length, anorectal angle, thickness of anococcygeal ligament, depth of Minor triangle, width between subcutaneous sphincters, vascularity of posterior commissure, visibility of posterosuperior projection of external sphincter, and angle between the distal anal canal and posterosuperior projection of external sphincter (H angle) in patients and in controls were compared and analyzed using t test, Mann-Whitney U test, and Spearman correlation. The patients with chronic anal fissure had longer anal canal (51.50 mm ± 0.91 vs. 44.11 mm ± 0.71; p = 0.000), thicker internal anal sphincter muscle at mid-anal level (4.18 ± 0.15 vs. 3.39 ± 0.07; p = 0.007), and wider space between subcutaneous external sphincters (11.39 ± 0.50 vs. 6.89 ± 0.22; p = 0.000). In patients, there was a positive correlation between H angle and external sphincter thickness at proximal (r = 0.347; p = 0.021), middle (r = 0427; p = 0.000), and distal (r = 0.518; p = 0.000)) levels of the anal canal. CONCLUSıON: 3.0 Tesla MR imaging provides detailed information about the morphometric changes in the anal sphincter muscles in patients with chronic anal fissure.

  17. Periurethral muscle-derived mononuclear cell injection improves urethral sphincter restoration in rats.

    PubMed

    Turco, Marcelo Pitelli; de Souza, Alex Balduino; de Campos Sousa, Isida; Fratini, Paula; Veras, Mariana Matera; Rodrigues, Marcio Nogueira; de Bessa, José; Brolio, Marina Pandolphi; Leite, Katia Ramos Moreira; Bruschini, Homero; Srougi, Miguel; Miglino, Maria Angélica; Gomes, Cristiano Mendes

    2017-03-27

    Investigate the effect of a novel cell-based therapy with skeletal muscle-derived mononuclear cells (SMDMCs) in a rat model of stress urinary incontinence. Male Wistar-Kyoto rats' hind limb muscles were enzymatically dissociated, and SMDMCs were isolated without needing expansion. The cell population was characterized. Twenty female rats underwent urethrolysis. One week later, 10 rats received periurethral injection of 10(6) cells (SMDMC group), and 10 rats received saline injections (Saline group). Ten rats underwent sham surgery (Sham group). Four weeks after injection, animals were euthanized and the urethra was removed. The incorporation of SMDMCs in the female urethra was evaluated with fluorescence in situ hybridization for the detection of Y-chromosomes. Hematoxylin and eosin, Masson's trichrome staining, and immunohistochemistry for actin and myosin were performed. The muscle/connective tissue, actin and myosin ratios were calculated. Morphological evaluation of the urethral diameters and fractional areas of the lumen, mucosa, and muscular layer was performed. SMDMCs population was consistent with the presence of muscle cells, muscle satellite cells, perivascular cells, muscle progenitor cells, and endothelial cells. SMDMCs were incorporated into the urethra. A significant decrease in the muscle/connective tissue ratio was observed in the Saline group compared with the SMDMC and Sham groups. The proportions of actin and myosin were significantly decreased in the Saline group. No differences were observed in the morphometric parameters. SDMSC were incorporated into the rat urethra and promoted histological recovery of the damaged urethral sphincter, resulting in decreased connective tissue deposition and increased muscle content. © 2017 Wiley Periodicals, Inc.

  18. Are obstetric anal sphincter ruptures preventable?-- large and consistent rupture rate variations between the Nordic countries and between delivery units in Norway.

    PubMed

    Laine, Katariina; Rotvold, Wenche; Staff, Anne Cathrine

    2013-01-01

    To study changes in the incidence of obstetric anal sphincter rupture (OASR) during recent years in Denmark, Finland, Sweden and Norway and hospital-based incidence in recent years in Norway. Retrospective birth register study. Unselected population of delivering women in four Nordic countries. All deliveries (574 175) registered in Denmark, Finland, Norway and Sweden, 2004-2010. Parity data, including maternal, obstetrical and fetal characteristics, were obtained. The incidence of OASR was calculated from vaginal deliveries. A chi-squared test was used to analyse differences between countries and time periods. Incidence of OASR. During the study period, the OASR incidence in Finland was notably lower (0.7-1.0%) than in the other three Nordic countries (4.2-2.3%). A significant and constant reduction in OASR incidence was observed in Norway only (from 4.1 to 2.3%, from 2004 to 2010, p < 0.001). This reduction occurred simultaneously with introduction of a national intervention program of improved delivery techniques that aimed to reduce the incidence of OASR. No major alterations in maternal or fetal risk factors for OASR or registration routines could explain this rapid reduction in the rate of OASR. Differences in the incidence of OASR between Norwegian delivery units were significant, with a threefold difference when comparing the units with lowest and highest incidences. Obstetric anal sphincter rupture seems to be preventable to a considerable extent, as indicated by the rapid and lasting reduction of OASR incidence after implementation of perineal protection programs in Norway. Improved delivery techniques should be implemented in all delivery units to prevent OASR as much as possible. © 2012 The Authors © 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

  19. Anal Fissure

    PubMed Central

    Zaghiyan, Karen N.; Fleshner, Phillip

    2011-01-01

    Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure. PMID:22379402

  20. Female Longitudinal Anal Muscles or Conjoint Longitudinal Coats Extend into the Subcutaneous Tissue along the Vaginal Vestibule: A Histological Study Using Human Fetuses

    PubMed Central

    Arakawa, Takashi; Abe, Hiroshi; Rodríguez-Vízquez, Jose Francisco; Murakami, Gen; Sugihara, Kenichi

    2013-01-01

    Purpose It is still unclear whether the longitudinal anal muscles or conjoint longitudinal coats (CLCs) are attached to the vagina, although such an attachment, if present, would appear to make an important contribution to the integrated supportive system of the female pelvic floor. Materials and Methods Using immunohistochemistry for smooth muscle actin, we examined semiserial frontal sections of 1) eleven female late-stage fetuses at 28-37 weeks of gestation, 2) two female middle-stage fetus (2 specimens at 13 weeks), and, 3) six male fetuses at 12 and 37 weeks as a comparison of the morphology. Results In late-stage female fetuses, the CLCs consistently (11/11) extended into the subcutaneous tissue along the vaginal vestibule on the anterior side of the external anal sphincter. Lateral to the CLCs, the external anal sphincter also extended anteriorly toward the vaginal side walls. The anterior part of the CLCs originated from the perimysium of the levator ani muscle without any contribution of the rectal longitudinal muscle layer. However, in 2 female middle-stage fetuses, smooth muscles along the vestibulum extended superiorly toward the levetor ani sling. In male fetuses, the CLCs were separated from another subcutaneous smooth muscle along the scrotal raphe (posterior parts of the dartos layer) by fatty tissue. Conclusion In terms of topographical anatomy, the female anterior CLCs are likely to correspond to the lateral extension of the perineal body (a bulky subcutaneous smooth muscle mass present in adult women), supporting the vaginal vestibule by transmission of force from the levator ani. PMID:23549829

  1. Circular and longitudinal muscles shortening indicates sliding patterns during peristalsis and transient lower esophageal sphincter relaxation

    PubMed Central

    Patel, Nirali; Jiang, Yanfen; Mittal, Ravinder K.; Kim, Tae Ho; Ledgerwood, Melissa

    2015-01-01

    Esophageal axial shortening is caused by longitudinal muscle (LM) contraction, but circular muscle (CM) may also contribute to axial shortening because of its spiral morphology. The goal of our study was to show patterns of contraction of CM and LM layers during peristalsis and transient lower esophageal sphincter (LES) relaxation (TLESR). In rats, esophageal and LES morphology was assessed by histology and immunohistochemistry, and function with the use of piezo-electric crystals and manometry. Electrical stimulation of the vagus nerve was used to induce esophageal contractions. In 18 healthy subjects, manometry and high frequency intraluminal ultrasound imaging during swallow-induced esophageal contractions and TLESR were evaluated. CM and LM thicknesses were measured (40 swallows and 30 TLESRs) as markers of axial shortening, before and at peak contraction, as well as during TLESRs. Animal studies revealed muscular connections between the LM and CM layers of the LES but not in the esophagus. During vagal stimulated esophageal contraction there was relative movement between the LM and CM. Human studies show that LM-to-CM (LM/CM) thickness ratio at baseline was 1. At the peak of swallow-induced contraction LM/CM ratio decreased significantly (<1), whereas the reverse was the case during TLESR (>2). The pattern of contraction of CM and LM suggests sliding of the two muscles. Furthermore, the sliding patterns are in the opposite direction during peristalsis and TLESR. PMID:26045610

  2. Circular and longitudinal muscles shortening indicates sliding patterns during peristalsis and transient lower esophageal sphincter relaxation.

    PubMed

    Patel, Nirali; Jiang, Yanfen; Mittal, Ravinder K; Kim, Tae Ho; Ledgerwood, Melissa; Bhargava, Valmik

    2015-09-01

    Esophageal axial shortening is caused by longitudinal muscle (LM) contraction, but circular muscle (CM) may also contribute to axial shortening because of its spiral morphology. The goal of our study was to show patterns of contraction of CM and LM layers during peristalsis and transient lower esophageal sphincter (LES) relaxation (TLESR). In rats, esophageal and LES morphology was assessed by histology and immunohistochemistry, and function with the use of piezo-electric crystals and manometry. Electrical stimulation of the vagus nerve was used to induce esophageal contractions. In 18 healthy subjects, manometry and high frequency intraluminal ultrasound imaging during swallow-induced esophageal contractions and TLESR were evaluated. CM and LM thicknesses were measured (40 swallows and 30 TLESRs) as markers of axial shortening, before and at peak contraction, as well as during TLESRs. Animal studies revealed muscular connections between the LM and CM layers of the LES but not in the esophagus. During vagal stimulated esophageal contraction there was relative movement between the LM and CM. Human studies show that LM-to-CM (LM/CM) thickness ratio at baseline was 1. At the peak of swallow-induced contraction LM/CM ratio decreased significantly (<1), whereas the reverse was the case during TLESR (>2). The pattern of contraction of CM and LM suggests sliding of the two muscles. Furthermore, the sliding patterns are in the opposite direction during peristalsis and TLESR.

  3. Characterization of ionic currents of circular smooth muscle cells of the canine pyloric sphincter.

    PubMed

    Vogalis, F; Sanders, K M

    1991-05-01

    1. The ionic currents of circular muscle cells from canine pyloric sphincter were characterized using the whole-cell patch clamp technique. 2. Subpopulations of circular muscle cells from the myenteric and submucosal halves of the circular layer were isolated and studied separately to determine whether differences in the currents expressed by these cells could explain differences in electrical behaviour observed in situ. 3. Resting potentials of isolated cells were about 20 mV positive to cells in intact muscles. Polarization under current clamp to the level of tissue resting potentials caused spontaneous discharge of action potentials in many cells. 4. Outward current measured under voltage clamp could be divided into a voltage-dependent component and a voltage- and Ca(2+)-dependent component. The latter was affected by manipulations of external [Ca2+], nifedipine and dialysis of cells with EGTA. 5. A few cells exhibited a channel that was activated with hyperpolarization. These channels produced inward current at potentials positive to the potassium reversal potential, EK, and reversed at -13 mV. 6. Inward currents, recorded from Cs(+)-loaded cells, were characterized by a transient phase and a sustained phase that persisted throughout the test depolarization. The inward current was reduced by nifedipine but in some cells a nifedipine-resistant component was observed. 7. There were no fundamental differences in the ionic currents recorded from circular muscle cells from the myenteric and submucosal regions, suggesting that the electrical activity of the tissue must be dependent upon structural characteristics (i.e. electrical coupling, fibre bundle dimensions, etc.) of the tissue. 8. The ionic conductance characterized can be related to many of the excitable events recorded from pyloric muscles.

  4. Evaluation of long-term pelvic floor symptoms after an obstetric anal sphincter injury (OASI) at least one year after delivery: A retrospective cohort study of 159 cases.

    PubMed

    Desseauve, D; Proust, S; Carlier-Guerin, C; Rutten, C; Pierre, F; Fritel, X

    2016-01-01

    The aim of this study was to assess long-term pelvic floor symptoms after an obstetric anal sphincter injury (OASI). This retrospective cohort study included 237 cases of OASI (0.86% of deliveries) identified at Poitiers University Hospital between 2000 and 2011. Symptoms were assessed using validated self-administered questionnaires, including Female Pelvic Floor Questionnaire, Pescatori anal incontinence score, EuroQoL five-dimension score, and pain visual analogue scale (VAS). One hundred and sixty women (67%) filled out the questionnaires, on average 46 months after delivery (8-152). Among them, 93 (54%) reported at least one symptom occurring "frequently" (the most common being dyspareunia), and 45 (28%) a symptom occurring "daily" (the most common being flatus incontinence). Anal incontinence was reported by 32 (20%) women, flatus incontinence "frequently" or "daily" by 28 (18%), and stool incontinence "frequently" or "daily" by 9 (6%). Urinary incontinence was reported "frequently" or "daily" by 27 women (17%) at stress, 17 (11%) at urge, and 11 (7%) at mixed circumstances. Prolapse symptoms were reported "frequently" or "daily" by 6 women (4%). Pain during intercourse was reported "frequently" or "daily" by 17 women (11%). Twenty-four women (18%) reported chronic pelvic pain (VAS score≥4/10). Ninety-five percent of women reported a normal quality of life for mobility, self-care, and usual activities; however, alterations in pain/discomfort (32%) and anxiety/depression (33%) domains were frequently reported. Pelvic floor symptoms 4 years after OASI were highly prevalent. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  5. The Dose-Effect Safety Profile of Skeletal Muscle Precursor Cell Therapy in a Dog Model of Intrinsic Urinary Sphincter Deficiency

    PubMed Central

    Eckman, Delrae; Dean, Ashley; Moradi, Mahmoudreza; Allickson, Julie; Cline, J. Mark; Yoo, James J.; Atala, Anthony

    2015-01-01

    Locally injected skeletal muscle precursor cells (skMPCs) integrate into and restore the muscle layers, innervation, vasculature, and function of the sphincter complex in animal models of intrinsic urinary sphincter deficiency (ISD). The goal of the present study was to test the dose-effect safety profile of skMPC therapy in a dog model of ISD. Sphincter deficiency was created in 20 adult female dogs by surgically removing the skeletal muscle layer of the urinary sphincter complex. skMPCs isolated from the hind leg were expanded in culture and injected 4 weeks later into the sphincter complex at a dose of 25 million cells (n = 5), 50 million cells (n = 5), or 100 million cells (n = 5) per milliliter in a 2-ml volume. Five dogs received no sphincter injection. The measures of maximal sphincter pressure, complete blood count, and blood chemistry were performed monthly until their sacrifice at 9 months. At that point, full necropsy was performed to assess the safety of the skMPC injections. Injection of different doses of cells had no effects on the body weight, blood cell count, or kidney or liver function test results (p > .05 among the skMPC doses). Some incidental pathologic features were found in the lower urinary tract in all groups and were most likely associated with repeat catheterization. The maximal urinary sphincter pressure was higher in the 50 million cells per milliliter treatment group than in the other experimental groups (p < .05). The findings of the present study have confirmed that urinary sphincter injection of skMPCs results in no significant local or systemic pathologic features within the dose range that improves sphincter pressures. PMID:25637189

  6. Anal fissure - slideshow

    MedlinePlus

    ... this page: //medlineplus.gov/ency/presentations/100154.htm Anal fissure - series—Normal anatomy To use the sharing ... rectum through which passes stool during defecation. The anal sphincter is a critical mechanism for control of ...

  7. Ascending and descending reflex motor activity of recto-anal region-cholinergic and nitrergic implications in a rat model.

    PubMed

    Radomirov, Radomir; Ivancheva, Christina; Brading, Alison F; Itzev, Dimitar; Rakovska, Angelina; Negrev, Negrin

    2009-04-29

    The implications of cholinergic and nitrergic transmissions in ascending and descending reflex motor pathways of recto-anal region in rat model were evaluated using: (i) electrical stimulation; (ii) triple organ bath; and (iii) morphological techniques. Electrical stimulation to anal canal induced simultaneous ascending contractile responses of longitudinal and circular muscles of proximal rectum, local contraction of anal canal or contraction followed by relaxation of internal anal sphincter when external sphincter was dissected off. The stimulation of proximal rectum elicited local contractions of both rectal layers and descending contractions of internal sphincter or anal canal. Tetrodotoxin (0.1 microM) prevented the electrically elicited events. The ascending excitatory responses and the local and ascending contractions of longitudinal muscle were more pronounced than those of circular muscle suggesting dominant role of ascending reflex pathways and of longitudinal muscle in rectal motor activity. Choline acetyltransferase (ChAT)-containing fibres and nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase-positive neurons were observed in myenteric ganglia of rectum and anal canal. NG-nitro-l-arginine (0.5mM) increased the contractile ascending and descending responses. During atropine (0.3 microM) treatment the ascending and descending contractions were suppressed but not abolished and a relaxation revealed in ascending response of circular muscle and in descending responses of internal anal sphincter and anal canal. The relaxation was decreased by NG-nitro-l-arginine and increased by l-arginine (0.5mM). The results suggest that cholinergic excitatory ascending and descending pathways and nitric oxide-dependent inhibitory ascending neurotransmission(s) to rectal circular muscle and inhibitory descending to internal anal sphincter and anal canal are involved in reflex circuitry controlling motor activity of recto-anal region.

  8. Defensive anality and anal narcissism.

    PubMed

    Shengold, L

    1985-01-01

    This paper aims at demonstrating a currently beleaguered assumption: the central importance, the continuing vitality, and the appropriate complexity of Freud's theory of the drives and of his idea of the primacy of the body ego. It is not enough to consider man a thinking machine or a social being; his animal nature must be given a central place in psychology. The paper postulates that 'anal or sphincter defensiveness' is one of the precursors of the repression barrier. Anality has been comparatively neglected in recent psychoanalytic literature, and so has its explorer, Karl Abraham. The paper's thesis is that there is a special defensive importance to anal erogeneity and libido, and to those aspects of ego and superego that are functionally operative (as the 'sadistic-anal organization' (Freud, 1917)) during the so-called 'sadistic-anal' developmental phase. Any of the psychic danger situations can evoke regression to manifestations of 'anal narcissim'--an attempt to master overwhelming feeling by a kind of emotional sphincter action, narrowing down the world to the controllable and the predictable. The basic assumption here is Fliess's idea that the attainment of anal sphincter control functions--with, as-it-were, 'psychic resonance'--as a means to master primal (murderous, cannibalistic) affect. For optimal psychic development, a proper balance must be attained between anal control of, and anal expression of, instinctual derivatives--especially of affect laden with aggression.

  9. Improvement of Anal Function by Adipose-Derived Stem Cell Sheets.

    PubMed

    Inoue, Yusuke; Fujita, Fumihiko; Yamaguchi, Izumi; Kinoe, Hiroko; Kawahara, Daisuke; Sakai, Yusuke; Kuroki, Tamotsu; Eguchi, Susumu

    2017-05-12

    One of the most troublesome complications of anal preserving surgery is anal sphincter dysfunction. The aim of this study was to evaluate functional recovery after implantation of adipose-derived stem cell (ADSC) sheets, novel biotechnology, for an anal sphincter resection animal model. Eighteen female Sprague-Dawley rats underwent removal of the nearest half of the internal and external anal sphincter muscle. Nine rats received transplantation with ADSC sheets to the resected area while the remaining rats received no transplantation. The rats were evaluated for the anal function by measuring their resting pressure before surgery and on postoperative days 1, 7, 14, 28, and 56. In addition, the rats were examined for the presence of smooth muscle and also to determine its origin. The improvement of the anal pressure was significantly greater in the ADSC sheet transplantation group compared with the control group. Histologically, at the vicinity of the remaining smooth muscle, reproduction of smooth muscle was detected. Using in fluorescence in situ hybridization, the cells were shown to be from the recipient. Regenerative therapy using ADSC sheet has the potential to recover anal sphincter dysfunction due to anorectal surgery. © 2017 S. Karger AG, Basel.

  10. Californium-252 neutron intracavity brachytherapy alone for T1N0 low-lying rectal adenocarcinoma: A definitive anal sphincter-preserving radiotherapy.

    PubMed

    Xiong, Yanli; Shan, Jinlu; Liu, Jia; Zhao, Kewei; Chen, Shu; Xu, Wenjing; Zhou, Qian; Yang, Mei; Lei, Xin

    2017-01-17

    This study evaluated the 4-year results of 32 patients with T1N0 low-lying rectal adenocarcinoma treated solely with californium-252 (Cf-252) neutron intracavity brachytherapy (ICBT). Patients were solicited into the study from January 2008 to June 2011. All the patients had refused surgery or surgery was contraindicated. The patients were treated with Cf-252 neutron ICBT using a novel 3.5-cm diameter off-axis 4-channel intrarectal applicator designed by the authors. The dose reference point was defined on the mucosa surface, with a total dose of 55-62 Gy-eq/4 f (13-16 Gy-eq/f/wk). All the patients completed the radiotherapy in accordance with our protocol. The rectal lesions regressed completely, and the acute rectal toxicity was mild (≤G2). The 4-year local control, overall survival, disease-free survival, and late complication (≥G2) rates were 96.9%, 90.6%, 87.5% and 15.6%, respectively. No severe late complication (≥G3) occurred. The mean follow-up was 56.1 ± 16.0 months. At the end of last follow-up, 29 patients remained alive. The mean survival time was 82.1 ± 2.7 months. Cf-252 neutron ICBT administered as the sole treatment (without surgery) for patients with T1N0 low-lying rectal adenocarcinoma is effective with acceptable late complications. Our study and method offers a definitive anal sphincter-preserving radiotherapy for T1N0 low-lying rectal adenocarcinoma patients.

  11. Californium-252 neutron intracavity brachytherapy alone for T1N0 low-lying rectal adenocarcinoma: A definitive anal sphincter-preserving radiotherapy

    PubMed Central

    Xiong, Yanli; Shan, Jinlu; Liu, Jia; Zhao, Kewei; Chen, Shu; Xu, Wenjing; Zhou, Qian; Yang, Mei; Lei, Xin

    2017-01-01

    This study evaluated the 4-year results of 32 patients with T1N0 low-lying rectal adenocarcinoma treated solely with californium-252 (Cf-252) neutron intracavity brachytherapy (ICBT). Patients were solicited into the study from January 2008 to June 2011. All the patients had refused surgery or surgery was contraindicated. The patients were treated with Cf-252 neutron ICBT using a novel 3.5-cm diameter off-axis 4-channel intrarectal applicator designed by the authors. The dose reference point was defined on the mucosa surface, with a total dose of 55–62 Gy-eq/4 f (13–16 Gy-eq/f/wk). All the patients completed the radiotherapy in accordance with our protocol. The rectal lesions regressed completely, and the acute rectal toxicity was mild (≤G2). The 4-year local control, overall survival, disease-free survival, and late complication (≥G2) rates were 96.9%, 90.6%, 87.5% and 15.6%, respectively. No severe late complication (≥G3) occurred. The mean follow-up was 56.1 ± 16.0 months. At the end of last follow-up, 29 patients remained alive. The mean survival time was 82.1 ± 2.7 months. Cf-252 neutron ICBT administered as the sole treatment (without surgery) for patients with T1N0 low-lying rectal adenocarcinoma is effective with acceptable late complications. Our study and method offers a definitive anal sphincter-preserving radiotherapy for T1N0 low-lying rectal adenocarcinoma patients. PMID:28094790

  12. Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001-2009.

    PubMed

    Ampt, Amanda J; Ford, Jane B; Roberts, Christine L; Morris, Jonathan M

    2013-02-01

    Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries (OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth (aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS. © 2013 The Authors ANZJOG © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

  13. Smooth Muscle Progenitor Cells Derived From Human Pluripotent Stem Cells Induce Histologic Changes in Injured Urethral Sphincter.

    PubMed

    Li, Yanhui; Wen, Yan; Wang, Zhe; Wei, Yi; Wani, Prachi; Green, Morgaine; Swaminathan, Ganesh; Ramamurthi, Anand; Pera, Renee Reijo; Chen, Bertha

    2016-12-01

    : Data suggest that myoblasts from various sources, including bone marrow, skeletal muscle, and adipose tissue, can restore muscle function in patients with urinary incontinence. Animal data have indicated that these progenitor cells exert mostly a paracrine effect on the native tissues rather than cell regeneration. Limited knowledge is available on the in vivo effect of human stem cells or muscle progenitors on injured muscles. We examined in vivo integration of smooth muscle progenitor cells (pSMCs) derived from human pluripotent stem cells (hPSCs). pSMCs were derived from a human embryonic stem cell line (H9-ESCs) and two induced pluripotent stem cell (iPSC) lines. pSMCs were injected periurethrally into urethral injury rat models (2 × 10(6) cells per rat) or intramuscularly into severe combined immunodeficiency mice. Histologic and quantitative image analysis revealed that the urethras in pSMC-treated rats contained abundant elastic fibers and thicker muscle layers compared with the control rats. Western blot confirmed increased elastin/collagen III content in the urethra and bladder of the H9-pSMC-treated rats compared with controls. iPSC-pSMC treatment also showed similar trends in elastin and collagen III. Human elastin gene expression was not detectable in rodent tissues, suggesting that the extracellular matrix synthesis resulted from the native rodent tissues rather than from the implanted human cells. Immunofluorescence staining and in vivo bioluminescence imaging confirmed long-term engraftment of pSMCs into the host urethra and the persistence of the smooth muscle phenotype. Taken together, the data suggest that hPSC-derived pSMCs facilitate restoration of urethral sphincter function by direct smooth muscle cell regeneration and by inducing native tissue elastin/collagen III remodeling. The present study provides evidence that a pure population of human smooth muscle progenitor cells (pSMCs) derived from human pluripotent stem cells (hPSCs) (human

  14. Anal Fissure

    PubMed Central

    Beaty, Jennifer Sam; Shashidharan, M.

    2016-01-01

    Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures. PMID:26929749

  15. Anal Fissure.

    PubMed

    Beaty, Jennifer Sam; Shashidharan, M

    2016-03-01

    Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures.

  16. Reflection of the State of Hunger in Impulse Activity of Nose Wing Muscles and Upper Esophageal Sphincter during Search behavior in Rabbits.

    PubMed

    Kromin, A A; Dvoenko, E E; Zenina, O Yu

    2016-07-01

    Reflection of the state of hunger in impulse activity of nose wing muscles and upper esophageal sphincter muscles was studied in chronic experiments on rabbits subjected to 24-h food deprivation in the absence of locomotion and during search behavior. In the absence of apparent behavioral activity, including sniffing, alai nasi muscles of hungry rabbits constantly generated bursts of action potentials synchronous with breathing, while upper esophageal sphincter muscles exhibited regular aperiodic low-amplitude impulse activity of tonic type. Latent form of food motivation was reflected in the structure of temporal organization of impulse activity of alai nasi muscles in the form of bimodal distribution of interpulse intervals and in temporal structure of impulse activity of upper esophageal sphincter muscles in the form of monomodal distribution. The latent form of food motivation was manifested in the structure of temporal organization of periods of the action potentials burst-like rhythm, generated by alai nasi muscles, in the form of monomodal distribution, characterized by a high degree of dispersion of respiratory cycle periods. In the absence of physical activity hungry animals sporadically exhibited sniffing activity, manifested in the change from the burst-like impulse activity of alai nasi muscles to the single-burst activity type with bimodal distribution of interpulse intervals and monomodal distribution of the burst-like action potentials rhythm periods, the maximum of which was shifted towards lower values, which was the cause of increased respiratory rate. At the same time, the monomodal temporal structure of impulse activity of the upper esophageal sphincter muscles was not changed. With increasing food motivation in the process of search behavior temporal structure of periods of the burst-like action potentials rhythm, generated by alai nasi muscles, became similar to that observed during sniffing, not accompanied by animal's locomotion, which is

  17. Diffuse large B cell lymphoma presenting as a peri-anal abscess.

    PubMed

    Jayasekera, Hasanga; Gorissen, Kym; Francis, Leo; Chow, Carina

    2014-06-04

    A non-healing peri-anal abscess can be difficult to manage and is often attributed to chronic disease. This case documents a male in his seventh decade who presented with multiple peri-anal collections. The abscess cavity had caused necrosis of the internal sphincter muscles resulting in faecal incontinence. Biopsies were conclusive for diffuse large B-cell lymphoma. A de-functioning colostomy was performed and the patient was initiated on CHOP-R chemotherapy. Anal lymphoma masquerading as a peri-anal abscess is rare. A high degree of suspicion must be maintained for an anal abscess which does not resolve with conservative management.

  18. “Topographic and Manometric characterization of the Recto-Anal Inhibitory Reflex (RAIR)”

    PubMed Central

    Cheeney, G; Nguyen, M; Valestin, J; Rao, SSC

    2013-01-01

    INTRODUCTION (RAIR) Recto-anal inhibitory reflex is an integral part of normal defecation. The physiological characteristics of RAIR along anal length and anterior-posterior axis are unknown. AIM To perform topographic and vector-graphic evaluation of RAIR along anal canal using high definition manometry (HDM), and examine the role of various muscle components. METHODS Anorectal topography was assessed in 10 healthy volunteers using HDM probe with 256 sensors. RAIR data were analyzed every mm along the length of anal canal for topographic, baseline, residual, and plateau pressures during 5 mean volumes of balloon inflation (15cc, 40cc, 71cc, 101cc, 177cc), and in 3D by dividing anal canal into 4×2.1 mm grids. RESULTS Relaxation pressure progressively increases along anal canal with increasing balloon volume up to 71 cc and thereafter plateaus. In 3-D, RAIR is maximally seen at the middle and upper portions of anal canal (levels 1.2-3.2 cm) and posteriorly. Peak residual pressure was seen at proximal anal canal. CONCLUSION RAIR is characterized by differential anal relaxation along Anterior-Posterior axis, longitudinally along the length of anal canal, and it depends on the rectal distention volume. It is maximally seen at internal anal sphincter pressure zone. Multidimensional analyses indicate that external anal sphincter provides bulk of anal residual pressure. Our findings emphasize importance of sensor location and orientation; as anterior and more distal location may miss RAIR. PMID:22235880

  19. Antagonistic effects of vasotocin and isotocin on the upper esophageal sphincter muscle of the eel acclimated to seawater.

    PubMed

    Watanabe, Yohei; Sakihara, Takashi; Mukuda, Takao; Ando, Masaaki

    2007-11-01

    The effects of isotocin (IT) and vasotocin (VT), which are fish analogues of mammalian oxytocin and vasopressin respectively, were examined in the isolated upper esophageal sphincter (UES) muscle. IT relaxed and VT constricted the UES muscle in a concentration-dependent manner. The relaxation by IT and the contraction by VT were completely blocked by H-9405 (an oxytocin receptor antagonist) and by H-5350 (a V(1)-receptor antagonist), respectively, suggesting that the eel UES possesses both IT and VT receptors. Truncated fragments of VT did not show any significant effects, indicating that all nine residues are essential for the VT and IT actions. IT may relax the UES muscle through enhancing cAMP production, since similar relaxation was also observed after treatment with 3-isobutyl-1-methylxantine, forskolin and 8-bromoadenosine, 3', 5'-cyclic mono-phosphate (8BrcAMP). Although 8-bromoguanosine, 3', 5'-cyclic monophosphate also relaxed the UES, its effect was less than 1/3 of that 8BrcAMP, suggesting minor contribution of nitric oxide (NO) in the relaxation of the UES muscle. Both peptides seem to act directly on the UES muscle, not through release of other substances from the epithelial cells, since similar relaxation and contraction were observed even in the scraped UES preparations. When IT and VT were intravenously administrated (in vivo experiments), the drinking rate of the seawater eel was enhanced by IT and was inhibited by VT. These effects correspond to the in vitro results described above, relaxation by IT and contraction by VT in the UES muscle. The significance of the relaxing effect by IT is discussed with respect to controlling the drinking behavior of the eel.

  20. Molecular and pharmacological characterization of a functional tachykinin NK3 receptor cloned from the rabbit iris sphincter muscle

    PubMed Central

    Medhurst, Andrew D; Hirst, Warren D; Jerman, Jeffery C; Meakin, Jacqueline; Roberts, Jennifer C; Testa, Tania; Smart, Darren

    1999-01-01

    A functional tachykinin NK3 receptor was cloned from the rabbit iris sphincter muscle and its distribution investigated in ocular tissues.Standard polymerase chain reaction (PCR) techniques were used to clone a full length rabbit NK3 receptor cDNA consisting of 1404 nucleotides. This cDNA encoded a protein of 467 amino acids with 91 and 87% homology to the human and rat NK3 receptors respectively.In CHO-K1 cells transiently expressing the recombinant rabbit NK3 receptor, the relative order of potency of NKB>>NKA⩾SP to displace [125I]-[MePhe7]-NKB binding and to increase intracellular calcium, together with the high affinity of NK3 selective agonists (e.g. senktide, [MePhe7]-NKB) and antagonists (e.g. SR 142801, SB 223412) in both assays was consistent with NK3 receptor pharmacology. In binding and functional experiments, agonist concentration response curves were shallow (0.7–0.8), suggesting the possibility of multiple affinity states of the receptor.Quantitative real time PCR analysis revealed highest expression of rabbit NK3 receptor mRNA in iris sphincter muscle, lower expression in retina and iris dilator muscle, and no expression in lens and cornea. In situ hybridization histochemistry revealed discrete specific localization of NK3 receptor mRNA in the iris muscle and associated ciliary processes. Discrete specific labelling of NK3 receptors with the selective NK3 receptor agonist [125I]-[MePhe7]-NKB was also observed in the ciliary processes using autoradiography.Our study reveals a high molecular similarity between rabbit and human NK3 receptor mRNAs, as predicted from previous pharmacological studies, and provide the first evidence that NK3 receptors are precisely located on ciliary processes in the rabbit eye. In addition, there could be two affinity states of the receptor which may correspond to the typical and ‘atypical' NK3 receptor subtypes previously reported. PMID:10516642

  1. Regenerative medicine provides alternative strategies for the treatment of anal incontinence.

    PubMed

    Gräs, Søren; Tolstrup, Cæcilie Krogsgaard; Lose, Gunnar

    2017-03-01

    Anal incontinence is a common disorder but current treatment modalities are not ideal and the development of new treatments is needed. The aim of this review was to identify the existing knowledge of regenerative medicine strategies in the form of cellular therapies or bioengineering as a treatment for anal incontinence caused by anal sphincter defects. PubMed was searched for preclinical and clinical studies in English published from January 2005 to January 2016. Animal studies have demonstrated that cellular therapy in the form of local injections of culture-expanded skeletal myogenic cells stimulates repair of both acute and 2 - 4-week-old anal sphincter injuries. The results from a small clinical trial with ten patients and a case report support the preclinical findings. Animal studies have also demonstrated that local injections of mesenchymal stem cells stimulate repair of sphincter injuries, and a complex bioengineering strategy for creation and implantation of an intrinsically innervated internal anal sphincter construct has been successfully developed in a series of animal studies. Cellular therapies with myogenic cells and mesenchymal stem cells and the use of bioengineering technology to create an anal sphincter are new potential strategies to treat anal incontinence caused by anal sphincter defects, but the clinical evidence is extremely limited. The use of culture-expanded autologous skeletal myogenic cells has been most intensively investigated and several clinical trials were ongoing at the time of this report. The cost-effectiveness of such a therapy is an issue and muscle fragmentation is suggested as a simple alternative.

  2. Pelvic floor muscles and the external urethral sphincter have different responses to applied bladder pressure during continence

    PubMed Central

    Jiang, Hai-Hong; Salcedo, Levilester B.; Song, Bo; Damaser, Margot S.

    2010-01-01

    Objectives To determine the functional innervation of the pelvic floor muscles (PFM) and if there is PFM activity during an external pressure increase to the bladder in female rats. Methods Thirty-one female adult virgin Sprague Dawley rats received an external increase in bladder pressure until urinary leakage was noted while bladder pressure was recorded (leak point pressure; LPP) under urethane anesthesia. Six of the rats underwent repeat LPP testing after bilateral transection of the levator ani nerve. Another 6 rats underwent repeat LPP testing after bilateral transection of the pudendal nerve. Simultaneous recordings of PFM (pubo-/iliococcygeus muscles) electromyogram (EMG) and external urethral sphincter (EUS) EMG were recorded during cystometry and LPP testing. Results Thirteen rats (42%) showed tonic PFM EMG activity during filling cystometry. Eighteen rats (58%) showed no tonic PFM EMG activity at baseline, but PFM EMG could be activated by pinching the perineal skin. This activity could be maintained unless voiding occurred. The external increase in bladder pressure caused significantly increased EUS EMG activity as demonstrated by increased amplitude and frequency. However, there was no such response in PFM EMG. LPP was not significantly different after levator ani nerve transection, but was significantly decreased after pudendal nerve transection. Conclusions PFM activity was not increased during external pressure increases to the bladder in female rats. Experimental designs using rats should consider this result. PMID:20206969

  3. Gracilis muscle transposition as a workhorse flap for anal incontinence: Quality of life and functional outcome in adults

    PubMed Central

    Kalra, Guru Dayal Singh; Sharma, Amit Kumar; Shende, Kaustubh Sharad

    2016-01-01

    Background/Purpose: Anal incontinence is one of the most psychologically and socially debilitating conditions in an otherwise healthy individual. It can lead to social isolation, loss of self-esteem, self-confidence and depression. This study is devoted to the problem of anal incontinence in the adult patients. The aim of our study is to analyse the results of gracilis muscle transposition for anal incontinence and improvement in quality of life (QOL) of patients. Materials and Methods: This was a retrospective study. A total of 18 patients with complaint of anal incontinence were enrolled in this study. All patients were treated with gracilis muscle transposition. Results: All patients are continent, and there is an improvement in their QOL. Conclusion: Gracilis muscle transposition is a good option for patients of anal incontinence who are not treated by non-surgical means. PMID:28216815

  4. Macrophage density in pharyngeal and laryngeal muscles greatly exceeds that in other striated muscles: an immunohistochemical study using elderly human cadavers

    PubMed Central

    Rhee, Sunki; Kitamura, Kei; Masaaki, Kasahara; Katori, Yukio; Murakami, Gen; Abe, Shin-ichi

    2016-01-01

    Macrophages play an important role in aging-related muscle atrophy (i.e., sarcopenia). We examined macrophage density in six striated muscles (cricopharyngeus muscle, posterior cricoarytenoideus muscle, genioglossus muscle, masseter muscle, infraspinatus muscle, and external anal sphincter). We examined 14 donated male cadavers and utilized CD68 immunohistochemistry to clarify macrophage density in muscles. The numbers of macrophages per striated muscle fiber in the larynx and pharynx (0.34 and 0.31) were 5–6 times greater than those in the tongue, shoulder, and anus (0.05–0.07) with high statistical significance. Thick muscle fibers over 80 µm in diameter were seen in the pharynx, larynx, and anal sphincter of two limited specimens. Conversely, in the other sites or specimens, muscle fibers were thinner than 50 µm. We did not find any multinuclear muscle cells suggestive of regeneration. At the beginning of the study, we suspected that mucosal macrophages might have invaded into the muscle layer of the larynx and pharynx, but we found no evidence of inflammation in the mucosa. Likewise, the internal anal sphincter (a smooth muscle layer near the mucosa) usually contained fewer macrophages than the external sphincter. The present result suggest that, in elderly men, thinning and death of striated muscle fibers occur more frequently in the larynx and pharynx than in other parts of the body. PMID:27722010

  5. German S3 guidelines: anal abscess and fistula (second revised version).

    PubMed

    Ommer, Andreas; Herold, Alexander; Berg, Eugen; Fürst, Alois; Post, Stefan; Ruppert, Reinhard; Schiedeck, Thomas; Schwandner, Oliver; Strittmatter, Bernhard

    2017-03-01

    The incidence of anal abscess and fistula is relatively high, and the condition is most common in young men. This is a revised version of the German S3 guidelines first published in 2011. It is based on a systematic review of pertinent literature. Cryptoglandular abscesses and fistulas usually originate in the proctodeal glands of the intersphincteric space. Classification depends on their relation to the anal sphincter. Patient history and clinical examination are diagnostically sufficient in order to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in complex abscesses or fistulas. The goal of surgery for an abscess is thorough drainage of the focus of infection while preserving the sphincter muscles. The risk of abscess recurrence or secondary fistula formation is low overall. However, they may result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas. Moreover, it should be done by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. Anal fistulas can be treated only by surgical intervention with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter (flap, sphincter repair, LIFT), and occlusion with biomaterials. Only superficial fistulas should be laid open. The risk of postoperative incontinence is directly related to the thickness of the sphincter muscle that is divided. All high anal fistulas should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterial results in lower cure rate. In this revision of the German S3 guidelines, instructions for diagnosis and treatment of anal abscess and fistula are described based on a review of current literature.

  6. [The artificial sphincter: therapy for faecal incontinence].

    PubMed

    Baumgartner, U

    2012-08-01

    Faecal incontinence (FI) challenges a patient's professional, social and sexual life. Often the patient becomes depressive and socially isolated. If able to break open for therapy the patient should receive as first line a conservative treatment (like dietary measures, pelvic re-education, biofeedback, bulking agents, irrigation). When is the time to implant an artificial anal sphincter? If conservative therapy fails as well as surgical options (like a sphincteroplasty - if indicated a reconstruction of the pelvic floor if insufficient, or a sacral nerve stimulation) an ultimo surgical procedure should be offered to appropriate and compliant patients: an artificial anal sphincter. Worldwide, there are two established devices on the market: the artificial bowel sphincter® (ABS) from A. M. S. (Minnetonka, MN, USA) and the soft anal band® from A. M. I. (Feldkirch, Austria). How to implant the artificial anal sphincter? Both devices consist of a silicon cuff which can be filled with fluid. Under absolute aseptic conditions this cuff is placed in the lithotomy position by perianal incisions around the anal canal below the pelvic floor. A silicon tube connects the anal cuff with a reservoir (containing fluid) which is placed either behind the pubis bone in front of the bladder (ABS) or below the costal arch (anal band). With a pump placed in the scrotum/labia (ABS) or by pressing the balloon (anal band) in both types operated by the patient the fluid is shifted forth and back between the anal cuff and the reservoir closing or opening the anal canal. Both systems are placed completely subcutaneously. Both devices improve significantly the anal continence. Both systems have a high rate of reoperations. However, the causes for the redos are different. The ABS is associated with high infection and anal penetration rates of the cuff leading to an explantation rate to up to 60 % of the implants. This kind of complication seems to be much lower with the anal band. The major

  7. More than meets the smile: facial muscle expression in children with Ochoa syndrome.

    PubMed

    Ganesan, I; Thomas, T

    2011-12-01

    The Ochoa syndrome is the association of a non-neurogenic neurogenic bladder with abnormal facial muscle expression. Patients are at risk for renal failure due to obstructive uropathy. We report a family of three siblings, with an emphasis on the abnormalities in facial expression. Careful examination shows an unusual co-contraction of the orbicularis oculi and orbicularis oris muscles only when full facial expressions are exhibited, across a range of emotional or voluntary situations. This suggests a peripheral disorder in facial muscle control. Two thirds of patients have anal sphincter abnormalities. Aberrant organisation of the facial motor and urinary-anal sphincter nuclei may explain these symptoms.

  8. [Stretch sphincter of the esophagus : Paradoxical sphincter with angiomyoelastic architecture].

    PubMed

    Stelzner, F

    2015-08-01

    The investigations described in this article clearly show that the lower esophageal sphincter (LES) represents a variation of circular muscular occlusive mechanisms found elsewhere in the gastrointestinal tract. The LES is a double layer stretch sphincter that operates in an apparently paradoxical manner: it closes when under stretch but opens when the muscle fibers contract. Impedance manometry studies demonstrate that the entire esophagus is involved in the normal functioning of the esophagus as well as in esophageal disorders. The pronounced elasticity of esophageal tissue is a functional feature that has its basis in the singular architecture of elastic fibers located between the muscle layers. All traditional forms of operative treatment of gastroesophageal reflux disease (GERD) impede the natural functioning of the stretch sphincter to a greater or lesser degree by locking it up. The cause of GERD is mainly by contraction of the esophagus brought about by the cephalad transposition of the stretch sphincter segment into the chest. In a sense this is an incipient axial hernia that frequently remains undiagnosed in the early stages. The operative repositioning of the stretch sphincter segment into the abdominal cavity provides sufficient restoration of the natural topographic relationships to achieve a cure of GERD. Whether this straightforward repair restores the function of the entire esophagus remains to be elucidated. The concept of the stretch provides a good explanation of the pathophysiology of achalasia, a condition in which a paralyzed paradoxical ring sphincter remains occluded. Successful myotomy approaches only split the muscularis propria layer of the stretch sphincter while leaving subepithelial muscle fibers intact that remain paralyzed. This limited intervention provides a good relief of symptoms.

  9. Efficacy and Safety of Immuno‐Magnetically Sorted Smooth Muscle Progenitor Cells Derived from Human‐Induced Pluripotent Stem Cells for Restoring Urethral Sphincter Function

    PubMed Central

    Li, Yanhui; Green, Morgaine; Wei, Yi; Wani, Prachi; Wang, Zhe; Reijo Pera, Renee; Chen, Bertha

    2017-01-01

    Abstract Human‐induced pluripotent stem cells (hiPSCs)‐based cell therapy holds promise for treating stress urinary incontinence (SUI). However, safety concerns, especially tumorgenic potential of residual undifferentiated cells in hiPSC derivatives, are major barriers for its clinical translation. An efficient, fast and clinical‐scale strategy for purifying committed cells is also required. Our previous studies demonstrated the regenerative effects of hiPSC‐derived smooth muscle progenitor cells (pSMCs) on the injured urethral sphincter in SUI, but the differentiation protocol required fluorescence‐activated cell sorting (FACS) which is not practical for autologous clinical applications. In this study, we examined the efficacy and safety of hiPSC‐derived pSMC populations sorted by FDA‐approved magnetic‐activated cell sorting (MACS) using cell‐surface marker CD34 for restoring urethral sphincter function. Although the heterogeneity of MACS‐sorted pSMCs was higher than that of FACS‐sorted pSMCs, the percentage of undifferentiated cells dramatically decreased after directed differentiation in vitro. In vivo studies demonstrated long‐term cell integration and no tumor formation of MACS‐sorted pSMCs after transplantation. Furthermore, transplantation of MACS‐sorted pSMCs into immunodeficient SUI rats was comparable to transplantation with FACS‐sorted pSMCs for restoration of the extracellular matrix metabolism and function of the urethral sphincter. In summary, purification of hiPSC derivatives using MACS sorting for CD34 expression represent an efficient approach for production of clinical‐scale pSMCs for autologous stem cell therapy for regeneration of smooth muscle tissues. Stem Cells Translational Medicine 2017;6:1158–1167 PMID:28213970

  10. Efficacy and Safety of Immuno-Magnetically Sorted Smooth Muscle Progenitor Cells Derived from Human-Induced Pluripotent Stem Cells for Restoring Urethral Sphincter Function.

    PubMed

    Li, Yanhui; Green, Morgaine; Wen, Yan; Wei, Yi; Wani, Prachi; Wang, Zhe; Reijo Pera, Renee; Chen, Bertha

    2017-04-01

    Human-induced pluripotent stem cells (hiPSCs)-based cell therapy holds promise for treating stress urinary incontinence (SUI). However, safety concerns, especially tumorgenic potential of residual undifferentiated cells in hiPSC derivatives, are major barriers for its clinical translation. An efficient, fast and clinical-scale strategy for purifying committed cells is also required. Our previous studies demonstrated the regenerative effects of hiPSC-derived smooth muscle progenitor cells (pSMCs) on the injured urethral sphincter in SUI, but the differentiation protocol required fluorescence-activated cell sorting (FACS) which is not practical for autologous clinical applications. In this study, we examined the efficacy and safety of hiPSC-derived pSMC populations sorted by FDA-approved magnetic-activated cell sorting (MACS) using cell-surface marker CD34 for restoring urethral sphincter function. Although the heterogeneity of MACS-sorted pSMCs was higher than that of FACS-sorted pSMCs, the percentage of undifferentiated cells dramatically decreased after directed differentiation in vitro. In vivo studies demonstrated long-term cell integration and no tumor formation of MACS-sorted pSMCs after transplantation. Furthermore, transplantation of MACS-sorted pSMCs into immunodeficient SUI rats was comparable to transplantation with FACS-sorted pSMCs for restoration of the extracellular matrix metabolism and function of the urethral sphincter. In summary, purification of hiPSC derivatives using MACS sorting for CD34 expression represent an efficient approach for production of clinical-scale pSMCs for autologous stem cell therapy for regeneration of smooth muscle tissues. Stem Cells Translational Medicine 2017;6:1158-1167.

  11. Management of low transsphincteric anal fistula with serial setons and interval muscle-cutting fistulotomy.

    PubMed

    Wang, Chen; Rosen, Lester

    2016-03-01

    This study evaluates low transsphincteric anal fistula managed by serial setons and interval fistulotomy, with attention to healing without recurrence and preservation of continence. Following Institutional Review Board approval, consecutive anal fistula operations performed by a single surgeon from January 1, 2009 to December 31, 2013 were retrospectively reviewed using electronic medical records and telephone interviews for patients lost to follow up. Of the 71 patients, 26 (37%) had low transsphincteric fistula (23 males and 3 females; mean age: 46 years), treated at our institution by seton placement followed by interval surgical muscle cutting and subsequent seton replacement or final fistulotomy. Of the 26 patients, 22 (85%) were initially referred due to previous failed treatment, with a 30.6 month mean duration of fistula prior to referral and a mean of 2.2 (range: 0 -6) prior anorectal surgeries. At a mean follow-up of 11.9 months, none of the 21 patients experienced recurrence or fecal incontinence. Serial seton with interval muscle-cutting sphincterotomy followed by complete fistulotomy is an effective treatment for the management of patients who are either initially seen for low transsphincteric fistula, or referred after failed anorectal surgery for that condition.

  12. Signal-transduction pathways that regulate smooth muscle function I. Signal transduction in phasic (esophageal) and tonic (gastroesophageal sphincter) smooth muscles.

    PubMed

    Harnett, Karen M; Cao, Weibiao; Biancani, Piero

    2005-03-01

    Contraction of esophageal (Eso) and lower esophageal sphincter (LES) circular muscle depends on distinct signal-transduction pathways. ACh-induced contraction of Eso muscle is linked to phosphatidylcholine metabolism, production of diacylglycerol and arachidonic acid (AA), and activation of the Ca(2+)-insensitive PKCepsilon. Although PKCepsilon does not require Ca(2+) for activation, either influx of extracellular Ca(2+) or release of Ca(2+) from stores is needed to activate the phospholipases responsible for hydrolysis of membrane phospholipids and production of second messengers, which activate PKCepsilon. In contrast, the LES uses two distinct intracellular pathways: 1) a PKC-dependent pathway activated by low doses of agonists or during maintenance of spontaneous tone, and 2) a Ca(2+)-calmodulin-myosin light chain kinase (MLCK)-dependent pathway activated in response to maximally effective doses of agonists during the initial phase of contraction. The Ca(2+) levels, released by agonist-induced activity of phospholipase C, determine which contractile pathway is activated in the LES. The Ca(2+)-calmodulin-MLCK-dependent contractile pathway has been well characterized in a variety of smooth muscles. The steps linking activation of PKC to myosin light chain (MLC20) phosphorylation and contraction, however, have not been clearly defined for LES, Eso, or other smooth muscles. In addition, in LES circular muscle, a low-molecular weight pancreatic-like phospholipase A2 (group I PLA2) causes production of AA, which is metabolized to prostaglandins and thromboxanes. These AA metabolites act on receptors linked to heterotrimeric G proteins to induce activation of phospholipases and production of second messengers to maintain contraction of LES circular muscle. We have examined the signal-transduction pathways activated by PGF(2alpha) and by thromboxane analogs during the initial contractile phase and found that these pathways are the same as those activated by other

  13. Post- and pre-synaptic action of isotocin in the upper esophageal sphincter muscle of the eel: its role in water drinking.

    PubMed

    Sakihara, Takashi; Watanabe, Yohei; Mukuda, Takao; Ando, Masaaki

    2007-11-01

    Isotocin is a fish analogue of the mammalian hormone oxytocin. To elucidate sites of action of isotocin (IT) in the upper esophageal sphincter (UES) muscle, a key muscle in swallowing, IT was applied after treatment with tetrodotoxin (TTX). Even after blocking nerve activity with TTX, IT relaxes the UES muscle in a concentration-dependent manner, suggesting that IT receptor(s) is present on the muscle cells. Similar relaxation was also obtained by application of 3-isobutyl-1-methylxanthine (IBMX), forskolin (FSK) and 8-bromo-adenosine, 3',5'-cyclic monophosphate (8BrcAMP) after pretreatment with TTX, suggesting that the relaxing effect (postsynaptic action) of IT may be mediated by cAMP. In contrast to such relaxing effect, IT enhanced the UES contraction induced by repetitive electrical field stimulation (EFS). Such enhancement was blocked by an IT receptor antagonist, suggesting that this effect is also mediated by IT receptor(s). Similar enhancement was also induced by IBMX, FSK and 8BrcAMP, suggesting the enhancing effect is also mediated by cAMP. However, no enhancing effect of IT was observed when the muscle was stimulated by carbachol, or after treatment with curare or TTX, denying the postsynaptic modulatory action of IT and suggesting presynaptic action for IT, i.e., accelerating acetylcholine release. Summarizing these results, role of IT in precisely regulating the drinking rate in the seawater eel is discussed.

  14. 2D DIGE Does Not Reveal all: A Scotopic Report Suggests Differential Expression of a Single "Calponin Family Member" Protein for Tetany of Sphincters!

    PubMed

    Chaudhury, Arun

    2015-01-01

    Using 2D differential gel electrophoresis (DIGE) and mass spectrometry (MS), a recent report by Rattan and Ali (2015) compared proteome expression between tonically contracted sphincteric smooth muscles of the internal anal sphincter (IAS), in comparison to the adjacent rectum [rectal smooth muscles (RSM)] that contracts in a phasic fashion. The study showed the differential expression of a single 23 kDa protein SM22, which was 1.87 fold, overexpressed in RSM in comparison to IAS. Earlier studies have shown differences in expression of different proteins like Rho-associated protein kinase II, myosin light chain kinase, myosin phosphatase, and protein kinase C between IAS and RSM. The currently employed methods, despite its high-throughput potential, failed to identify these well-characterized differences between phasic and tonic muscles. This calls into question the fidelity and validatory potential of the otherwise powerful technology of 2D DIGE/MS. These discrepancies, when redressed in future studies, will evolve this recent report as an important baseline study of "sphincter proteome." Proteomics techniques are currently underutilized in examining pathophysiology of hypertensive/hypotensive disorders involving gastrointestinal sphincters, including achalasia, gastroesophageal reflux disease (GERD), spastic pylorus, seen during diabetes or chronic chemotherapy, intestinal pseudo-obstruction, and recto-anal incontinence. Global proteome mapping may provide instant snapshot of the complete repertoire of differential proteins, thus expediting to identify the molecular pathology of gastrointestinal motility disorders currently labeled "idiopathic" and facilitating practice of precision medicine.

  15. Modern management of anal fistula

    PubMed Central

    Limura, Elsa; Giordano, Pasquale

    2015-01-01

    Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of

  16. Modern management of anal fistula.

    PubMed

    Limura, Elsa; Giordano, Pasquale

    2015-01-07

    Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of

  17. [Treatment of anal fissures with botulinum toxin].

    PubMed

    Wollina, U

    2008-04-01

    Chronic anal fissure is a common proctological disease. Botulinum toxin (BTX) can be used for temporary chemical denervation. The administration is by intramuscular injections into either the external or the internal anal sphincter muscles. The mode of action, administration techniques and possible complications or adverse effects of BTX therapy are discussed. The healing rate is dependent on the BTX dosage. The short-term healing rate (< or = 6 months) is between 60 and 90 %. In long-term follow-up studies (> 1 year), about 50 % of patients show a complete response. Adverse effects are generally mild but relapses occur more often compared to surgery. Conservative therapies including BTX are currently considered mostly as the first-line treatment. Among the surgical procedures, lateral sphincterotomy is the most effective treatment but shows higher incontinence and general morbidity rates than BTX.

  18. Sphincter lesions observed on ultrasound after transanal endoscopic surgery

    PubMed Central

    Mora López, Laura; Serra-Aracil, Xavier; Navarro Soto, Salvador

    2015-01-01

    AIM: To assess the morphological impact of transanal endoscopic surgery on the sphincter apparatus using the modified Starck classification. METHODS: A prospective, observational study of 118 consecutive patients undergoing Transanal Endoscopic Operation/Transanal Endoscopic Microsurgery (TEO/TEM) from March 2013 to May 2014 was performed. All the patients underwent an endoanal ultrasound prior to surgery and one and four months postoperatively in order to measure sphincter width, identify sphincter defects and to quantify them in terms of the level, depth and size of the affected anal canal. To assess the lesions, we used the “modified” Starck classification, which incorporates the variable “sphincter fragmentation”. The results were correlated with the Wexner incontinence questionnaire. RESULTS: Of the 118 patients, twelve (sphincter lesions) were excluded. The results of the 106 patients were as follows after one month: 31 (29.2%) lesions found on ultrasound after one month, median overall Starck score of 4 (range 3-6); 10 (9.4%) defects in the internal anal sphincter (IAS) and 3 (2.8%) in the external anal sphincter (EAS); 17 patients (16%) had fragmentation of the sphincter apparatus with both sphincters affected in one case. At four months: 7 (6.6%) defects, all in the IAS, overall median Starck score of 4 (range 3-6). Mean IAS widths were 3.5 mm (SD 1.14) preoperatively, 4.38 mm (SD 2.1) one month postoperatively and 4.03 mm (SD 1.46) four months postoperatively. The only statistically significant difference in sphincter width in the IAS measurements was between preoperatively and one month postoperatively. No incontinence was reported, even in cases of ultrasound abnormalities. CONCLUSION: TEO/TEM may produce ultrasound abnormalities but this is not accompanied by clinical changes in continence. The modified Starck classification is useful for describing and managing these disorders. PMID:26674666

  19. Investigation of anal motor characteristics of the sensorimotor response (SMR) using 3-D anorectal pressure topography

    PubMed Central

    Cheeney, Gregory; Remes-Troche, Jose M.; Attaluri, Ashok

    2011-01-01

    Desire to defecate is associated with a unique anal contractile response, the sensorimotor response (SMR). However, the precise muscle(s) involved is not known. We aimed to examine the role of external and internal anal sphincter and the puborectalis muscle in the genesis of SMR. Anorectal 3-D pressure topography was performed in 10 healthy subjects during graded rectal balloon distention using a novel high-definition manometry system consisting of a probe with 256 pressure sensors arranged circumferentially. The anal pressure changes before, during, and after the onset of SMR were measured at every millimeter along the length of anal canal and in 3-D by dividing the anal canal into 4 × 2.1-mm grids. Pressures were assessed in the longitudinal and anterior-posterior axis. Anal ultrasound was performed to assess puborectalis morphology. 3-D topography demonstrated that rectal distention produced an SMR coinciding with desire to defecate and predominantly induced by contraction of puborectalis. Anal ultrasound showed that the puborectalis was located at mean distance of 3.5 cm from anal verge, which corresponded with peak pressure difference between the anterior and posterior vectors observed at 3.4 cm with 3-D topography (r = 0.77). The highest absolute and percentage increases in pressure during SMR were seen in the superior-posterior portion of anal canal, reaffirming the role of puborectalis. The SMR anal pressure profile showed a peak pressure at 1.6 cm from anal verge in the anterior and posterior vectors and distinct increase in pressure only posteriorly at 3.2 cm corresponding to puborectalis. We concluded that SMR is primarily induced by the activation and contraction of the puborectalis muscle in response to a sensation of a desire to defecate. PMID:21109594

  20. Anal metastasis of rectal cancer-adenocarcinoma of squamous cells: a case report and literature review.

    PubMed

    Sasaki, Shun; Sugiyama, Masahiko; Nakaji, Yu; Nakanishi, Ryota; Nakashima, Yuichiro; Saeki, Hiroshi; Oki, Eiji; Oda, Yoshinao; Maehara, Yoshihiko

    2017-12-01

    Anal metastasis of colorectal cancer is very rare and is usually associated with a history of anal disease, including anal fistula, fissure, hemorrhoidectomy, and anastomotic injury. We report a case of rectal cancer with a synchronous anal metastasis consisting of adenocarcinoma of squamous cells without a history of anal disease. A 60-year-old woman had a chief complaint of melena. She had a 1.5-cm anal tumor on the perianal skin, and a Bollman type 2 rectal tumor on the Ra portion was found on colonoscopy. Biopsy of both tumors revealed a similar histology of well- to moderately differentiated adenocarcinoma. There was no sign of metastases in lymph nodes or other organs. For the purpose of diagnosis and treatment, transperineal local resection of the anal tumor was performed, and it was histologically identified as adenocarcinoma of squamous cells with no invasion to muscles, lymph ducts, or microvessels. The pathological margin was free. Then, to achieve radical cure, laparoscopic low anterior resection (LAR) with D3 lymphadenectomy was performed. The histological diagnosis of the anal tumor was adenocarcinoma of squamous cells without invasion to muscles, lymph ducts, or vessels. The surgical margin was completely free. Immunohistochemical analysis of both tumors revealed similar staining patterns, and the final diagnosis was rectal cancer with metastasis to the anal skin. The patient received no postoperative therapy, and no recurrences have been observed 12 months after surgery. We expect that our sphincter-preserving surgical strategy provided a good prognosis for the synchronous rectal cancer and anal metastasis. This is a rare report of a case with an anal metastasis of colorectal cancer on perianal squamous cells without a history of anal disease that was resected while preserving anal function.

  1. Brain Connectivity Associated with Muscle Synergies in Humans

    PubMed Central

    Rana, Manku; Yani, Moheb S.; Asavasopon, Skulpan; Fisher, Beth E.

    2015-01-01

    The human brain is believed to simplify the control of the large number of muscles in the body by flexibly combining muscle coordination patterns, termed muscle synergies. However, the neural connectivity allowing the human brain to access and coordinate muscle synergies to accomplish functional tasks remains unknown. Here, we use a surprising pair of synergists in humans, the flexor hallucis longus (FHL, a toe flexor) and the anal sphincter, as a model that we show to be well suited in elucidating the neural connectivity underlying muscle synergy control. First, using electromyographic recordings, we demonstrate that voluntary FHL contraction is associated with synergistic anal sphincter contraction, but voluntary anal sphincter contraction occurs without FHL contraction. Second, using fMRI, we show that two important medial wall motor cortical regions emerge in relation to these tasks: one located more posteriorly that preferentially activates during voluntary FHL contraction and one located more anteriorly that activates during both voluntary FHL contraction as well as voluntary anal sphincter contraction. Third, using transcranial magnetic stimulation, we demonstrate that the anterior region is more likely to generate anal sphincter contraction than FHL contraction. Finally, using a repository resting-state fMRI dataset, we demonstrate that the anterior and posterior motor cortical regions have significantly different functional connectivity with distinct and distant brain regions. We conclude that specific motor cortical regions in humans provide access to different muscle synergies, which may allow distinct brain networks to coordinate muscle synergies during functional tasks. SIGNIFICANCE STATEMENT How the human nervous system coordinates activity in a large number of muscles is a fundamental question. The brain and spinal cord are believed to simplify the control of muscles by grouping them into functional units called muscle synergies. Motor cortex is

  2. Brain Connectivity Associated with Muscle Synergies in Humans.

    PubMed

    Rana, Manku; Yani, Moheb S; Asavasopon, Skulpan; Fisher, Beth E; Kutch, Jason J

    2015-11-04

    The human brain is believed to simplify the control of the large number of muscles in the body by flexibly combining muscle coordination patterns, termed muscle synergies. However, the neural connectivity allowing the human brain to access and coordinate muscle synergies to accomplish functional tasks remains unknown. Here, we use a surprising pair of synergists in humans, the flexor hallucis longus (FHL, a toe flexor) and the anal sphincter, as a model that we show to be well suited in elucidating the neural connectivity underlying muscle synergy control. First, using electromyographic recordings, we demonstrate that voluntary FHL contraction is associated with synergistic anal sphincter contraction, but voluntary anal sphincter contraction occurs without FHL contraction. Second, using fMRI, we show that two important medial wall motor cortical regions emerge in relation to these tasks: one located more posteriorly that preferentially activates during voluntary FHL contraction and one located more anteriorly that activates during both voluntary FHL contraction as well as voluntary anal sphincter contraction. Third, using transcranial magnetic stimulation, we demonstrate that the anterior region is more likely to generate anal sphincter contraction than FHL contraction. Finally, using a repository resting-state fMRI dataset, we demonstrate that the anterior and posterior motor cortical regions have significantly different functional connectivity with distinct and distant brain regions. We conclude that specific motor cortical regions in humans provide access to different muscle synergies, which may allow distinct brain networks to coordinate muscle synergies during functional tasks. How the human nervous system coordinates activity in a large number of muscles is a fundamental question. The brain and spinal cord are believed to simplify the control of muscles by grouping them into functional units called muscle synergies. Motor cortex is involved in activating

  3. Pelvic Floor Muscle Training in Women With Stress Urinary Incontinence Causes Hypertrophy of the Urethral Sphincters and Reduces Bladder Neck Mobility During Coughing

    PubMed Central

    McLean, Linda; Varette, Kevin; Gentilcore-Saulnier, Evelyne; Harvey, Marie-Andree; Baker, Kevin; Sauerbrei, Eric

    2016-01-01

    Aims The purpose of this study was to determine the effect of a 12-week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI). Methods Forty women with SUI were randomly assigned to one of two groups: the treatment group received 12 weekly physiotherapy sessions during which they learned how to properly contract their pelvic floor muscles (PFMs) and a home exercise program was prescribed, reviewed, and progressed; the control group received no treatment. Before and after the 12-week study period, ultrasound imaging was used to evaluate bladder neck position and mobility during coughing and Valsalva maneuver in supine and in standing, as well as urethral morphology. Secondary outcome measures included a 3-day bladder diary, 30-min pad test, the Incontinence Impact Questionnaire (IIQ-7) and the Urogenital Distress Inventory (UDI-6). Results The women in the treatment group demonstrated reduced bladder neck mobility during coughing and increased cross-sectional area of their urethra after as compared to before the training. These changes were not evident in the control group. No differences in the resting position of the bladder neck or in bladder neck excursion during Valsalva maneuver were noted in either group. Concomitantly the women in the treatment group demonstrated significant improvements in the 3-day bladder diary and IIQ-7 after the PFM training and improved significantly more than the control group. Conclusion Physiotherapist-supervised PFM training reduces bladder neck motion during coughing, and results in hypertrophy of the urethral sphincter in women who present with SUI. PMID:23861324

  4. Why do we have so much trouble treating anal fistula?

    PubMed

    Dudukgian, Haig; Abcarian, Herand

    2011-07-28

    Anal fistula is among the most common illnesses affecting man. Medical literature dating back to 400 BC has discussed this problem. Various causative factors have been proposed throughout the centuries, but it appears that the majority of fistulas unrelated to specific causes (e.g. Tuberculosis, Crohn's disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces. The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases. The problem with this single, yet effective, treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses, the patient will have varying degrees of fecal incontinence from minor to total. In an attempt to preserve continence, various procedures have been proposed to deal with the fistulas. These include: (1) simple drainage (Seton); (2) closure of fistula tract using fibrin sealant or anal fistula plug; (3) closure of primary opening using endorectal or dermal flaps, and more recently; and (4) ligation of intersphincteric fistula tract (LIFT). In most complex cases (i.e. Crohn's disease), a proximal fecal diversion offers a measure of symptomatic relief. The fact remains that an "ideal" procedure for anal fistula remains elusive. The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations. In essence, the price of preservation of continence at all cost is multiple and often different operations, prolonged disability and disappointment for the patient and the surgeon. Nevertheless, the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist. Conversely, an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient.

  5. Why do we have so much trouble treating anal fistula?

    PubMed Central

    Dudukgian, Haig; Abcarian, Herand

    2011-01-01

    Anal fistula is among the most common illnesses affecting man. Medical literature dating back to 400 BC has discussed this problem. Various causative factors have been proposed throughout the centuries, but it appears that the majority of fistulas unrelated to specific causes (e.g. Tuberculosis, Crohn’s disease) result from infection (abscess) in anal glands extending from the intersphincteric plane to various anorectal spaces. The tubular structure of an anal fistula easily yields itself to division or unroofing (fistulotomy) or excision (fistulectomy) in most cases. The problem with this single, yet effective, treatment plan is that depending on the thickness of sphincter muscle the fistula transgresses, the patient will have varying degrees of fecal incontinence from minor to total. In an attempt to preserve continence, various procedures have been proposed to deal with the fistulas. These include: (1) simple drainage (Seton); (2) closure of fistula tract using fibrin sealant or anal fistula plug; (3) closure of primary opening using endorectal or dermal flaps, and more recently; and (4) ligation of intersphincteric fistula tract (LIFT). In most complex cases (i.e. Crohn’s disease), a proximal fecal diversion offers a measure of symptomatic relief. The fact remains that an “ideal” procedure for anal fistula remains elusive. The failure of each sphincter-preserving procedure (30%-50% recurrence) often results in multiple operations. In essence, the price of preservation of continence at all cost is multiple and often different operations, prolonged disability and disappointment for the patient and the surgeon. Nevertheless, the surgeon treating anal fistulas on an occasional basis should never hesitate in referring the patient to a specialist. Conversely, an expert colorectal surgeon must be familiar with many different operations in order to selectively tailor an operation to the individual patient. PMID:21876616

  6. Abnormal transient internal sphincter relaxation in idiopathic pruritus ani: physiological evidence from ambulatory monitoring.

    PubMed

    Farouk, R; Duthie, G S; Pryde, A; Bartolo, D C

    1994-04-01

    Patients with idiopathic pruritus ani have an abnormal rectoanal inhibitory reflex and a lower threshold for internal sphincter relaxation during the saline continence test. This led to the hypothesis that these patients may exhibit abnormalities of the transient internal anal sphincter relaxation reflex. To study this, 23 men of median age 41 (range 27-64) years with idiopathic pruritus ani and 16 male controls of median age 39 (range 26-68) years were assessed using computerized ambulatory anorectal electromyography and manometry. Resting anal pressure, maximum anal squeeze pressure, internal sphincter electromyogram frequency, the number of internal sphincter relaxations and pudendal nerve terminal motor latency were similar for the two groups. The rise in rectal pressure during internal sphincter relaxation was higher in patients with pruritus than in controls (median (range) 29 (18-60) versus 18 (11-37) cmH2O, P < 0.01). Furthermore, the fall in anal pressure was greater in patients with pruritus than in controls (median (range) 39 (15-52) versus 29 (21-43) cmH2O, P < 0.01). The duration of internal sphincter relaxation was prolonged in patients compared with controls (median (range) 29 (18-55) versus 8 (5-12) s, P < 0.001). Fourteen patients reported staining of underclothes and 17 complained of perianal itch within 1 h of these episodes of abnormal internal sphincter relaxation. Pruritus ani may result from occult faecal leakage as a result of abnormal transient internal sphincter relaxation.

  7. Association of urinary and anal incontinence with measures of pelvic floor muscle contractility.

    PubMed

    Oversand, S H; Atan, I K; Shek, K L; Dietz, H P

    2016-05-01

    To assess the association between clinical and sonographic measures of pelvic floor muscle (PFM) function and symptoms of urinary and anal incontinence (AI). This was a retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including Modified Oxford Scale (MOS) grading, urodynamic testing and four-dimensional translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction in the hiatal anteroposterior (AP) diameter were measured using ultrasound volumes acquired on maximal PFM contraction, blinded against all clinical data. Data from 726 women with a mean age of 56 ± 13.7 (range, 18-88) years and a mean body mass index of 29 ± 6.1 (range, 17-55) kg/m(2) were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72%, respectively, and 13% had AI. Mean MOS grade was 2.4 ± 1.1 (range, 0-5). Mean cranioventral BN shift on TLUS was 7.1 ± 4.4 (range, 0.3-25.3) mm; mean reduction in AP hiatal diameter was 8.6 ± 4.8 (range, 0.3-31.3) mm. On univariate analysis, neither MOS nor TLUS measures were strongly associated with symptoms of urinary incontinence or AI; associations were non-significant except for BN displacement/SI (7.3 mm vs 6.5 mm; P = 0.028), BN displacement/UI (6.85 vs 7.75; P = 0.019), hiatal AP diameter/AI (9.6 mm vs 8.5 mm; P = 0.047) and MOS/SI (2.42 vs 2.19; P = 0.013). In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of PFM function and symptoms of urinary incontinence or AI. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

  8. Diagnostic imaging features of normal anal sacs in dogs and cats

    PubMed Central

    Jung, Yechan; Jeong, Eunseok; Park, Sangjun; Jeong, Jimo; Choi, Ul Soo; Kim, Min-Su; Kim, Namsoo

    2016-01-01

    This study was conducted to provide normal reference features for canine and feline anal sacs using ultrasound, low-field magnetic resonance imaging (MRI) and radiograph contrast as diagnostic imaging tools. A total of ten clinically normal beagle dogs and eight clinically normally cats were included. General radiography with contrast, ultrasonography and low-field MRI scans were performed. The visualization of anal sacs, which are located at distinct sites in dogs and cats, is possible with a contrast study on radiography. Most surfaces of the anal sacs tissue, occasionally appearing as a hyperechoic thin line, were surrounded by the hypoechoic external sphincter muscle on ultrasonography. The normal anal sac contents of dogs and cats had variable echogenicity. Signals of anal sac contents on low-field MRI varied in cats and dogs, and contrast medium using T1-weighted images enhanced the anal sac walls more obviously than that on ultrasonography. In conclusion, this study provides the normal features of anal sacs from dogs and cats on diagnostic imaging. Further studies including anal sac evaluation are expected to investigate disease conditions. PMID:26645338

  9. Diagnostic imaging features of normal anal sacs in dogs and cats.

    PubMed

    Jung, Yechan; Jeong, Eunseok; Park, Sangjun; Jeong, Jimo; Choi, Ul Soo; Kim, Min-Su; Kim, Namsoo; Lee, Kichang

    2016-09-30

    This study was conducted to provide normal reference features for canine and feline anal sacs using ultrasound, low-field magnetic resonance imaging (MRI) and radiograph contrast as diagnostic imaging tools. A total of ten clinically normal beagle dogs and eight clinically normally cats were included. General radiography with contrast, ultrasonography and low-field MRI scans were performed. The visualization of anal sacs, which are located at distinct sites in dogs and cats, is possible with a contrast study on radiography. Most surfaces of the anal sacs tissue, occasionally appearing as a hyperechoic thin line, were surrounded by the hypoechoic external sphincter muscle on ultrasonography. The normal anal sac contents of dogs and cats had variable echogenicity. Signals of anal sac contents on low-field MRI varied in cats and dogs, and contrast medium using T1-weighted images enhanced the anal sac walls more obviously than that on ultrasonography. In conclusion, this study provides the normal features of anal sacs from dogs and cats on diagnostic imaging. Further studies including anal sac evaluation are expected to investigate disease conditions.

  10. The anal reflex elicited by cough and sniff: validation of a neglected clinical sign

    PubMed Central

    Chan, C; Ponsford, S; Swash, M

    2004-01-01

    Background: It is unclear whether contraction of the external anal sphincter (EAS) following a voluntary cough is an integral component of the cough response itself, or a reflex response to the abdominal and pelvic floor dynamics induced by the cough. Clinical experience suggests a reflex origin for this response. Objective: To compare motor latencies for intercostal, abdominal, and EAS muscle contraction after transcranial magnetic stimulation with those following voluntary coughing and sniffing. Methods: A needle electrode inserted into the EAS measured responses, which were confirmed by tonic electromyographic recording. Direct motor latencies from the cerebral cortex to the intercostal, rectus abdominis and EAS muscles were obtained using transcranial magnetic stimulation. Sniff and cough induced responses were also recorded in these muscles. Results: The results suggest that EAS responses following a voluntary cough or sniff represent a polysynaptic reflex. Conclusions: As the cough induced anal reflex response is consistent and easily elicited, its use in clinical neurological examination is appropriate. PMID:15377694

  11. Endothelin-1 activates p38 mitogen-activated protein kinase and cytosolic phospholipase A2 in cat iris sphincter smooth muscle cells.

    PubMed Central

    Husain, S; Abdel-Latif, A A

    1999-01-01

    We have shown previously that cytosolic phospholipase A(2) (cPLA(2)) is responsible for endothelin-1-induced release of arachidonic acid for prostaglandin synthesis in cat iris sphincter smooth muscle (CISM) cells [Husain and Abdel-Latif (1998) Biochim. Biophys. Acta 1392, 127-144]. Here we show that p38 mitogen-activated protein (MAP) kinase, but not p42/p44 MAP kinases, plays an important role in the phosphorylation and activation of cPLA(2) in endothelin-1-stimulated CISM cells. This conclusion is supported by the following findings. Both p38 MAP kinase and p42/p44 MAP kinases were present in the CISM cells and both were activated by endothelin-1. SB203580, a potent specific inhibitor of p38 MAP kinase, but not the p42/p44 MAP kinases specific inhibitor, PD98059, markedly suppressed endothelin-1-enhanced cPLA(2) phosphorylation, cPLA(2) activity and arachidonic acid release. The addition of endothelin-1 resulted in the phosphorylation and activation of cPLA(2). Endothelin-1 stimulated p38 MAP kinase activity in a time- and concentration-dependent manner, and these effects were mediated through the endothelin-A receptor subtype. The protein kinase C (PKC) inhibitor, RO 31-8220, had no inhibitory effect on endothelin-1-induced p38 MAP kinase activation, suggesting that endothelin-1 activation of p38 MAP kinase is independent of PKC. Pertussis toxin inhibited both endothelin-1 and mastoparan stimulation of p38 MAP kinase activity and arachidonic acid release. The inhibitory effects of pertussis toxin are not mediated through cAMP formation. Mastoparan-stimulated [(3)H]arachidonic acid release and cPLA(2) activation was inhibited by SB203580, but not by RO 31-8220. These data suggest that endothelin-1 binds to the endothelin-A receptor to activate the Gi-protein which, through a series of kinases, leads to the activation of p38 MAP kinase and subsequently to phosphorylation and activation of cPLA(2). Activation of cPLA(2) leads to the liberation of arachidonic acid

  12. Cryptoglandular anal fistula.

    PubMed

    de Parades, V; Zeitoun, J-D; Atienza, P

    2010-08-01

    Fistula arising from the glands of the anal crypts is the most common form of anoperineal sepsis. It is characterized by a primary internal orifice in the anal canal, a fistulous tract, and an abscess and/or secondary perineal orifice with purulent discharge. Antibiotics are not curative. The treatment of an abscess is urgent and consists, whenever possible, of incision and drainage under local anesthesia. Definitive treatment of the fistulous tract can await a second stage. The primary aim is to control infection without sacrificing anal continence. Fistulotomy is the basis for all treatments but the specific technique depends on the height of the fistula in relation to the sphincteric mechanism. Overall results of fistulotomy are excellent but there is some risk of anal incontinence. This explains the growing interest in sphincter sparing techniques such as the mucosal advancement flap, the injection of fibrin glue, and the plug procedure. However, results of these procedures are not yet good enough and leave much room for improvement.

  13. Inflatable artificial sphincter - slideshow

    MedlinePlus

    ... presentations/100115.htm Inflatable artificial sphincter - series—Normal anatomy To use the sharing features on this page, ... Bethesda, MD 20894 U.S. Department of Health and Human Services National Institutes of Health Page last updated: ...

  14. Prosthetic Sphincter Controls Urination

    NASA Technical Reports Server (NTRS)

    Tenny, John B., Jr

    1986-01-01

    People who lost muscular control of urinary canal through disease or injury aided by prosthetic sphincter. Implanted so it surrounds uretha, sphincter deflated and inflated at will by wearer to start and stop urina tion. Operating pressure adjusted after implantation to accommodate growth or atrophy of urinary canal and prevent tissue damage from excess pressure. Principle adapted to other organs, such as colon, ureter, or ileum.

  15. Prosthetic Sphincter Controls Urination

    NASA Technical Reports Server (NTRS)

    Tenny, John B., Jr

    1986-01-01

    People who lost muscular control of urinary canal through disease or injury aided by prosthetic sphincter. Implanted so it surrounds uretha, sphincter deflated and inflated at will by wearer to start and stop urina tion. Operating pressure adjusted after implantation to accommodate growth or atrophy of urinary canal and prevent tissue damage from excess pressure. Principle adapted to other organs, such as colon, ureter, or ileum.

  16. [Surgical treatment of anal fistula].

    PubMed

    Zeng, Xiandong; Zhang, Yong

    2014-12-01

    Anal fistula is a common disease. It is also quite difficult to be solved without recurrence or damage to the anal sphincter. Several techniques have been described for the management of anal fistula, but there is no final conclusion of their application in the treatment. This article summarizes the history of anal fistula management, the current techniques available, and describes new technologies. Internet online searches were performed from the CNKI and Wanfang databases to identify articles about anal fistula management including seton, fistulotomy, fistulectomy, LIFT operation, biomaterial treatment and new technology application. Every fistula surgery technique has its own place, so it is reasonable to give comprehensive individualized treatment to different patients, which may lead to reduced recurrence and avoidance of damage to the anal sphincter. New technologies provide promising alternatives to traditional methods of management. Surgeons still need to focus on the invention and improvement of the minimally invasive techniques. Besides, a new therapeutic idea is worth to explore that the focus of surgical treatment should be transferred to prevention of the formation of anal fistula after perianal abscess.

  17. Anal cancer

    MedlinePlus

    Cancer - anus; Squamous cell carcinoma - anal; HPV - anal cancer ... Anal cancer can start anywhere in the anus. Where it starts determines the kind of cancer it is. Squamous cell carcinoma. This is the most common type of anal cancer. It ...

  18. [Perianal fistula and anal fissure].

    PubMed

    Heitland, W

    2012-12-01

    CRYPTOGLANDULAR ANAL FISTULA: Perianal abscesses are caused by cryptoglandular infections. Not every abscess will end in a fistula. The formation of a fistula is determined by the anatomy of the anal sphincter and perianal fistulas will not heal on their own. The therapy of a fistula is oriented between a more aggressive approach (operation) and a conservative treatment with fibrin glue or a plug. Definitive healing and the development of incontinence are the most important key points. ANAL FISSURES: Acute anal fissures should be treated conservatively by topical ointments, consisting of nitrates, calcium channel blockers and if all else fails by botulinum toxin. Treatment of chronic fissures will start conservatively but operative options are necessary in many cases. Operation of first choice is fissurectomy, including excision of fibrotic margins, curettage of the base and excision of the sentinel pile and anal polyps. Lateral internal sphincterotomy is associated with a certain degree of incontinence and needs critical long-term observation.

  19. Gonyautoxin: new treatment for healing acute and chronic anal fissures.

    PubMed

    Garrido, Rogelio; Lagos, Nestor; Lattes, Karinna; Abedrapo, Mario; Bocic, Gunther; Cuneo, Aldo; Chiong, Hector; Jensen, Christian; Azolas, Rodrigo; Henriquez, Ana; Garcia, Carlos

    2005-02-01

    The mayor symptoms of chronic anal fissure are permanent pain, intense pain during defecation that lasts for hours, blood in the stools, and sphincter cramps. It is subsequent to formation of fibrosis infiltrate that leads to an increased anal tone with poor healing tendency. This vicious circle leads to fissure recurrence and chronicity. This study was designed to show the efficacy of gonyautoxin infiltration in healing patients with anal fissures. Gonyautoxin is a paralyzing phytotoxin produced by dinoflagellates. Fifty recruited patients received clinical examination, including proctoscopy and questionnaire to evaluate the symptoms. Anorectal manometries were performed before and after toxin injection. Doses of 100 units of gonyautoxin in a volume of 1 ml were infiltrated into both sides of the anal fissure in the internal anal sphincter. Total remission of acute and chronic anal fissures were achieved within 15 and 28 days respectively. Ninety-eight percent of the patients healed before 28 days with a mean time healing of 17.6 +/- 9 days. Only one relapsed during 14 months of follow-up. Neither fecal incontinence nor other side effects were observed. All patients showed immediate sphincter relaxation. The maximum anal resting pressures recorded after two minutes decreased to 56.2 +/- 12.5 percent of baseline. Gonyautoxin breaks the vicious circle of pain and spasm that leads to anal fissure. This study proposes gonyautoxin anal sphincter infiltration as safe and effective alternative therapeutic approach to conservative, surgical, and botulinum toxin therapies for anal fissures.

  20. Pulmonary venous sphincters in cattle.

    PubMed

    Aharinejad, S; Egerbacher, M; Nourani, F; Böck, P; Friederici, C; Schraufnagel, D E

    1996-11-01

    The pulmonary veins of rats have regular focal narrowing by tufts of smooth muscle (sphincters) that can contract in response to a variety of stimuli, but these structures are not well studied in other species, and there is little information about their innervation and control. The pulmonary veins of 21 cattle were cast with methacrylate, and the casts were studied by scanning electron microscopy, or the fixed tissue was studied by light microscopy with immunocytochemistry and transmission electron microscopy. Constrictions occurred in series along the course of veins (9.6/500 microns), giving the cast veins a string-of-pearl look, with narrowing of 33-81% of the outer diameter. No resin appeared beyond the most narrowed veins. The percentage of contraction did not correlate with the diameter of the veins. With immunohistochemistry using antibodies to S-100, protein gene peptide 9.5, neuron-specific enolase, neurofilament 200, and glial fibrillary acidic protein and with transmission electron microscopy, we could identify no neuronal elements associated with the venous smooth muscle tufts. Bronchial smooth muscle bundles in the same sections stained positively. The veins of cattle are unlike the rat because the focal venous smooth muscle protrudes deeply into the venous lumen and may completely obstruct perfusion. If the focal venous muscle has no innervation (this study) and can constrict without blood flow (as shown previously), then the venous constriction and, hence, local blood flow regulation must be controlled by local mediators.

  1. Neural control of the female urethral and anal rhabdosphincters and pelvic floor muscles

    PubMed Central

    de Groat, William C.

    2010-01-01

    The urethral rhabdosphincter and pelvic floor muscles are important in maintenance of urinary continence and in preventing descent of pelvic organs [i.e., pelvic organ prolapse (POP)]. Despite its clinical importance and complexity, a comprehensive review of neural control of the rhabdosphincter and pelvic floor muscles is lacking. The present review places historical and recent basic science findings on neural control into the context of functional anatomy of the pelvic muscles and their coordination with visceral function and correlates basic science findings with clinical findings when possible. This review briefly describes the striated muscles of the pelvis and then provides details on the peripheral innervation and, in particular, the contributions of the pudendal and levator ani nerves to the function of the various pelvic muscles. The locations and unique phenotypic characteristics of rhabdosphincter motor neurons located in Onuf's nucleus, and levator ani motor neurons located diffusely in the sacral ventral horn, are provided along with the locations and phenotypes of primary afferent neurons that convey sensory information from these muscles. Spinal and supraspinal pathways mediating excitatory and inhibitory inputs to the motor neurons are described; the relative contributions of the nerves to urethral function and their involvement in POP and incontinence are discussed. Finally, a detailed summary of the neurochemical anatomy of Onuf's nucleus and the pharmacological control of the rhabdosphincter are provided. PMID:20484700

  2. Non-sphincter splitting fistulectomy vs conventional fistulotomy for high trans-sphincteric fistula-in-ano: a prospective functional and manometric study.

    PubMed

    Toyonaga, Takayuki; Matsushima, Makoto; Tanaka, Yoshiaki; Suzuki, Kazunori; Sogawa, Nobuhito; Kanyama, Hiroki; Shimojima, Yasuhiro; Hatakeyama, Tomoaki; Tanaka, Masao

    2007-09-01

    This study compared the clinical and physiological results of non-sphincter splitting fistulectomy (N-SSF) with those of sphincter splitting fistulotomy (SSF) for treatment of high trans-sphincteric fistula-in-ano. A prospective, observational study was undertaken in 70 consecutive patients with high trans-sphincteric fistula treated by SSF (n = 35) or N-SSF (n = 35). Anal manometry was performed before and 3 months after surgery. Anal continence was assessed using the Cleveland Clinic Florida Incontinence Score. There was no difference between the two groups in age, gender, presence of horseshoe extension, preoperative incontinence score and manometric values. The incidence of recurrence was similar between the two groups. The postoperative incontinence score of the SSF group was significantly higher than that of the N-SSF group (1.9 +/- 2.9 vs 1.1 +/- 2.9, P = 0.0347). Maximum resting pressure showed significant decrease after surgery in both groups (83.2 to 56.1 mmHg, P = 0.0001 and 85.1 to 58.4 mmHg, P = 0.0001). Voluntary contraction pressure and functional anal canal length did not change after N-SSF (137.6 to 138.2 mmHg, P = 0.9524 and 4.06 to 4.07 cm, P = 0.9524), but significantly decreased after SSF (120.2 to 96.7 mmHg, P = 0.0085 and 4.12 to 3.74 cm, P = 0.0183). Non-sphincter splitting fistulectomy for high trans-sphincteric fistula provided better functional results than fistulotomy. Less impairment of anal continence was achieved possibly not only by maintenance of the external anal sphincter function but also by preservation of the length of the high-pressure zone.

  3. Anal fistula: intraoperative difficulties and unexpected findings.

    PubMed

    Abou-Zeid, Ahmed A

    2011-07-28

    Anal fistula surgery is a commonly performed procedure. The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence. Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination, endoanal ultrasound or magnetic resonance imaging, on many occasions, unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial. In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them.

  4. Anal fistula: Intraoperative difficulties and unexpected findings

    PubMed Central

    Abou-Zeid, Ahmed A

    2011-01-01

    Anal fistula surgery is a commonly performed procedure. The diverse anatomy of anal fistulae and their proximity to anal sphincters make accurate preoperative diagnosis essential to avoid recurrence and fecal incontinence. Despite the fact that proper preoperative diagnosis can be reached in the majority of patients by simple clinical examination, endoanal ultrasound or magnetic resonance imaging, on many occasions, unexpected findings can be encountered during surgery that can make the operation difficult and correct decision-making crucial. In this article we discuss the difficulties and unexpected findings that can be encountered during anal fistula surgery and how to overcome them. PMID:21876613

  5. New Techniques for Treating an Anal Fistula

    PubMed Central

    2012-01-01

    Surgery for an anal fistula may result in recurrence or impairment of continence. The ideal treatment for an anal fistula should be associated with low recurrence rates, minimal incontinence and good quality of life. Because of the risk of a change in continence with conventional techniques, sphincter-preserving techniques for the management complex anal fistulae have been evaluated. First, the anal fistula plug is made of lyophilized porcine intestinal submucosa. The anal fistula plug is expected to provide a collagen scaffold to promote tissue in growth and fistula healing. Another addition to the sphincter-preserving options is the ligation of intersphincteric fistula tract procedure. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane. Recently, cell therapy for an anal fistula has been described. Adipose-derived stem cells have two biologic properties, namely, ability to suppress inflammation and differentiation potential. These properties are useful for the regeneration or the repair of damaged tissues. This article discusses the rationales for, the estimated efficacies of, and the limitations of new sphincter-preserving techniques for the treatment of anal fistulae. PMID:22413076

  6. New techniques for treating an anal fistula.

    PubMed

    Song, Kee Ho

    2012-02-01

    Surgery for an anal fistula may result in recurrence or impairment of continence. The ideal treatment for an anal fistula should be associated with low recurrence rates, minimal incontinence and good quality of life. Because of the risk of a change in continence with conventional techniques, sphincter-preserving techniques for the management complex anal fistulae have been evaluated. First, the anal fistula plug is made of lyophilized porcine intestinal submucosa. The anal fistula plug is expected to provide a collagen scaffold to promote tissue in growth and fistula healing. Another addition to the sphincter-preserving options is the ligation of intersphincteric fistula tract procedure. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane. Recently, cell therapy for an anal fistula has been described. Adipose-derived stem cells have two biologic properties, namely, ability to suppress inflammation and differentiation potential. These properties are useful for the regeneration or the repair of damaged tissues. This article discusses the rationales for, the estimated efficacies of, and the limitations of new sphincter-preserving techniques for the treatment of anal fistulae.

  7. Anal Cancer

    MedlinePlus

    Anal cancer Overview Anal cancer is an uncommon type of cancer that occurs in the anal canal. The anal canal is a short tube at the end ... your rectum through which stool leaves your body. Anal cancer can cause signs and symptoms such as ...

  8. Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery?

    PubMed Central

    Gupta, Pravin J.

    2004-01-01

    AIM: Hypertrophied anal papillae and fibrous anal polyps are not given due importance in the proctology practice. They are mostly ignored being considered as normal structures. The present study was aimed to demonstrate that hypertrophied anal papillae and fibrous anal polyps could cause symptoms to the patients and that they should be removed in treatment of patients with chronic fissure in anus. METHODS: Two groups of patients were studied. A hundred patients were studied in group A in which the associated fibrous polyp or papillae were removed by radio frequency surgical device after a lateral subcutaneous sphincterotomy for relieving the sphincter spasm. Another group of a hundred patients who also had papillae or fibrous polyps, were treated by lateral sphincterotomy alone. They were followed up for one year. RESULTS: Eighty-nine percent patients from group A expressed their satisfaction with the treatment in comparison to only 64% from group B who underwent sphincterotomy alone with the papillae or anal polyps left untreated. Group A patients showed a marked reduction with regard to pain and irritation during defecation (P = 0.0011), pricking or foreign body sensation in the anus (P = 0.0006) and pruritus or wetness around the anal verge (P = 0.0008). CONCLUSION: Hypertrophied anal papillae and fibrous anal polyps should be removed during treatment of chronic anal fissure. This would add to effectiveness and completeness of the procedure. PMID:15285031

  9. Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery?

    PubMed

    Gupta, Pravin-J

    2004-08-15

    Hypertrophied anal papillae and fibrous anal polyps are not given due importance in the proctology practice. They are mostly ignored being considered as normal structures. The present study was aimed to demonstrate that hypertrophied anal papillae and fibrous anal polyps could cause symptoms to the patients and that they should be removed in treatment of patients with chronic fissure in anus. Two groups of patients were studied. A hundred patients were studied in group A in which the associated fibrous polyp or papillae were removed by radio frequency surgical device after a lateral subcutaneous sphincterotomy for relieving the sphincter spasm. Another group of a hundred patients who also had papillae or fibrous polyps, were treated by lateral sphincterotomy alone. They were followed up for one year. Eighty-nine percent patients from group A expressed their satisfaction with the treatment in comparison to only 64% from group B who underwent sphincterotomy alone with the papillae or anal polyps left untreated. Group A patients showed a marked reduction with regard to pain and irritation during defecation (P = 0.0011), pricking or foreign body sensation in the anus (P = 0.0006) and pruritus or wetness around the anal verge (P = 0.0008). Hypertrophied anal papillae and fibrous anal polyps should be removed during treatment of chronic anal fissure. This would add to effectiveness and completeness of the procedure.

  10. Anal Cancer

    MedlinePlus

    ... 2345 Phone Search Search Category Cancer A-Z Anal Cancer If you have anal cancer or are close to someone who does, ... cope. Here you can find out all about anal cancer, including risk factors, symptoms, how it is ...

  11. [Cryptoglandular anal fistulas].

    PubMed

    de Parades, Vincent; Zeitoun, Jean-David; Bauer, Pierre; Atienza, Patrick

    2008-10-31

    Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis. Characteristically they have an endoanal primary opening, a fistula track and an abscess and/or an external purulent opening. Antibiotic therapy is not of use in initial management except in special cases. Treatment of an abscess, if present, is required urgently and when possible, consists of its incision under local anaesthesia. Treating the fistula track occurs afterwards and aims to dry up the purulent discharge and avoid recurrence of the abscess by means of surgical fistulotomy. These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence. This explains the increasing interest in sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue.

  12. Anal Cancer

    MedlinePlus

    ... are here Home > Types of Cancer > Anal Cancer Anal Cancer This is Cancer.Net’s Guide to Anal Cancer. Use the menu below to choose the ... social workers, and patient advocates. Cancer.Net Guide Anal Cancer Introduction Statistics Risk Factors and Prevention Screening ...

  13. Contractility of sphincter pharyngoplasty: Relevance to speech outcomes

    PubMed Central

    Hubbard, Bradley A; Rice, Gale; Muzaffar, Arshad R

    2013-01-01

    BACKGROUND: Sphincter pharyngoplasty has demonstrated time-tested results as a surgical treatment for velopharyngeal incompetence (VPI). However, controversy surrounding the contractility of the transposed muscles persists. Completely unaddressed in the literature is whether the dynamism of the sphincter affects speech outcomes. OBJECTIVE: To determine whether active sphincter contraction following sphincter pharyngoplasty influences velopharyngeal closure, nasal emission and hypernasality. METHODS: A prospective analysis of patients with VPI after cleft palate repair undergoing sphincter pharyngoplasty by a single surgeon was performed. Video nasendoscopy and videofluoroscopy were performed preoperatively and postoperatively at three and 12 months. Eighteen consecutive patients with cleft palate with or without cleft lip and VPI were reviewed. The average age of the patients at initial evaluation was 7.3 years, with a range of three to 19 years. Dynamicity of sphincter pharyngoplasty, velar closing ratio (VCR), and lateral wall movement (LWM) were assessed by nasendoscopy and videofluoroscopy. Nasal emission and hypernasality were assessed by perceptual speech examination. RESULTS: For longitudinal comparison, three groups were created: dynamic at three and 12 months (n=12); adynamic at three months and dynamic at 12 months (n=4); and adynamic at three and 12 months (n=2). Perceived hypernasality scores significantly improved at three months (P=0.0001) and showed continued improvement at 12 months (P=0.03), despite no change in VCR and LWM from three to 12 months. There were no significant differences among the three groups at any time point. DISCUSSION: Sphincter pharyngoplasty effectively treats VPI in appropriately selected patients. Although the VCR and LWM remained stable between three months and one year, four of six adynamic sphincters became dynamic. Considering all patients, hypernasality showed continued improvement from three months to one year

  14. Nonsurgical approaches for the treatment of anal fissures.

    PubMed

    Dhawan, Sanju; Chopra, Sunny

    2007-06-01

    Chronic anal fissure (CAF) is usually associated with internal anal sphincter spasm, the relief of which is central to provide fissure healing. The treatment for CAF has undergone a transformation in recent years from surgical to medical. Both the approaches share the common goal of reducing the spasm. Though surgical treatment has a high success rate, it can permanently impair fecal continence in a large number of patients. Smooth muscle relaxation seems to be a novel way by which more than 60% of the patients can be cured with the topical use of the agents. This treatment is in addition to the normalization of stools mostly. Smooth muscle relaxation is well tolerated, can be administered on an outpatient basis, does not cause any lesion of the continence organ, and subsequently, does not lead to any permanent latent or apparent fecal incontinence. This review encompasses various agents that are used for smooth muscle relaxation. In addition, it describes various clinical studies reported in the literature with their success rates and side effects.

  15. Women's pelvic floor muscle strength and urinary and anal incontinence after childbirth: a cross-sectional study.

    PubMed

    Zizzi, Priscila Tavares; Trevisan, Karina Fernandes; Leister, Nathalie; Cruz, Camila da Silva; Riesco, Maria Luiza Gonzalez

    2017-04-10

    To analyse pelvic floor muscle strength (PFMS) and urinary and anal incontinence (UI and AI) in the postpartum period. Cross-sectional study carried out with women in their first seven months after child birth. Data were collected through interviews, perineometry (Peritron™), and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). 128 women participated in the study. The PFMS mean was 33.1 (SD=16.0) cmH2O and the prevalence of UI and AI was 7.8% and 5.5%, respectively. In the multiple analyses, the variables associated with PFMS were type of birth and cohabitation with a partner. Newborn's weight, previous pregnancy, UI during pregnancy, and sexual activity showed an association with UI after child birth. Only AI prior to pregnancy was associated with AI after childbirth. Vaginal birth predisposes to the reduction of PFMS, and caesarean section had a protective effect to its reduction. The occurrence of UI during pregnancy is a predictor of UI after childbirth, and women with previous pregnancies and newborns with higher weights are more likely to have UI after childbirth.AI prior to pregnancy is the only risk factor for its occurrence after childbirth. Associations between PFMS and cohabitation with a partner, and between UI and sexual activity do not make possible to conclude that these variables are directly associated. Analisar a força dos músculos do assoalho pélvico e a incontinência urinária e anal no período pós-parto. Estudo transversal realizado com mulheres nos primeiros 7 meses após o parto. Os dados foram coletados por meio de entrevista, da perineometria (Peritron™) e do International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Participaram do estudo 128 mulheres. A média da força dos músculos do assoalho pélvico foi 33,1 (d.p.=16,0) cmH2O e a prevalência de incontinência urinária e incontinência anal foi de 7,8% e 5,5%, respectivamente. Na análise múltipla, as vari

  16. Sphincteric musculature of female canine urethra in comparison to woman including 3D reconstruction.

    PubMed

    Stolzenburg, Jens-Uwe; Dorschner, Wolfgang; Postenjak, Marijana; Salomon, Franz-Viktor; Jurina, Konrad; Do, Minh; Neuhaus, Jochen

    2002-01-01

    The circular arranged sphincteric musculature of bladder neck of female dogs and women were studied histomorphologically. 3D reconstructions of the anatomy of the bladder neck improve the understanding of construction principles of the musculature of the lower urinary tract and help to compare both species. Our own investigations based on 12 adult female canine and 15 female human autopsy preparations. The special feature of our study was the extensive en bloc preparation of all the organs of the lower urinary tract and surrounding organs. The organ blocks were reprocessed in complete serial sections from the bladder outlet down to the bulb of vestibuli. Despite different detailed construction, in both species the striated sphincter musculature of the urethra is an independent morphological unit. There is no continuation of pelvic floor muscles to the urethra. In humans, the urethral sphincter consists of a smooth muscular part (m. sphincter urethrae glaber) and a striated part (m. sphincter urethrae transversostriatus). In the female dog, striated muscle fibres encircle the urethra in the middle third exclusively. In the distal third of the urethra, it encircles the urethra and the vagina. In the female dog, the lamellae of detrusor continue directly to the urethra. Throughout the cranial and middle third of the urethra, smooth muscle cell bundles form a homogenous compact sphincteric muscle originating from the middle circular layer of detrusor. In that way, no true bladder neck sphincter according to the m. sphincter vesicae in women exists in dogs. According to the smooth muscular part of the m. sphincter urethrae in women, for this musculature the term m. sphincter urethrae glaber is suggested. Despite a superficial resemblance, this study revealed a considerable difference of circular sphincteric muscle components between female dog and woman suggesting that functional studies in respect to urinary continence obtained in dogs cannot be attributed without

  17. [Anal cytology].

    PubMed

    Tóth, Béla; Sápi, Zoltán; Bánhegyi, Dénes; Marschalkó, Márta; Kárpáti, Sarolta

    2015-01-04

    The incidence of anal cancer has increased in recent decades, particularly among human immunodeficiency virus infected men who have sex with men. Anal intraepithelial neoplasia is a potential precursor lesion of anal cancer. Anal cytology is the primary screening test for anal intraeptithelial neoplasia. The authors aimed to analyze the results of anal cytology of patients with human immunodeficiency virus infection at the National Centre of STD, Department of Dermatology, Dermatooncology and Venereology, Semmelweis University. 155 anal cytological examinations were performed in 140 patients between November 1, 2012 and August 31, 2014. 44% of patients were found to have anal dysplasia, and only 1.6% of patients had high-grade lesions. This rate is lower as compared to published studies including larger number of patients. The study underlines the necessity of screening for anal lesions in the population at-risk.

  18. The interaction of glucagon and pentagastrin on the lower oesophageal sphincter in man and dog

    PubMed Central

    Jennewein, H. M.; Waldeck, F.; Siewert, R.; Weiser, F.; Thimm, R.

    1973-01-01

    The effect of glucagon on the pressure inside the lower oesophageal sphincter in conscious human subjects and anaesthetized dogs was investigated using the continuous withdrawal method. Glucagon causes a decrease in sphincteric resting pressure in both man and dog and antagonizes the pentagastrin-induced pressure increase of the lower oesophageal sphincter. In experiments on isolated muscle strips of the lower oesophageal sphincter of dogs glucagon decreases the tension and antagonizes the increase in tension induced by pentagastrin. The elevated pressure in patients suffering from achalasia is significantly reduced by glucagon. PMID:4761605

  19. [Anatomy of the urethral sphincteric vesico-prostatic complex].

    PubMed

    Gadda, F; Carmignani, L; Favini, P; Acquati, P; Avogadro, A; Rocco, F

    2001-09-01

    As 27 different names have been proposed for the components of the urethral sphincter, it is difficult to build a clear anatomical model of it. Starting from a review of the literature and from some personal observations of surgical anatomy, our aim is to draw a vision as much organic as possible of the anatomy of the urethral sphincter. The components of the urethral sphincter are: the bladder neck (preprostatic sphincter), the smooth muscle urethral sphincter, the rhabdosphincter and levator ani muscle. Recently the rhabdosphincter has been proposed as a vertical structure that extends from the pelvic cavity (bladder base) to the perineal cavity. It can be round-shaped or omega-shaped. The anterior insertions are along the anterolateral aspect of the prostate (superiorly) and on the perineal fascia (inferiorly). The posterior insertions are on the Denonvilliers fascia and posterior aspect of the prostatic apex (superiorly) and on the central perineal tendon (inferiorly). The rhabdosphincter has strong means of fixations: anteriorly it is fixed to the pubis by the pubo-urethral ligaments, posteriorly it is supported by the medial fibrous raphe of the perineum. The anteromedial fibres of levator ani muscle are involved in the continence mechanism by their strong relation with the rhabdosphincter and the prostate.

  20. [Pay attention to the imaging diagnosis of complex anal fistula].

    PubMed

    Zhou, Zhiyang

    2015-12-01

    The diagnosis and treatment of complex anal fistula has been a significant challenge. Unwise incision and excessive exploration will lead to the secondary branch, sinus and perforation. A simple fistula may become a surgical problem and result in disastrous consequences. Preoperative accurate diagnosis of anal fistula, including in the internal opening, primary track and location of the fistula, extensions and abscess, is important for anal fistula treatment. In the diagnosis of anal fistula, imaging examination, especially MRI plays a crucial role. Localization and demarcation of anal fistula and the relationship with sphincter are important. MRI has been an indispensable confirmatory imaging examination.

  1. Prosthetic urinary sphincter

    NASA Technical Reports Server (NTRS)

    Helms, C. R.; Smyly, H. M. (Inventor)

    1981-01-01

    A pump/valve unit for controlling the inflation and deflation of a urethral collar in a prosthetic urinary sphincter device is described. A compressible bulb pump defining a reservoir was integrated with a valve unit for implantation. The valve unit includes a movable valve member operable by depression of a flexible portion of the valve unit housing for controlling fluid flow between the reservoir and collar; and a pressure sensing means which operates the valve member to relieve an excess pressure in the collar should too much pressure be applied by the patient.

  2. Anal Warts

    MedlinePlus

    ... Assessment and Safety Committee Initiatives Past Presidents Healthcare Economics Committee Search ... ANAL WARTS Anal warts (condyloma acuminata) are caused by the human papilloma virus (HPV), the most common sexually transmitted ...

  3. Vagal control of lower oesophageal sphincter motility in the cat

    PubMed Central

    Gonella, J.; Niel, J. P.; Roman, C.

    1977-01-01

    1. The effects of vagal efferent fibre stimulation on the smooth muscle of the lower oesophageal sphincter have been studied on the anaesthetized animal and on the isolated and perfused organ. 2. In both muscle layers (longitudinal and circular) vagal stimulation elicits two types of electromyographic (e.m.g.) potentials: (a) excitatory junction potentials (e.j.p.s) where there is a depolarization of the smooth muscle fibres. E.j.p.s can give rise to spike potentials inducing a contraction of the sphincter; (b) inhibitory junction potentials (i.j.p.s) where there is hyperpolarization of the smooth muscle fibres, often followed by a transient depolarization which may initiate spikes (post-inhibitory rebound). 3. Pure i.j.p.s are observed after atropine treatment which suppresses e.j.p.s. Under these conditions, a long lasting vagal stimulation induces a long duration hyperpolarization concomitant with an opening of the lower oesophageal sphincter followed after the cessation of stimulation by a powerful rebound leading to a strong contraction which closes the sphincter. 4. Several arguments, pharmacological (action of acetylcholine (ACh), atropine and hexamethonium) and physiological (threshold and latency of responses) lead to the following conclusions. Preganglionic vagal fibres are cholinergic and they activate (a) intramural excitatory cholinergic neurones; (b) intramural non-adrenergic inhibitory neurones (purinergic neurones). Preganglionic fibres leading to inhibition have a higher threshold than those leading to excitation. Both excitatory and inhibitory pathways are interconnected inside the intramural network. In particular, activation of intramural inhibitory neurones, by relaxing the oesophagus orally to the lower oesophageal sphincter, inhibits intramural excitatory neurones and subsequently blocks vagal excitatory responses. 5. Two functions may be attributed to the vagal extrinsic innervation: (a) closure of the lower oesophageal sphincter by

  4. Biomechanical properties of an implanted engineered tubular gut-sphincter complex.

    PubMed

    Zakhem, Elie; El Bahrawy, Mostafa; Orlando, Giuseppe; Bitar, Khalil N

    2016-11-23

    Neuromuscular diseases of the gut alter the normal motility patterns. Although surgical intervention remains the standard treatment, preservation of the sphincter attached to the rest of the gut is challenging. The present study aimed to evaluate a bioengineered gut-sphincter complex following its subcutaneous implantation for 4 weeks in rats. Engineered innervated human smooth muscle sheets and innervated human sphincters with a predefined alignment were placed around tubular scaffolds to create a gut-sphincter complex. The engineered complex was subcutaneously implanted in the abdomen of the rats for 4 weeks. The implanted tissues were vascularized. In vivo manometry revealed luminal pressure at the gut and the sphincter zone. Tensile strength, elongation at break and Young's modulus of the engineered complexes were similar to those of native rat intestine. Histological and immunofluorescence assays showed maintenance of smooth muscle circular alignment in the engineered tissue, maintenance of smooth muscle contractile phenotype and innervation of the smooth muscle. Electrical field stimulation induced relaxation of the smooth muscle of both the sphincter and the gut parts. Relaxation was partly inhibited by nitric oxide inhibitor indicating nitrergic contribution to relaxation. The present study has demonstrated for the first time a successfully developed and subcutaneously implanted a tubular human-derived gut-sphincter complex. The sphincteric part of Tubular Gut-Sphincter Complex (TGSC) maintained the basal tone characteristic of a native sphincter. The gut part also maintained its specific neuromuscular characteristics. The results of this study provide a promising therapeutic approach to restore gut continuity and motility. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  5. [Genital and sphincter disorders].

    PubMed

    Joseph, P A; de Sèze, M

    2001-09-01

    Symptomatic bladder dysfunction occurs at some time in most patients with multiple sclerosis. Detrusor hypereflexia and sphincter dyssynergia are the main dysfunctions. Anticholinergic medication is currently the most effective and the most common treatment of overactive bladder with reduced bladder capacity and uninhibited detrusor contractions. Desmopressin, surgery, permanent indwelling catheter or external device are used in some cases. Nevertheless essential to bladder management is understanding to what extent the patient has incomplete emptying while complaining predominantly of symptoms of detrusor overactivity: frequency and urgency, with or without urge incontinence. Intravesical capsaicin and botulinum toxin injected into the detrusor seems promising means of treating intractable bladder hyperreflexia. If the post-micturition residual volume is raised, intermittent self-catheterization is the most adequate method to achieve bladder emptying of patients with MS. Physical and cognitive disability as well as patients motivation can reduce their ability to perform catheterization. In such situation, alphablockers show moderate efficacy and botulinum toxin urethral sphincter injection or surgical solution may be discussed. Disturbed anorectal physiology is common in MS, but there are as yet few specific treatments. The efficacy of oral sildenafil for treatment of neurogenic erectile failure increases the range of treatment available for men with sexual dysfunction. In women, mechanical remedies, treatment of motor and sensory loss are effective for dyspareunia. Patients of both sexes are likely to welcome to discuss their problem, and counselling or psychotherapy may be of use.

  6. Natural progression of anal incontinence after childbirth.

    PubMed

    Nordenstam, Johan; Altman, Daniel; Brismar, Sophia; Zetterström, Jan

    2009-09-01

    The aim of work is to study the natural progression of anal incontinence (AI) in women 10 years after their first delivery and to identify risk factors associated with persistent AI. A prospective cohort study of 304 primiparous women with singleton, cephalic delivery giving vaginal childbirth in 1995. Questionnaires distributed and collected at delivery, 9 months, 5 years and 10 years after, assessing anorectal symptoms, subsequent treatment, and obstetrical events. Women, 246 of 304, answered all questionnaires (81%). Thirty-five of 246 (14%) had a sphincter tear at the first delivery. One hundred ninety-six of 246 (80%) women had additional vaginal deliveries and no caesarean sections. The prevalence of AI at 10 years after the first delivery was 57% in women with a sphincter tear and 28% in women, a nonsignificant increase compared to the 5-year follow-up. Women who sustained a sphincter tear at the first delivery had an increased risk of severe AI (RR 3.9, 95% CI 1.3-11.8). Neither age, nor subsequent deliveries added to the risk. Severe AI at baseline and 5 years after delivery were independently strong predictors of severe AI at 10 years (RR 12.6, CI 3.3-48.3, and RR 8.3, CI 3.9-17.8, respectively). Persistent anal incontinence 10 years after the first parturition is frequent and sometimes severe, especially if vaginal delivery was complicated by an anal sphincter disruption.

  7. Pharmacological dissection of the human gastro-oesophageal segment into three sphincteric components

    PubMed Central

    Brasseur, James G; Ulerich, Rhys; Dai, Qing; Patel, Dalipkumar K; Soliman, Ahmed M S; Miller, Larry S

    2007-01-01

    Quantifications of gastro-oesophageal anatomy in cadavers have led some to identify the lower oesophageal sphincter (LOS) with the anatomical gastric sling-clasp fibres at the oesophago-cardiac junction (OCJ). However, in vivo studies have led others to argue for two overlapping components proximally displaced from the OCJ: an extrinsic crural sphincter of skeletal muscle and an intrinsic physiological sphincter of circular smooth-muscle fibres within the abdominal oesophagus. Our aims were to separate and quantify in vivo the skeletal and smooth muscle sphincteric components pharmacologically and clarify the description of the LOS. In two protocols an endoluminal ultrasound-manometry assembly was drawn through the human gastro-oesophageal segment to correlate sphincteric pressure with the anatomic crus. In protocol I, fifteen normal subjects maintained the costal diaphragm at inferior/superior positions by full inspiration/expiration (FI/FE) during pull-throughs. These were repeated after administering atropine to suppress the cholinergic smooth-muscle sphincter. The cholinergic component was reconstructed by subtracting the atropine-resistant pressures from the full pressures, referenced to the anatomic crus. To evaluate the extent to which the cholinergic contribution approximated the full smooth-muscle sphincter, in protocol II seven patients undergoing general anaesthesia for non-oesophageal pathology were administered cisatracurium to paralyse the crus. The smooth-muscle sphincter pressures were measured after lung inflation to approximate FI. The cholinergic smooth-muscle pressure profile in protocol I (FI) matched closely the post-cisatracurium smooth-muscle pressure profile in protocol II, and the atropine-resistant pressure profiles correlated spatially with the crural sling during diaphragmatic displacement. Thus, the atropine-resistant and cholinergic pressure contributions in protocol I approximated the skeletal and smooth muscle sphincteric components

  8. Use of Anal Acoustic Reflectometry in the Evaluation of Men With Passive Fecal Leakage.

    PubMed

    Hornung, Benjamin R; Telford, Karen J; Carlson, Gordon L; Mitchell, Peter J; Klarskov, Niels; Kiff, Edward S

    2017-05-01

    Men with passive fecal leakage represent a distinct clinical entity in which the pathophysiology remains unclear. Standard anorectal investigations fail to demonstrate consistent abnormalities in this group. Anal acoustic reflectometry is a new test of anal sphincter function with greater sensitivity and discriminatory ability than conventional anal manometry. The aim of this study was to determine whether men with fecal leakage have an abnormality in anal sphincter function that is detectable by anal acoustic reflectometry. This was an age-matched study of continent and incontinent men. The study was conducted at a university teaching hospital. Male patients with isolated symptoms of fecal leakage were recruited. Anal acoustic reflectometry, followed by conventional anal manometry, was performed. Results were then compared with those from an age-matched group of men with no symptoms of anal incontinence or anorectal pathology. Variables measured with anal acoustic reflectometry and anal manometry in the incontinent and continent men were compared. Thirty subjects were recruited, of whom 15 were men with fecal leakage and 15 were continent men. There was a significantly higher incidence of previous anorectal surgery in the men with leakage. The anal acoustic reflectometry variables of opening and closing pressure were significantly lower in leakers compared with continent subjects (p = 0.003 and p = 0.001). Hysteresis was significantly greater in the male leaker group (p = 0.026). No difference was seen in anal manometry. With a larger sample size, the effect of previous anorectal surgery and the presence of an anal sphincter defect could be clarified. Anal acoustic reflectometry is a sensitive test of anal sphincter function and, unlike anal manometry, can discriminate male leakers from continent subjects. An identifiable abnormality has been detected using anal acoustic reflectometry, which may further our understanding of the pathogenesis in this group.

  9. Studies on the properties of myo-inositol-1,4,5-trisphosphate 5-phosphatase and myo-inositol monophosphatase in bovine iris sphincter smooth muscle: effects of okadaic acid and protein phosphorylation.

    PubMed

    Wang, X L; Akhtar, R A; Abdel-Latif, A A

    1994-05-26

    In bovine iris sphincter, myo-inositol 1,4,5-trisphosphate (IP3) 5-phosphatase and myo-inositol 1-phosphate (IP1) monophosphatase are mainly localized in the microsomal and soluble fractions, respectively. Studies on the properties of these enzymes can be summarized as follows. (1) The microsomal IP3 5-phosphatase hydrolyzed IP3 to myo-inositol 1,4-bisphosphate with an apparent Km of 28 microM and Vmax of 32 nmol/min per mg protein. The IP1 monophosphatase in the soluble fraction hydrolyzed IP1 into free inositol with an apparent Km of 89 microM and Vmax of 7 nmol/min per mg protein. (2) IP3 5-phosphatase and IP1 monophosphatase had optimal pH values at 8.0 and 7.0, respectively. (3) Both enzymes required Mg2+ and their highest specific activities were at a cation concentration of 2 mM. (4) Ca2+ (> 0.5 microM) exerted an inhibitory effect on IP3 5-phosphatase activity, and marked inhibition (47%) was observed at a concentration of 10 microM. Higher concentrations of the cation (> 100 microM) were required to inhibit IP1 monophosphatase. (5) IP1 monophosphatase, but not IP3 5-phosphatase, was inhibited by Li+. Li+ had no effect on the contractile response in this smooth muscle. (6) Both enzymes were inhibited by ATP and by the thiol-blocking agent, disulfiram. In addition, thimerosal, a thiol reagent, also inhibited the IP3 5-phosphatase activity. (7) Protein phosphorylation of the microsomal and soluble fractions with PKA or PKC had no effect on the activities of these enzymes. (8) Okadaic acid, a protein phosphatase inhibitor, had no effect on the activity of IP3 5-phosphatase. However, in the intact iris sphincter the toxin significantly reduced the carbachol-induced IP3 production, 1,2-diacylglycerol formation, measured as phosphatidic acid, and caused muscle relaxation.

  10. [Current indications, surgical technique and results of anterior sphincter repair as a treatment of faecal incontinence].

    PubMed

    Dorcaratto, Dimitri; Martínez-Vilalta, Miquel; Parés, David

    2010-05-01

    Faecal incontinence is a high prevalence disease in the general population. This pathology is commonly under-estimated and causes a great impact on clinical status and on the quality of life of affected patients. The prevalence of faecal incontinence in several studies has been estimated between 2% and 15% of the general population. The prevalence increases if we study selected populations, such as elderly people. The main cause of faecal incontinence is obstetric anal sphincter damage. In the past years, the presence of incontinence due to sphincter lesions, especially the obstetric ones, was an absolute indication of anterior anal sphincter repair. Actually, after knowing the long term follow up results of this technique, as well as the evolving knowledge on faecal incontinence and the development of new diagnostic and therapeutic techniques, this technique might be selected for cases with large sphincter defects. However there is limited information in the current literature on indications, surgical technique and results of anterior sphincter repair. The aim of this review is to analyse scientific evidence on current indications, surgical technique features and results of anterior sphincter repair as a therapy for faecal incontinence, also giving our point of view on controversial issues. A bibliography search was undertaken using Medline database including articles published from January 1985 to January 2009. Copyright 2009 AEC. Published by Elsevier Espana. All rights reserved.

  11. Velopharyngeal sphincter physiology in deaf individuals.

    PubMed

    Ysunza, A; Vazquez, M C

    1993-03-01

    Fifty-three deaf subjects with a history of prelingual profound bilateral sensorineural hearing loss, similar language habilitation with hearing aids, and normal velopharyngeal structures underwent a study protocol including speech evaluation, behavioral pure-tone audiometry, videonasopharyngoscopy, multiview videofluoroscopy, and electromyography of the velopharyngeal muscles. Subjects were divided into two groups: the first group included 13 subjects with normal nasal resonance or mild hypernasality (four normals and nine with mild hypernasality); the second group had subjects with severe hypernasality and severe articulation deficits. Pure-tone thresholds, velopharyngeal closure patterns, and electromyographic activity of velopharyngeal muscles were similar for both groups of subjects. However, in subjects with severe hypernasality, despite normal muscle activity as observed by electromyography, velopharyngeal valving activity lacked rhythm and strength during speech. It is concluded that deaf subjects may present a functional disorder of the velopharyngeal sphincter related to absence of auditory regulation during phonation. Visual biofeedback using videonasopharyngoscopy may be useful for treating this disorder.

  12. Dose-Effect Relationships for Individual Pelvic Floor Muscles and Anorectal Complaints After Prostate Radiotherapy

    SciTech Connect

    Smeenk, Robert Jan; Hoffmann, Aswin L.; Hopman, Wim P.M.; Lin, Emile N.J. Th. van; Kaanders, Johannes H.A.M.

    2012-06-01

    Purpose: To delineate the individual pelvic floor muscles considered to be involved in anorectal toxicity and to investigate dose-effect relationships for fecal incontinence-related complaints after prostate radiotherapy (RT). Methods and Materials: In 48 patients treated for localized prostate cancer, the internal anal sphincter (IAS) muscle, the external anal sphincter (EAS) muscle, the puborectalis muscle (PRM), and the levator ani muscles (LAM) in addition to the anal wall (Awall) and rectal wall (Rwall) were retrospectively delineated on planning computed tomography scans. Dose parameters were obtained and compared between patients with and without fecal urgency, incontinence, and frequency. Dose-effect curves were constructed. Finally, the effect of an endorectal balloon, which was applied in 28 patients, was investigated. Results: The total volume of the pelvic floor muscles together was about three times that of the Awall. The PRM was exposed to the highest RT dose, whereas the EAS received the lowest dose. Several anal and rectal dose parameters, as well as doses to all separate pelvic floor muscles, were associated with urgency, while incontinence was associated mainly with doses to the EAS and PRM. Based on the dose-effect curves, the following constraints regarding mean doses could be deduced to reduce the risk of urgency: {<=}30 Gy to the IAS; {<=}10 Gy to the EAS; {<=}50 Gy to the PRM; and {<=}40 Gy to the LAM. No dose-effect relationships for frequency were observed. Patients treated with an endorectal balloon reported significantly less urgency and incontinence, while their treatment plans showed significantly lower doses to the Awall, Rwall, and all pelvic floor muscles. Conclusions: Incontinence-related complaints show specific dose-effect relationships to individual pelvic floor muscles. Dose constraints for each muscle can be identified for RT planning. When only the Awall is delineated, substantial components of the continence apparatus are

  13. Management of Complex Anal Fistulas

    PubMed Central

    Bubbers, Emily J.; Cologne, Kyle G.

    2016-01-01

    Complex anal fistulas require careful evaluation. Prior to any attempts at definitive repair, the anatomy must be well defined and the sepsis resolved. Several muscle-sparing approaches to anal fistula are appropriate, and are often catered to the patient based on their presentation and previous repairs. Emerging technologies show promise for fistula repair, but lack long-term data. PMID:26929751

  14. Vagal Afferent Innervation of the Lower Esophageal Sphincter

    PubMed Central

    Powley, Terry L.; Baronowsky, Elizabeth A.; Gilbert, Jared M.; Hudson, Cherie N.; Martin, Felecia N.; Mason, Jacqueline K.; McAdams, Jennifer L.; Phillips, Robert J.

    2013-01-01

    To supply a fuller morphological characterization of the vagal afferents innervating the lower esophageal sphincter (LES), specifically to label vagal terminals in the tissues forming the LES in the gastroesophageal junction, the present experiment employed injections of dextran biotin into the nodose ganglia of rats. Four types of vagal afferents innervated the LES. Clasp and sling muscle fibers were directly and prominently innervated by intramuscular arrays (IMAs). Individual IMA terminals subtended about 16° of arc of the esophageal circumference, and, collectively, the terminal fields were distributed within the muscle ring to establish a 360° annulus of mechanoreceptors in the sphincter wall. 3D morphometry of the terminals established that, compared to sling muscle IMAs, clasp muscle IMAs had more extensive arbors and larger receptive fields. In addition, at the cardia, local myenteric ganglia between smooth muscle sheets and striated muscle bundles were innervated by intraganglionic laminar endings (IGLEs), in a pattern similar to the innervation of the myenteric plexus throughout the stomach and esophagus. Finally, as previously described, the principle bundle of sling muscle fibers that links LES sphincter tissue to the antropyloric region of the lesser curvature was innervated by exceptionally long IMAs as well as by unique web ending specializations at the distal attachment of the bundle. Overall, the specialized varieties of densely distributed vagal afferents innervating the LES underscore the conclusion that these sensory projections are critically involved in generating LES reflexes and may be promising targets for managing esophageal dysfunctions. PMID:23583280

  15. Functional coupling between motor and sensory nerves through contraction of sphincters in the pudendal area of the female cat.

    PubMed

    Lagunes-Córdoba, Roberto; Hernández, Pablo Rogelio; Raya, José Guadalupe; Muñoz-Martínez, E J

    2010-01-01

    The question of whether skin receptors might help in the perception of muscle contraction and body movement has not been settled. The present study gives direct evidence of skin receptor firing in close coincidence with the contraction of the vaginal and anal sphincters. The distal stump of the sectioned motor pudendal nerve was stimulated. Single shocks induced a wavelike increase in the lumen pressure of the distal vagina and the anal canal, as well as constriction of the vaginal introitus and the anus. The constriction pulls on and moves the surrounding skin, which was initially detected visually. In the present experiments, a thin strain gauge that pressed on the skin surface detected its displacement. Single shocks to the motor nerve induced a wave of skin movement with maximal amplitude at 5 mm from the anus and propagated with decrement beyond 35 mm. The peripheral terminals of the sensory pudendal nerve and the posterior femoral nerve supply the skin that moves. Sensory axons from both nerves fired in response to both tactile stimulation and the skin movement produced by the constriction of the orifices (motor-sensory coupling). In cats with all nerves intact, a single shock to the sensory nerves induced reflex waves of skin movement and lumen pressure (sensory-motor coupling). Both couplings provide evidence for a feedforward action that might help to maintain the female posture during mating and to the perception of muscle contraction.

  16. Relation between rectal sensation and anal function in normal subjects and patients with faecal incontinence.

    PubMed Central

    Sun, W M; Read, N W; Miner, P B

    1990-01-01

    The relation between sensory perception of rapid balloon distension of the rectum and the motor responses of the rectum and external and internal anal sphincters in 27 normal subjects and 16 patients with faecal incontinence who had impaired rectal sensation but normal sphincter pressures was studied. In both patients and normal subjects, the onset and duration of rectal sensation correlated closely with the external anal sphincter electrical activity (r = 0.8, p less than 0.0001) and with rectal contraction (r = 0.51, p less than 0.001), but not with internal sphincter relaxation. All normal subjects perceived a rectal sensation within one second of rapid inflation of a rectal balloon with volumes of 20 ml or less air. Six patients did not perceive any rectal sensation until 60 ml had been introduced, while in the remaining nine patients the sensation was delayed by at least two seconds. Internal sphincter relaxation occurred before the sensation was perceived in three of 27 normal subjects and 11 of 16 patients (p less than 0.001), and could be associated with anal leakage, which stopped as soon as sensation was perceived. The lowest rectal volumes required to induce anal relaxation, to cause sustained relaxation, or to elicit sensations of a desire to defecate or pain were similar in patients and normal subjects. In conclusion, these results show the close association between rectal sensation and external anal sphincter contraction, and show that faecal incontinence may occur as a result of delayed or absent external anal sphincter contraction when the internal anal sphincter is relaxed. PMID:2210452

  17. Effect of autologous muscle-derived cells in the treatment of urinary incontinence in female patients with intrinsic sphincter deficiency and epispadias: A prospective study.

    PubMed

    Sharifiaghdas, Farzaneh; Tajalli, Farzam; Taheri, Maryam; Naji, Mohammad; Moghadasali, Reza; Aghdami, Nasser; Baharvand, Hossein; Azimian, Vajihe; Jaroughi, Neda

    2016-07-01

    To evaluate the effect of autologous muscle-derived cells injection in the treatment of complicated stress urinary incontinence in female patients. Female patients presenting with severe and complicated stress urinary incontinence secondary to the bladder neck and/or urethral trauma or congenital epispadias (with or without exstrophy) were enrolled in this prospective study. They underwent transurethral injection of autologous muscle-derived cells. In selected cases, another injection was given after 6 months, as per the surgeon's assessment. All patients were monitored for 1 year, and the effect of autologous muscle-derived cells was evaluated by cough stress test, 1-h pad test and Incontinence Impact Questionnaire-short form score. A multichannel urodynamic study and maximum urethral closure pressure were carried out before and 12 months after the last treatment session. Cough stress test, 1-h pad test and uroflowmetry were repeated 36 months after the last injection. Severity and occurrence of complications were recorded at each visit. All 10 patients who completed the study were monitored for 36 months. Three patients were cured, four had improved and three did not respond to the treatment. There was no major adverse effect related to the treatment. Muscle-derived cell therapy might represent a minimally-invasive and a safe procedure in the treatment of patients with severe and complicated stress urinary incontinence. © 2016 The Japanese Urological Association.

  18. Designing micro- and nanostructures for artificial urinary sphincters

    NASA Astrophysics Data System (ADS)

    Weiss, Florian M.; Deyhle, Hans; Kovacs, Gabor; Müller, Bert

    2012-04-01

    The dielectric elastomers are functional materials that have promising potential as actuators with muscle-like mechanical properties due to their inherent compliancy and overall performance: the combination of large deformations, high energy densities and unique sensory capabilities. Consequently, such actuators should be realized to replace the currently available artificial urinary sphincters building dielectric thin film structures that work with several 10 V. The present communication describes the determination of the forces (1 - 10 N) and deformation levels (~10%) necessary for the appropriate operation of the artificial sphincter as well as the response time to master stress incontinence (reaction time less than 0.1 s). Knowing the dimensions of the presently used artificial urinary sphincters, these macroscopic parameters form the basis of the actuator design. Here, we follow the strategy to start from organic thin films maybe even monolayers, which should work with low voltages but only provide small deformations. Actuators out of 10,000 or 100,000 layers will finally provide the necessary force. The suitable choice of elastomer and electrode materials is vital for the success. As the number of incontinent patients is steadily increasing worldwide, it becomes more and more important to reveal the sphincter's function under static and stress conditions to realize artificial urinary sphincters, based on sophisticated, biologically inspired concepts to become nature analogue.

  19. Anal self-massage in the treatment of acute anal fissure: a randomized prospective study.

    PubMed

    Gaj, Fabio; Biviano, Ivano; Candeloro, Laura; Andreuccetti, Jacopo

    2017-01-01

    An anal fissure (AF) is a tear in the epithelial lining of the anal canal. This is a very common condition, but the choice of treatment is unclear. The use of anal dilators is effective, economic, and safe. The aim of the study was to compare the efficacy of two conservative treatments, the use of anal dilators or a finger for anal dilatation, in reducing anal pressure and resolving anal fissures. Fifty patients with a clinical diagnosis of AF were randomly assigned to one of the treatments, self-massage of the anal sphincter (group A, 25 patients) or passive dilatation using dilators (group B, 25 patients). All patients were evaluated at baseline, at the end of treatment, and after 12 weeks and 6 months. Pain was measured using a visual analog scale. After the treatment, 60% of patients treated with dilators and 80% of patients treated with anal self-massage using a finger showed disappearance of their anal fissures. A comparison between signs and symptoms reported by the patients in the two groups showed a statistically significant reduction in anal pain (group A, P=0.0001; group B, P=0.0001) and bleeding after defecation (group A, P=0.001, group B, P=0.001). At 6 months after treatment, a significantly greater reduction in anal pain was observed in Group A compared to Group B (P=0.02). The use of anal self-massage with a finger appears to induce a better resolution of acute anal fissure than do anal dilators, and in a shorter time.

  20. Anal self-massage in the treatment of acute anal fissure: a randomized prospective study

    PubMed Central

    Gaj, Fabio; Biviano, Ivano; Candeloro, Laura; Andreuccetti, Jacopo

    2017-01-01

    Background An anal fissure (AF) is a tear in the epithelial lining of the anal canal. This is a very common condition, but the choice of treatment is unclear. The use of anal dilators is effective, economic, and safe. The aim of the study was to compare the efficacy of two conservative treatments, the use of anal dilators or a finger for anal dilatation, in reducing anal pressure and resolving anal fissures. Methods Fifty patients with a clinical diagnosis of AF were randomly assigned to one of the treatments, self-massage of the anal sphincter (group A, 25 patients) or passive dilatation using dilators (group B, 25 patients). All patients were evaluated at baseline, at the end of treatment, and after 12 weeks and 6 months. Pain was measured using a visual analog scale. Results After the treatment, 60% of patients treated with dilators and 80% of patients treated with anal self-massage using a finger showed disappearance of their anal fissures. A comparison between signs and symptoms reported by the patients in the two groups showed a statistically significant reduction in anal pain (group A, P=0.0001; group B, P=0.0001) and bleeding after defecation (group A, P=0.001, group B, P=0.001). At 6 months after treatment, a significantly greater reduction in anal pain was observed in Group A compared to Group B (P=0.02). Conclusion The use of anal self-massage with a finger appears to induce a better resolution of acute anal fissure than do anal dilators, and in a shorter time. PMID:28655981

  1. Pharmacological Sphincterotomy for Chronic Anal Fissures by Botulinum Toxin A

    PubMed Central

    Wollina, Uwe

    2008-01-01

    Chronic anal fissure is a common proctologic disease. Botulinum toxin (BTX) can be used for temporary chemical denervation to treat this painful disorder. Its application is by intramuscular injections into either the external or internal anal sphincter muscle. The mode of action, application techniques, and possible complications or adverse effects of BTX therapy are discussed in this report. The healing rate is dependent on the BTX dosage. The short-term healing rate (≤ 6 months) is 60–90%, whereas about 50% of the patients show a complete response in long-term follow-up studies (> 1 year). Adverse effects are generally mild, but relapses occur more often than with surgery. Conservative therapy is currently considered as a first-line treatment. With increasing evidence for its efficacy, BTX can now be considered among the first-line nonsurgical treatements. Although, surgical management by lateral sphincterotomy is the most effective treatment, it shows a higher incidence of incontinence and greater general morbidity rate than BTX. BTX is a useful alternative to surgery and in many cases, surgery can be avoided with the use of BTX. PMID:20300345

  2. Pharmacological sphincterotomy for chronic anal fissures by botulinum toxin a.

    PubMed

    Wollina, Uwe

    2008-07-01

    Chronic anal fissure is a common proctologic disease. Botulinum toxin (BTX) can be used for temporary chemical denervation to treat this painful disorder. Its application is by intramuscular injections into either the external or internal anal sphincter muscle. The mode of action, application techniques, and possible complications or adverse effects of BTX therapy are discussed in this report. The healing rate is dependent on the BTX dosage. The short-term healing rate ( 1 year). Adverse effects are generally mild, but relapses occur more often than with surgery. Conservative therapy is currently considered as a first-line treatment. With increasing evidence for its efficacy, BTX can now be considered among the first-line nonsurgical treatements. Although, surgical management by lateral sphincterotomy is the most effective treatment, it shows a higher incidence of incontinence and greater general morbidity rate than BTX. BTX is a useful alternative to surgery and in many cases, surgery can be avoided with the use of BTX.

  3. [Botulinum toxin and chronic anal fissure].

    PubMed

    Daniel, Fady; de Parades, Vincent; Siproudhis, Laurent; Atienza, Patrick

    2006-05-01

    Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

  4. Anal fissure.

    PubMed

    Schlichtemeier, Steven; Engel, Alexander

    2016-02-01

    An anal fissure is a common, mostly benign, condition that can be acute or chronic. The diagnosis is usually made on history and physical examination, but further investigations are sometimes necessary. Primary fissures are usually benign and located in the posterior or anterior position. Secondary fissures are lateral or multiple and often indicate a more serious underlying pathology. The management of primary anal fissures is generally non-operative and includes increased dietary fibre, sitz baths, topical ointments and botulinum toxin injections. If these treatments are ineffective the patient will need a surgical referral. Secondary anal fissures require further investigation. Multidisciplinary management is preferable and is essential in the case of malignancy.

  5. Current management of anal fistulas in Crohn's disease

    PubMed Central

    Eder, Piotr; Banasiewicz, Tomasz; Matysiak, Konrad; Łykowska-Szuber, Liliana

    2015-01-01

    Anal fistulas occurring in Crohn's disease (CD) comprise a risk factor of severe course of inflammation. They are frequently intractable due to various factors such as penetration of the anal canal or rectal wall, impaired wound healing, and immunosuppression, among others. Anal fistulas typical to CD develop from fissures or ulcers of the anal canal or rectum. Accurate identification of the type of fistula, such as low and simple or high and complex, is crucial for prognosis as well as for the choice of treatment. If fistulotomy remains the gold standard in the surgical treatment of the former, it is contraindicated in high and complex fistulas due to possible risk of damage to the anal sphincter with subsequent faecal incontinence. Therefore, the latter require a conservative and palliative approach, such as an incision and drainage of abscesses accompanying fistulas or prolonged non-cutting seton placement. Currently, conservative, sphincter-preserving, and definitive procedures such as mucosal advancement or dermal island flaps, the use of plugs or glue, video assisted anal fistula treatment, ligation of the intersphincteric track, and vacuum assisted closure are gaining a great deal of interest. Attempting to close the internal opening without injuring the sphincter is a major advantage of those methods. However, both the palliative and the definitive procedures require adjuvant therapy with medical measures. PMID:26557938

  6. Fissurectomy as a treatment for anal fissures in children.

    PubMed Central

    Lambe, G. F.; Driver, C. P.; Morton, S.; Turnock, R. R.

    2000-01-01

    INTRODUCTION: Anal fissures, characterised by painful defecation and rectal bleeding, are common in both children and infants. A significant proportion are resistant to simple laxative therapy, and no simple surgical treatment has been described which does not risk compromising sphincteric function. This study reports the initial experience of fissurectomy as a treatment of this condition. PATIENTS AND METHODS: Over a 36 month period, 37 children with an anal fissure were treated by fissurectomy. There were 14 boys and 23 girls, with an age range of 17 weeks to 12 years. Fissurectomy was performed under general anaesthetic, with additional caudal anaesthesia. Stay sutures were used to avoid the need for an anal retractor, thereby preventing stretching of the internal anal sphincter. Of the 37 operations, 36 (97%) were performed as day cases and all children were discharged on laxative therapy. RESULTS: At review, 6 weeks postoperatively, 30 (81%) were asymptomatic. Six (16%) patients were symptomatic; however, 4 of these had failed to comply with the postoperative laxative regimen. One patient failed follow-up. CONCLUSIONS: Fissurectomy is a successful treatment for anal fissures, when combined with postoperative laxative therapy. As dilatation of the internal anal sphincter is not involved, the risk of iatrogenic faecal incontinence is obviated. Images Figure 1 Figure 2 Figure 3 PMID:10932659

  7. Anal cushion lifting method is a novel radical management strategy for hemorrhoids that does not involve excision or cause postoperative anal complications.

    PubMed

    Ishiyama, Gentaro; Nishidate, Toshihiko; Ishiyama, Yuji; Nishio, Akihiko; Tarumi, Ken; Kawamura, Maiko; Okita, Kenji; Mizuguchi, Toru; Fujimiya, Mineko; Hirata, Koichi

    2015-10-27

    To describe the anal cushion lifting (ACL) method with preliminary clinical results. Between January to September 2007, 127 patients who received ACL method for hemorrhoid was investigated with informed consent. In this study, three surgeons who specialized in anorectal surgery performed the procedures. Patients with grade two or more severe hemorrhoids according to Goligher's classification were considered to be indicated for surgery. The patients were given the choice to undergo either the ACL method or the ligation and excision method. ACL method is an original technique for managing hemorrhoids without excision. After dissecting the anal cushion from the internal sphincter muscle, the anal cushion was lifted to oral side and ligated at the proper position. Clinical characteristics and outcomes of patients were recorded including complications after surgery. A total of 127 patients were enrolled. Their median age was 42 (19-84) years, and 74.8% were female. In addition, more than 99% of the patients had grade 3 or worse hemorrhoids. The median follow-up period was 26 (0-88) mo, and the median operative time was 15 (4-30) min. After surgery, analgesics were used for a median period of three days (0-21). Pain control was achieved using extra-oral analgesic drugs, although some patients required intravenous injections of analgesic drugs. The median duration of the patients' postoperative hospital stay was 7 (2-13) d. A total of 10 complications (7.9%) occurred. Bleeding was observed in one patient and was successfully controlled with manual compression. Urinary retention occurred in 6 patients, but it disappeared spontaneously in all cases. Recurrent hemorrhoids developed in 3 patients after 36, 47, and 61 mo, respectively. No anal stenosis or persistent anal pain occurred. We consider that the ACL method might be better than all other current methods for managing hemorrhoids.

  8. Anal cushion lifting method is a novel radical management strategy for hemorrhoids that does not involve excision or cause postoperative anal complications

    PubMed Central

    Ishiyama, Gentaro; Nishidate, Toshihiko; Ishiyama, Yuji; Nishio, Akihiko; Tarumi, Ken; Kawamura, Maiko; Okita, Kenji; Mizuguchi, Toru; Fujimiya, Mineko; Hirata, Koichi

    2015-01-01

    AIM: To describe the anal cushion lifting (ACL) method with preliminary clinical results. METHODS: Between January to September 2007, 127 patients who received ACL method for hemorrhoid was investigated with informed consent. In this study, three surgeons who specialized in anorectal surgery performed the procedures. Patients with grade two or more severe hemorrhoids according to Goligher’s classification were considered to be indicated for surgery. The patients were given the choice to undergo either the ACL method or the ligation and excision method. ACL method is an original technique for managing hemorrhoids without excision. After dissecting the anal cushion from the internal sphincter muscle, the anal cushion was lifted to oral side and ligated at the proper position. Clinical characteristics and outcomes of patients were recorded including complications after surgery. RESULTS: A total of 127 patients were enrolled. Their median age was 42 (19-84) years, and 74.8% were female. In addition, more than 99% of the patients had grade 3 or worse hemorrhoids. The median follow-up period was 26 (0-88) mo, and the median operative time was 15 (4-30) min. After surgery, analgesics were used for a median period of three days (0-21). Pain control was achieved using extra-oral analgesic drugs, although some patients required intravenous injections of analgesic drugs. The median duration of the patients’ postoperative hospital stay was 7 (2-13) d. A total of 10 complications (7.9%) occurred. Bleeding was observed in one patient and was successfully controlled with manual compression. Urinary retention occurred in 6 patients, but it disappeared spontaneously in all cases. Recurrent hemorrhoids developed in 3 patients after 36, 47, and 61 mo, respectively. No anal stenosis or persistent anal pain occurred. CONCLUSION: We consider that the ACL method might be better than all other current methods for managing hemorrhoids. PMID:26525139

  9. Anal Itching

    MedlinePlus

    ... irritants. Avoid bubble baths, genital deodorants, perfumed soaps, moist wipes, witch hazel products and other items that might irritate the anal area. Cut back on or avoid coffee, cola, alcohol, citrus fruits, chocolate, spicy foods, tomatoes ...

  10. HDR brachytherapy for anal cancer

    PubMed Central

    Kovács, Gyoergy

    2014-01-01

    The challenge of treating anal cancer is to preserve the anal sphincter function while giving high doses to the tumor and sparing the organ at risk. For that reason there has been a shift from radical surgical treatment with colostomy to conservative treatment. Radiotherapy combined with chemotherapy has an important role in the treatment of anal cancer patients. New techniques as intensity modulated radiotherapy (IMRT) have shown reduced acute toxicity and high rates of local control in combination with chemotherapy compared to conventional 3-D radiotherapy. Not only external beam radio-chemotherapy treatment (EBRT) is an established method for primary treatment of anal cancer, brachytherapy (BT) is also an approved method. BT is well known for boost irradiation in combination with EBRT (+/– chemotherapy). Because of technical developments like modern image based 3D treatment planning and the possibility of intensity modulation in brachytherapy (IMBT), BT today has even more therapeutic potential than it had in the era of linear sources. The combination of external beam radiotherapy (EBRT) and BT allows the clinician to deliver higher doses to the tumor and to reduce dose to the normal issue. Improvements in local control and reductions in toxicity therefore become possible. Various BT techniques and their results are discussed in this work. PMID:24982770

  11. Muscle complex saving posterior sagittal anorectoplasty.

    PubMed

    Zaiem, Maher; Zaiem, Feras

    2017-05-01

    Posterior sagittal anorectoplasty (PSARP) published by DeVries and Peña in 1982 had become the preferred surgical technique for the management of anorectal malformations (ARM). The original technique is based upon complete exposure of the anorectal region by means of a median sagittal incision that runs from the sacrum to the anal dimple, cutting through all muscle structures behind the rectum by dividing the levator muscle and the muscle complex. Then, the rectum is located in front of the levator and within the limits of the muscle complex. In this review, we described Muscle Complex Saving-Posterior Sagittal Anorectoplasty (MCS-PSARP), which is a less invasive technique that consists of keeping this funnel-shaped muscle complex completely intact and not divided, and pulling the rectum through this funnel, toward fixing the new anus to the skin. This technique aimed both to respect the lower part of the sphincter mechanism consisting of the muscle complex, and to avoid the disturbance of this important structure by dividing and resuturing it. We presented six cases of male patients who were born with anorectal malformation (ARM) and underwent MCS-PSARP. The surgical technique proved to be feasible to achieve the dissection of the rectal pouch and the division of the rectourethral fistula in all patients, by opening only the upper part of the sphincter mechanism, the levator muscle, and keeping the lower part consisting of intact muscle complex. The early results in our series are encouraging; however, long-term functional outcomes of these patients are awaited. The surgical tips were also discussed. This proposed approach in the management of anorectal malformation cases provides an opportunity to maximize preservation of the existing continence mechanisms. It preserves the muscle complex components of the levator muscle intact, allowing a better function of the continence mechanism. Copyright © 2016 Elsevier Inc. All rights reserved.

  12. Intramural neural pathways between the duodenum and sphincter of Oddi in the Australian brush-tailed possum in vivo.

    PubMed Central

    Saccone, G T; Harvey, J R; Baker, R A; Toouli, J

    1994-01-01

    1. Balloon distension of the duodenum 2 cm oral or anal to the sphincter of Oddi-duodenal junction elevated the amplitude of spontaneous sphincter of Oddi phasic contractions by 37.7 +/- 8.5 or 120.1 +/- 79.8%, respectively (mean +/- S.E.M., both n = 6, P < 0.05, Wilcoxon test). To further investigate this response, this study aimed to determine if: (i) electrical field stimulation (EFS) of the duodenum influences sphincter of Oddi activity; (ii) intramural nerves mediate the response; and (iii) nicotinic and/or muscarinic receptors are involved. 2. Electrical field stimulation (70 V, 0.5 ms; 5-60 Hz, 10-20 s) of the duodenal anterior serosal surface 2-4 cm oral or anal to the sphincter of Oddi-duodenal junction, produced excitatory responses in the sphincter of Oddi in anaesthetized Australian brush-tailed possums (n = 45). 3. These responses were frequency dependent, maximal at 30 Hz (n = 4) and abolished by tetrodotoxin (9 micrograms kg-1 I.A.; n = 6), or by crushing the duodenum (n = 3). Hexamethonium bromide (30 mg kg-1 I.V.) did not significantly alter the response to duodenal EFS either oral (n = 6) or anal (n = 8) to the sphincter of Oddi-duodenal junction. Atropine sulphate (30 micrograms kg-1 I.V.) reduced the response to duodenal EFS oral and anal to the sphincter of Oddi-duodenal junction to 11.2 +/- 5.8 (n = 6) and 45.0 +/- 26.8% (n = 8), respectively (both P < 0.05). 4. Bilateral cervical vagotomy and guanethidine infusion (10 mg kg-1 over 15 min I.V.) did not significantly alter the responses to duodenal EFS (n = 7). 5. Excitatory intramural neural pathways between the sphincter of Oddi and the segment of duodenum 4 cm oral and anal to the sphincter of Oddi-duodenal junction have been demonstrated. These postganglionic pathways may involve muscarinic receptors. PMID:7738836

  13. Carcinoma of the anal canal: small steps in treatment advances.

    PubMed

    Eng, Cathy

    2011-09-01

    For locally advanced squamous cell carcinoma of the anal canal, efforts to discover effective treatments that would protect sphincter preservation led to the development of combined chemoradiotherapy, which, when administered appropriately, is curative. While the standard of combined modality chemoradiotherapy has minimally changed over the past 30 years, various chemotherapeutic and biologic agents, as well as novel methods for delivering radiation, have enhanced the treatment of anal carcinoma and are continuously being explored. This review examines the risk factors associated with anal carcinoma, and subsequently discusses the current standard of care from diagnosis through surveillance, paying attention to the pivotal trials that have shaped modern treatment paradigms.

  14. Anal fissure

    PubMed Central

    Schlichtemeier, Steven; Engel, Alexander

    2016-01-01

    SUMMARY An anal fissure is a common, mostly benign, condition that can be acute or chronic. The diagnosis is usually made on history and physical examination, but further investigations are sometimes necessary. Primary fissures are usually benign and located in the posterior or anterior position. Secondary fissures are lateral or multiple and often indicate a more serious underlying pathology. The management of primary anal fissures is generally non-operative and includes increased dietary fibre, sitz baths, topical ointments and botulinum toxin injections. If these treatments are ineffective the patient will need a surgical referral. Secondary anal fissures require further investigation. Multidisciplinary management is preferable and is essential in the case of malignancy. PMID:27041801

  15. [Colo-anal anastomosis. Our experience].

    PubMed

    Morlino, A; Tramutola, G; Rossi, M T; Scutari, F

    2009-03-01

    The aim of study is to report the results of our experience about ultra-low rectum carcinomas treated with anterior resection and colo-anal anastomosis. The surgery still represents the treatment of choice for the cancer of the rectum. The problems concern the conservation of the sphincter functions (anal and urethral), and sexual function and the reduction of the locoregional recurrences. From 2005 to 2007, 33 patients underwent surgery for low and ultralow rectal carcinoma (30 treated with neoadjuvant radio-chemotherapy, and 3 only with surgery). In 16 of these we have performed a colo-anal anastomosis, in 11 an ultralow colorectal anastomosis and in 7 a Miles resection. We report our updated results.

  16. Sphincters of canine hepatic sublobular veins respond to endothelin-1 and 3.

    PubMed

    Aharinejad, S; Nourani, F; Egerbacher, M; Larson, E K; Miksovsky, A; Böck, P; Firbas, W; McCuskey, R S; Marks, S C

    1997-10-01

    The dog has been used repeatedly as a model in liver transplantation research. The microcirculation and its regulatory mechanisms play a crucial role during ischemia and reperfusion. Little is known about the role of venous sphincters in regulating blood flow in the dog liver. Hence, we performed this study to elucidate their potential role in regulating local blood flow. In 14 dogs mean systemic (MSP) and mean portal venous pressure (MPP) were measured. Light and electron microscopy (scanning and transmission) of tissue sections and vascular corrosion casts were used to elucidate the microvascular morphology. Immunocytochemistry was applied to identify smooth muscle cells and the innervation of venous sphincters. Endothelins 1 and 3 were injected to find whether the hepatic venous sphincters are sensitive to these vasoactive agents. Tufts of smooth muscle cells were found in the sublobular veins (SLV; 100 to 250 microm in diameter), that reduced the luminal diameters of veins by 34%. Nerve endings were not observed close to these venous sphincters. The MSP and MPP were 75.3+/-2.4 mmHg and 8.9+/-0.95 mmHg, respectively. Treatment with 1.0 microg/kg of endothelin-1 (ET-1) significantly increased the MSP, the MPP and the percentage of focal venous sphincter contraction by 39% (105+/-4.7 mmHg), 43% (12.8+/-1.7 mmHg) and 57% (53.5+/-4.7), respectively (P <0.01). Treatment with ET-3 caused a significant (P <0.01) decrease in the MSP, the MPP and the percentage of sphincter contraction by 19% (61.0+/-2.2 mmHg), 39% (5.8+/-2.9 mmHg) and 38% (20.9%+/-3.15). Sinusoids did not contain sphincters. Hepatic arterioles and central veins were not affected by ET-treatment. The contraction of SLV sphincters correlated with increases in MPP (r=0.81, P <0.01) and was related to the MSP (r=0.67, P <0.01). These data show that the smooth muscle sphincters in SLV of the dog liver are involved in the local regulation of blood flow and that these sphincters are stimulated by non

  17. Incontinence, bladder neck mobility, and sphincter ruptures in primiparous women

    PubMed Central

    2010-01-01

    Objective To compare the function of the pelvic floor in primiparae before and during pregnancy with the status post partum concerning symptoms of incontinence, sphincter ruptures, bladder-neck mobility and the influence of the different modes of deliveries. Methods Questionnaire evaluating symptoms of urinary and anal incontinence in nulliparous women before and after delivery and correlating these symptoms with functional changes of the pelvic floor based on a careful gynaecologic examination as well as perineal and endoanal ultrasound. Results 112 women were included in our study and came for the first visit, 99 women returned for follow-up 6 months after childbirth. Stress and flatus incontinence significantly increased from before pregnancy (3 and 12%) to after childbirth (21 and 28%) in women with spontaneous delivery or vacuum extraction. No new symptoms occurred after c-section. There was no significant difference between the bladder neck position before and after delivery. The mobility of the bladder neck was significantly higher after vaginal delivery using a vacuum extraction compared to spontaneous delivery or c-section. The bladder neck in women with post partum urinary stress incontinence was significantly more mobile than in continent controls. The endoanal ultrasound detected seven occult sphincter defects without any correlation to symptoms of anal incontinence. Conclusion Several statistically significant changes of the pelvic floor after delivery were demonstrated. Spontaneous vaginal delivery or vacuum extraction increases the risk for stress or anal incontinence, delivery with vacuum extraction leads to higher bladder neck mobility and stress incontinent women have more mobile bladder necks than continent women. PMID:20696633

  18. [Intrinsic sphincter deficiency and female urinary incontinence].

    PubMed

    Cour, F; Le Normand, L; Lapray, J-F; Hermieu, J-F; Peyrat, L; Yiou, R; Donon, L; Wagner, L; Vidart, A

    2015-06-01

    Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article. This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association. Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary. Clinical and

  19. [Upper anal imperforation, treatment and results].

    PubMed

    Mollard, P

    1984-01-01

    As shown by Stephens the only element of the sphincteric mechanism which persists in case of high imperforate anus is the pubo rectalis sling of the levator. It is essential that the néo rectum be brought down to the perineum throught the sling which must be meticulously dissected and preserved. An operative technique with definition of the sling by an anterior perineal approach was described by the author. Results of the procedure in 43 patients are reported: early post operative complications (1 death, 4 occlusions, 2 ischemia of the neo rectum), anal complications (stricture, prolapses and ectropion) and urinary complications. Concerning the continence the author studied 19 patients: 16 children operated over 10 years ago and 3 adults. Of these 19: 2 are failures with stool incontinence, 10 are excellent and 7 fair. A "perfect" result was never obtained but many are compatible with a normal social life. Age is of great importance (our 3 adults became continent within several months), morning evacuations, diet, cleanliners, some drugs such a imodium are helpful adjuncts. Then the paper discusses 16 patients with desastrous results after previous surgery in another hospital. In 10 patients the new ano-rectum has been placed some that it missed a portion or all of the pubo-rectalis muscule. A further operation with re-routing resulted in marked improvement in 7 patients. A poor result with the neo-rectum in a good position means that the incontinence is related to a hypoplastic or denervated sling. A free autogenous muscle transplantation (Hakelius and Grotte) gave 4 excellent, 2 fair and 2 poor results.

  20. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results.

    PubMed

    Arroyo, Antonio; Pérez-Legaz, Juan; Moya, Pedro; Armañanzas, Laura; Lacueva, Javier; Pérez-Vicente, Francisco; Candela, Fernando; Calpena, Rafael

    2012-05-01

    To evaluate the long-term clinical and manometric results of fistulotomy and sphincter reconstruction for the treatment of complex fistula-in-ano. Complex fistula-in-ano is difficult to treat due to the occurrence of postoperative anal incontinence and the high rate of recurrence. Seventy patients who were diagnosed with complex fistula-in-ano and underwent fistulotomy and sphincter reconstruction between October 2000 and October 2006 were analyzed in the present study. Preoperative assessment included physical examination, anorectal manometry, and anal endosonography. Appointments were scheduled every 6 months during the first and second year of treatment and every 2 years thereafter. Recurrence and incontinence were evaluated during each visit. Continence was assessed according to the Wexner continence grading scale. Anal manometry was performed 3 and 12 months after treatment and every 2 years thereafter. Anal endosonography was conducted 6 months after treatment. Fistulas were classified as medium-high trans-sphincteric in 64 patients (91.42%) and were recurrent in 22 patients (32%). Before surgery, 22 patients (32%) reported fecal incontinence, which improved after surgery in 15 cases (70%), from 6.75 to 1.88 (P < 0.005) on the Wexner Scale. Eight preoperative continent patients (16.6%) reported postoperative incontinence (Wexner Score < 3), and 6 patients (8.5%) had recurrent incontinence. Among these patients, 2 developed recurrent incontinence 6 months after treatment, 2 developed recurrent incontinence 1 year after treatment, 1 developed recurrent incontinence 2 years after treatment, and 1 developed incontinence 5 years after treatment. Fistulotomy with sphincter reconstruction is an effective technique for the treatment of complex fistula-in-ano. Continence and anal manometry results were improved in incontinent patients and were not jeopardized in continent ones. Fistulotomy with sphincter reconstruction is an especially suitable technique for

  1. Anal erogeneity: the goose and the rat.

    PubMed

    Shengold, L

    1982-01-01

    A case is presented in which the patient's traumatically derived intense anal erogeneity (associated with traumatic anxiety as well as with castration anxiety) inhibited his phallic sensations and potency and also his power to sustain productive thought. His passive cravings were disguised and reacted against in his compulsive-exhibitionistically phallic role of a Don Juan. He described at least two levels of anal feelings: a dangerous but exciting, tolerable or even pleasurable tension associated with the imago of the goose; and an unbearable, terrifying overcharged level embodied in the imago of the rat. (He had read of, and had felt himself identified with, Freud's Rat Man.) Contrasts are presented with François Rabelais' account of the instinctual development and anal training of Gargantua, in which the connotations of the goose lead to a happy anal, phallic and intellectual control. Generalizations are ventured about the crucial attainment of command over the anal sphincter for the taming of 'primal affect'(Fliess). With early psychopathology there is a defensive overcathexis of anal control (and of anal mechanisms and character traits) to try to contain over-stimulation. In contrast true anal mastery contributes to the acquisition of optimal genital feelings and functioning and to the capacity for sustaining integrative thinking so necessary for 'owning' one's affects and impulses, and therefore for a feeling of identity. Finally, some remarks of Freud on Rabelais are reviewed in relation to levels of urethral erogeneity, seen as developmental way stations between the anal and the phallic, and partaking of both.

  2. Cost considerations in the treatment of anal fissures.

    PubMed

    Brisinda, Giuseppe; Bianco, Giuseppe; Silvestrini, Nicola; Maria, Giorgio

    2014-08-01

    Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.

  3. Is Preoperative Chemoradiotherapy Beneficial for Sphincter Preservation in Low-Lying Rectal Cancer Patients?

    PubMed Central

    Park, In Ja; Yu, Chang Sik; Lim, Seok-Byung; Lee, Jong Lyul; Kim, Chan Wook; Yoon, Yong Sik; Park, Seong Ho; Kim, Jin Cheon

    2016-01-01

    Abstract The present study explored the benefit of preoperative chemoradiotherapy (PCRT) for sphincter preservation in locally advanced low-lying rectal cancer patients who underwent stapled anastomosis, especially in those with deep and narrow pelvises determined by magnetic resonance imaging. Patients with locally advanced low-lying rectal cancer (≤5 cm from the anal verge) who underwent stapled anastomosis were included. Patients were categorized into two groups (PCRT+ vs. PCRT–) according to PCRT application. Patients in the PCRT+ group were matched to those in the PCRT– group according to potential confounding factors (age, gender, clinical stage, and body mass index) for sphincter preservation. Sphincter preservation, permanent stoma, and anastomosis-related complications were compared between the groups. Pelvic magnetic resonance imaging was used to measure 12 dimensions representing pelvic cavity depth and width with which deep and narrow pelvis was defined. The impact of PCRT on sphincter preservation and permanent stoma in pelvic dimensions defined as deep and narrow pelvis was evaluated, and factors associated with sphincter preservation and permanent stoma were analyzed. One hundred sixty-six patients were one-to-one matched between the PCRT+ and PCRT− groups. Overall, sphincter-saving surgery was performed in 66.3% and the rates were not different between the 2 groups. Anastomotic complications and permanent stoma occurred nonsignificantly more frequently in the PCRT+ group. PCRT was not associated with higher rate of sphincter preservation in all pelvic dimensions defined as deep and narrow pelvis, while PCRT was related to higher rate of permanent stoma in shorter transverse diameter and interspinous distance. On logistic regression analysis, PCRT was not shown to influence both sphincter preservation and permanent stoma, while longer transverse diameter and interspinous distance were associated with lower rate of permanent stoma. PCRT had

  4. Is Preoperative Chemoradiotherapy Beneficial for Sphincter Preservation in Low-Lying Rectal Cancer Patients?

    PubMed

    Park, In Ja; Yu, Chang Sik; Lim, Seok-Byung; Lee, Jong Lyul; Kim, Chan Wook; Yoon, Yong Sik; Park, Seong Ho; Kim, Jin Cheon

    2016-05-01

    The present study explored the benefit of preoperative chemoradiotherapy (PCRT) for sphincter preservation in locally advanced low-lying rectal cancer patients who underwent stapled anastomosis, especially in those with deep and narrow pelvises determined by magnetic resonance imaging.Patients with locally advanced low-lying rectal cancer (≤5 cm from the anal verge) who underwent stapled anastomosis were included. Patients were categorized into two groups (PCRT+ vs. PCRT-) according to PCRT application. Patients in the PCRT+ group were matched to those in the PCRT- group according to potential confounding factors (age, gender, clinical stage, and body mass index) for sphincter preservation. Sphincter preservation, permanent stoma, and anastomosis-related complications were compared between the groups. Pelvic magnetic resonance imaging was used to measure 12 dimensions representing pelvic cavity depth and width with which deep and narrow pelvis was defined. The impact of PCRT on sphincter preservation and permanent stoma in pelvic dimensions defined as deep and narrow pelvis was evaluated, and factors associated with sphincter preservation and permanent stoma were analyzed.One hundred sixty-six patients were one-to-one matched between the PCRT+ and PCRT- groups. Overall, sphincter-saving surgery was performed in 66.3% and the rates were not different between the 2 groups. Anastomotic complications and permanent stoma occurred nonsignificantly more frequently in the PCRT+ group. PCRT was not associated with higher rate of sphincter preservation in all pelvic dimensions defined as deep and narrow pelvis, while PCRT was related to higher rate of permanent stoma in shorter transverse diameter and interspinous distance. On logistic regression analysis, PCRT was not shown to influence both sphincter preservation and permanent stoma, while longer transverse diameter and interspinous distance were associated with lower rate of permanent stoma.PCRT had no beneficial

  5. [Evaluation of the efficacy of a new graduated anal dilator in the treatment of acute anal fissures].

    PubMed

    Gaja, Fabio; Trecca, Antonello

    2007-01-01

    Dilatation of the anal sphincter with anal dilators for the treatment of acute anal fissure is efficacious, economic and safe but not always correctly executed with a negative repercussions on the technical results. Our study was aimed at comparing the efficacy of new graduated dilator with a progressively graduated diameter, using a standard treatment schedule, or a free schedule in comparison with the use of multiple classic dilators currently available for the resolution of anal fissures. A series of 60 patients, 35 female and 25 male, with a clinical diagnosis of acute anal fissure in the absence of a hypotonic anal sphincter, abscess or perianal fistula, hemorrhoidal thrombosis, chronic inflammatory bowel diseases or lower gastrointestinal neoplasms were preliminarily evaluated with the solid sphere test and randomly divided into three groups: the first was treated with the new graduated dilator with a standard treatment schedule (20 patients); the second was treated with multiple anal dilators (20, 23, 27 mm) (20 patients) using a standard treatment schedule, and the third group (20 patients) was treated with the new graduated dilator according to a free treatment schedule. After four weeks of treatment, 91% of all patients showed resolution of the anal fissure. Patients treated with new graduated dilator and those treated with multiple dilators according to the standard schedule showed similar 90% rates of fissure healing in comparison to the 92% treated with the graduated dilator according to the free schedule. The tolerability and manageability of the new single graduated dilator was judged positively by all patients in the treated groups. The use of the graduated anal dilator according to a free treatment schedule seems to induce lasting resolution of acute anal fissures with similar results to those achieved using traditional multiple dilators, while proving better tolerated by the patients.

  6. Efficacy of LIFT for recurrent anal fistula.

    PubMed

    Lehmann, J-P; Graf, W

    2013-05-01

    Ligation of the intersphincteric fistula tract (LIFT) is a novel sphincter-preserving technique for anal fistula. This pilot study was designed to evaluate the results in patients with a recurrent fistula. Seventeen patients [nine men; median age 49 (range, 30-76) years] with a recurrent trans-sphincteric fistula were treated with a LIFT procedure between June 2008 and February 2011. All were followed prospectively for a median of 16 (range, 5-27) weeks with clinical examination. Fifteen followed for 13.5 (range, 8-26) months by clinical examination also had three-dimensional (3D) anal ultrasound. The duration of the procedure was 35 (range, 18-70) min. One patient developed a small local haematoma and one had a subcutaneous infection, but otherwise there was no morbidity. At follow up, 11 (65%) patients had a successful closure, two (12%) had a remaining sinus and four (23%) had a persistent fistula. The incidence of persistent or recurrent fistulae at 13.5 months was six (40%) of 15 patients. No de novo faecal incontinence was reported. LIFT is a safe procedure for patients with recurrent anal fistula, with healing at short-term and medium-term follow-up comparable with or superior to that of other sphincter-preserving techniques. Larger studies with a longer follow up are needed to define the ultimate role of LIFT in patients with recurrence. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.

  7. Nerves in the intersphincteric space of the human anal canal with special reference to their continuation to the enteric nerve plexus of the rectum.

    PubMed

    Hieda, Keisuke; Cho, Kwang Ho; Arakawa, Takashi; Fujimiya, Mineko; Murakami, Gen; Matsubara, Akio

    2013-10-01

    In the intersphincteric space of the anal canal, nerves are thought to "change" from autonomic to somatic at the level of the squamous-columnar epithelial junction of the anal canal. To compare the nerve configuration in the intersphincteric space with the configuration in adjacent areas of the human rectum, we immunohistochemically assessed tissue samples from 12 donated cadavers, using antibodies to S100, neuronal nitric oxide synthase (nNOS), and tyrosine hydroxylase (TH). Antibody to S100 revealed a clear difference in intramuscular nerve distribution patterns between the circular and longitudinal muscle layers of the most inferior part of the rectum, with the former having a plexus-like configuration, while the latter contained short, longitudinally running nerves. Most of the intramural ganglion cells in the anal canal were restricted to above the epithelial junction, but some were located just below that level. Near or at the level of the epithelial junction, the nerves along the rectal adventitia and Auerbach's nerve plexus joined to form intersphincteric nerves, with all these nerves containing both nNOS-positive parasympathetic and TH-positive sympathetic nerve fibers. Thus, it was histologically difficult to distinguish somatic intersphincteric nerves from the autonomic Auerbach's plexus. In the intersphincteric space, the autonomic nerve elements with intrapelvic courses seemed to "borrow" a nerve pathway in the peripheral branches of the pudendal nerve. Injury to the intersphincteric nerve during surgery may result in loss of innervation in the major part of the internal anal sphincter. Copyright © 2013 Wiley Periodicals, Inc.

  8. [Choice of surgical procedure and management of postoperative incision for anal fistula].

    PubMed

    Chen, Chaowen; Peng, Bo

    2015-12-01

    Anal fistula is a common disease in general surgery. It is difficult to heal without intervention and surgical treatment is the major treatment. Method of surgical treatment and management of postoperative incision are based on features and classifications of anal fistula. Choosing the appropriate approach in accordance with specific conditions of patients can obtain effective healing and proper protection against anal sphincter, along with the improvement of life quality. Comprehensive evaluation on methods of surgical treatment and managements of postoperative incision for anal fistula is presented in this paper.

  9. Lower esophageal sphincter pressure in histologic esophagitis.

    PubMed

    Welch, R W; Luckmann, K; Ricks, P; Drake, S T; Bannayan, G; Owensby, L

    1980-06-01

    The fasting lower esophageal sphincter pressure of 18 normal volunteers was compared to 22 patients with symptoms and objective evidence of gastroesophageal reflux. Lower esophageal sphincter pressure was measured by rapid pull-through using an 8-lumen radially perfused catheter that sampled pressure every45 degrees around the circumference of the sphincter. The 22 reflux patients were subdivided for analysis into two groups, those with an acute inflammatory infiltrate on biopsy and those without inflammation. Those patients without inflammatory esophagitis had normal sphincter pressures. Those with a definite inflammatory infiltrate had pressures significantly less than normal. The least reliable separation between normals and those with inflammatory esophagitis occurred in the anterior orientations. We conclude that while basal lower esophageal sphincter pressure measurement may identify patients with reflux and inflammatory esophagitis, it is of no help in identifying those patients with reflux unassociated with inflammation. Decreased basal fasting LESP does not appear to be the most important primary determinant of gastroesophageal reflux.

  10. Neo-adjuvant chemoradiotherapy; an opportunity in sphincter preserving procedure for rectal cancer

    PubMed Central

    Mozafar, Mohammad; Adhami, Farideh; Atqiaee, Khashayar; Lotfollahzadeh, Saran; Amraei, Razie; Baikpour, Maryam

    2014-01-01

    Aim The present study was designed to assess the impact of neo-adjuvant chemoradiotherapy on the possibility of utilizing sphincter preserving techniques in rectal cancer surgery. Background For both patients and surgeons anal sphincter preserving surgery serves as the ideal procedure to treat rectal cancer. Patients and methods Patients with rectal cancer who were admitted to Shohadaye Tajrish hospital between 2001 and 2011 and underwent sphincter preserving or non-preserving surgery were identified. They were divided into those who had received neo-adjuvant chemo-radiotherapy prior to surgery and those who didn't, and the type of surgical procedure they underwent was compared between the two arms. Data regarding tumor pathology, tumor size and distance from anal verge before and after neo-adjuvant therapy, together with the duration of chemo-radiotherapy were also assessed. Results 103 patients with documented rectal cancer were included in our analysis. Among 47 patients who had not received neo-adjuvant therapy, 26 (55%) underwent APR while 15(32%) and 6(13%) patients were treated with LAR and VLAR respectively. Of the 56 patients who had gone through chemo-radiotherapy prior to surgery, 30 (53%) underwent APR while 14 (25%) and 10 (18%) patients were treated with LAR and VLAR respectively. 2 patients had unresectable tumor. Tumor staging before and after neo-adjuvant therapy showed a statistically significant difference (p=0.0001). Conclusion Neo-adjuvant chemo-radiotherpy can decrease tumor size, increase the distance between the tumor and anal verge, and downgrade the staging. However, it does not necessarily increase the possibility of performing sphincter preserving surgery on patients suffering from low-lying tumors. PMID:25436095

  11. [Preliminary efficacy of video-assisted anal fistula treatment for complex anal fistula].

    PubMed

    Liu, Hailong; Xiao, Yihua; Zhang, Yong; Pan, Zhihui; Peng, Jian; Tang, Wenxian; Li, Ajian; Zhou, Lulu; Yin, Lu; Lin, Moubin

    2015-12-01

    To evaluate the preliminary efficacy of video-assisted anal fistula treatment (VAAFT) for complex anal fistula. Clinical data of 11 consecutive patients with complex anal fistula undergoing VAAFT in our department from May to July 2015 were reviewed. VAAFT was performed to manage the fistula under endoscope without cutting or resection. VAAFT was successfully performed in all the 11 patients. The internal ostium was closed using mattress suture in 10 cases, and Endo-GIA stapler in 1 case. The mean operative time was (42.0±12.4) min, mean hospital stay was (4.1±1.5) d. Complication included bleeding and perianal infection in 1 case respectively. After 1 to 3.2 months follow-up, success rate was 72.7%(8/11), and no fecal incontinence was observed. Video-assisted anal fistula treatment is an effective, safe and minimally invasive surgical procedure for complex anal fistula with preservation of anal sphincter function.

  12. Video-Assisted Anal Fistula Treatment (VAAFT) for Complex Anal Fistula: A Preliminary Evaluation in China.

    PubMed

    Jiang, Hui-Hong; Liu, Hai-Long; Li, Zhen; Xiao, Yi-Hua; Li, A-Jian; Chang, Yi; Zhang, Yong; Lv, Liang; Lin, Mou-Bin

    2017-04-30

    BACKGROUND Although many attempts have been made to advance the treatment of complex anal fistula, it continues to be a difficult surgical problem. This study aimed to describe the novel technique of video-assisted anal fistula treatment (VAAFT) and our preliminary experiences using VAAFT with patients with complex anal fistula. MATERIAL AND METHODS From May 2015 to May 2016, 52 patients with complex anal fistula were treated with VAAFT at Yangpu Hospital of Tongji University School of Medicine, and the clinical data of these patients were reviewed. RESULTS VAAFT was performed successfully in all 52 patients. The median operation time was 55 minutes. Internal openings were identified in all cases. 50 cases were closed with sutures, and 2 were closed with staplers. Complications included perianal sepsis in 3 cases and bleeding in another 3 cases. Complete healing without recurrence was achieved in 44 patients (84.6%) after 9 months of follow-up. No fecal incontinence was observed. Furthermore, a significant improvement in Gastrointestinal Quality of Life Index (GIQLI) score was observed from preoperative baseline (mean, 85.5) to 3-month follow-up (mean, 105.4; p<0.001), and this increase was maintained at 9-months follow-up (mean, 109.6; p<0.001). CONCLUSIONS VAAFT is a safe and minimally invasive technique for treating complex anal fistula with preservation of anal sphincter function.

  13. Video-Assisted Anal Fistula Treatment (VAAFT) for Complex Anal Fistula: A Preliminary Evaluation in China

    PubMed Central

    Jiang, Hui-hong; Liu, Hai-long; Li, Zhen; Xiao, Yi-hua; Li, A-jian; Chang, Yi; Zhang, Yong; Lv, Liang; Lin, Mou-bin

    2017-01-01

    Background Although many attempts have been made to advance the treatment of complex anal fistula, it continues to be a difficult surgical problem. This study aimed to describe the novel technique of video-assisted anal fistula treatment (VAAFT) and our preliminary experiences using VAAFT with patients with complex anal fistula. Material/Methods From May 2015 to May 2016, 52 patients with complex anal fistula were treated with VAAFT at Yangpu Hospital of Tongji University School of Medicine, and the clinical data of these patients were reviewed. Results VAAFT was performed successfully in all 52 patients. The median operation time was 55 minutes. Internal openings were identified in all cases. 50 cases were closed with sutures, and 2 were closed with staplers. Complications included perianal sepsis in 3 cases and bleeding in another 3 cases. Complete healing without recurrence was achieved in 44 patients (84.6%) after 9 months of follow-up. No fecal incontinence was observed. Furthermore, a significant improvement in Gastrointestinal Quality of Life Index (GIQLI) score was observed from preoperative baseline (mean, 85.5) to 3-month follow-up (mean, 105.4; p<0.001), and this increase was maintained at 9-months follow-up (mean, 109.6; p<0.001). Conclusions VAAFT is a safe and minimally invasive technique for treating complex anal fistula with preservation of anal sphincter function. PMID:28456815

  14. Study of Operated Patients of Lateral Internal Anal Sphincterotomy for Chronic Anal Fissure

    PubMed Central

    Patel, Harshad Shankarlal; Chavda, Jagdish; Parikh, Jayesh; Naik, Nehal

    2013-01-01

    Introduction: Anal fissure causes significant morbidity in the population. It is proposed that elevated sphincter pressures may cause ischaemia of the anal lining and this may be responsible for the pain of anal fissures and their failure to heal. When pharmacologic therapy fails or fissures recur frequently, lateral internal sphincterotomy is the surgical treatment of choice. Material and Methods: Retrospective analysis was done of admitted and operated patients of anal fissure by lateral anal internal sphincterotomy either by open or closed technique between April 2010 and November 2011 in Gujarat Medical Education & Research Society Medical College, Sola, Ahmedabad, India. The follow-up data of all patients was evaluated for pain relief, recurrence, wound infection, incontinence to flatus or stool or both for a period of up to 6 months. Results: Wound infection rate was 10.3% in open method and 4.2% in closed method. Incontinence to flatus was 8.3% in closed method and 3.4% in open method. This was temporary and controlled within a 1 week. Incontinence to stool was 3.4% in open method which was temporary and controlled within 2 weeks while none in closed method. None of the patients in either group had come with recurrence within 6 months follow-up. Conclusion: Lateral anal internal sphincterotomy is safe regarding long term incontinence and effective regarding recurrence. PMID:24551659

  15. Treatment of anal fistula and abscess.

    PubMed

    Pigot, F

    2015-04-01

    The glands of Hermann and Desfosses, located in the thickness of the anal canal, drain into the canal at the dentate line. Infection of these anal glands is responsible for the formation of abscesses and/or fistulas. When this presents as an abscess, emergency drainage of the infected cavity is required. At the stage of fistula, treatment has two sometimes conflicting objectives: effective drainage and preservation of continence. These two opposing constraints explain the existence of two therapeutic concepts. On one hand the laying-open of the fistulous tract (fistulotomy) in one or several operative sessions remains the treatment of choice because of its high cure rates. On the other hand surgical closure with tract ligation or obturation with biological components preserves sphincter function but suffers from a higher failure rate. Copyright © 2014. Published by Elsevier Masson SAS.

  16. Anal Cancer Treatment

    MedlinePlus

    ... cancer that remains after treatment with external-beam radiation therapy. Patients who have had treatment that saves the sphincter ... cancer remains or comes back after treatment with radiation therapy and chemotherapy. ... options. Patients who have had treatment that saves the sphincter ...

  17. Stages of Anal Cancer

    MedlinePlus

    ... cancer that remains after treatment with external-beam radiation therapy. Patients who have had treatment that saves the sphincter ... cancer remains or comes back after treatment with radiation therapy and chemotherapy. ... options. Patients who have had treatment that saves the sphincter ...

  18. Vaginal delivery after ileal pouch-anal anastomosis: a word of caution.

    PubMed

    Remzi, Feza H; Gorgun, Emre; Bast, Jane; Schroeder, Tom; Hammel, Jeffrey; Philipson, Elliot; Hull, Tracy L; Church, James M; Fazio, Victor W

    2005-09-01

    This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis. The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique. Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery

  19. Modern Perspectives in the Treatment of Chronic Anal Fissures

    PubMed Central

    Bhardwaj, R; Parker, MC

    2007-01-01

    INTRODUCTION Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely. METHODS Data were obtained from Medline publications citing ‘anal fissure’. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures. FINDINGS Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable. PMID:17688717

  20. Modern perspectives in the treatment of chronic anal fissures.

    PubMed

    Bhardwaj, R; Parker, M C

    2007-07-01

    Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely. Data were obtained from Medline publications citing 'anal fissure'. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures. Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.

  1. [Application and development of suture-dragging therapy for anal fistula].

    PubMed

    Wang, Chen; Yao, Yibo; Dong, Qingjun; Liang, Hongtao; Guo, Xiutian; Cao, Yongqing; Lu, Jingen

    2015-12-01

    Traditional Chinese surgical treatment "suture-dragging" therapy is based on medical thread therapy and tight seton drainage in combination of minimal invasive surgical principle. It can preserve the integrity of anal sphincter musculature involved in fistulous tract or abscess and maintain anal function. This article not only describes in detail about the operation points and mechanisms of "suture-dragging" therapy of anorectal fistula, but also reviews the application and modification of anorectal disease.

  2. Fissurectomy combined with botulinum toxin A injection for medically resistant chronic anal fissures.

    PubMed

    Witte, M E; Klaase, J M; Koop, R

    2010-07-01

    Chemical sphincterotomy, the use of pharmacological agents to reduce anal sphincter resting pressure, has become more and more popular in the treatment of chronic anal fissures (CAFs). It offers the possibility to avoid a lateral internal sphincterotomy and its associated risk of incontinence. In our hospital, patient with a chronic anal fissure are consecutively treated with isosorbide dinitrate 1% ointment, applied 6 times a day for 8 weeks, followed by diltiazem 2% ointment, applied 2 times a day for 8 weeks and Botulin Toxin A injections (Dysport; Ipsen, Hoofddorp, the Netherlands) in the internal anal sphincter. In a previous study (1), we describe high healing rates with this regime. Objective The objective of this study is to evaluate the effect of the combination of fissurectomy and Botulin Toxin A in the treatment of CAFs. Twenty-one patients (10 male patients, median age 48 years) with persistent symptoms of chronic anal fissures after following the above mentioned treatment, were enrolled in this study. Fissurectomy was combined with Botulinum Toxin A (80 U of Dysport) under regional anaesthesia in day care. Results After 12 weeks 19/21 CAFs (90%) had healed. Median follow-up was 16 (9-30) months. No recurrences were seen. Fissurectomy in combination with Botulinum Toxin A injection in the internal anal sphincter is an effective treatment for medically resistant CAFs.

  3. Controlling anal incontinence in women by performing anal exercises with biofeedback or loperamide (CAPABLe) trial: Design and methods

    PubMed Central

    Jelovsek, J. Eric; Markland, Alayne D.; Whitehead, William E.; Barber, Matthew D.; Newman, Diane K.; Rogers, Rebecca G.; Dyer, Keisha; Visco, Anthony; Sung, Vivian W.; Sutkin, Gary; Meikle, Susan F.; Gantz, Marie G.

    2015-01-01

    The goals of this trial are to determine the efficacy and safety of two treatments for women experiencing fecal incontinence. First, we aim to compare the use of loperamide to placebo and second, to compare the use of anal sphincter exercises with biofeedback to usual care. The primary outcome is the change from baseline in the St. Mark's (Vaizey) Score 24 weeks after treatment initiation. As a Pelvic Floor Disorders Network (PFDN) trial, subjects are enrolling from eight PFDN clinical centers across the United States. A centralized data coordinating center supervises data collection and analysis. These two first-line treatments for fecal incontinence are being investigated simultaneously using a two-by-two randomized factorial design: a medication intervention (loperamide versus placebo) and a pelvic floor strength and sensory training intervention (anal sphincter exercises with manometry-assisted biofeedback versus usual care using an educational pamphlet). Interventionists providing the anal sphincter exercise training with biofeedback have received standardized training and assessment. Symptom severity, diary, standardized anorectal manometry and health-related quality of life outcomes are assessed using validated instruments administered by researchers masked to randomized interventions. Cost effectiveness analyses will be performed using prospectively collected data on care costs and resource utilization. This article describes the rationale and design of this randomized trial, focusing on specific research concepts of interest to researchers in the field of female pelvic floor disorders and all other providers who care for patients with fecal incontinence. PMID:26291917

  4. Video-assisted anal fistula treatment: a new concept of treating anal fistulas.

    PubMed

    Meinero, Piercarlo; Mori, Lorenzo; Gasloli, Giorgio

    2014-03-01

    The surgical treatment of complex anal fistulas is very challenging because of the incidence of incontinence and recurrence after traditional approaches. Video-assisted anal fistula treatment is a novel endoscopic sphincter-saving technique. The aim of this article is to evaluate the results of treating complex anal fistulas from the inside and to focus on the rationale and the advantages of this innovative approach. This is a retrospective observational study. The study was conducted at a tertiary care public hospital in Italy. From February 2006 to February 2012, video-assisted anal fistula treatment was performed on 203 patients (124 men and 79 women; median age, 42 years; range, 21-77 years) who had complex anal fistulas. One hundred forty-nine had undergone previous anal fistula surgery. Video-assisted anal fistula treatment has 2 phases: diagnostic and operative. The fistuloscope is introduced through the external opening to identify the main tract, possible secondary tracts or abscess cavities, and the internal opening. With the use of an electrode, the fistula and its branches are destroyed under direct vision and cleaned. The internal opening is closed by a stapler or a flap. Half a milliliter of synthetic cyanoacrylate is used for suture reinforcement. Successful healing of the fistula was assessed with clinical evaluation. Continence was evaluated by using patient self-reports of the presence/absence of postdefecation soiling. Follow-up was at 2, 4, 6, 12, and 24 months. The 6-month cumulative probability of freedom from fistula estimated according to a Kaplan-Meier analysis is 70% (95%CI, 64%-76%). No major complications occurred. No patients reported a reduction in their postoperative continence score. The limitations of this study included potential single-institution bias, lack of anorectal manometry, and potential selection bias. Video-assisted anal fistula treatment is effective and safe for the treatment of fistula-in-ano.

  5. Diagnosis of hypertonic Oddi's sphincter dyskinesia

    SciTech Connect

    Varro, V.; Doebroente, Z.; Hajnal, F.; Csernay, L.; Nemessanyi, Z.; Lang, J.; Narai, G.; Szabo, E.

    1983-11-01

    The diagnostic possibility of hypertonic Oddi's sphincter dysfunction was evaluated in 100 cholecystectomized and 28 noncholecystectomized patients. An organic lesion interfering with free bile flow was ruled out in every case. The existence of the syndrome, i.e., the dysfunction of the Oddi's musculature, was verified using the morphine-choleretic test combined with either dynamic hepatobiliary scintigraphy or (in selected cases) percutaneous transhepatic cholangiography. Hypertonic Oddi's sphincter dyskinesia can be regarded as an independent clinical syndrome.

  6. Reducing the incidence of Obstetric Sphincter Injuries using a hands-on technique: an interventional quality improvement project

    PubMed Central

    Rasmussen, Ole Bredahl; Yding, Annika; Anh Ø, Jacob; Sander Andersen, Charlotte; Boris, Jane

    2016-01-01

    A main concern for women giving birth is the risk of obstetric anal sphincter injuries. In our department the incidence of sphincter injuries was around 8 % among vaginally delivering first time mothers. We aimed to halve the incidence to 4 % or less. A prospective interventional program was instituted. We implemented a hands-on technique with four elements in a bundle of care together with a certification process for all staff on the delivery ward. The incidence of episiotomies served as a balancing indicator. The adherence to three of the four elements of the care bundle rose significantly while the all-or-nothing indicator leveled around 80 %. The median number of deliveries between cases with a sphincter injury increased from 9.5 in the baseline period to 20 during the intervention period. This corresponded with a reduction in the incidence from 7.0 % to 3.4 %. The rate of episiotomy remained low at 8.4 % in this group. By implementing the hands-on technique, we halved the risk of obstetric anal sphincter injuries. Our data suggest that further improvement may be anticipated. The study has demonstrated how implementation of a hands-on technique can be carried out within a quality improvement framework with rapid and sustainable results. PMID:28074131

  7. Anal function after ligation of the intersphincteric fistula tract.

    PubMed

    Tsunoda, Akira; Sada, Haruki; Sugimoto, Takuya; Nagata, Hiroshi; Kano, Nobuyasu

    2013-07-01

    Although the ligation of the intersphincteric fistula tract is a promising anal sphincter-saving procedure for fistula-in-ano, the objective assessment of the sphincter preservation remains unknown. The primary end point was to measure the anal function before and after this procedure. The secondary end point measured was cure of the disease. This study is a prospective observational study. This study was conducted at the Department of Surgery, Kameda Medical Center, Japan, from March 2010 to August 2012. Twenty patients with transsphincteric or complex fistulas were evaluated. All patients underwent the ligation of the intersphincteric fistula tract with a loose seton for anal fistulas. Anal manometric study was performed before and 3 months after the procedure. Fecal incontinence was evaluated by using the fecal incontinence severity index. Failure was defined as nonhealing of the surgical wound or fistula. The median operation time was 42 minutes. No intraoperative complications were documented. The median follow-up duration was 18 (3-32) months. No patients reported any incontinence postoperatively. The median score of the fecal incontinence severity index before and 3 months after the procedure was 0. The median maximum resting pressure measured before and after operation were 125 (71-175) cm H2O and 133 (95-169) cm H2O. The median maximum squeeze pressure measured before and after operation were 390 (170-815) cm H2O and 432 (200-902) cm H2O. There were no significant postoperative changes in either the resting pressure or the squeeze pressure. Primary healing was observed in 19 (95%) patients, and the median healing time was 7 weeks; 1 wound remained incompletely healed. Short-term follow-up may not justify the use of the term definitive cure. The ligation of the intersphincteric fistula tract with a loose seton showed no postoperative deterioration on anal sphincter function with favorable healing rates.

  8. The role of anal ultrasound in the management of anal fistulas.

    PubMed

    Lindsey, I; Humphreys, M. M; George, B. D; Mortensen, N. J. M. C

    2002-03-01

    OBJECTIVE: To assess the accuracy of anal ultrasound (AUS) for anal fistulas, and the impact of routine pre-operative AUS on their surgical management. METHODS: Pre-operative AUS was performed in 38 consecutive patients with an anal fistula using a 10-MHz Brüel & Kjaer probe. All patients underwent subsequent examination under anaesthetic (EUA) with documentation of the anatomy of the fistula before the surgeon was shown the AUS results. Agreement between AUS and EUA findings and any modification to the surgical treatment was recorded. RESULTS: There was 84% agreement between AUS and EUA findings regarding presence and site of fistulas. One fistula not seen at AUS was found at EUA, and 5 fistulas seen on AUS were not demonstrated at EUA. AUS influenced the surgery undertaken in 9/24 (38%) patients; demonstrating occult sphincter defects (2 patients), reclassifying fistulas from low to higher fistulas (3 patients), deciding a surgical treatment open to doubt (2 patients) and helping identify an obscure fistula not initially found at EUA (2 patients). CONCLUSIONS: Accuracy of AUS in the assessment of anal fistulas is confirmed. Operative management is influenced in 38% of cases, usually towards more conservative treatment. We recommend the use of pre-operative AUS in the assessment of anal fistulas.

  9. Premalignant Lesions of the Anal Canal and Squamous Cell Carcinoma of the Anal Canal

    PubMed Central

    Poggio, Juan Lucas

    2011-01-01

    Squamous cell carcinoma of the anus (SCCA) is a rare tumor. However, its incidence has been increasing in men and women over the past 25 years worldwide. Risk factors associated with this cancer are those behaviors that predispose individuals to human papillomavirus (HPV) infection and immunosuppression. Anal cancer is generally preceded by high-grade anal intraepithelial neoplasia (HGAIN), which is most prevalent in human immunodeficiency virus-positive men who have sex with men. High-risk patients may benefit from screening. The most common presentation is rectal bleeding, which is present in nearly 50% of patients. Twenty percent of patients have no symptoms at the time of presentation. Clinical staging of anal cancer requires a digital rectal exam and a positron emission tomography/computed tomography scan of the chest, abdomen, and pelvis. Endorectal/endoanal ultrasound appears to add more-specific staging information when compared with digital rectal examination alone. Treatment of anal cancer prior to the 1970s involved an abdominoperineal resection. However, the current standard of care for localized anal cancer is concurrent chemoradiation therapy, primarily because of its sphincter-saving and colostomy-sparing potential. Studies have addressed alternative chemoradiation regimens to improve the standard protocol of fluorouracil, misogynic, and radiation, but no alternative regimen has proven superior. Surgery is reserved for those patients with residual disease or recurrence. PMID:22942800

  10. Anal lesions presenting in a cohort of child gastroenterological examinations. Implications for sexual traumatic injuries.

    PubMed

    Rougé-Maillart, Clotilde; Houdu, Sora; Darviot, Estelle; Buchaillet, Céline; Baron, Céline

    2015-05-01

    The purpose of this study was to describe the anal lesions found in children during a pediatric gastroenterology consultation when the reason for the complaint was related to a digestive disease. This prospective descriptive study included 100 children under 15 years of age over a 13-month period, consulting due to digestive symptoms. The children were under 8 years old (90%) and 25% were under 3.1 years old. Constipation was the most frequent reason for consultation (69%). Fifty-one anal lesions were observed, of which 58.8% were anal fissures, 15.7% were skin tags and 5.8% were venous congestions related to straining. Anal fissures and skin tags were located at the median line, according to the clock-face method in supine position. No child had more than two anal lesions. No anal dilatation, sphincter hypotonia, anal scars, anal lacerations or bruises were found. The two most common anal lesions were anal fissures and skin tags. These anal lesions were mainly observed at the median line and were due to constipation. No cases of multiple anal lesions were found in terms of common digestive diseases. Copyright © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

  11. Relationship between anal symptoms and anal findings

    PubMed Central

    Kuehn, Hans Georg; Gebbensleben, Ole; Hilger, York; Rohde, Henning

    2009-01-01

    Background: The frequencies and types of anal symptoms were compared with the frequencies and types of benign anal diseases (BAD). Methods: Patients transferred from GPs, physicians or gynaecologists for anal and/or abdominal complaints/signs were enrolled and asked to complete a questionnaire about their symptoms. Proctologic assessment was performed in the knee-chest position. Definitions of BAD were tested in a two year pilot study. Findings were entered into a PC immediately after the assessment of each individual. Results: Eight hundred seven individuals, 539 (66.8%) with and 268 without BAD were analysed. Almost one third (31.2%) of patients with BAD had more than one BAD. Concomitant anal findings such as skin tags were more frequently seen in patients with than without BAD (<0.01). After haemorrhoids (401 patients), pruritus ani (317 patients) was the second most frequently found BAD. The distribution of stages in 317 pruritus ani patients was: mild (91), moderate (178), severe (29), and chronic (19). Anal symptoms in patients with BAD included: bleeding (58.6%), itch (53.7%), pain (33.7%), burning (32.9%), and soreness (26.6%). Anal lesions could be predicted according to patients' answers in the questionnaire: haemorrhoids by anal bleeding (p=0.032), weeping (p=0.017), and non-existence of anal pain (p=0.005); anal fissures by anal pain (p=0.001) and anal bleeding (p=0.006); pruritus ani by anal pain (p=0.001), itching (p=0.001), and soreness (p=0.006). Conclusions: The knee-chest position may allow for the accumulation of more detailed information about BAD than the left lateral Sims' position, thus enabling physicians to make more reliable anal diagnoses and provide better differentiated therapies. PMID:19277253

  12. Electromagnetic assessment of embedded micro antenna for a novel sphincter in the human body.

    PubMed

    Zan, Peng; Liu, Jinding; Ai, Yutao; Jiang, Enyu

    2013-05-01

    This paper presents a wireless, miniaturized, bi-directional telemetric artificial anal sphincter system that can be used for controlling patients' anal incontinence. The artificial anal sphincter system is mainly composed of an executive mechanism, a wireless power supply system and a wireless communication system. The wireless communication system consists of an internal RF transceiver, an internal RF antenna, a data transmission pathway, an external RF antenna and an external RF control transceiver. A micro NMHA (Normal Mode Helical Antenna) has been used for the transceiver of the internal wireless communication system and a quarter wave-length whip antenna of 7.75 cm has been used for the external wireless communication system. The RF carrier frequency of wireless communication is located in a license-free 433.1 MHz ISM (Industry, Science, and Medical) band. The radiation characteristics and SAR (Specific Absorption Rate) are evaluated using the finite difference time-domain method and 3D human body model. Results show that the SAR values of the antenna satisfy the ICNIRP (International Commission on Nonionizing Radiation Protection) limitations.

  13. Injections of botulinum A toxin for the treatment of anal fissures.

    PubMed

    Trzciński, Radzisław; Dziki, Adam; Tchórzewski, Marcin

    2002-01-01

    To find out how injections of botulinum A toxin influence the healing of anal fissures. Retrospective study. Medical University of Lodz, Poland. 13 patients (6 women, 7 men), mean age 49 (range 31-78), treated with injections of botulinum A toxin 50 units on either side of the anal fissure into the internal anal sphincter from May to December 1999. Complications and relapse. Seven fissures had healed by one month and four by two months. Two remained unhealed but asymptomatic. There was no incontinence of flatus or faeces after three months of treatment. Resting anal pressure was significantly lower in 10 of 13 patients compared with before treatment (p < 0.05). One fissure relapsed after 4 months and this patient had a successful anal stretch. Injection of botulinum A toxin gives good results in the treatment of anal fissures.

  14. [Treatment of deep anal fistulas using a flap from the rectal wall].

    PubMed

    Detry, R; Kartheuser, A; Remacle, G

    1994-01-01

    Classic treatment of high anal fistulas by the laying open technique requires total or subtotal section of the sphincter muscles and results in anal incontinence. This study assesses the efficacy of the flap advancement technique in these cases. It entails the resection of the crypt at the origin of the fistula, the area being covered by a mucomuscular flap of the rectal wall. From 1977 to early 1992, 18 patients (13 female and 5 male patients; mean age: 40 years) presenting with a deep anal fistula underwent such an operation. There were 16 suprasphincteric and 2 high transsphincteric tracts. Associated IBD was noted in 7 cases (5 Crohn's colitis, 2 UC). Five fistulas were of obstetrical origin. In 8 cases, patients had undergone previous surgical treatments without success. All patients had a flap advancement. In 2 cases, a colostomy had been previously carried out. Two more diverting stomies were performed (combined abdominal procedures). No mortality or morbidity was encountered. Mean postoperative stay was 8 days. Current status could be established in all patients. Three immediate failures were observed (1 case of Crohn's disease, two recurring cases). All the other patients did well with persistent healing of the fistula after a mean follow-up of 61 months (range, 6-150). Three stomies were closed; one patient delayed the procedure. Functional results were excellent. In the "success" group, all the evaluable patients (14/15) had normal fecal continence. Two female patients are still complaining of mild flatus incontinence. In the failure group, the preoperative anorectal function was maintained.(ABSTRACT TRUNCATED AT 250 WORDS)

  15. Lateral internal sphincterotomy for surgically recurrent chronic anal fissure.

    PubMed

    Liang, Jennifer; Church, James M

    2015-10-01

    Lateral internal sphincterotomy cures chronic anal fissure by preventing internal sphincter hypertonia. However, cutting sphincter predisposes to sphincter dysfunction, manifests as incontinence of gas, liquid, or stool. Surgeons, therefore, can be too cautious in its use, making ineffective superficial incisions or avoiding the operation altogether. This study is designed to confirm the role of redo lateral internal sphincterotomy in the treatment of surgically recurrent chronic anal fissure. Patients undergoing repeat lateral internal sphincterotomy for surgically recurrent chronic anal fissure were accessed from a prospectively maintained database. Chronicity was defined by symptoms persisting more than 3 weeks. Contralateral sphincterotomy was performed with electrocautery through a stab incision over the intersphincteric plane. The length of sphincter division was the same as the length of the fissure. Phone questionnaire was administered and fecal continence was assessed by modified Cleveland Clinic Incontinence Score. Patients were asked to rank their overall satisfaction with the operation, and pre- and postoperative quality of life. There were 57 patients, 24 women and 33 men; mean age was 47.9 ± 14.8 years. Mean follow-up was 12.5 ± 4.2 years (range 6.2 to 25.2 years). Presenting symptoms included pain (100%), bleeding (80%), pruritus ani (39%), constipation (26%), and diarrhea. Fifty patients (90%) presented with 1 fissure, and 40 were posterior. Most procedures were performed on an outpatient basis. Fissure healing rate was 98%, and 2 patients (4%) developed minor incontinence postoperatively (one of gas, the other, gas and seepage). Overall satisfaction was 9.7 ± .9 out of 10 with a significant improvement in the quality of life from 5.7 ± 2.4 out of 10 to 9.3 ± 1.4 out of 10 (P < .001). Judicious repeat lateral sphincterotomy cures recurrent chronic fissures with minimal risk of incontinence. Copyright © 2015 Elsevier Inc. All rights reserved.

  16. Chronic anal fissures: Open lateral internal sphincterotomy result; a case series study.

    PubMed

    Salih, Abdulwahid M

    2017-03-01

    Anal fissure are defined as a tear in the skin of the anal canal distal to dentate line. Although still there are controversies about the exact management, lateral sphincterotomy is promising. The aim of this series is to present the outcome of lateral sphincterotomy for internal anal sphincter in term of patient satisfaction and complication. A prospective single cohort study, 190 patients, who were undergone lateral sphincterotomy for internal anal sphincter from 2010 to 2014, were analyzed. The operation was performed as a day case procedure. The median duration of follow up was 5 years (ranging from 3 to 6). The data were analyzed using the Statistical Package for Social sciences (SPSS) version 22. Descriptive statistic was used to describe findings. Forty three males (22.6%) and 147 females (77.4%) with a mean ± SD of age of 31.19 ± 7.78 years. Constipation was reported in 152 (80%) patients, bleeding in 131 (68.6%) cases, and pain in 142 (74.7%) patients. The median duration of the disease was 20 months (ranging from 1 to 30 months). Post-operatively, patient satisfaction was high (98.4%) with only 3 cases (1.6%) of recurrence. Conclusion: lateral sphincterotomy for internal anal sphincter, along, is the procedure of choice for management of CAF because it is effective and it can cure the disease in nearly all patients with good patient satisfaction.

  17. Novel biological strategies in the management of anal fistula.

    PubMed

    Lewis, R; Lunniss, P J; Hammond, T M

    2012-12-01

    The mostly widely studied biomaterials for the sphincter sparing treatment of anal fistulas are fibrin glue and the anal fistula plug (AFP). However their overall mean clinical success is only 50-60%. As the understanding of the pathology of anal fistula, wound healing and the host response to materials has improved, so new biological sphincter-sparing strategies have been developed. The aim of this review is to assess the safety and efficacy of these novel techniques. PubMed, the Cochrane database and EMBASE were independently searched. All studies that investigated the potential of a biomaterial (defined as any synthetic or biologically derived substance in contact with host tissue) to augment the healing of anal fistula without sphincter division were included. Studies solely describing the role of fibrin glue or an AFP were excluded. Data extraction included type of material, fistula aetiology, treatment of the primary tract, fistula healing, incontinence, duration of follow-up and any specific complications. Systematic quality assessment of the included articles was performed. Twenty-three articles were finally selected for review. These included a variety of biological and synthetic systems that were employed to deliver selected components of the extracellular matrix, growth factors, cytokines, stem cells or drugs to the fistula tract. To date no study matches fistulotomy with regard to long-term fistula eradication rate. This is probably due to implant extrusion, inadequate track preparation or an unsuitable material. Future techniques need to address all these issues to ensure success. Success should be validated by MRI or long-term follow-up. © 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.

  18. Sphincter of Oddi Dysfunction: A Perplexing Presentation

    PubMed Central

    Din, Sana Ahmad; Naimi, Iman; Beg, Mirza

    2016-01-01

    Sphincter of Oddi dysfunction is caused by stenosis or dyskinesia of the sphincter of Oddi, leading to blockage of bile drainage from the common bile duct. We present the case of a 16-year-old female with chronic abdominal pain who underwent laparoscopic cholecystectomy for cholelithiasis but continued to experience abdominal pain, nausea, and vomiting along with persistently elevated ALT and AST levels. Postoperative abdominal ultrasound was nondiagnostic. Esophagogastroduodenoscopy showed mild reflux esophagitis and mild chronic Helicobacter pylori-negative gastritis. Omeprazole was started, but it did not decrease the frequency and severity of the abdominal symptoms. Magnetic resonance cholangiopancreatography did not reveal any pathology. Endoscopic retrograde cholangiopancreatography with manometry confirmed an elevated biliary sphincter pressure. Biliary sphincterotomy was performed, and the symptoms improved. PMID:28100991

  19. Simultaneous penile prosthesis and male sling/artificial urinary sphincter.

    PubMed

    Lee, Dominic; Romero, Claudio; Alba, Frances; Westney, O Lenaine; Wang, Run

    2013-01-01

    Erectile dysfunction (ED) and stress urinary incontinence (SUI) from urethral sphincteric deficiency is not an uncommon problem. The commonest etiology is intervention for localized prostate cancer and/or radical cystoprostatectomy for muscle invasive bladder cancer. Despite advances in surgical technology with robotic assisted laparoscopic prostatectomy and nerve sparing techniques, the rates of ED and SUI remain relatively unchanged. They both impact greatly on quality of life domains and have been associated with poor performance outcomes. Both the artificial urinary sphincter and penile prosthesis are gold standard treatments with proven efficacy, satisfaction and durability for end-stage SUI and ED respectively. Simultaneous prosthesis implantation for concurrent conditions has been well described, mostly in small retrospective series. The uptake of combination surgery has been slow due in part to technical demands of the surgery and to an extent, a heightened anxiety over potential complications. This paper aims to discuss the technical aspect of concurrent surgery for both disease entity and the current published outcomes of the various surgical techniques with this approach.

  20. Simultaneous penile prosthesis and male sling/artificial urinary sphincter

    PubMed Central

    Lee, Dominic; Romero, Claudio; Alba, Frances; Westney, O Lenaine; Wang, Run

    2013-01-01

    Erectile dysfunction (ED) and stress urinary incontinence (SUI) from urethral sphincteric deficiency is not an uncommon problem. The commonest etiology is intervention for localized prostate cancer and/or radical cystoprostatectomy for muscle invasive bladder cancer. Despite advances in surgical technology with robotic assisted laparoscopic prostatectomy and nerve sparing techniques, the rates of ED and SUI remain relatively unchanged. They both impact greatly on quality of life domains and have been associated with poor performance outcomes. Both the artificial urinary sphincter and penile prosthesis are gold standard treatments with proven efficacy, satisfaction and durability for end-stage SUI and ED respectively. Simultaneous prosthesis implantation for concurrent conditions has been well described, mostly in small retrospective series. The uptake of combination surgery has been slow due in part to technical demands of the surgery and to an extent, a heightened anxiety over potential complications. This paper aims to discuss the technical aspect of concurrent surgery for both disease entity and the current published outcomes of the various surgical techniques with this approach. PMID:23202702

  1. Anorectal conditions: anal fissure and anorectal fistula.

    PubMed

    Fox, Audralan; Tietze, Pamela H; Ramakrishnan, Kalyanakrishnan

    2014-04-01

    Anal fissures are linear splits in the anal mucosa. Acute fissures typically resolve within a few weeks; chronic fissures persist longer than 8 to 12 weeks. Most fissures are posterior and midline and are related to constipation or anal trauma. Painful defecation and rectal bleeding are common symptoms. The diagnosis typically is clinical. High-fiber diet, stool softeners, and medicated ointments relieve symptoms and speed healing of acute fissures but offer limited benefit in chronic fissures. Lateral internal sphincterotomy is the surgical management of choice for chronic and refractory acute fissures. Anorectal fistula is an abnormal tract connecting the anorectal mucosa to the exterior skin. Fistulas typically develop after rupture or drainage of a perianal abscess. Fistulas are classified as simple or complex; low or high; and intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric. Inspection of the perianal area identifies the skin opening, and anoscopy visualizes internal openings. The goal of management is to obliterate the tract and openings with negligible sphincter disruption to minimize incontinence. Fistulotomy is effective for simple fistulas; patients with complex fistulas may require fistulectomy. Other procedures that are used include injection of fibrin glue or insertion of a bioprosthetic plug into the fistula opening.

  2. [German Artificial Sphincter System--GASS. Development and in vitro evaluation of a novel, fully-implantable, highly integrated sphincter prosthesis for therapy of high-grade fecal incontinence].

    PubMed

    Schrag, Hans J; Padilla, Federico F; Doll, A; Goldschmidtböing, Frank; Woias, Peter; Hopt, Ulrich T

    2004-10-01

    No highly integrated sphincter prosthesis for therapy of major fecal incontinence exists. Therefore, we developed a novel neosphincter, made of polyurethane. The GASS consists of a support ring (SR) which includes a fluid reservoir, fixed on the outer diameter of the SR, and a multi-chamber occluding cuff (C(int)) on the inside diameter. The total inflation volume of C(int) is about 23 cc. The integrated micropump based on piezotechnology measures 30x13x1 mm3 (flowrate 1.4 cc/min, max. backpressure 40,000 Pa) . GASS was evaluated around the external sphincter of isolated porcine anal canals. The threshold of continence was defined as the inflating volume which water ceased to leak through the area occluded by C(int) under an induced rectal pressure of 150 cm H2O. Minimal filling volumes maintained continence for liquids against high luminal pressures. A low intraanal resting pressure (delta p(anal)) induced by activated GASS indicates a little risk of ischemic injury of the anal canal in vivo (median delta p(anal) 24.1 mm hg:15 cc vs 46.9 mm hg:21 cc). In summary, a highly integrated and efficient high-tech neosphincter for the therapy of major fecal incontinence could be realized.

  3. Obstetric Sphincter Injury Interacts with Diarrhea and Urgency to Increase the Risk of Fecal Incontinence in Women with IBS

    PubMed Central

    Robinson, Barbara L.; Matthews, Catherine A.; Palsson, Olafur S; Geller, Elizabeth; Turner, Marsha; Parnell, Brent; Crane, Andrea; Jannelli, Mary; Wells, Ellen; Connolly, AnnaMarie; Lin, Feng-Chang; Whitehead, William E.

    2014-01-01

    Objectives To confirm that fecal urgency and diarrhea are independent risk factors for fecal incontinence (FI), to identify obstetrical risk factors associated with FI in women with IBS (irritable bowel syndrome), and to determine whether obstetric anal sphincter injuries interact with diarrhea or urgency to explain the occurrence of FI. Methods The study is a supplement to a diary study of bowel symptoms in 164 female patients with IBS. Subjects completed daily bowel symptom diaries for 90 consecutive days and rated each bowel movement (BM) for stool consistency and presence of urgency, pain, and FI. All female participants from the parent study were invited to complete a telephone-administered 33-item bowel symptom and obstetric history questionnaire which included the Fecal Incontinence Severity Index (FISI). Results Out of 164 women in the parent study, 115 (70.1%) completed the interview. Seventy-four (45.1%) reported FI on their diary including 34 (29.6%) who reported at least one episode per month, 112 (97.4%) reported episodes of urgency, and 106 (92.2%) reported episodes of diarrhea. The mean FISI score was 13.9±9.7. Upon multivariable analysis, FI was significantly associated with parity (p=0.007), operative vaginal delivery (p=0.049), obstetrical sphincter lacerations (p=0.007), fecal urgency (p=0.005), diarrhea (p=0.008), and hysterectomy (p=0.004), but was not associated with episiotomy, pelvic organ prolapse, or urinary incontinence. The synergistic interactions of obstetric anal sphincter laceration with urgency (p=0.002) and diarrhea (p=0.004) were significant risk factors for FI. Conclusion Fecal urgency and diarrhea are independent risk factors for FI, and they interact with obstetric anal sphincter laceration to amplify the risk of FI. PMID:23321658

  4. Sphincter-saving surgeries for rectal cancer: A single center study from Kashmir

    PubMed Central

    Mir, Shabeer Ahmed; Chowdri, Nisar A.; Parray, Fazl Q.; Mir, Parvez Ahmed; Bashir, Yasir; Nafae, Muntakhab

    2013-01-01

    Summary and Background Data: The goals in the treatment of rectal cancer are cure, local control, and preservation of sphincter, bladder and sexual function. Surgical resection using sharp mesorectal dissection is important for achieving these goals. Objectives: The current treatment of choice for carcinoma rectum is sphincter saving procedures, which have practically replaced the previously done abdominoperineal resection. We performed a study in our institute to evaluate the surgical outcome and complications of rectal cancer. Materials and Methods: This prospectivestudy included 117 patients, treated for primary rectal cancer by low anterior resection (LAR) from May 2007 to December 2010. All patients underwent standard total mesorectal excision (TME) followed by restoration of continuity. Results: The peri-operative mortality rate was 2.5% (3/117). Post-operative complications occurred in 32% of the patients. After a median follow up of 42 months, local recurrences developed in 6 (5%) patients and distant metastasis in 5 (4.2%). The survival rate was 93%. Conclusion: The concept of total mesorectal excision (TME), advances in stapling technology and neoadjuvant therapy have made it possible to preserve the anal sphincter in most of the patients. Rectal cancer needs to be managed especially in a specialized unit for better results. PMID:24455643

  5. Effects of thienorphine on contraction of the guinea pig sphincter of Oddi, choledochus and gall bladder.

    PubMed

    Zhou, Peilan; Li, Tingting; Su, Ruibin; Gong, Zehui

    2014-08-15

    Opioid analgesics are widely believed to cause spasm of the bile duct sphincter and so impede bile flow. Thienorphine is a partial opioid agonist that is a good candidate for the treatment of opioid dependence; however, to date, no studies have reported the effects of thienorphine on the function of the biliary tract. This study examined the in vivo effects of thienorphine on the guinea pig isolated sphincter of Oddi, choledochus and gall bladder and on bile flow. The area under the curve (AUC) of isolated sphincter of Oddi was not influenced by thienorphine or buprenorphine, whereas morphine increased the AUC of the isolated sphincter of Oddi in a concentration-dependent manner. Thienorphine and buprenorphine concentration-dependently decreased the AUC of isolated choledochus, while morphine increased the AUC of isolated choledochus. Thienorphine had no effect on the contractile amplitude or basal tension of isolated gall bladder muscle strips. In contrast, buprenorphine and morphine increased the contractile basal tension of isolated gall bladder muscle strips in a concentration-dependent manner. Thienorphine (0.01-1.0mg/kg) had no significant inhibitory effect on bile flow. However, morphine (1.0-10mg/kg) and buprenorphine (1.0mg/kg) significantly inhibited bile flow. The maximum inhibition of bile flow by buprenorphine was 63.9±12.9% and by morphine was 74.1±11.3%. In summary, thienorphine has little influence on the guinea pig isolated sphincter of Oddi, choledochus and gall bladder or on bile flow, which may result in a lack of adverse biliary colic effects. Copyright © 2014 Elsevier B.V. All rights reserved.

  6. [Some critical issues in the diagnosis and treatment of complex anal fistula].

    PubMed

    Ren, Donglin; Zhang, Heng

    2015-12-01

    In the past thirty years, colorectal surgeons have made great progress regarding the diagnosis and treatment of complex anal fistula, including the improvement of the accuracy of the preoperative evaluation of complex anal fistula, the improvement and standardization of the diagnosis and treatment of perianal fistulising Crohn's disease, the application of various "sphincter-sparing" procedures. However, complex anal fistula continues to prove a formidable challenge with a high recurrence rate and high incontinence rate. The variety of the surgical treatment also means that there is still no established "golden standard" with respect to that of the complex anal fistula. According to recent relevant literatures and personal experience, some critical issues in the diagnosis and treatment of complex anal fistula, including the approach to the accurate diagnosis, the value and significance of seton technique, the individual algorithm between the minimal invasive and extensive surgical treatments, the value of biopsy, are discussed in this article.

  7. Anal Health Care Basics.

    PubMed

    Chang, Jason; Mclemore, Elisabeth; Tejirian, Talar

    2016-01-01

    Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. When treating a patient with an anal complaint, the primary goals are to first diagnose the etiology of the symptoms correctly, then to provide an effective and appropriate treatment strategy.The first step in this process is to take an accurate history and physical examination. Specific questions include details about bowel habits, anal hygiene, and fiber supplementation. Specific components of the physical examination include an external anal examination, a digital rectal examination, and anoscopy if appropriate.Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags. However, each problem presents differently and requires a different approach for management. It is of paramount importance that the correct diagnosis is reached. Common errors include an inaccurate diagnosis of hemorrhoids when other pathology is present and subsequent treatment with a steroid product, which is harmful to the anal area.Most of these problems can be avoided by improving bowel habits. Adequate fiber intake with 30 g to 40 g daily is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases.In this Special Report, we provide an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.

  8. Anal Health Care Basics

    PubMed Central

    Chang, Jason; McLemore, Elisabeth; Tejirian, Talar

    2016-01-01

    Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. When treating a patient with an anal complaint, the primary goals are to first diagnose the etiology of the symptoms correctly, then to provide an effective and appropriate treatment strategy. The first step in this process is to take an accurate history and physical examination. Specific questions include details about bowel habits, anal hygiene, and fiber supplementation. Specific components of the physical examination include an external anal examination, a digital rectal examination, and anoscopy if appropriate. Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags. However, each problem presents differently and requires a different approach for management. It is of paramount importance that the correct diagnosis is reached. Common errors include an inaccurate diagnosis of hemorrhoids when other pathology is present and subsequent treatment with a steroid product, which is harmful to the anal area. Most of these problems can be avoided by improving bowel habits. Adequate fiber intake with 30 g to 40 g daily is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases. In this Special Report, we provide an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists. PMID:27723447

  9. Laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency: Mid-term outcomes.

    PubMed

    Ferreira, Carlos; Brychaert, Pierre-Emannuel; Menard, Johann; Mandron, Eric

    2017-04-01

    To analyze the safety and the mid-term continence rates of laparoscopic implantation of artificial urinary sphincter in women. A total of 52 women with intrinsic sphincter deficiency underwent a laparoscopic artificial urinary sphincter implantation from 2005 to 2015 at Surgical Clinic Du Pré, Le Mans, France. The artificial urinary sphincter was implanted around the bladder neck by a transperitoneal laparoscopic approach to the Retzius space. Urodynamic assessment was carried out. Postoperative functional outcome was defined as success (no leaking, no pad use), improvement (>50% decrease in number of leakages, >50% decrease in number of pads used or use of light protection) or failure (<50% improvement, persistent or increased leaking). Outcome measures also included perioperative and long-term complications. The mean age of the patients was 69.1 years (range 64-82 years). After a mean follow up of 37.5 months (median 24 months; range 1-125 months), 38 (77.6%) patients were considered to be continent (no leakage, no pads), and eight (16.3%) improved their grade of incontinence. Three patients abandoned the follow-up schedule and were excluded. There was no perioperative severe complication. Artificial urinary sphincter revision was needed in 11 (22.4%) patients, requiring a total of seven redo procedures and four permanent sphincter removals. The main reasons for redo procedures were six (11.2%) mechanical problems and one vaginal erosion (2%). Herein we report one of the largest series with the longest follow up evaluating the outcomes of laparoscopic artificial urinary sphincter implantation in female patients. This approach seems to be a safe and effective treatment option for patients with intrinsic sphincter deficiency. © 2017 The Japanese Urological Association.

  10. Sphincter of Oddi Function and Risk Factors for Dysfunction.

    PubMed

    Afghani, Elham; Lo, Simon K; Covington, Paul S; Cash, Brooks D; Pandol, Stephen J

    2017-01-01

    The sphincter of Oddi (SO) is a smooth muscle valve regulating the flow of biliary and pancreatic secretions into the duodenum, initially described in 1887 by the Italian anatomist, Ruggero Oddi. SO dysfunction (SOD) is a broad term referring to numerous biliary, pancreatic, and hepatic disorders resulting from spasms, strictures, and relaxation of this valve at inappropriate times. This review brings attention to various factors that may increase the risk of SOD, including but not limited to: cholecystectomy, opiates, and alcohol. Lack of proper recognition and treatment of SOD may be associated with clinical events, including pancreatitis and biliary symptoms with hepatic enzyme elevation. Pharmacologic and non-pharmacologic approaches are discussed to help recognize, prevent, and treat SOD. Future studies are needed to assess the treatment benefit of agents such as calcium-channel blockers, glyceryl trinitrate, or tricyclic antidepressants in patients with SOD.

  11. Sphincter of Oddi Function and Risk Factors for Dysfunction

    PubMed Central

    Afghani, Elham; Lo, Simon K.; Covington, Paul S.; Cash, Brooks D.; Pandol, Stephen J.

    2017-01-01

    The sphincter of Oddi (SO) is a smooth muscle valve regulating the flow of biliary and pancreatic secretions into the duodenum, initially described in 1887 by the Italian anatomist, Ruggero Oddi. SO dysfunction (SOD) is a broad term referring to numerous biliary, pancreatic, and hepatic disorders resulting from spasms, strictures, and relaxation of this valve at inappropriate times. This review brings attention to various factors that may increase the risk of SOD, including but not limited to: cholecystectomy, opiates, and alcohol. Lack of proper recognition and treatment of SOD may be associated with clinical events, including pancreatitis and biliary symptoms with hepatic enzyme elevation. Pharmacologic and non-pharmacologic approaches are discussed to help recognize, prevent, and treat SOD. Future studies are needed to assess the treatment benefit of agents such as calcium-channel blockers, glyceryl trinitrate, or tricyclic antidepressants in patients with SOD. PMID:28194398

  12. Treatment of gastrointestinal sphincters spasms with botulinum toxin A.

    PubMed

    Brisinda, Giuseppe; Sivestrini, Nicola; Bianco, Giuseppe; Maria, Giorgio

    2015-05-29

    Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.

  13. Treatment of Gastrointestinal Sphincters Spasms with Botulinum Toxin A

    PubMed Central

    Brisinda, Giuseppe; Sivestrini, Nicola; Bianco, Giuseppe; Maria, Giorgio

    2015-01-01

    Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract. PMID:26035487

  14. Endometriosis and Vesico-Sphincteral Disorders.

    PubMed

    Fadhlaoui, Anis; Gillon, Tessa; Lebbi, Issam; Bouquet de Jolinière, Jean; Feki, Anis

    2015-01-01

    The aim of this mini review is to determine the relationship between endometriosis and urinary tract symptoms and to investigate the consequences of surgical treatment of mild to severe endometriosis, especially deep lesions, on the vesico-sphincteral function (lower urinary tract function). We performed a literature review by searching the MEDLINE database for articles published between 2000 and 2014, limiting the searches to the words: urinary tract, vesico-sphincteral, dysfunction, endometriosis, symptoms, and surgery. The incidence of vesico-sphincteral symptoms in endometriosis varies from 3.4 up to 15.4%. The frequency of such symptoms seems to be under estimated because of a lack of specific questionnaire including urinary symptoms. Urodynamic evaluation could help to detect unsuspected abnormalities. It seems that endometriosis surgery (particularly deep infiltrating lesions) is a purveyor of de novo urinary dysfunction, with an incidence varying from 6.8 up to 17.5%. Nerve sparing processes such as neuro-navigators or neuro-stimulators seem to be promising techniques to avoid postoperative urinary tract dysfunction. A precise anamnesis and the use of specific validated questionnaires (IPSS and BFLUTS) improve the screening of vesico-sphincteral symptoms in case of endometriosis. No recommendation can be found in the literature about the place of urodynamic evaluation. Most publications lack of proof and therefore do not allow making recommendations about optimal treatment of endometriotic lesions to avoid urinary tract disorders.

  15. Treatment of non-IBD anal fistula.

    PubMed

    Lundby, Lilli; Hagen, Kikke; Christensen, Peter; Buntzen, Steen; Thorlacius-Ussing, Ole; Andersen, Jens; Krupa, Marek; Qvist, Niels

    2015-05-01

    The course of the fistula tract in relation to the anal sphincter is identified by clinical examination under general anaesthesia using a fistula probe and injection of fluid into the external fistula opening. In the event of a complex fistula or in the case of fistula recurrence, this should be supplemented with an endoluminal ultrasound scan and/or an MRI scan. St. Mark's fistula chart should be used for the description. Simple fistulas are amenable to fistulotomy, whereas treatment of complex fistulas requires special expertise and management of all available treatment modalities to tailor the right operation to the individual patient. The given levels of evidence and grades of recommendations are according to the Oxford Centre for Evidence-based Medicine (www.cemb.net).

  16. Video-assisted anal fistula treatment.

    PubMed

    Kochhar, Gaurav; Saha, Sudipta; Andley, Manoj; Kumar, Ashok; Saurabh, Gyan; Pusuluri, Rahul; Bhise, Vikas; Kumar, Ajay

    2014-01-01

    Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. The latest addition to the list of treatment options is video-assisted anal fistula treatment (VAAFT). It is a minimally invasive, sphincter-saving procedure with low morbidity. The aim of our study was to compare the results with a premier study done previously. The procedure involves diagnostic fistuloscopy and visualization of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with a stapling device or suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source. The study was conducted from July 2010 to March 2014. Eighty-two patients with fistula in ano were operated on with VAAFT and were followed up according to the study protocol. The recurrence rate was 15.85%, with recurrences developing in 13 cases. Postoperative pain and discomfort were minimal. VAAFT is a minimally invasive procedure performed under direct visualization. It enables visualization of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite encouraging.

  17. Dilated common duct sign. A potential indicator of a sphincter of Oddi dyskinesia

    SciTech Connect

    DeRidder, P.; Fink-Bennett, D.

    1984-05-01

    The cholescintigraphic findings of a Sphincter of Oddi dyskinesia (SOD) in a 45-year-old woman with persistent right upper quadrant pain and biliary colic are reported. After an overnight fast, the patient was injected with 5 mCi of Tc-99 disofenin and .02 micrograms/kg of cholecystokinin (CCK) post maximal gallbladder filling. Pre and postcholescintiscans were obtained and gallbladder ejection fractions determined. The hepatobiliary scan was normal, except for a delay in biliary-bowel transit. The gallbladder responded normally to CCK, however, the Sphincter of Oddi responded abnormally, as there was a paradoxical response to CCK manifested by a marked dilatation of the common bile duct. It was postulate that this dilatation (the dilated common duct sign) was due to an inappropriate response of the smooth muscle of the Sphincter of Oddi (contraction vs relaxation) to CCK and was the cause of this patient's biliary colic. The dilated common duct sign should alert the physician to the possibility of a Sphincter of Oddi dyskinesia.

  18. Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis.

    PubMed

    Hong, K D; Kang, S; Kalaskar, S; Wexner, S D

    2014-08-01

    Sphincter-preserving approaches to treat anal fistula do not jeopardize continence; however, healing rates are suboptimal. In this context, ligation of the intersphincteric fistula tract (LIFT) can be considered promising offering high success rates and a relatively simple procedure. This review aimed to investigate the outcomes of LIFT to treat anal fistula. We conducted a systematic review of the Pubmed, Web of Science, and Cochrane databases, to retrieve all relevant scientific original articles and scientific abstracts (Web of Science) related to the LIFT procedure for anal fistula between January 2007 and March 2013. The search yielded 24 original articles including 1,110 patients; these included one randomized controlled study, three case control studies, and 20 case series. Most studies included patients with trans-sphincteric or complex fistula, not amenable to fistulotomy. During a pooled mean 10.3 months of follow-up, the mean success, incontinence, intraoperative, and postoperative complication rates were 76.4, 0, 0, and 5.5%, respectively. A sensitivity analysis showed that the impact on success in terms of follow-up duration, study size, and combining other procedures was limited. There was no association between pre-LIFT drainage seton and success of LIFT. Ligation of the intersphincteric fistula tract appears to be an effective and safe treatment for trans-sphincteric or complex anal fistula. Combining other procedures and a pre-LIFT drainage seton does not seem to confer any added benefit in terms of success. However, given the lack of prospective randomized trials, interpretation of these data must be cautious. Further trials are mandatory to identify predictive factors for success, and true effectiveness of the LIFT compared to other sphincter-preserving procedures to treat anal fistula.

  19. Comparison of Endoanal Ultrasound with Clinical Diagnosis in Anal Fistula Assessment.

    PubMed

    Sirikurnpiboon, Siripong; Phadhana-anake, Oradee; Awapittaya, Burin

    2016-02-01

    Anal fistula anatomy and its relationship with anal sphincters are important factors influencing the results of surgical management. Pre-operative definitions of fistulous track(s) and the internal opening play a primary role in minimizing damage to the sphincters and recurrence of the fistula. To evaluate the relative accuracy of digital examination and endoanal ultrasound for pre-operative assessment of anal fistula by comparing operative findings. A retrospective review was conducted of all patients with anal fistula admitted to the surgical unit between May 2008 and May 2012. Physical examination and hydrogen peroxide-enhanced endoanal ultrasound (utilising a 10 MHz endoprobe, HITACHI: EUB-7500), were performed in 142 consecutive patients. Results were matched with surgical features to establish their accuracy in preoperative anal fistula assessment. A total of 142 patients (107 men, 35 women), 28 of whom had had previous surgery, were included in the study. Their mean age was 40 (range 18-71) years and their mean BMI was 26.37 (range 17.30-36.11) kg/m². The majority of the fistulas were transphincteric (90.4%) and the rest were intersphincteric (9.6%). The accuracy rates of clinical examination and endoanal ultrasound were 55.63 and 95.07 percent (p < 0.01), respectively. Endoanal ultrasound is superior to digital examination for pre-operative classification of anal fistula

  20. V-Y advancement flap as first-line treatment for all chronic anal fissures.

    PubMed

    Chambers, William; Sajal, Rai; Dixon, Anthony

    2010-05-01

    It was suggested that anal advancement flap be used to treat patients with chronic anal fissures that have failed medical management and have a low-pressure sphincter complex. We wished to assess anal advancement flap as a treatment for all chronic anal fissures. All patients with chronic anal fissures regardless of their previous management underwent V-Y advancement flap. Patient demographics, symptom duration, previous treatments, short-term postoperative outcome and long-term follow-up were recorded. Fifty-four consecutive patients, median age 39 years (22-66), underwent a V-Y advancement flap over a 7-year period; 34 were men. Duration of symptoms ranged from 2 to 36 months with a median of 8 months. Forty-two patients (78%) had failed a previous therapy: glyceryl trinitrate (GTN) (25), GTN and diltiazem (16) and lateral sphincterotomy (one). Wound dehiscence occurred in three patients of which only one required a surgical intervention. On follow-up at 6 months, all but one patient had a healed wound and was asymptomatic. We have shown excellent rates of healing of chronic anal fissures treated with a V-Y advancement flap regardless of sphincter pressures, previous treatment and symptom chronicity. These results show the technique can be applied to all chronic fissures with success and used as a primary therapy.

  1. Endoanal ultrasonographic evaluation of an unhealed anal fissure after the lateral internal sphincterotomy.

    PubMed

    Yucel, E; Akin, M L; Sucullu, I; Filiz, A I; Ozdemir, Y; Yildiz, M

    2013-01-01

    The aim of this study was to evaluate the outcomes of the lateral internal sphincterotomy in patients who had unhealed anal fissures using the endoanal ultrasonography. Lateral internal sphincterotomy is an effective method in treatment of chronic anal fissures, but it is associated with 1 to 5 % unhealing and recurrence rates. Endoanal ultrasonography can be used to evaluate the sphincterotomy and the efficiency of the treatment. Totally, 40 patients with unhealed anal fissures after the lateral internal sphincterotomy were enrolled consecutively. The fissures were diagnosed by proctologic examination in every patient. The results of sphincterotomy were evaluated by the endoanal ultrasonography. There were 23 men and 17 women with the median age 29.7 years (range, 20-44 years). Using the endoanal ultrasonography, an incomplete internal sphincterotomy was detected in 26 of patients. In 12 patients, while the internal sphincter was completely intact, a superficial (subcutaneous) external anal sphincterotomy was found. In two patients, although the internal sphincterotomy was observed to be sufficient, a localized abscess formation of less than 1 cm was detected at the anal crypts level. The use of endoanal ultrasonography in patients with unhealed or recurrent anal fissure is a beneficial diagnostic method in assessing the situations of sphincters after the lateral internal sphincterotomy. Although the lateral internal sphincterotomy is a successful surgical treatment and can be performed easily as an outpatient procedure, it should be performed with the correct and rigorously surgical technique (Tab. 2, Fig. 3, Ref. 31).

  2. BPC 157 therapy to detriment sphincters failure-esophagitis-pancreatitis in rat and acute pancreatitis patients low sphincters pressure.

    PubMed

    Petrovic, I; Dobric, I; Drmic, D; Sever, M; Klicek, R; Radic, B; Brcic, L; Kolenc, D; Zlatar, M; Kunjko, K; Jurcic, D; Martinac, M; Rasic, Z; Boban Blagaic, A; Romic, Z; Seiwerth, S; Sikiric, P

    2011-10-01

    Possibly, acute esophagitis and pancreatitis cause each other, and we focused on sphincteric failure as the common causative key able to induce either esophagitis and acute pancreatitis or both of them, and thereby investigate the presence of a common therapy nominator. This may be an anti-ulcer pentadecapeptide BPC 157 (tested for inflammatory bowel disease, wound treatment) affecting esophagitis, lower esophageal and pyloric sphincters failure and acute pancreatitis (10 μg/kg, 10 ng/kg intraperitoneally or in drinking water). The esophagitis-sphincter failure procedure (i.e., insertion of the tubes into the sphincters, lower esophageal and pyloric) and acute pancreatitis procedure (i.e., bile duct ligation) were combined in rats. Esophageal manometry was done in acute pancreatitis patients. In rats acute pancreatitis procedure produced also esophagitis and both sphincter failure, decreased pressure 24 h post-surgery. Furthermore, bile duct ligation alone immediately declines the pressure in both sphincters. Vice versa, the esophagitis-sphincter failure procedure alone produced acute pancreatitis. What's more, these lesions (esophagitis, sphincter failure, acute pancreatitis when combined) aggravate each other (tubes into sphincters and ligated bile duct). Counteraction occurred by BPC 157 therapies. In acute pancreatitis patients lower pressure at rest was in both esophageal sphincters in acute pancreatitis patients. We conclude that BPC 157 could cure esophagitis/sphincter/acute pancreatitis healing failure.

  3. Long-term results of the cutting seton for high anal fistula.

    PubMed

    Patton, Vicki; Chen, Chung Ming; Lubowski, David

    2015-10-01

    No single procedure for high anal fistula delivers a high cure rate while also completely protecting sphincter function. This paper reports our long-term results with the cutting seton for high fistulae and draws comparisons with advancement flap and ligation of intersphincteric fistula track (LIFT) procedures. A retrospective study of prospectively collected data in consecutive patients undergoing treatment with cutting seton for high cryptoglandular fistulae was carried out. A strict protocol dictated tightening intervals of at least 4 weeks and no muscle division. In 59 patients (male : female = 39:20) followed-up at mean 9.4 years (range 1.7-15.6 years) healing rates, continence (St Mark's score 0-24), patient-perceived overall change in bowel control (-5 to +5), faecal incontinence quality of life (FIQL) and overall patient satisfaction (visual analogue score 0-10) were assessed. Primary and secondary healing rates were 93% and 98%. Mean continence score was 4.1, significantly worse in women than men (median 6, range 0-22 versus median 1, range 0-17; P = 0.006). Seventy-eight per cent of patients had normal continence or minor incontinence (score 0-6), 13.5% moderate incontinence (score 7-12) and 8.5% severe incontinence (score >12). Sixty-three per cent of patients had no change or improved patient-perceived overall bowel control. Mean FIQL scores were high and significantly correlated with continence. Median satisfaction score was 9. Cutting seton for high anal fistula achieved healing in 98% with good continence in the majority, particularly in males, and a high level of patient satisfaction. Multicentre prospective studies are needed to adequately compare cutting seton, flap and LIFT procedures. © 2015 Royal Australasian College of Surgeons.

  4. Amoebic anal fistula: new insight into an old disease.

    PubMed

    Agrawal, Vivek; Garg, Pankaj Kumar; Jain, Bhupendra Kumar; Mishra, Kiran; Mohanty, Debajyoti

    2014-04-01

    A 67-year-old gentleman underwent fistulectomy for low trans-sphincteric anal fistula along with curettage for an associated abscess extending proximally for half a centimeter into the intersphincteric plane. The roof of the cavity became clearly visible after satisfactory culmination of the surgical procedure. Histopathological examination of the fistulous tract and the curetted granulation tissue revealed presence of multiple trophozoites of Entamoeba histolytica exhibiting erythrophagocytosis in the background of mixed inflammatory infiltrate. This case report provides the outlook that yields the novel insight into the possible role of Entamoeba histolytica in the pathogenesis and persistence of the fistulous tract.

  5. Physiology of ileal pouch-anal anastomosis. Current concepts.

    PubMed

    Goes, R; Beart, R W

    1995-09-01

    Increasing experience with ileal pouch-anal anastomosis (IPAA) associated with increasing knowledge about anorectal physiology has lead to a large number of publications. The purpose of this review is to evaluate the current understanding of fecal continence as revealed by the evolution of the ileoanal procedure. Review of the literature covering the most important physiologic parameters involved in fecal continence was undertaken. Rectoanal inhibitory reflex is probably absent after IPAA but is preserved when distal anorectal mucosa is spared. Anal resting pressure decreases but is less affected when the internal anal sphincter is less traumatized. Squeeze pressure is not importantly affected, and the importance of reservoir function as a determinant of stool frequency is emphasized. IPAA does not affect the coordination between pouch and anal canal motility in the majority of cases. Normal continence is preserved, even during the night, by preserving a gradient of pressure between the pouch and anal canal. Physiologic concepts are well established, but controversies about the continence mechanism related to IPAA remain. The IPAA procedure has allowed discrimination of details about the function of multiple structures involved in fecal continence.

  6. Preservation of anal function after total excision of the anal mucosa for Bowen's disease.

    PubMed Central

    Reynolds, V H; Madden, J J; Franklin, J D; Burnett, L S; Jones, H W; Lynch, J B

    1984-01-01

    Six women with Bowen's disease of the anogenital area were treated by total excision of the anal mucosa, perianal skin and, in some cases, partial vulvectomy. Two patients had foci of microinvasive squamous carcinoma. Adequate tumor margins were determined by frozen sections. The resulting mucosal and cutaneous defects were grafted with medium split-thickness skin grafts applied to the anal canal and sutured circumferentially to the rectal mucosa. Grafts were held in place by a finger cot inserted in the anal canal and stuffed with cotton balls. Patients were constipated five or six days with codeine. The skin grafts healed per primam. One additional patient was similarly treated for a chronic herpetic ulceration of the anus and healed. Contrary to dire predictions, all patients were able to distinguish between gaseous and solid rectal contents and sphincter function was preserved. In one patient, Bowen's disease has recurred in the grafted perianal skin. Images Fig. 1. Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 6. PMID:6372711

  7. Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure.

    PubMed

    Aslam, Muhammad I; Pervaiz, Arif; Figueiredo, Rodrigo

    2014-01-01

    Anal fissure is a common benign condition. An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge. Chronic anal fissure is defined by a history of symptoms present for more than 2 months' duration and with a triad of external skin tags, namely, a hypertrophied anal papilla, an ulcer with rolled edges, and a base exposing the internal sphincter. Because complications such as incontinence are associated with surgical treatment, chemical sphincterotomy is currently favored. The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2% nitroglycerin ointment for the treatment of chronic anal fissure. This was a quasi-experimental study carried out between January 16, 2007 and January 15, 2008 in the Surgical Department of Jinnah Hospital, Lahore, Pakistan. Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study. All recruited patients met the study inclusion criteria and were randomly assigned to one of the two groups. Group A was managed conservatively using topical 0.2% nitroglycerin ointment, whereas Group B underwent open partial lateral anal sphincterotomy. Both groups were followed up at 1 week, 2 weeks, 4 weeks, and 6 weeks after the treatment. All the patients complained of pain. A total of 43 (71.7%) patients had pain with constipation, whereas 31 (51.7%) patients had bleeding per rectum. Upon clinically examining the anal area, tenderness was elicited in all 60 (100%) patients. Group A included 30 (11 females and 19 males) cases treated with topical 0.2% nitroglycerin ointment and Group B included 30 (11 females and 19 males) cases who underwent open partial lateral anal sphincterotomy. In Group A, only 15 patients with fissures were successfully treated (50%). By contrast, 28 (93%) patients with fissures in Group B were successfully treated, and only two (7

  8. Modifications to installed Sphincter design gloveports

    SciTech Connect

    Shetty, S.S.; Gilkison, J.M.

    1993-02-01

    This paper presents the results of a study of alternative methods for replacing Sphincter designed gloveports in gloveboxes. In addition, the paper discusses modifications that are required on metal glovebox wall panels to allow replacement of the Sphincter gloveports. A review of Westinghouse Savannah River Co. (WSRC) maintenance records showed that gloveports manufactured by Central Research, Incorporated, provide the lowest risk for failure. This assessment is based on the records of glove-to-port seal life and air in-leakage. These records also indicate the glove changes are made in shorter times with fewer workers than required by alternate gloveport designs studied. These attributes culminate in a significant decrease in radiation exposure and assimilation risk of maintenance personnel replacing gloves. Further, the Central Research design reduces the number of expandable hardware parts required to achieve a glove replacement. This reduction in expendable materials can result in a significant reduction in contaminated waste volume generated during a glove replacement.

  9. [German Artificial Sphincter System--GASSII: first in vivo evaluation of a novel and highly integrated sphincter prosthesis for therapy of major fecale incontinence].

    PubMed

    Schrag, H J; Ruthmann, O; Doll, A; Woias, P; Hopt, U T

    2005-11-01

    The German Artificial Sphincter System GASS consists of a support ring which includes a fluid reservoir on the outer side and an occlusive cuff on the inner side. The cuffs are designed as polyurethane hollow bodies with a pre-determined inflation volume and are connected to an integrated piezo micropump/valve unit. To evaluate the threshold of continence, the GASS was placed around the anorectal junction via a perineal approach in one mini pig. The novel cuff design reduces the occlusion pressure and allows low compression volumes. Low operating pressures indicate a minor risk of ischemia injury of the bowel. The operation time is estimated at about 6 days with no recharging of the battery. The novel remote controlled GASS is a highly integrated prosthesis for placement around the anal canal or lower rectum and is effective in restoring continence for liquids and solids in vitro and in vivo.

  10. Multivariate Analysis of Risk Factors Associated With the Nonreversal Ileostomy Following Sphincter-Preserving Surgery for Rectal Cancer

    PubMed Central

    Kim, Young Ah; Lee, Gil Jae; Park, Sung Won; Lee, Won-Suk

    2015-01-01

    Purpose A loop ileostomy is used to protect an anastomosis after anal sphincter-preserving surgery, especially in patients with low rectal cancer, but little information is available concerning risk factors associated with a nonreversal ileostomy. The purpose of this study was to identify risk factors of ileostomy nonreversibility after a sphincter-saving resection for rectal cancer. Methods Six hundred seventy-nine (679) patients with rectal cancer who underwent sphincter-preserving surgery between January 2004 and December 2011 were evaluated retrospectively. Of the 679, 135 (19.9%) underwent a defunctioning loop ileostomy of temporary intent, and these patients were divided into two groups, that is, a reversal group (RG, 112 patients) and a nonreversal group (NRG, 23 patients) according to the reversibility of the ileostomy. Results In 23 of the 135 rectal cancer patients (17.0%) that underwent a diverting ileostomy, stoma reversal was not possible for the following reasons; stage IV rectal cancer (11, 47.8%), poor tone of the anal sphincter (4, 17.4%), local recurrence (2, 8.7%), anastomotic leakage (1, 4.3%), radiation proctitis (1, 4.3%), and patient refusal (4, 17.4%). The independent risk factors of the nonreversal group were anastomotic leakage or fistula, stage IV cancer, local recurrence, and comorbidity. Conclusion Postoperative complications such as anastomotic leakage or fistula, advanced primary disease (stage IV), local recurrence and comorbidity were identified as risk factors of a nonreversal ileostomy. These factors should be considered when drafting prudential guidelines for ileostomy closure. PMID:26161377

  11. Anal abscess and fistula.

    PubMed

    Sneider, Erica B; Maykel, Justin A

    2013-12-01

    Benign anorectal diseases, such as anal abscesses and fistula, are commonly seen by primary care physicians, gastroenterologists, emergency physicians, general surgeons, and colorectal surgeons. It is important to have a thorough understanding of the complexity of these 2 disease processes so as to provide appropriate and timely treatment. We review the pathophysiology, presentation, diagnosis, and treatment options for both anal abscesses and fistulas.

  12. Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures.

    PubMed

    Brisinda, Giuseppe; Maria, Giorgio; Sganga, Gabriele; Bentivoglio, Anna Rita; Albanese, Alberto; Castagneto, Marco

    2002-02-01

    Botulinum toxin induces healing in patients with idiopathic anal fissures. One hundred-fifty patients with posterior anal fissures were treated with botulinum toxin injected in the internal anal sphincter on each side of the anterior midline. Subjects were randomized into 2 treatment groups based on the number of units of botulinum toxin injected. Patients in group I were treated with 20 units of botulinum toxin and, if the fissure persisted, were retreated with 30 units. Patients in group II were treated with 30 units and retreated with 50 units, if the fissure persisted. The 2 groups were comparable in age, gender distribution, duration of symptoms, resting pressure, and maximum voluntary pressure at anorectal manometry. One month after the injection, examinations revealed complete healing in 55 patients (73%) from group I and 65 patients (87%) from group II (P =.04). Five patients from group II reported a mild incontinence of flatus that lasted 2 weeks after the treatment and disappeared spontaneously. The values of the resting anal pressure (P=.3) and the maximum voluntary pressure (P =.2) did not differ between the 2 groups. At 2 months' evaluation, a healing scar was found in 67 patients (89%) from group I and 72 patients (96%) from group II. A relapse of the fissure was observed in 6 patients (8%) from group I who had a healing scar at 1 month, and 2 other patients never healed. A persistent fissure was present in 3 patients from group II who had no other symptoms. Botulinum toxin injected into the internal anal sphincter is effective in managing anal fissures and avoiding permanent complications. All patients were treated with the active drug and healed after 1 or 2 successive treatments. The results also confirm that higher doses account for a higher success rate, with little increase in complications or side effects, which is probably related to the diffusion of the toxin to the external sphincter.

  13. Application of YAG laser technique in the treatment of anal fistula

    NASA Astrophysics Data System (ADS)

    Liu, Jian-xun; Zhang, Xinrong

    1993-03-01

    The method of treating anal fistula with YAG laser technique is described in this essay. One-hundred-twenty patients have been treated successfully with this method and no recurrence was found in our series. Anal fistula is a common disorder in the anus and rectum. The tunnel of fistula zigzags around the external or internal sphincters. If the drainage is poor, and the skin around the external opening grows rapidly, false healing may occur and cause recurrent abscess. In this case, a fistula can not be cured except by operation.

  14. Manometric vector volume analysis to assess lower esophageal sphincter function.

    PubMed

    Stein, H J; Korn, O; Liebermann-Meffert, D

    1995-01-01

    The resistance provided by the manometric high pressure zone at the gastroesophageal junction, is the major barrier against gastroesophageal reflux in man. Recent studies have shown that this high pressure zone has its correlate in the architecture of the gastric 'sling' fibres at the gastric notch and the semicircular 'clasps' at the lesser curvature side of the gastroesophageal junction. Pull-back manometry with radially oriented pressure transducers allows to assess these distinct components of the human lower esophageal sphincter. With the recent introduction of personal computers into the manometry laboratory, three-dimensional manometric images of the lower esophageal sphincter can be easily constructed, based on radially oriented pressures. The application of this new technology has shown that calculation of the sphincter pressure vector volume, i.e. the volume circumscribed by the three-dimensional manometric sphincter image, is superior to standard manometric techniques in the assessment of lower esophageal sphincter function. The sphincter pressure vector volume is a particularly helpful parameter to identify patients with gastroesophageal reflux disease who will not benefit from medical therapy and should consequently undergo early antireflux surgery. Vector volume analysis is also helpful in assessing the cause of recurrent symptoms in patients with previous antireflux surgery. In patients with achalasia three-dimensional sphincter imaging and vector volume analysis can illustrate a severely asymmetric and hypertensive sphincter and show the effect of myotomy with or without a concomitant antireflux procedure on the sphincter pressure profile.

  15. The changes in resting anal pressure after performing full-thickness rectal advancement flaps.

    PubMed

    Balciscueta, Zutoia; Uribe, Natalia; Mínguez, Miguel; García-Granero, Eduardo

    2017-09-01

    Advancement flap is an accepted approach for treating complex fistula-in-ano.The purpose was to evaluate the changes in resting pressure along the anal canal after performing a full-thickness flap. Manometric review of patients who have undergone a full-thickness rectal advancement flap procedure for complex anal fistulas of cryptoglandular origin. Recurrence and continence were evaluated. Resting Anal Pressure was assessed along the anal canal by two measures: maximum resting pressure(MRP) and inferior resting pressure(IRP) at 0.5 cm from the anal verge. 119 patients were evaluated. Overall recurrence rate was5.9%. Anal continence was maintained intact in 76.5%. Manometric study showed a significant decrease in postoperative MRP(90.6 ± 31.9 to 45.2 ± 20 mmHg; p < 0.001), while IRP values did not differ significantly(28.2 ± 18.3 to 23.2 ± 13.5 mmHg; p = 0.1). Performing a full-thickness rectal flap causes a decrease of the MRP in the middle third of the anal canal, due to the inclusion of the internal sphincter in flap. It seems crucial to preserve the distal internal sphincter intact as it helps both to maintain the resting pressure in the lower third and avoid deformities of the anal margin. Copyright © 2017 Elsevier Inc. All rights reserved.

  16. Prospective multicenter study of a synthetic bioabsorbable anal fistula plug to treat cryptoglandular transsphincteric anal fistulas.

    PubMed

    Stamos, Michael J; Snyder, Michael; Robb, Bruce W; Ky, Alex; Singer, Marc; Stewart, David B; Sonoda, Toyooki; Abcarian, Herand

    2015-03-01

    Although interest in sphincter-sparing treatments for anal fistulas is increasing, few large prospective studies of these approaches have been conducted. The study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug. A prospective, multicenter investigation was performed. The study was conducted at 11 colon and rectal centers. Ninety-three patients (71 men; mean age, 47 years) with complex cryptoglandular transsphincteric anal fistulas were enrolled. Exclusion criteria included Crohn's disease, an active infection, a multitract fistula, and an immunocompromised status. Draining setons were used at the surgeon's discretion. Patients had follow-up evaluations at 1, 3, 6, and 12 months postoperatively. The primary end point was healing of the fistula, defined as drainage cessation plus closure of the external opening, at 6 and 12 months. Secondary end points were fecal continence, duration of drainage from the fistula, pain, and adverse events during follow-up. Thirteen patients were lost to follow-up and 21 were withdrawn, primarily to undergo an alternative treatment. The fistula healing rates at 6 and 12 months were 41% (95% CI, 30%-52%; total n = 74) and 49% (95% CI, 38%-61%; total n = 73). Half the patients in whom a previous treatment failed had healing. By 6 months, the mean Wexner score had improved significantly (p = 0.0003). By 12 months, 93% of patients had no or minimal pain. Adverse events included 11 infections/abscesses, 2 new fistulas, and 8 total and 5 partial plug extrusions. The fistula healed in 3 patients with a partial extrusion. The study was nonrandomized and had relatively high rates of loss to follow-up. Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure.

  17. Static hydraulic urethral sphincter for treatment of urethral sphincter mechanism incompetence in 11 dogs.

    PubMed

    Delisser, P J; Friend, E J; Chanoit, G P A; Parsons, K J

    2012-06-01

    To review the postoperative results and complications associated with urethral sphincter mechanism incompetence managed with a static hydraulic urethral sphincter. Case records and a telephone owner questionnaire were retrospectively used to assess postoperative urinary continence scores (1 - dripping constantly to 10 - completely dry) and presence and frequency of complications. Eleven spayed females were included. Median continence score/10 (range) awarded preoperatively was 3 (2 to 6), and scores at two weeks, three and six months were 8 (4 to 10), 9 (4 to 10) and 8 (4 to 10), respectively. At the last survey, the median continence score of 9 (5 to 10) was significantly better (P=0·004) than before surgery. Complete continence was achieved in 36·4% of dogs. The median (range) follow-up time was 412 (118 to 749) days. Complications occurred in 9 of 11 dogs and included dysuria (n=7), bacterial cystitis (n=7), longer urination time (n=8), urinary retention (n=3), haematuria (n=1), pain (n=3) and incisional seroma (n=3). Static hydraulic urethral sphincter was frequently associated with minor complications but no major complications (i.e. those requiring further surgery). Continence scores were significantly improved compared with those before surgery, with the possibility of further improvement following inflation of the sphincter. © 2012 British Small Animal Veterinary Association.

  18. Esophageal sphincter device for gastroesophageal reflux disease.

    PubMed

    Ganz, Robert A; Peters, Jeffrey H; Horgan, Santiago; Bemelman, Willem A; Dunst, Christy M; Edmundowicz, Steven A; Lipham, John C; Luketich, James D; Melvin, W Scott; Oelschlager, Brant K; Schlack-Haerer, Steven C; Smith, C Daniel; Smith, Christopher C; Dunn, Dan; Taiganides, Paul A

    2013-02-21

    Patients with gastroesophageal reflux disease who have a partial response to proton-pump inhibitors often seek alternative therapy. We evaluated the safety and effectiveness of a new magnetic device to augment the lower esophageal sphincter. We prospectively assessed 100 patients with gastroesophageal reflux disease before and after sphincter augmentation. The study did not include a concurrent control group. The primary outcome measure was normalization of esophageal acid exposure or a 50% or greater reduction in exposure at 1 year. Secondary outcomes were 50% or greater improvement in quality of life related to gastroesophageal reflux disease and a 50% or greater reduction in the use of proton-pump inhibitors at 1 year. For each outcome, the prespecified definition of successful treatment was achievement of the outcome in at least 60% of the patients. The 3-year results of a 5-year study are reported. The primary outcome was achieved in 64% of patients (95% confidence interval [CI], 54 to 73). For the secondary outcomes, a reduction of 50% or more in the use of proton-pump inhibitors occurred in 93% of patients, and there was improvement of 50% or more in quality-of-life scores in 92%, as compared with scores for patients assessed at baseline while they were not taking proton-pump inhibitors. The most frequent adverse event was dysphagia (in 68% of patients postoperatively, in 11% at 1 year, and in 4% at 3 years). Serious adverse events occurred in six patients, and in six patients the device was removed. In this single-group evaluation of 100 patients before and after sphincter augmentation with a magnetic device, exposure to esophageal acid decreased, reflux symptoms improved, and use of proton-pump inhibitors decreased. Follow-up studies are needed to assess long-term safety. (Funded by Torax Medical; ClinicalTrials.gov number, NCT00776997.).

  19. Pathology of Anal Cancer.

    PubMed

    Hoff, Paulo M; Coudry, Renata; Moniz, Camila Motta Venchiarutti

    2017-01-01

    Anal canal cancer is rather an uncommon disease but its incidence is increasing. Squamous cell carcinoma (SCC) is the most frequent primary anal neoplasm and can encompass a variety of morphologies. HPV infection has a key role in precancerous lesions and cancer development by the production of E6 and E7 oncoproteins. Anal squamous precancerous lesions are now classified according to the same criteria and terminology as their cervical counterparts. The p16 expression by immunohistochemistry is a surrogate marker for human papilloma virus (HPV). Many other tumor types can arise in the anal canal, including adenocarcinomas, neuroendocrine tumors, malignant melanomas, lymphomas and various types of mesenchymal tumors. For differential diagnosis, immunostaining markers such as CK5/6 and p63 can be used to distinguish SCC and CK7 for adenocarcinoma. Other classical panels can also be applied as in other locations. Currently, there are no biomarkers able to predict prognosis or response to treatment in clinical practice.

  20. Anal Disorders - Multiple Languages

    MedlinePlus

    ... Supplements Videos & Tools You Are Here: Home → Multiple Languages → All Health Topics → Anal Disorders URL of this page: https://medlineplus.gov/languages/analdisorders.html Other topics A-Z Expand Section ...

  1. Complex anal fistula remains a challenge for colorectal surgeon.

    PubMed

    Cadeddu, F; Salis, F; Lisi, G; Ciangola, I; Milito, G

    2015-05-01

    Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm. The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities. Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.

  2. An outcome and cost analysis of anal fistula plug insertion vs endorectal advancement flap for complex anal fistulae.

    PubMed

    Fisher, O M; Raptis, D A; Vetter, D; Novak, A; Dindo, D; Hahnloser, D; Clavien, P-A; Nocito, A

    2015-07-01

    The study aimed to compare the rate of success and cost of anal fistula plug (AFP) insertion and endorectal advancement flap (ERAF) for anal fistula. Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than a third of the longitudinal length of of the anal sphincter, were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost. Seventy-one patients (AFP 31, ERAF 40) were analysed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF group (P = 1.00). The median length of stay was 1.23 and 2.0 days (P < 0.001), respectively, and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 (P = 0.021), respectively. On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost (P = 0.023). Anal fistula plug and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay. Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.

  3. Similar mechanisms of traumatic rectal injuries in patients who had anal sex with animals to those who were butt-fisted by human sexual partner.

    PubMed

    Sendler, Damian Jacob

    2017-10-01

    Sexual pleasure comes in various forms of physical play, for many it involves stimulation of the vagina, while the anus for others; some enjoy both. A recent report by Cappelletti et al.(1) shows a meta-analysis of cases describing anal trauma due to sexual fisting in human partners. This clinical article reports four cases of males diagnosed with zoophilia, and who received anal sex from animals, resulting in injuries. Surgical and psychiatric evaluations are summarized. Unusual etiology of sexual activity with animals caused peri-anal trauma in men who engaged in anal sex with dogs and farm animals. Injuries to patients who receive anal sex from animals are mechanistically similar to fisting-induced rectal damage. Among zoophiles, the mode of harm occurs through blood-engorged, interlocked penis that causes tissue lacerations upon retraction from an anus. In people experimenting with fisting, repetitive stretching within anal canal and of external sphincter causes the internal injuries. The mode of physical stimulation explains the extent of injuries in fisters vs. zoophiles: in fisting, the pressure applied by hand is controllable proximally around and within anal sphincter, while penetration by the animal penis is unpredictable and occurs within the proximal anal canal. Forensically, the findings presented in this article describe a significant mechanism of injury in fisters versus passive zoophiles. These descriptions may aid in clinically differentiating pleasurable and pathological rectal stimulation. Copyright © 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

  4. Rectal atresia and anal stenosis: the difference in the operative technique for these two distinct congenital anorectal malformations.

    PubMed

    Lane, V A; Wood, R J; Reck, C; Skerritt, C; Levitt, M A

    2016-04-01

    Rectal atresia and anal stenosis are rare forms of anorectal malformations. The aim of the definitive surgical repair in such cases is to preserve the anal canal, the dentate line, and the sphincter complex. We present a case of rectal atresia and anal stenosis to demonstrate the differences in the operative repair. The techniques described leave the anterior wall of the very distal anal canal untouched in both rectal stenosis and anal atresia; however, the dissection of the rectum differs. The atretic rectum in rectal atresia is mobilized and sutured to the anal canal circumferentially. In anal stenosis, the posterior rectum is mobilized in the form of rectal advancement, and the posterior 180° is anastomosed directly to the skin (as in a standard PSARP) with preservation of the anal canal as the anterior 180° of the final anoplasty. These patients have an excellent prognosis for bowel control and fecal continence, and therefore, complete mobilization and resection of the anal canal must be avoided.

  5. Optimization of the artificial urinary sphincter: modelling and experimental validation

    NASA Astrophysics Data System (ADS)

    Marti, Florian; Leippold, Thomas; John, Hubert; Blunschi, Nadine; Müller, Bert

    2006-03-01

    The artificial urinary sphincter should be long enough to prevent strangulation effects of the urethral tissue and short enough to avoid the improper dissection of the surrounding tissue. To optimize the sphincter length, the empirical three-parameter urethra compression model is proposed based on the mechanical properties of the urethra: wall pressure, tissue response rim force and sphincter periphery length. In vitro studies using explanted animal or human urethras and different artificial sphincters demonstrate its applicability. The pressure of the sphincter to close the urethra is shown to be a linear function of the bladder pressure. The force to close the urethra depends on the sphincter length linearly. Human urethras display the same dependences as the urethras of pig, dog, sheep and calf. Quantitatively, however, sow urethras resemble best the human ones. For the human urethras, the mean wall pressure corresponds to (-12.6 ± 0.9) cmH2O and (-8.7 ± 1.1) cmH2O, the rim length to (3.0 ± 0.3) mm and (5.1 ± 0.3) mm and the rim force to (60 ± 20) mN and (100 ± 20) mN for urethra opening and closing, respectively. Assuming an intravesical pressure of 40 cmH2O, and an external pressure on the urethra of 60 cmH2O, the model leads to the optimized sphincter length of (17.3 ± 3.8) mm.

  6. Pharmacotherapy of Anal Cancer.

    PubMed

    Rogers, Jane E; Eng, Cathy

    2017-08-02

    Anal squamous cell carcinoma (SCCA), among other malignancies, is associated with the human papillomavirus (HPV) and its incidence continues to rise. Anal SCCA will likely remain an existing healthcare concern given compliance issues with the HPV vaccination seen in the US. Localized disease is predominantly treated with standard of care (SOC) definitive chemoradiation that has remained unchanged for decades. Clinical and molecular prognostic factors have emerged to characterize patients unresponsive to SOC, revealing the need for an alternate approach. Metastatic disease is an extremely small subset and understudied population due to its rarity. Recent prospective trials and mutational analysis have opened treatment options for this subset in need. Our review details the pharmacotherapeutic treatment in localized and metastatic anal SCCA chronologically, while also describing future outlooks.

  7. Heterosexual anal sexuality and anal sex behaviors: a review.

    PubMed

    McBride, Kimberly R; Fortenberry, J Dennis

    2010-03-01

    Little research addresses the role of anal sexuality and anal sexual behaviors as a widely practiced but relatively less frequent element of a heterosexual sexual repertoire. However, the importance of anal sex in sexual health is increasingly well-defined by epidemiological and clinical studies. This article reviews existing data on a range of heterosexual anal sex practices and provides conceptual and methodological recommendations for new research.

  8. Role of SM22 in the differential regulation of phasic vs. tonic smooth muscle

    PubMed Central

    Ali, Mehboob

    2015-01-01

    Preliminary proteomics studies between tonic vs. phasic smooth muscles identified three distinct protein spots identified to be those of transgelin (SM22). The latter was found to be distinctly downregulated in the internal anal sphincter (IAS) vs. rectal smooth muscle (RSM) SMC. The major focus of the present studies was to examine the differential molecular control mechanisms by SM22 in the functionality of truly tonic smooth muscle of the IAS vs. the adjoining phasic smooth muscle of the RSM. We monitored SMC lengths before and after incubation with pFLAG-SM22 (for SM22 overexpression), and SM22 small-interfering RNA. pFLAG-SM22 caused concentration-dependent and significantly greater relaxation in the IAS vs. the RSM SMCs. Conversely, temporary silencing of SM22 caused contraction in both types of the SMCs. Further studies revealed a significant reverse relationship between the levels of SM22 phosphorylation and the amount of SM22-actin binding in the IAS and RSM SMC. Data showed higher phospho-SM22 levels and decreased SM22-actin binding in the IAS, and reverse to be the case in the RSM SMCs. Experiments determining the mechanism for SM22 phosphorylation in these smooth muscles revealed that Y-27632 (Rho kinase inhibitor) but not Gö-6850 (protein kinase C inhibitor) caused concentration-dependent decreased phosphorylation of SM22. We speculate that SM22 plays an important role in the regulation of basal tone via Rho kinase-induced phosphorylation of SM22. PMID:25617350

  9. Anal itching -- self-care

    MedlinePlus

    ... this page: //medlineplus.gov/ency/patientinstructions/000689.htm Anal itching - self-care To use the sharing features on this page, please enable JavaScript. Anal itching occurs when the skin around your anus ...

  10. [Acute anal pain].

    PubMed

    Pittet, O; Demartines, N; Hahnloser, D

    2014-03-05

    Anal pain is a common reason for consultation, whose etiology is varied and should not be limited to the hemorrhoidal disease. The purpose of this article is to conduct a review of the literature on anorectal pathologies most frequently encountered and make recommendations regarding their management.

  11. Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

    PubMed Central

    Dimitriou, Nikoletta; Michail, Othon; Moris, Dimitrios; Griniatsos, John

    2015-01-01

    Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery. PMID:26191350

  12. Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes.

    PubMed

    Dimitriou, Nikoletta; Michail, Othon; Moris, Dimitrios; Griniatsos, John

    2015-07-15

    Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.

  13. Recto-anal manometric characteristics of type 2 diabetic patients who have sensation of incomplete defecation.

    PubMed

    Jorge, João Xavier; Borges, Cláudia Iracema Cardoso; Panão, Edgard Augusto; Delgado, Fernando Jorge; Simões, Mário Amaral; Coelho, Álvaro Correia; Silva, Amílcar Lima; Almeida, Carlos Costa

    2013-01-01

    Many diabetic patients report symptoms of incomplete defecation. We aimed to clarify the recto-anal manometric characteristics related to these symptoms. A questionnaire regarding gastrointestinal symptoms was distributed to 35 diabetics (19 women and 16 men) aged between 39 and 81 years. Nineteen reported incomplete defecation sensation (WS) and 16 did not (NS). Recto-anal manometry was performed for all patients. Data are presented as mean±SD. Resting rectal pressure was 14.4±10.1 mmHg and 8.8±3.9 mmHg, p<.03; first sensation was 61.0±27.8 ml and 83.1±35.7 ml, p<.04; and maximum tolerable volume was 174.2±81.5 ml and 235.0±89.5 ml, p<.04 for WS and NS, respectively. The WS group was further divided into 2 groups according to symptom severity (less severe and very severe). Significant differences were found in resting external anal sphincter pressure (50.4±15.6 and 34.3±17.4, p<.04) and the recto anal inhibitory reflex (48.6±19.8 and 26.3±23.2, p<.03) between the less severe and very severe groups, respectively. (1) Resting rectal pressure was significantly higher in symptomatic individuals. (2) First sensation and maximum tolerable volume were higher in asymptomatic diabetics. (3) In diabetics with more severe symptoms, the resting external anal sphincter pressures were significantly lower. (4) The degree of relaxation in the recto-anal inhibitory reflex was significantly higher in individuals without complaints. Copyright © 2013 Elsevier Inc. All rights reserved.

  14. Sphincter-saving procedures for distal carcinoma of the rectum.

    PubMed Central

    Yeatman, T J; Bland, K I

    1989-01-01

    Methods of sphincter preservation were developed more than a century ago. Combining these techniques with adequate anterior resection has permitted the resurrection of sphincter-saving procedures that are currently being applied in the therapy of cancer at every level of the rectum. Although Miles' abdominoperineal resection still remains the "gold standard" for the treatment of low rectal neoplasms, restorative resection may now be possible with equivalent oncologic disease control and survival. Further, current trends also suggest that the abdominoperineal resection is being used less frequently in the treatment of most rectal cancers and is being replaced with sphincter-preserving techniques that afford excellent functional results. In this review, the pertinent anorectal anatomy, current issues, and sphincter-saving surgical techniques presently available for the treatment of distal cancers of the rectum are presented. PMID:2642688

  15. A new possibility for repairing the anal dysfunction by promoting regeneration of the reflex pathways in the enteric nervous system.

    PubMed

    Katsui, Renta; Kojima, Yu; Kuniyasu, Hiroki; Shimizu, Juichiro; Koyama, Fumikazu; Fujii, Hisao; Nakajima, Yoshiyuki; Takaki, Miyako

    2008-04-01

    Moderate rectal distension elicits recto-rectal reflex contractions and simultaneous recto-internal anal sphincter reflex relaxations that together comprise the defecation reflex. Both reflexes are controlled by 1) pelvic nerves, 2) lumbar colonic nerves, and 3) enteric nervous system. The aim of the present study was to explore a novel approach to repairing the defecation reflex dysfunction by using the plasticity of enteric nervous pathways. Experiments were performed in anesthetized guinea pigs with ethyl carbamate. The rectum 30 mm oral from the anal verge was transected without damage to extrinsic nerves, and subsequent end-to-end one-layer anastomosis was performed. Recovery of the defecation reflex and associated reflex pathways were evaluated. Eight weeks after sectioning of intrinsic reflex nerve pathways in the rectum, the defecation reflex recovered to the control level, accompanied with regeneration of reflex pathways. The 5-HT(4)-receptor agonist mosapride (0.5 and 1.0 mg/kg) significantly (P < 0.01) enhanced the recovered defecation reflex 8 wk after surgery. Two weeks after local treatment with brain-derived neurotrophic factor (BDNF: 10(-6) g/ml) at the rectal anastomotic site, the recto-internal anal sphincter reflex relaxations recovered and some bundles of fine nerve fibers were shown to interconnect the oral and anal ends of the myenteric plexus. These results suggested a possibility for repairing the anal dysfunction by promoting regeneration of the reflex pathways in the enteric nervous system with local application of BDNF.

  16. Anal endosonography and bowel function in patients undergoing different types of endorectal pull-through procedures for Hirschsprung disease.

    PubMed

    Stensrud, Kjetil J; Emblem, Ragnhild; Bjørnland, Kristin

    2015-08-01

    The reasons for fecal incontinence after surgery for Hirschsprung disease (HD) remain unclear. The aim of this study was to examine the anal sphincters by anal endosonography and manometry after transanal endorectal pull-through, with or without laparotomy or laparoscopy, in HD patients. Furthermore, we aimed to correlate these findings to bowel function. Fifty-two HD patients were followed after endorectal pull-through. Anal endosonography and manometry were performed without sedation at the age of 3 to 16 years. Endosonographic internal anal sphincter (IAS) defects were found in 24/50 patients, more frequently after transanal than transabdominal procedures (69 vs. 19%, p=0.001). In a multiple variable logistic regression model, operative approach was the only significant predictor for IAS defects. Anal resting pressure (median 40mm Hg, range 15-120) was not correlated to presence of IAS defects. Daily fecal incontinence occurred more often in patients with IAS defects (54 vs. 25%, p=0.03). Postoperative IAS defects were frequently detected and were associated with daily fecal incontinence. IAS defects occurred more often after solely transanal procedures. We propose that these surgical approaches are compared in a randomized controlled trial before solely transanal endorectal pull-through is performed as a routine procedure. Copyright © 2015 Elsevier Inc. All rights reserved.

  17. Translational and clinical perspectives on sphincter of Oddi dysfunction

    PubMed Central

    Kyanam Kabir Baig, Kondal Rao; Wilcox, Charles Melbern

    2016-01-01

    Sphincter of Oddi dysfunction is a complex pathophysiologic entity that is associated with significant morbidity causing abdominal pain, nausea, and vomiting. The purpose of this review is to describe the anatomy and physiology of the sphincter of Oddi, to understand the pathologic mechanisms thought to be responsible for symptomatology, review recent major studies, explore endoscopic and pharmacologic therapies and their efficacy, and to explore future research avenues. PMID:27555792

  18. Mesenchymal Stromal Cells for Sphincter Regeneration: Role of Laminin Isoforms upon Myogenic Differentiation.

    PubMed

    Seeger, Tanja; Hart, Melanie; Patarroyo, Manuel; Rolauffs, Bernd; Aicher, Wilhelm K; Klein, Gerd

    2015-01-01

    Multipotent mesenchymal stromal cells (MSCs) are well known for their tri-lineage potential and ability to differentiate in vitro into osteogenic, chondrogenic or adipogenic lineages. By selecting appropriate conditions MSCs can also be differentiated in vitro into the myogenic lineage and are therefore a promising option for cell-based regeneration of muscle tissue such as an aged or damaged sphincter muscle. For the differentiation into the myogenic lineage there is still a need to evaluate the effects of extracellular matrix proteins such as laminins (LM) which are crucial for different stem cell types and for normal muscle function. The laminin family consists of 16 functionally different isoforms with LM-211 being the most abundant isoform of adult muscle tissues. In the sphincter tissue a strong expression of the isoforms LM-211/221, LM-411/421 and LM-511/521 can be detected in the different cell layers. Bone marrow-derived MSCs in culture, however, mainly express the isoforms LM-411 and LM-511, but not LM-211. Even after myogenic differentiation, LM-211 can hardly be detected. All laminin isoforms tested (LM-211, LM-411, LM-511 and LM-521) showed a significant inhibition of the proliferation of undifferentiated MSCs but, with the exception of LM-521, they had no influence on the proliferation of MSCs cultivated in myogenic medium. The strongest cellular adhesion of MSCs was to LM-511 and LM-521, whereas LM-211 was only a weakly-adhesive substrate for MSCs. Myogenic differentiation of MSCs even reduced the interaction with LM-211, but it did not affect the interaction with LM-511 and LM-521. Since during normal myogenesis the latter two isoforms are the major laminins surrounding developing myogenic progenitors, α5 chain-containing laminins are recommended for further improvements of myogenic differentiation protocols of MSCs into smooth muscle cells.

  19. Mesenchymal Stromal Cells for Sphincter Regeneration: Role of Laminin Isoforms upon Myogenic Differentiation

    PubMed Central

    Seeger, Tanja; Hart, Melanie; Patarroyo, Manuel; Rolauffs, Bernd; Aicher, Wilhelm K.; Klein, Gerd

    2015-01-01

    Multipotent mesenchymal stromal cells (MSCs) are well known for their tri-lineage potential and ability to differentiate in vitro into osteogenic, chondrogenic or adipogenic lineages. By selecting appropriate conditions MSCs can also be differentiated in vitro into the myogenic lineage and are therefore a promising option for cell-based regeneration of muscle tissue such as an aged or damaged sphincter muscle. For the differentiation into the myogenic lineage there is still a need to evaluate the effects of extracellular matrix proteins such as laminins (LM) which are crucial for different stem cell types and for normal muscle function. The laminin family consists of 16 functionally different isoforms with LM-211 being the most abundant isoform of adult muscle tissues. In the sphincter tissue a strong expression of the isoforms LM-211/221, LM-411/421 and LM-511/521 can be detected in the different cell layers. Bone marrow-derived MSCs in culture, however, mainly express the isoforms LM-411 and LM-511, but not LM-211. Even after myogenic differentiation, LM-211 can hardly be detected. All laminin isoforms tested (LM-211, LM-411, LM-511 and LM-521) showed a significant inhibition of the proliferation of undifferentiated MSCs but, with the exception of LM-521, they had no influence on the proliferation of MSCs cultivated in myogenic medium. The strongest cellular adhesion of MSCs was to LM-511 and LM-521, whereas LM-211 was only a weakly-adhesive substrate for MSCs. Myogenic differentiation of MSCs even reduced the interaction with LM-211, but it did not affect the interaction with LM-511 and LM-521. Since during normal myogenesis the latter two isoforms are the major laminins surrounding developing myogenic progenitors, α5 chain-containing laminins are recommended for further improvements of myogenic differentiation protocols of MSCs into smooth muscle cells. PMID:26406476

  20. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study.

    PubMed

    Wong, W Douglas; Congliosi, Susan M; Spencer, Michael P; Corman, Marvin L; Tan, Patrick; Opelka, Frank G; Burnstein, Marcus; Nogueras, Juan J; Bailey, H Randolph; Devesa, Jose Manuel; Fry, Robert D; Cagir, Burt; Birnbaum, Elisa; Fleshman, James W; Lawrence, Mallory A; Buie, W Donald; Heine, John; Edelstein, Peter S; Gregorcyk, Sharon; Lehur, Paul Antoine; Michot, Francis; Phang, P Terry; Schoetz, David J; Potenti, Fabio; Tsai, Josephine Y

    2002-09-01

    The aim of this trial was to evaluate the safety, efficacy, and impact on quality of life of the Acticon trade mark artificial bowel sphincter for fecal incontinence. A multicenter, prospective, nonrandomized clinical trial was conducted under a common protocol. Patients were evaluated with anal physiology, endoanal ultrasonography, a fecal incontinence scoring system, fecal incontinence quality of life assessment, and overall health evaluation. Patients with a fecal incontinence score of 88 or greater (scale, 1-120) were considered candidates for the study. Implanted patients underwent identical reevaluation at 6 and 12 months postimplant. One hundred twelve of 115 patients (86 females) enrolled were implanted. Mean age was 49 (range, 18-81) years. A total of 384 device-related or potentially device-related adverse events were reported in 99 enrolled patients. Of these events, 246 required no intervention or only noninvasive intervention. Seventy-three revisional operations were required in 51 (46 percent) of the 112 implanted patients. Infection rate necessitating surgical revision was 25 percent. Forty-one patients (37 percent) have had their devices completely explanted, of which 7 have had successful reimplantations. In patients with a functioning neosphincter, improvement in quality of life and anal continence was documented. Mean matched fecal incontinence scores in 63 patients at 6 months follow-up was improved from 105 preimplant to 51 postimplant. In 55 patients at 12 months follow-up, mean matched fecal incontinence scores were 105 preimplant 48 postimplant. A successful outcome was achieved in 85 percent of patients with a functioning device. Intention to treat success rate was 53 percent. Although morbidity and the need for revisional surgery are high, the artificial bowel sphincter can improve anal incontinence and quality of life in patients with severe fecal incontinence.

  1. Partial fistulotomy and multiple setons in high anal fistulae.

    PubMed

    Chatterjee, Gautam; Ray, Dipankar; Chakravartty, Saurav

    2009-08-01

    Setons are employed in high perianal fistulae. Our study aimed to use multiple setons in addition to a partial fistulotomy in high perianal fistulae involving the sphincter complex to combine the effects of cutting and drainage of the fistulous tract. This prospective study included 16 patients over a period of 4 years who presented with high perianal fistulae. The internal opening was identified and tract laid open till the dentate line. Four prolene threads were passed along the remainder of the tract and taken out through the external opening. One was tied tightly while the others were tightened every 7 days. No patients developed major faecal incontinence. Fistula recurred in one patient within a year and one patient had occasional incontinence to flatus. Multiple setons after partial fistulotomy is an effective treatment for high anal fistulae with low incidence of incontinence and recurrence and adequate patient satisfaction.

  2. Overview of anal fistula and systematic review of ligation of the intersphincteric fistula tract (LIFT).

    PubMed

    Alasari, S; Kim, N K

    2014-01-01

    Anal fistula management has long been a challenge for surgeons. Presently, no technique exists that is ideal for treating all types of anal fistula, whether simple or complex. A higher incidence of poor sphincter function and recurrence after surgery has encouraged the development of a new sphincter-sparing procedure, ligation of the intersphincteric fistula tract (LIFT), first described by Van der Hagen et al. in 2006. We assessed the safety, feasibility, success rate, and continence of LIFT as a sphincter-saving procedure. A literature search of articles in electronic databases published from January 2006 to August 2012 was performed. Analysis followed Preferred Reporting Items for Systematic Reviews recommendations. All LIFT-related articles published in the English language were included. We excluded case reports, abstracts, letters, non-English language articles, and comments. The procedure was described in detail as reported by Rojanasakul. Thirteen original studies, including 435 patients, were reviewed. The most common fistula procedure type was transsphincteric (92.64 %). The overall median operative time was 39 (±20.16) min. Eight authors performed LIFT as a same-day surgery, whereas the others admitted patients to the hospital, with an overall median stay of 1.25 days (range 1-5 days). Postoperative complications occurred in 1.88 % of patients. All patients remained continent postoperatively. The overall mean length of follow-up was 33.92 (±17.0) weeks. The overall mean healing rate was 81.37 (±16.35) % with an overall mean healing period of 8.15 (±5.96) weeks. Fistula recurrence occurred in 7.58 % of patients. LIFT represents a new, easy-to-learn, and inexpensive sphincter-sparing procedure that provides reasonable results. LIFT is safe and feasible, with favorable short- and long-term outcomes. However, additional prospective randomized studies are required to confirm these findings.

  3. Artificial urinary sphincter for post-prostatectomy incontinence: a review.

    PubMed

    James, Mary H; McCammon, Kurt A

    2014-06-01

    The artificial urinary sphincter remains the gold standard for treatment of post-prostatectomy urinary incontinence. The AMS 800 (American Medical Systems, Minnetonka, MN, USA) is the most common