Effects of short term sacral nerve stimulation on anal and rectal function in patients with anal incontinence.
BACKGROUND: Some patients with faecal incontinence are not amenable to simple surgical sphincter repair, due to sphincter weakness in the absence of a structural defect. AIMS: To evaluate the efficacy and possible mode of action of short term stimulation of sacral nerves in patients with faecal incontinence and a structurally intact external anal sphincter. PATIENTS: Twelve patients with faecal incontinence for solid or liquid stool at least once per week. METHODS: A stimulating electrode was placed (percutaneously in 10 patients, operatively in two) into the S3 or S4 foramen. The electrode was left in situ for a minimum of one week with chronic stimulation. RESULTS: Evaluable results were obtained in nine patients, with early electrode displacement in the other three. Incontinence ceased in seven of nine patients and improved notably in one; one patient with previous imperforate anus and sacral agenesis had no symptomatic response. Stimulation seemed to enhance maximum squeeze pressure but did not alter resting pressure. The rectum became less sensitive to distension with no change in rectal compliance. Ambulatory studies showed a possible reduction in rectal contractile activity and diminished episodes of spontaneous anal relaxation. CONCLUSIONS: Short term sacral nerve stimulation notably decreases episodes of faecal incontinence. The effect may be mediated via facilitation of striated sphincter muscle function, and via neuromodulation of sacral reflexes which regulate rectal sensitivity and contractility, and anal motility. (+info)
Perception of and adaptation to rectal isobaric distension in patients with faecal incontinence.
BACKGROUND: Perception of, and adaptation of the rectum to, distension probably play an important role in the maintenance of continence, but perception studies in faecal incontinence provide controversial conclusions possibly related to methodological biases. In order to better understand perception disorders, the aim of this study was to analyse anorectal adaptation to rectal isobaric distension in subjects with incontinence. PATIENTS/METHODS: Between June 95 and December 97, 97 consecutive patients (nine men and 88 women, mean (SEM) age 55 (1) years) suffering from incontinence were evaluated and compared with 15 healthy volunteers (four men and 11 women, mean age 48 (3) years). The patients were classified into three groups according to their perception status to rectal isobaric distensions (impaired, 22; normal, 61; enhanced, 14). Anal and rectal adaptations to increasing rectal pressure were analysed using a model of rectal isobaric distension. RESULTS: The four groups did not differ with respect to age, parity, or sex ratio. Magnitude of incontinence, prevalence of pelvic disorders, and sphincter defects were similar in the incontinent groups. When compared with healthy controls, anal pressure and rectal adaptation to distension were decreased in incontinent patients. When compared with incontinent patients with normal perception, patients with enhanced perception experienced similar rectal adaptation but had reduced anal pressure. In contrast, patients with impaired perception showed considerably decreased rectal adaptation but had similar anal pressure. CONCLUSION: Abnormal sensations during rectal distension are observed in one third of subjects suffering from incontinence. These abnormalities may reflect hyperreactivity or neuropathological damage of the rectal wall. (+info)
Anal ultrasound predicts the response to nonoperative treatment of fecal incontinence in men.
OBJECTIVE: To assess the etiology, treatment, and utility of anal ultrasound in men with fecal incontinence and to review the outcomes of conservative (nonoperative) treatment. SUMMARY BACKGROUND DATA: The etiology of fecal incontinence in women is almost exclusively from obstetric or iatrogenic surgical injuries resulting in damage to the anal sphincters and/or pudendal nerves. Corresponding data on men with fecal incontinence are sparse. METHODS: Between January 1995 and January 1998, 37 men with fecal incontinence were evaluated in the John Radcliffe Hospital anorectal ultrasound unit. Their clinical histories, anal ultrasound results, anorectal physiology studies, and responses to conservative therapy were reviewed. RESULTS: Median age was 57 years. Major incontinence was present in 27% of the patients. Anal ultrasound localized anal sphincter damage in nine patients, and the characteristics of these nine patients with sphincter damage were then compared with the remaining 28 without sphincter damage. Prior anal surgery was more common in patients with sphincter damage. Hemorrhoids were more common in patients without sphincter damage. Anorectal physiology studies revealed significantly lower mean maximum resting and squeeze pressures in patients with sphincter damage, confirming poor sphincter function. With 92% follow-up, patients without sphincter damage were more likely to improve with nonoperative therapy. CONCLUSIONS: Anal ultrasound is extremely useful in the evaluation of fecal incontinence in men. Unlike women, the majority of men do not have a sphincter defect by anal ultrasound, and conservative management is usually successful in these patients. In contrast, in men with anal sphincter damage, almost all of these defects resulted from previous anal surgery. Conservative management rarely is successful in these cases, and surgical repair of the anal sphincter may be indicated. Therefore, because the presence or absence of sphincter damage on anal ultrasound usually predicts the response to nonoperative treatment, anal ultrasound should be used to guide the initial management of men with fecal incontinence. (+info)
Long-term results of artificial anal sphincter implantation for severe anal incontinence.
OBJECTIVE: To evaluate the long-term results of implantation of an artificial anal sphincter (AAS) for severe anal incontinence. SUMMARY BACKGROUND DATA: Implantation of an AAS is one of the options for treatment of anal incontinence when standard operations have failed. It is the only surgical option for treatment of anal incontinence in patients with neurologic disease that affects the pelvic floor and the muscles of the lower limb. METHODS: Seventeen patients underwent implantation of an AAS before 1993. These patients have been followed and their continence status evaluated. RESULTS: Two patients died of unrelated causes within the first 3 years after surgery, and in three patients the AAS was explanted because of infection. During the follow-up period, four patients had the AAS removed because of malfunction, and eight patients had a functioning AAS > or =5 years after the primary implantation. Five of these patients had revisional procedures, mainly because of technical problems in the early part of the study, when a urinary sphincter or slightly modified urinary sphincter was used. Continence at follow-up was good in four patients and acceptable in three, whereas one patient still had occasional leakage of solid stool. One patient had rectal emptying problems, which she managed by enema. CONCLUSIONS: An AAS based on the same principles as the artificial urinary sphincter seems to be a valid alternative in selected patients when standard surgical procedures have failed or are unsuitable. Approximately half of the patients have an adequate long-term result. Infectious complications still present a problem, whereas mechanical problems are less frequent with the modification of the device now available. (+info)
Functional disorders of the anus and rectum.
In this report the functional anorectal disorders, the etiology of which is currently unknown or related to the abnormal functioning of normally innervated and structurally intact muscles, are discussed. These disorders include functional fecal incontinence, functional anorectal pain, including levator ani syndrome and proctalgia fugax, and pelvic floor dyssynergia. The epidemiology of each disorder is defined and discussed, their pathophysiology is summarized and diagnostic approaches and treatment are suggested. Some suggestions for the direction of future research on these disorders are also given. (+info)
Mortality in relation to urinary and faecal incontinence in elderly people living at home.
OBJECTIVE: To examine the relationship between incontinence and mortality in elderly people living at home. DESIGN: Of the randomly selected people aged 65 years and older living in Settsu city, Osaka in October 1992, 1405 were contacted and constituted the study cohort. Follow-up for 42 months was completed for 1318 (93.8%; 1129 alive, 189 dead). MEASURES: Data on general health status, history of health management, psychosocial conditions and urinary and faecal incontinence were collected by interview during home visits at the time of enrolment. RESULTS: From the Kaplan-Meier analysis, the estimated survival rates decreased with a decline in continence in both the 65-74 and 75 years and older age groups. From the Cox proportional hazards model, unadjusted hazard ratios of minor, moderate and severe incontinence for mortality, compared with continence, were 2.27, 2.96 and 5.94, respectively. Multivariate analysis yielded adjusted hazard ratios of minor, moderate and severe incontinence of 0.99, 1.17 and 1.91, respectively, leaving severe incontinence as the significant factor, when other indicators are controlled. CONCLUSIONS: Incontinence is related to mortality and severe incontinence represents an increased risk factor for mortality in elderly people living at home. (+info)
Long-term functional outcome and quality of life after stapled restorative proctocolectomy.
OBJECTIVE: To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients. SUMMARY BACKGROUND DATA: Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking. METHODS: Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score. RESULTS: Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others. CONCLUSIONS: Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions. (+info)
Midline episiotomy and anal incontinence: retrospective cohort study.
OBJECTIVE: To evaluate the relation between midline episiotomy and postpartum anal incontinence. DESIGN: Retrospective cohort study with three study arms and six months of follow up. SETTING: University teaching hospital. PARTICIPANTS: Primiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration. MAIN OUTCOME MEASURES: Self reported faecal and flatus incontinence at three and six months postpartum. RESULTS: Women who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour. CONCLUSIONS: Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence. (+info)