Postdelivery anal function in primiparous females: ultrasound and manometric study

PREDICTORS OF UNSUCCESSFUL OF TREATMENT FOR FECAL INCONTINENCE BIOFEEDBACK FOR FECAL INCONTINENCE IN FEMALE

BACKGROUND

Biofeedback is an effective method of treatment for fecal incontinence but there is controversy regarding factors that may be correlated with its effectiveness.

OBJECTIVE

To evaluate the efficacy of biofeedback in the treatment of fecal incontinence, identifying the predictive factors for unsuccessful treatment.

METHODS

Consecutive female patients who had fecal incontinence and were treated with a full course of biofeedback were screened. The symptoms were evaluated using Cleveland Clinic incontinence (CCF) score before and six months after the completion of therapy. Patients had a satisfactory clinical response to biofeedback if the CCF score had decreased by more than 50% at six months (GI) and an unsatisfactory response if the CCF score did not decrease or if the score decreased by <50% (GII). The groups were compared with regard to age, score, anal resting and squeeze pressures and sustained squeeze pressure by manometry, history of vaginal delivery, number of vaginal deliveries, menopause, hysterectomy, and previous anorectal surgery.

RESULTS

Of 124 women were included, 70 (56%) in GI and 54 (44%) in GII. The median CCF score decreased significantly from 10 to 5 (P=0.00). FI scores were higher in GII. Patients from GII had more previous vaginal deliveries and previous surgeries. The mean sustained squeeze pressure was higher in GI. Patients from GI and GII had similar ages, number of vaginal deliveries, menopause, hysterectomy, anal pressures, and sphincter defects. The median sustained squeeze pressure increased significantly before and after biofeedback in GI.

CONCLUSION

Biofeedback therapy shows effective treatment with 50% reductions in FI score in half of patients. Factors associated with unsuccessful outcome include FI score ≥10, previous vaginal delivery, previous anorectal and/or colorectal surgery, and reduced mean sustained squeeze pressure.

Exoanal Imaging of the Anal Sphincters

Since its introduction in the early 1990s, endoanal sonography has become the mainstay of morphologic assessment of the anal canal and sphincter, especially for obstetric anal sphincter trauma. Lack of availability of suitable systems and the invasive nature of the method have limited uptake and clinical utility. More recently, exoanal or transperineal/translabial tomographic imaging has been developed as a noninvasive alternative. This pictorial overview aims to introduce the reader to this new diagnostic modality and to demonstrate common findings in asymptomatic and symptomatic women.

[Management of postpartum anal incontinence: A systematic review]

AIM

To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management.

MATERIALS AND METHODS

A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery.

RESULTS

The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years).

CONCLUSION

Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

Obstetrics anal sphincter injury and repair technique: a review

The Urogynecology Committee of the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) has held seminars and workshops on various urogynecological problems in each country in the Asia-Oceania area in order to encourage young obstetricians and gynecologists. In 2013, we organized the operative seminar for obstetrical anal sphincter injuries (OASIS) in which we prepared porcine models to educate young physicians in a hands-on workshop at the 23rd Asian and Oceanic Congress of Obstetrics and Gynaecology in Bangkok, Thailand. Laceration of the anal sphincter mostly occurs during vaginal delivery and it can develop into anal sphincter deficiency, which causes fecal incontinence, if an appropriate suture is not performed. OASIS has become an important issue, especially in developing countries. The prevalence of OASIS of more than the third degree is around 5% in primary parous women and the frequency is higher when detected by ultrasonographic evaluation. Several risk factors, such as macrosomia, instrumental labor, perineal episiotomy and high maternal age, have been recognized. In a society where pregnant women are getting older, OASIS is becoming a more serious issue. An intrapartum primary appropriate stitch is important, but the 1-year outcome of a delayed operation after 2 weeks postpartum is similar. A randomized controlled study showed that overlapping suture of the external sphincter is better than that of end-to-end surgical repair. The Urogynecology Committee of the AOFOG would like to continue with educative programs about the appropriate therapy for OASIS.

Long-term outcome after overlapping anterior anal sphincter repair for fecal incontinence

PURPOSE

The aim was to assess long-term results and quality of life following anterior anal sphincter repair for anal incontinence.

PATIENTS AND METHODS

Twenty-three female patients underwent anterior anal sphincteroplasty over a 10-year period between January 1999 and January 2009 in a gynecological surgery department. Patients were asked to complete pre- and postoperative questionnaires comprising the Jorge and Wexner incontinence score. The secondary objective was to assess pre- and post-sphincteroplasty symptom severity and sexual quality of life. Mean follow-up was 87 months (median, 91.5 months). Kaplan-Meier time-to-event analysis was applied.

RESULTS

Mean age was 52 years (±15.2), and mean postoperative Jorge and Wexner score, 7.5/20 (±4.1). Seventeen patients (85 %) declared themselves satisfied by the repair; 12 (60 %) showed good fecal continence. Fecal incontinence had a negative impact on quality of life for 15 % and on sexuality for 50 % of patients. Kaplan-Meier analysis showed 85 % conservation of anal continence correction at 1 year, 74 % at 48 months, 67 % at 60 months, and 48 % at 84 months.

CONCLUSIONS

Overlapping anterior anal sphincter repair provided lasting improvement in fecal incontinence, with satisfactory long-term functional results. At 84 months' follow-up, 48 % of patients maintained good fecal continence, with a satisfaction rate of 85 %. Anal sphincteroplasty may be a first-line attitude in young female fecal incontinence patients with a recent sphincter defect following initially undiagnosed obstetric trauma and also restores perineal comfort.

Anal resting pressures at manometry correlate with the Fecal Incontinence Severity Index and with presence of sphincter defects on ultrasound

INTRODUCTION

We describe the relationship between anorectal manometry, fecal incontinence severity, and findings at endoanal ultrasound.

METHODS

A total of 351 women completed the Fecal Incontinence Severity Index, underwent anorectal manometry, and endoanal ultrasound. Severity index and manometry pressures in 203 women with intact sphincters on ultrasound were compared with pressures in 148 women with sphincter defects. Relationships between resting and squeeze pressures, severity index, and size of sphincter defects were evaluated.

RESULTS

Mean severity index in patients with and without sphincter defect was 35.7 vs. 36.7 (not significant). Worsening index correlated with worsening mean and maximum resting pressure (P < 0.0001). Differences were observed in mean and maximum resting pressure between the patients with and without sphincter defects (26.6 vs. 37.2, P < 0.0001; 39.4 vs. 51.7, P < 0.001). Resting pressures correlated with the sizes of defect (P < 0.0001).

CONCLUSIONS

Patients with and without sphincter defects had similar severity scores, but patients with defects had a significant decrease in resting pressures. Patients with larger sphincter defects had lower severity scores and resting pressures. Until a manometry cutoff can be set to discriminate between absence and presence of defects, both manometry and ultrasound should be offered to patients with history of anal trauma.

Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review

OBJECTIVES

To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.

DESIGN

Systematic review of all relevant studies in English.

DATA SOURCES

Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.

STUDY SELECTION AND DATA EXTRACTION

Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 x 2 contingency tables were used to generate odds ratios.

RESULTS

Eighteen studies met the inclusion criteria with 12,237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47-2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04-1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22-1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19-1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97-1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.

CONCLUSION

Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.

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

BACKGROUND AND AIMS

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.

METHOD

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.

RESULTS

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.

CONCLUSIONS

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 management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

Translabial ultrasound assessment of the anal sphincter complex: normal measurements of the internal and external anal sphincters at the proximal, mid-, and distal levels

The purpose of this study was to measure the internal and external anal sphincters using translabial ultrasound (TLU) at the proximal, mid, and distal levels of the anal sphincter complex. The human review committee approval was obtained and all women gave written informed consent. Sixty women presenting for gynecologic ultrasound for symptoms other than pelvic organ prolapse or urinary or anal incontinence underwent TLU. Thirty-six (60%) were asymptomatic and intact, 13 symptomatic and intact, and 11 disrupted. Anterior-posterior diameters of the internal anal sphincter at all levels and the external anal sphincter at the distal level were measured in four quadrants. Mean sphincter measurements are given for symptomatic and asymptomatic intact women and are comparable to previously reported endoanal MRI and ultrasound measurements.

Age effects on anorectal pressure in anal continent women with lower urinary tract dysfunction

The objective of this paper is to evaluate age and associated factors affecting anorectal pressure profilometry in anal-continent women with lower urinary tract symptoms. One hundred and ten anal-continent women (mean age, 47.7+/-12.8 years; range, 23-87 years) with lower urinary tract symptoms voluntarily participated in this study after undergoing a complete urogynecological evaluation including a multichannel urodynamic study. Anorectal pressure was evaluated by using a radial four-channel manometry with a water-filled catheter, which was placed 10 cm into the anorectum above the anal verge. We divided the anorectal pressure profile into five segments and four axes to clarify the axis-specific defect or site-specific damage in the sphincter profile. The aging process had a negative effect on the peak resting pressure from the 41 to 100th percentile of the anorectal pressure profile at 12 o'clock, 3 o'clock, and 6 o'clock (P<0.05). With voluntary squeezing, aging had negative effects on the peak squeeze pressure from the 41 to 100th percentile of the anorectal pressure profile at 3 o'clock, and 61 to 80 percentile at 12 o'clock (P<0.05). There is a trend where anorectal pressure reduces as a woman ages, especially at the anal sphincter area in women with lower urinary tract symptoms. The anterior and left sides of the anorectal sphincter seem to be the most vulnerable in the aging process.

Long-term consequences of first vaginal delivery-induced anal sphincter defect

PURPOSE

This study was designed to investigate the long-term consequences of anal sphincter defects detected after a first vaginal delivery.

METHODS

A cohort of 197 primiparous females was evaluated for anal continence and anal sphincter defects in 1997. In June 2003 (6 years later), a postal questionnaire was sent to 74 females of this cohort, and answers from 54 (73 percent) were analyzed.

RESULTS

In 1997, a transanal ultrasound found 66 anal sphincter defects (33.5 percent). Twenty-one females (10.6 percent) had persistent signs of anal incontinence 12 weeks after the index delivery. There was a significant correlation between the presence of anal sphincter defect and anal incontinence. Six years later, 11 of 54 females reported signs of anal incontinence: 50 percent of females with anal sphincter defect and only 8.1 percent of females without (P = 0.002). Large defects were more frequently associated with anal incontinence. Anal incontinence after the index vaginal delivery also was significantly associated with anal incontinence six years later. Multivariate analysis showed anal sphincter defect to be the only variable predictive of anal incontinence (odds ratio, 10.5; 95 percent confidence interval, 2.1-52.4).

CONCLUSIONS

Anal sphincter defects detected after the first vaginal delivery appear as the main risk factor for anal incontinence six years later.

[Factors associated with fecal incontinence after childbirth. Prospective study in 525 women]

OBJECTIVE

To determine the prevalence of fecal incontinence after childbirth and to identify the risk factors.

METHODS

This was a prospective observational study with a consecutive inclusion of 525 women who delivered over a three months period. Women were questioned about their fecal continence four days and six weeks after delivery.

RESULTS

The incidence of fecal incontinence four days and six weeks after childbirth was respectively 8.8% and 3.3%. The risk factors for fecal incontinence at 4 days after childbirth were instrumental delivery by forceps (adjusted odds ratio 8.64, 95% confidence interval 3.55-21.0, p < 0.001) and unassisted delivery at home (adjusted OR 8.06, 95% CI 1.30-50.0, p = 0.025). Independent risk factors for the presence of fecal incontinence 6 weeks later were: instrumental forceps delivery (adjusted OR 10.8, 95% CI 2.82-41.3, p = 0.001), unassisted delivery at home (adjusted OR 50.0, 95% CI 3.09-802, p = 0.006), bi-parietal diameter of the newborn > 93 mm (adjusted OR 4.56, 95% CI 1.46-14.1, p = 0.009) and maternal age >30 years (adjusted OR 4.60, 95% CI 1.11-19.1, p = 0.036).

CONCLUSION

Fecal incontinence is common after childbirth and its prevalence is predominantly associated with instrumental delivery, unassisted delivery at home, bi-parietal diameter of the newborn and maternal age.

Episiotomy and perineal tears presumed to be imminent: the influence on the urethral pressure profile, analmanometric and other pelvic floor findings--follow-up study of a randomized controlled trial

BACKGROUND

The influence of the restrictive use of episiotomy at perineal tears judged to be imminent on the urethral pressure profile, analmanometric, and other pelvic floor findings is unknown.

METHODS

Follow-up study of a randomized controlled trial with two perineal management policies includes the use of episiotomy: (a) only for fetal indications and (b) in addition at a tear presumed to be imminent. Participants were 146 primiparous women with an uncomplicated singleton pregnancy >34 weeks of gestation. For the intention-to-treat analysis, 68 women after vaginal delivery were included who delivered a live full-term baby between January 1999 and September 2000.

OUTCOME MEASURES

Maximum urethral closure pressure (MUCP, cmH2O), functional urethral length (mm), maximum anal pressure (MAP, mmHg), functional anal sphincter length (ASL, mmHg) at rest and during contraction, and pelvic floor muscle strength (5-grade Oxford score) are the outcome measures. The rate of dyspareunia, urinary incontinence, and anorectal incontinence was documented.

RESULTS

At a mean follow up of 7.3 months, there were no statistically significant differences between the two groups (a versus b): mean MUCP at rest (98 versus 101 cmH2O), during contraction (95 versus 103 cmH2O), mean MAP at rest (113 versus 121 mmHg), during contraction (143 versus 166 mmHg), mean ASL at rest (50 versus 50 mmHg), during contraction (42 versus 45 mmHg), mean pelvic floor muscle strength (2.2 versus 2.6), no pain during sexual intercourse (79 versus 67%), prevalence of urinary incontinence (48 versus 27%), and anorectal incontinence (19 versus 24%).

CONCLUSIONS

Episiotomy at a perineal tear presumed to be imminent does not have any advantage with regard to pelvic floor function and should be avoided.

Patient choice cesarean: an evidence-based review

Primary elective cesarean performed on a patient's request now comprises 4% to 18% of all cesareans and 14% to 22% of elective cesareans in reported series. Patients most commonly choose cesarean because of tocophobia, or fear of childbirth. Almost two thirds of obstetricians surveyed are willing to perform cesarean on request, citing decreased risk of pelvic floor or fetal injury, maintenance of sexual functioning, and physician and patient convenience. Contrasting these beliefs are the limited available data on short- and long-term maternal and perinatal morbidity and mortality that generally favor vaginal delivery. Moreover, comprehensive economic impact assessments of cesarean on request are lacking, and professional organizations do not agree on the ethics of offering patient choice cesarean.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the reasons that women and obstetricians choose elective cesarean delivery, to outline the ethical aspects of cesarean delivery, and to describe the material and fetal morbidity and mortality associated with cesarean delivery compared to vaginal delivery.

Frequency of anal incontinence and results of pelvic viscerography in 291 women with pelvic organ prolapse

OBJECTIVES

To determine the prevalence of anal incontinence in a population of 291 women with pelvic organ prolapse and evaluate the results of pelvic viscerogram in this situation.

MATERIALS AND METHODS

Each patient answered a standardized questionnaire on medical, obstetric and surgical past histories and answers were logged in a database. The viscerograms were performed by a single specialized radiologist.

RESULTS

All patients but one were parous. The prevalence of anal incontinence was 26.1%. Stress urinary incontinence and urge urinary incontinence were significantly associated with anal incontinence. No obstetric or surgical risk factor for anal incontinence was demonstrated. Viscerography demonstrated rectoceles (n=86, 29.1%), enteroceles (n=77, 26.5%), cystoceles (n=174, 59.8%), and intra-anal rectal prolapse (n=106, 36.4%). A significant association was found between intra-anal rectal prolapse and anal incontinence.

CONCLUSION

Anal incontinence is frequent in patients with pelvic organ prolapse, even more so in the presence of urinary incontinence, and should be investigated by pelvic viscerography. Pelvic floor dysfunction is frequently associated with enteroceles, rectoceles and rectal prolapse. Pelvic viscerograms should be systematically performed in the diagnostic work-up in patients with pelvic organ prolapse when surgical treatment is considered.

Fecal incontinence in females with a past history of vaginal delivery: significance of anal sphincter defects detected by ultrasound

PURPOSE

The aim of this study was to determine the significance of anal sphincter defects detected by ultrasonography, in a population of fecal incontinent parous females without previous anoperineal surgery.

METHODS

From 100 consecutive incontinent patients, 61 females with at least one previous vaginal delivery and no past anoperineal surgery were studied. The severity of fecal incontinence was assessed by the Cleveland Clinic questionnaire score. Lesions of the internal or external anal sphincters, and the radial size of these defects were assessed by ultrasonography. Anal vector manometry was performed to measure anal pressures at rest and during voluntary squeeze, and the anal asymmetry index.

RESULTS

Twenty-three had a normal sphincter (38 percent), and 38 (62 percent) had a defect detected by ultrasonography: 20 isolated defects of the external sphincter and 18 combined defects of the internal and external sphincters. Combined defects were significantly larger. The radial size of the defects was positively correlated with the severity of clinical symptoms. Anal pressure asymmetry index was significantly increased in the group with combined defects compared with the two other groups. An index of 25 percent or greater had a very high (100 percent) negative predictive value for the presence of a defect larger than 90 degrees.

CONCLUSIONS

This study confirms the high prevalence of anal sphincter defects detected by ultrasonography in a population of incontinent parous females without previous proctologic surgery. The clinical symptoms are related to the size of these defects. Anal vector manometry may be a useful tool to confirm the relation between echographic anal sphincter lesions and fecal incontinence.

Do occult anal sphincter injuries, vector volume manometry and delivery variables have any predictive value for bowel symptoms after first time vaginal delivery without third and fourth degree rupture? A prospective study

BACKGROUND

The aim of this study was to determine whether there exists a correlation between anal incontinence, occult sphincter injuries, anal manometry values, and delivery variables in primiparous women after first time vaginal delivery.

METHODS

Eighty-six primigravida women were recruited for this study. Transanal ultrasonography (TAUS) and vector volume manometry (VVM) was performed and bowel symptoms were recorded at 25 weeks of pregnancy and 5 months after labor. Incontinent women at 5 months after vaginal delivery were interviewed again at 12 months.

RESULTS

Nineteen women (25%) experienced flatus incontinence postpartum. After 12 months, only one-third of the women were still incontinent. Fourteen women (19%) showed abnormal TAUS of the anal sphincter. Of the delivery variables, only baby head circumference was significantly associated with flatus incontinence (p = 0.01). There was no correlation between flatus incontinence or delivery variables and anal sphincter injuries; VVM values were not associated with either anal sphincter injuries or flatus incontinence at 5 months, but VVM values were negatively associated with flatus incontinence at 12 months after labor.

CONCLUSIONS

At 5 months after labor, flatus incontinence is relatively common, and is not associated with reduced VVM values. Two-thirds of women recover from flatus incontinence during the first year. Women who had flatus incontinence persisting for a minimum of 1 year had reduced VVM values. Anal sphincter injuries as seen by TAUS are not associated with either VVM values or any delivery variable. Baby head circumference is the only delivery variable significantly associated with flatus incontinence.

Trans-perineal versus endo-anal ultrasound in the detection of anal sphincter tears

OBJECTIVE

To compare endo-anal and trans-perineal ultrasonography in the detection of anal sphincter lesions.

STUDY DESIGN

Sixty-four patients sent for a uro-gynaecological consultation were given tests by two ultrasound methods using the same apparatus (Aloka) with different probes. The endo-anal ultrasound (EAUS) was carried out in a supine position using a rotary circular probe at 7.5 MHz. The trans-perineal ultrasound (TPUS) was carried out using a curved linear probe at 5 MHz, applied to the perineum in the transverse direction, allowing a proximal view of the sphincter. For each image the thicknesses of the two components of the sphincter (internal and external) were noted, as well as the presence of any ultrasonographic tear, its position, and its width on the sphincterian circumference.

RESULTS

The average of the internal and external thickness of the sphincters was of 2.8 and 5.6 mm, respectively for the TPUS, and 2.1 and 6.2 mm for the EAUS. Among the 64 patients, 15 external lesions of the anal sphincter were found with the TPUS, and 14 with the EAUS. The kappa correlation coefficient was 48%, with a confidence interval of 95%.

CONCLUSION

The endo-anal technique, which provides a staged analysis of the anal sphincter muscle, remains the benchmark of sphincterian imaging. TPUS is a useful method, in that it gives good visualisation of anatomical structures, but its sensitivity in detecting sphincter lesions remain to be demonstrated.

[Anal incontinence: echographic and manometric study]

STUDY AIM

The goal of this study was to evaluate the clinical and functional consequences of anal sphincter echographic lesions in patients with fecal incontinence.

PATIENTS AND METHOD

From January 1997 to April 2001, 100 patients with fecal incontinence (90 women, 10 men) were prospectively explored by transanal ultrasound and vectormanometry. Internal and external sphincter defects, as well as their extension, were analyzed with regard to their clinical and functional expressions (resting and squeeze anal sphincter pressures, anal sphincter asymmetry index).

RESULTS

Among the 100 patients, 42 had no echographic lesions, 58 had a defect: 26 had an isolated defect (internal sphincter (n = 3), external sphincter (n = 23) and 32 had combined internal and external sphincter defects. Squeeze anal pressures were significantly lower in the group of patients with combined defects, compared to the group with isolated defect or without defect. Anal asymmetry index was higher in the group of patients with combined defects, compared to the other groups. There was a positive correlation between the radial extension of the defect and the importance of clinical complaints.

CONCLUSION

Echographic anal sphincter lesions are frequent in fecal incontinence and are clinically and functionally significant.