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Subramaniam N, Dietz HP. Is posterior compartment prolapse associated with anal incontinence? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:642-648. [PMID: 36565432 DOI: 10.1002/uog.26145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 11/15/2022] [Accepted: 11/24/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVE It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. METHODS This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. RESULTS Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). CONCLUSION In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N Subramaniam
- Northern Beaches Hospital, Frenchs Forest, Sydney, Australia
| | - H P Dietz
- Sydney Urodynamic Centres, Sydney, Australia
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Dietz HP, Low G, Shek KL. Obstetric risk factors for anal sphincter trauma in a urogynecological population. Int Urogynecol J 2023; 34:425-430. [PMID: 36374329 DOI: 10.1007/s00192-022-05404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter tears are the single major modifiable risk factor for anal incontinence (AI) in women. We undertook a retrospective observational study in a tertiary urogynecology unit to describe the prevalence of sonographic anal sphincter defects in a urogynecological population and investigate obstetric risk factors. METHODS Files of women seen for investigation of pelvic floor disorders between January 2014 and May 2021 were reviewed. Sonographic defects of the external anal sphincter were analyzed using stored 4D ultrasound imaging data. Explanatory parameters were number of vaginal births, delivery mode, age at first vaginal birth, and birthweight of the first vaginally born baby. RESULTS Of 3,037 women seen during the inclusion period, data were missing in 219, leaving 2,818. AI was reported by 508 (18%), with a mean St Marks score of 11 (1-23) and a mean bother score of 5.9 (0-10). External sphincter defects were detected in 945 women (34%), with a "residual defect" in 343 (12%). The strongest risk factors for a residual defect were first vaginal birth and forceps, with higher-order multiparity adding risk. On multivariate analysis, forceps and vaginal parity >5 remained significant predictors, as opposed to age at first birth and birthweight of the firstborn. CONCLUSIONS In this observational study in urogynecological patients, 12% showed a residual EAS defect on imaging. The most obvious risk factors for the diagnosis of a residual defect on exo-anal imaging were the first vaginal birth and forceps, with higher-order vaginal parity conveying additional risk.
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Affiliation(s)
- Hans Peter Dietz
- Sydney Urodynamic Centres, Suite 2, Level 1 56 Kitchener Pde, Bankstown, NSW, 2200, Australia.
| | - Gary Low
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ka Lai Shek
- Sydney Urodynamic Centres, Suite 2, Level 1 56 Kitchener Pde, Bankstown, NSW, 2200, Australia
- Obstetrics and Gynaecology, Western Sydney University, Sydney, New South Wales, Australia
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Martín Prieto L, Pascual Migueláñez I, Fernández Cebrián JM, Martínez Puente MC, Varillas-Delgado D, Fernández Rodríguez M, Pascual Montero JA. Targeted Electromyographic Biofeedback With Endoanal Electrostimulation for Anal Incontinence. Surg Innov 2023; 30:56-63. [PMID: 35509238 DOI: 10.1177/15533506221096885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose. Anal incontinence (AI) is a disabling condition with a variable response to conservative physical therapies. We assess the utility of combining electromyographic biofeedback with endoanal electrostimulation targeted to the weakest areas of the pelvic floor using the MAPLe® probe (Multiple Array Probe Leiden Novuqare). Methods. Patients with AI unresponsive to conservative measures were assessed before and after treatment with anorectal manometry (ARM), electromyography (EMG), Wexner Continence Scoring, Visual Analog Scoring (VAS), FIQL and SF-12 quality of life determination. Results. Of 29 patients in the final analysis, there was an improvement in the mean Wexner continence score from 13.59 to 8.03 and a concomitant improvement in the reported VAS from 3.45 to 6.72. Both Wexner continence and VAS scores were maintained during follow-up. Maximum voluntary manometric contraction significantly improved from 91.76 mmHg to 110.33 mmHg with no changes in resting pressure. The EMG values (μV) that significantly improved included the average and peak resistance, the average general voluntary contraction, and the average and peak voluntary contraction for both the external anal sphincter and the puborectalis. In the FIQL, behavior, depression and shame domains improved after treatment and during follow-up with lifestyle improvements detected at 6 and 12 months. Physical and mental components of the SF-12 improved at 6 and 12 months. Conclusions. Targeted electromyographic biofeedback and endoanal electrostimulation using MAPLe® probe in AI patients sustainably improves objective ARM and EMG parameters along with subjective reporting of continence severity, VAS, and quality of life.
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Affiliation(s)
- L Martín Prieto
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain.,Department General and Digestive Surgery, 221912Hospital El Escorial, San Lorenzo de El Escorial, Spain
| | - I Pascual Migueláñez
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain.,Department General and Digestive Surgery, 16268University Hospital La Paz, Madrid, Spain
| | - J M Fernández Cebrián
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain.,Department General and Digestive Surgery, 16507University Hospital Ramón y Cajal, Madrid, Spain
| | - M C Martínez Puente
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain
| | - D Varillas-Delgado
- Faculty of Health Sciences, Exercise and Sport Sciences, 16447University Francisco de Vitoria, Madrid, Spain
| | - M Fernández Rodríguez
- Department General and Digestive Surgery, 16370University Hospital Puerta Hierro, Madrid, Spain
| | - J A Pascual Montero
- Department Coloproctology and General Surgery, 88129Clinica CEMTRO, Madrid, Spain
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Zhang Z, Cheng Y, Ju J, Shen W, Pan Z, Zhou Y. Analysis of the efficacy of biofeedback for faecal incontinence after surgery for anorectal malformation. Ann Med 2022; 54:2385-2390. [PMID: 36039487 PMCID: PMC9448432 DOI: 10.1080/07853890.2022.2114607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the therapeutic effects of biofeedback in the treatment of faecal incontinence (FI) after surgery for anorectal malformation (ARM). METHODS Clinical data were collected from paediatric patients for postoperative biofeedback due to FI caused by ARM between May 2017 and November 2021. The data included the duration of symptoms, the integrity of the anal sphincter, anorectal manometry parameters, and FI scores. These patients were divided into the low ARM group (group A) and the high ARM group (group B). RESULTS A total of 45 paediatric patients were enrolled in the study. There were 28 cases in group A and 17 cases in group B. The differences in age, gender, and body weight were not statistically significant between the two groups (p > 0.05). The differences in the clinical indicators were also not statistically significant between the two groups at the time of the initial evaluation. The duration of symptoms was 2.21 ± 0.71 years and 4.14 ± 1.89 years in groups A and B. There were 16 cases with an intact anal sphincter in group A and only two cases with an intact anal sphincter in group B. This difference was statistically significant between the two groups (p < .05). The anal resting pressure, initial sensitivity threshold, defaecation sensitivity threshold, defaecation urge threshold, and FI scores were significantly improved in both groups post-treatment compared to pre-treatment (p < .001). Strong impulses improved significantly in group A, while strong impulses did not improve significantly in group B. The multivariate logistic regression analysis with these variables further showed that symptom duration and anal sphincter integrity were the main factors influencing the therapeutic effects of biofeedback. CONCLUSION Biofeedback plays a positive role in the treatment of FI in paediatric patients following surgery for ARM. Symptom duration and anal sphincter integrity were found to be the main factors influencing the therapeutic effect of biofeedback.
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Affiliation(s)
- Zhenqiang Zhang
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Yuan Cheng
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Junjun Ju
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Weichen Shen
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Zhubin Pan
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
| | - Yuliang Zhou
- Department of General Surgery, Anhui Provincial Children's Hospital, Hefei, China
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Dietz HP, Shek KL, Low GK. Validation of new ultrasound algorithm for estimating prevalence of anal sphincter trauma in a urogynecological population. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:800-804. [PMID: 36350233 DOI: 10.1002/uog.26052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To estimate the prevalence of major perineal trauma in a urogynecological population, to test the predictive value of sonographic tear grading (Gillor algorithm) for anal incontinence (AI), AI bother score and St Mark's score, and to compare the predictive power of the Gillor algorithm with that of the residual-defect method. METHODS This was a retrospective study of 721 women attending a tertiary urogynecology unit between February 2019 and May 2021. All women underwent a standardized interview, including determination of St Mark's score and visual analog scale (VAS) bother score for AI, as well as exoanal (translabial) ultrasound with later offline analysis. Results were reported as the presence of a residual defect of the external anal sphincter (EAS), i.e. a discontinuity of ≥ 30° in ≥ 4/6 tomographic slices, and according to the Gillor algorithm (normal, Grade 3a, Grade 3b or Grade 3c/4). RESULTS Mean age at assessment was 57 (range, 19-93) years and mean body mass index was 30 (range, 17-57) kg/m2 . Six hundred and thirty-six (88.2%) women were vaginally parous and 161 (22.3%) had undergone at least one forceps delivery. AI was reported by 186/721 (25.8%) women, with a median St Mark's score of 10 (interquartile range (IQR), 6-14) and a median VAS score of 6.3 (IQR, 3.9-10). EAS defects were detected in 261 (36.2%) women, with a residual defect diagnosed in 88 (12.2%). On sonographic grading according to the Gillor algorithm, we identified 532 (73.8%) women with a normal sphincter, 66 (9.2%) with Grade-3a tear, 87 (12.1%) with Grade-3b tear and 36 (5.0%) with Grade-3c/4 tear. In total, the Gillor algorithm classified 189 (26.2%) women as having suffered a major perineal tear. The two grading systems were in moderate agreement (κ, 0.537 (95% CI, 0.49-0.56); P < 0.001). There were weak, albeit significant, associations between EAS defects and measures of AI (P = 0.009 to P = 0.047), both for residual defect as well as the Gillor algorithm. CONCLUSION Neither the Gillor algorithm nor the residual-defect method of quantifying sphincter trauma on imaging is clearly superior in terms of predicting AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H P Dietz
- Sydney Urodynamic Centres, Penrith, NSW, Australia
| | - K L Shek
- Western Sydney University, Liverpool, NSW, Australia
| | - G K Low
- Research Operations, Nepean Hospital, Nepean Blue Mountain Local Health District, Kingswood, NSW, Australia
- Professorial Unit, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Mengistu Z, Gillor M, Dietz HP. Is pelvic floor muscle contractility an important factor in anal incontinence? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:995-998. [PMID: 32959435 DOI: 10.1002/uog.23128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/06/2020] [Accepted: 09/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma. METHODS This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data. RESULTS Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m2 . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis. CONCLUSION Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Z Mengistu
- Department of Gynecology and Obstetrics, University of Gondar, Gondar, Ethiopia
| | - M Gillor
- University of Sydney, Sydney, NSW, Australia
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
| | - H P Dietz
- University of Sydney, Sydney, NSW, Australia
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Seifarth C, Slavova N, Degro C, Lehmann KS, Kreis ME, Weixler B. Sacral nerve stimulation in patients with ileal pouch-anal anastomosis. Int J Colorectal Dis 2021; 36:1937-1943. [PMID: 34160664 PMCID: PMC8346414 DOI: 10.1007/s00384-021-03981-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results after proctocolectomy and ileal pouch-anal anastomosis (IPAA) are generally good. However, some patients suffer from high stool frequency or fecal incontinence. Sacral nerve stimulation (SNS) may represent a therapeutic alternative in these patients, but little is known about indication and results. The aim of this study was to evaluate incontinence after IPAA and demonstrate SNS feasibility in these patients. METHODS This retrospective study includes patients who received a SNS between 1993 and 2020 for increased stool frequency or fecal incontinence after proctocolectomy with IPAA for ulcerative colitis. Proctocolectomy was performed in a two- or three-step approach with ileostomy closure as the last step. Demographic, follow-up data and functional results were obtained from the hospital database. RESULTS SNS was performed in 23 patients. Median follow-up time after SNS was 6.5 years (min. 4.2-max. 8.8). Two patients were lost to follow-up. The median time from ileostomy closure to SNS implantation was 6 years (min. 0.5-max. 14.5). Continence after SNS improved in 16 patients (69%) with a median St. Marks score for anal incontinence of 19 (min. 4-max. 22) before SNS compared to 4 (0-10) after SNS placement (p = 0.012). In seven patients, SNS therapy was not successful. CONCLUSION SNS implantation improves symptoms in over two-thirds of patients suffering from high stool frequency or fecal incontinence after proctocolectomy with IPAA. Awareness of the beneficial effects of SNS should be increased in physicians involved in the management of these patients.
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Affiliation(s)
- C. Seifarth
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - N. Slavova
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - C. Degro
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - K. S. Lehmann
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - M. E. Kreis
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - B. Weixler
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
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Melendez-Munoz J, Subramanian N, Friedman T, Dietz HP. Is levator trauma an independent risk factor for anal incontinence? Colorectal Dis 2020; 22:298-302. [PMID: 31561284 DOI: 10.1111/codi.14864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/27/2019] [Indexed: 02/08/2023]
Abstract
AIM To determine the role of levator ani trauma in anal incontinence (AI), whilst controlling for anal sphincter injury. METHODS The records of 1273 patients who had attended a tertiary urogynaecology unit between 1st of January to 31st December 2016 were reviewed. AI was assessed using St Mark's score and visual analogue scale (VAS). Levator muscle and anal sphincter trauma were examined by translabial ultrasound using tomographic imaging, with archived data sets investigated blinded against all clinical data. A complete avulsion was diagnosed if at least three central tomographic slices showed an abnormal muscle insertion, rated separately for each side. A significant anal sphincter defect was diagnosed if at least four out of six slices showed a defect of ≥ 30°. RESULTS Avulsion was associated with St Mark's score (P = 0.005) and VAS bother of AI (P = 0.022) both on univariate analysis and when controlling for external anal sphincter (EAS) trauma on translabial imaging, forceps, body mass index (BMI) and age (P = 0.011 and P = 0.04, respectively). AI expressed as a binary variable was significantly associated with avulsion on univariate analysis (P = 0.011), although the association became nonsignificant after controlling for anal sphincter trauma, age, BMI and forceps delivery (P = 0.084). CONCLUSION In this retrospective observational study, we found a weak association between levator ani avulsion and measures of AI, which largely remained significant when controlling for anal sphincter trauma. However, given the large data set, any clinical effect of levator trauma on AI is likely to be minor.
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Affiliation(s)
- J Melendez-Munoz
- Department of Obstetrics and Gynaecology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - N Subramanian
- Sydney Medical School Nepean, Nepean Hospital, The University of Sydney, Penrith, New South Wales, Australia
| | - T Friedman
- Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, The University of Sydney, Penrith, New South Wales, Australia
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Gommesen D, Nohr EA, Qvist N, Rasch V. Obstetric perineal ruptures-risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study. Am J Obstet Gynecol 2020; 222:165.e1-165.e11. [PMID: 31449804 DOI: 10.1016/j.ajog.2019.08.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/09/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anal incontinence leads to impairment of the quality of life and lower self-esteem with implications for social, physical, and sexual health; anal incontinence after vaginal delivery is a major concern for many women. Only about half of the cases of postpartum anal incontinence can be related to anal sphincter injuries, and the remaining cases must thus be related to other factors. OBJECTIVE The aim of this study was to examine the association between maternal and obstetric characteristics, including the degree of perineal rupture and anal incontinence 12 months postpartum. Furthermore, the aim was to investigate the association between anal sphincter muscle defects, perineal length, and perineal strength and the risk of anal incontinence. MATERIALS AND METHODS We conducted a prospective cohort study at 4 Danish hospitals: Odense University Hospital, Aarhus University Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data were obtained 2 weeks postpartum in relation to an evaluation of perineal wound healing. Symptoms of anal incontinence were evaluated 12 months postpartum by a Web-based questionnaire (St. Mark's incontinence score questionnaire). In addition, defects in the anal sphincter muscles were examined using endoanal ultrasound, perineal length was measured, and perineal strength was examined using anal manometry. The main outcome measurement was anal incontinence defined as a St. Mark's score of >4. We performed multivariate analyses to investigate the risk factors for anal incontinence and to investigate the risk of anal incontinence according to endoanal ultrasound scanning and anal manometry findings. RESULTS A total of 603 primiparous women (203 with no/labia/first-degree ruptures, 200 with second-degree ruptures, and 200 with third-/fourth-degree ruptures) were included between July 2015 and January 2018. At 12 months postpartum, 575 women (95%) answered the questionnaire; 193 with no/labia/first-degree ruptures, 193 with second-degree ruptures, and 189 with third-/fourth-degree ruptures. A total of 499 women underwent an endoanal ultrasound scanning and 482 women underwent anal manometry. Anal incontinence with a St. Mark's score of >4 was reported by 7% and 9% of women with no/labia/first-degree ruptures or second-degree ruptures, respectively, and by 14%, 15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4, respectively. Compared to women with no or minor tears, women with anal sphincter ruptures had a higher risk of anal incontinence (adjusted relative risk, 2.46; 95% confidence interval, 1.28-4.71). Ruptures of degree 3c and 4 were associated with a substantial increase in risk of anal incontinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98-11.3; and adjusted relative risk, 2.23; 95% confidence interval, 1.59-11.3, respectively), especially if a defect in the external or internal anal sphincter muscle was present (adjusted relative risk, 4.74; 95% confidence interval, 1.54-14.5; and adjusted relative risk, 6.58; 95% confidence interval, 3.35-12.9, respectively). The risk of anal incontinence increased by 8% per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95% confidence interval, 1.03-1.14). CONCLUSION Obesity with body mass index of >29.9 and a high-degree rupture (3c or 4), especially with a persistent defect in the internal or external anal sphincter muscle, increased the risk of anal incontinence.
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Shaunfield S, Jensen S, Fisher AP, Webster K, Shahabi S, Ganguli A, Cella D. Further content validation of the 18-item NCCN/FACT Ovarian Symptom Index and its Disease Related Symptom-Physical (DRS-P) subscale for use in advanced ovarian cancer clinical trials. Health Qual Life Outcomes 2019; 17:185. [PMID: 31856850 PMCID: PMC6921394 DOI: 10.1186/s12955-019-1253-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 11/29/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND This study evaluated pre-defined aspects of content validity of the 18-item NCCN FACT-Ovarian Symptom Index (NFOSI-18) and its Disease-Related Symptoms-Physical (DRS-P) subscale, as clinical trial outcome tools for patients with advanced ovarian cancer. METHODS Twenty-one women (mean age 59.5 years) diagnosed with advanced ovarian cancer completed the NFOSI-18 and participated in a cognitive interview to explore: (1) whether 'pain' and 'cramps' are considered redundant; (2) whether 'fatigue' and 'lack of energy' are overlapping concepts; (3) whether patients consider severity when responding to the item "I am bothered by constipation;" and (4) factors considered when responding to the item "I am sleeping well." Interviews were audio-recorded, transcribed, and analyzed qualitatively. RESULTS Pain was associated with discomfort, hurt, and life interference; 'cramps' was associated with pain, muscle tightening, and menstrual or digestive issues. Most (81%) considered the items "I have pain" and "I have cramps in my stomach area" to be more different than similar. Participants associated 'fatigue' with intense tiredness and 'lack of energy' with motivation and capability to complete daily activities. Item comparisons revealed a majority (65%) considered the items to be more different than similar. When responding to "I am bothered by constipation," patients indicated constipation severity was related to bother. Finally, patients considered disease, treatment, and other factors when responding to "I am sleeping well." CONCLUSIONS Findings support content validity of the NFOSI-18 and its DRS-P as originally constructed. We propose an alternative scoring option that excludes the item "I am sleeping well" from the DRS-P when used as a symptom-focused index for clinical research in a regulatory context.
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Affiliation(s)
- Sara Shaunfield
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave. Suite 2700, Chicago, IL, 60611, USA.
| | - Sally Jensen
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave. Suite 2700, Chicago, IL, 60611, USA
| | - Allison P Fisher
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave. Suite 2700, Chicago, IL, 60611, USA
| | - Kimberly Webster
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave. Suite 2700, Chicago, IL, 60611, USA
| | - Shohreh Shahabi
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 625 N. Michigan Ave. Suite 2700, Chicago, IL, 60611, USA
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11
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Cattani L, Van Schoubroeck D, Housmans S, Callewaert G, Werbrouck E, Verbakel JY, Deprest J. Exo-anal imaging of the anal sphincter: a comparison between introital and transperineal image acquisition. Int Urogynecol J 2019; 31:1107-1113. [PMID: 31802159 DOI: 10.1007/s00192-019-04122-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Three-dimensional exoanal ultrasound imaging of the anal sphincter may be obtained transperineally with a convex probe, or at the introitus with a transvaginal probe. We hypothesised that introital acquisition would yield better quality and more reproducible evaluation. METHODS We acquired three 3D volumes of the anal sphincter (one transperineal transverse with a 4- to 8-MHz convex probe and two introital with a 5- to 9-MHz probe in transverse and mid-sagittal view) in 20 representative women attending the gynaecology clinic. Each 3D dataset was anonymised and hence blinded for clinical data and for acquisition method. Images were analysed off-line by two expert specifically trained ultrasonographers in a random order to assess image quality, sphincter integrity and sphincteric measurements. We assessed the intra- and interrater agreement by the Cohen's kappa (κ) and by the intraclass correlation coefficient for categorical and continuous variables respectively. RESULTS The mid-sagittal introital acquisition had most inconclusive images owing to unsatisfactory quality, on which raters agreed (К = 0.80). Subsequently, agreement in the anal sphincter evaluation between transverse introital and transperineal acquisitions was compared. Agreement on internal anal sphincter gap was excellent for both transverse introital (К = 0.87) and transperineal acquisition (К = 0.93). Agreement on external anal sphincter discontinuity was excellent for the transperineal acquisition (К = 0.87) and good for the transverse introital acquisition (К = 0.73). Intra- and interrater agreement of external and internal anal sphincteric measurements were best for transperineal acquisitions. CONCLUSIONS In our hands, transperineal acquisition with a 4- to 8-MHz probe performed better than introital acquisition with a 5- to 9-MHz probe in the assessment of the anal sphincter complex.
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Affiliation(s)
- Laura Cattani
- Department Development and Regeneration, Cluster Urogenital Surgery and Department of Gynaecology and Obstetrics, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Dominique Van Schoubroeck
- Department Development and Regeneration, Cluster Urogenital Surgery and Department of Gynaecology and Obstetrics, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Susanne Housmans
- Department Development and Regeneration, Cluster Urogenital Surgery and Department of Gynaecology and Obstetrics, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Geertje Callewaert
- Department Development and Regeneration, Cluster Urogenital Surgery and Department of Gynaecology and Obstetrics, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Erika Werbrouck
- Department Development and Regeneration, Cluster Urogenital Surgery and Department of Gynaecology and Obstetrics, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Deprest
- Department Development and Regeneration, Cluster Urogenital Surgery and Department of Gynaecology and Obstetrics, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, London, UK.
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12
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Cattani L, Gillor M, Dietz HP. Does flatus incontinence matter? Int Urogynecol J 2019; 30:1673-1677. [PMID: 30643976 DOI: 10.1007/s00192-018-3835-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND HYPOTHESIS This study aimed to determine whether incontinence to flatus is associated with women's bother in a symptomatic population and with sonographically diagnosed external anal sphincter (EAS) trauma. METHODS This is a retrospective study of women attending a tertiary urogynecological unit between May 2013 and November 2015. Baseline evaluation included a standardized interview with St. Mark's Incontinence Score (SMIS) and visual analog scale (VAS) assessment for bother, as well as a physical examination and translabial pelvic floor ultrasound. At least one volume obtained covered the entire length of the EAS. These volumes were analyzed with the reviewer blinded to all clinical data. RESULTS During the inclusion period, 1104 patients visited the unit. Fifty-three patients were excluded from the study for missing data, leaving 1051 for final analysis. Mean age was 57 years (56-58) and mean body mass index (BMI) 29.1 kg/m2 (28.8-29.6). The prevalence of any anal incontinence (AI) and flatus incontinence were 16.4% (172/1051) and 13.9% (146/1051), respectively. In the group of patients with AI, mean SMIS was 11.8 (11.0-12.6), and mean VAS for AI bother was 5.4 (5.0-5.9). Significant EAS trauma was detected in 9.8% (103/1051) of patients and was associated with flatus incontinence (p = 0.002). Including a flatus incontinence question in the SMIS questionnaire improved the prediction of patient bother from AI (R2 87.8% versus R2 86.3%, p = 0.04). CONCLUSIONS Flatus incontinence is associated with ultrasound findings of EAS trauma and with higher patient bother from AI.
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Affiliation(s)
- Laura Cattani
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia. .,Department of Gynaecology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Moshe Gillor
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia.,Kaplan Medical Centre (Affiliated to the Hebrew University and Hadassah School of Medicine), Rehovot, Israel
| | - Hans Peter Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia
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13
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Kuismanen K, Nieminen K, Karjalainen K, Lehto K, Uotila J. Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment. Tech Coloproctol 2018; 22:209-214. [PMID: 29546469 PMCID: PMC5862944 DOI: 10.1007/s10151-018-1770-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 01/15/2018] [Indexed: 12/17/2022]
Abstract
Background The aim of the present study was to evaluate the subjective outcome of primary repair of obstetric anal sphincter injury (OASIS) at 6 months, the factors associated with the symptoms of anal incontinence (AI), and the role of a simple survey consisting in one question with three answer choices, combined with the Wexner incontinence score for the assessment of this patient population. Methods A retrospective cohort study was conducted on patients with third- or fourth-degree OASIS operated on between January 2007 and December 2013 inclusive at Tampere University Hospital, Finland. At 6 months, the patients were asked to report their Wexner’s score as well as the three-choice assessment regarding AI symptoms. Based on this assessment, the patients were divided into three groups: those, asymptomatic, those with mild symptoms who did not want further treatment and those with severe symptoms who were willing to undergo further evaluation and treatment. Results There were 325 patients (median age 30 years). A total of 310 patients answered the questionnaire. Of which, one hundred and ninety-eight (63.9%) patients were asymptomatic, 85 (27.4%) had mild AI, and 27 (8.7%) experienced severe symptoms. There was no statistical difference in the results between the two techniques used (overlapping vs. end-to-end), or the stage of specialization of the operating physician. Persistent symptoms were associated with instrumental vaginal delivery (OR 2.12, 95% CI 1.32–3.41), severity of the injury (OR 1.64, 95% CI 1.20–2.25), and increased maternal age (OR 1.07, 95% CI 1.02–1.13). The correlation between the three-choice symptom evaluation and the Wexner score was good (Spearman’s rho 0.82). Conclusions After 6 months, severe symptoms after OASIS repair were present in 9% of women and were more frequent in older women, women with high-degree tears and after instrumental vaginal delivery. A three-choice assessment of AI symptoms correlated well with the Wexner score and might be useful to triage patients who need further evaluation.
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Affiliation(s)
- K Kuismanen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland.
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
| | - K Nieminen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - K Karjalainen
- National Institute for Health and Welfare, Helsinki, Finland
| | - K Lehto
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J Uotila
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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14
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Relationship of Anatomy and Function: External Anal Sphincter on Transperineal Ultrasound and Anal Incontinence. Female Pelvic Med Reconstr Surg 2017; 23:238-243. [DOI: 10.1097/spv.0000000000000350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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15
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Devesa JM. Fecal incontinence: major problem or incidental finding? Tech Coloproctol 2015; 20:77-9. [PMID: 26711103 DOI: 10.1007/s10151-015-1411-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 11/30/2015] [Indexed: 12/17/2022]
Affiliation(s)
- J M Devesa
- University Hospital Ramón y Cajal, Madrid, Spain.
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