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Cattani L, Packet B, Samešova A, Williams H, Van Schoubroeck D, Deprest J. Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1673-1681. [PMID: 38867553 DOI: 10.1002/jum.16490] [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: 02/11/2024] [Revised: 04/22/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVES To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. METHODS Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings. RESULTS Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. CONCLUSION TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.
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Affiliation(s)
- Laura Cattani
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Bram Packet
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Adela Samešova
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Third Faculty of Medicine, Institute for the Care of Mother and Child, Charles University, Prague, Czech Republic
| | - Helena Williams
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Dominique Van Schoubroeck
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
- Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, London, UK
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Swartz JL, Zifan A, Tuttle LJ, Sheean G, Tam RM, Mittal RK. Fecal incontinence patients categorized based on anal pressure and electromyography: Anal sphincter damage and clinical symptoms. Neurogastroenterol Motil 2024; 36:e14810. [PMID: 38689439 DOI: 10.1111/nmo.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/01/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Disruption of external anal sphincter muscle (EAS) is an important factor in the multifactorial etiology of fecal incontinence (FI). OBJECTIVES We categorize FI patients into four groups based on the location of lesion in neuromuscular circuitry of EAS to determine if there are differences with regards to fecal incontinence symptoms severity (FISI) score, age, BMI, obstetrical history, and anal sphincter muscle damage. METHODS Female patients (151) without any neurological symptoms, who had undergone high-resolution manometry, anal sphincter EMG, and 3D ultrasound imaging of the anal sphincter were assessed. Patients were categorized into four groups: Group 1 (normal)-normal cough EMG (>10 μV), normal squeeze EMG (>10 μV), and normal anal squeeze pressure (>124 mmHg); Group 2 (cortical apraxia, i.e., poor cortical activation)-normal cough EMG, low squeeze EMG, and low anal squeeze pressure; Group 3 (muscle damage)-normal cough EMG, normal squeeze EMG, and low anal squeeze pressure; and Group 4 (pudendal nerve damage)-low cough EMG, low squeeze EMG, and low anal squeeze pressure. RESULTS The four patient groups were not different with regards to the patient's age, BMI, parity, and FISI scores. 3D ultrasound images of the anal sphincter complex revealed significant damage to the internal anal sphincter, external anal sphincter, and puborectalis muscles in all four groups. CONCLUSION The FI patients are a heterogeneous group; majority of these patients have significant damage to the muscles of the anal sphincter complex. Whether biofeedback therapy response is different among different patient groups requires study.
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Affiliation(s)
- Jessica L Swartz
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ali Zifan
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
| | - Lori J Tuttle
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | | | - Rowena M Tam
- Doctor of Physical Therapy Program, San Diego State University, San Diego, California, USA
| | - Ravinder K Mittal
- Department of Gastroenterology, UC San Diego, La Jolla, California, USA
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Woon Wong K, Okeahialam N, Thakar R, Sultan AH. Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 296:99-106. [PMID: 38422805 DOI: 10.1016/j.ejogrb.2024.02.044] [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: 06/20/2023] [Revised: 11/15/2023] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth. STUDY DESIGN OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I2statistic. RESULTS Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]). CONCLUSIONS This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.
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Affiliation(s)
| | | | - Ranee Thakar
- Croydon University Hospital, UK; St George's University of London, UK
| | - Abdul H Sultan
- Croydon University Hospital, UK; St George's University of London, UK.
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Carter D, Ram E, Engel T. Combined 3D Endoanal Ultrasound and Transperineal Ultrasound Improves the Detection of Anal Sphincter Defects. Diagnostics (Basel) 2023; 13:diagnostics13040682. [PMID: 36832170 PMCID: PMC9955566 DOI: 10.3390/diagnostics13040682] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Anal sphincter injury, mainly due to obstetric or iatrogenic etiology, is the most common cause of fecal incontinence (FI). Three-dimensional endoanal ultrasound (3D EAUS) is used for assessment of the integrity and the degree of anal muscle injury. However, 3D EAUS accuracy may be hampered by regional acoustic effects, such as intravaginal air. Therefore, our aim was to examine whether a combination of transperineal ultrasound (TPUS) and 3D EAUS would improve the accuracy of detection of anal sphincter injury. METHODS We prospectively performed 3D EAUS followed by TPUS in every patient evaluated for FI in our clinic between January 2020 and January 2021. The diagnosis of anal muscle defects was assessed in each ultrasound technique by two experienced observers that were blinded to each other's assessments. Interobserver agreement for the results of the 3D EAUS and the TPUS exams was examined. A final diagnosis of anal sphincter defect was based on the results of both ultrasound methods. Discordant results were re-analyzed by the two ultrasonographers for a final consensus on the presence or absence of defects. RESULTS A total of 108 patients underwent ultrasonographic assessment due to FI (mean age 69 ± 13). Interobserver agreement for the diagnosis of tear on EAUS and TPUS was high (83%) with Cohen's kappa of 0.62. EAUS confirmed anal muscle defects in 56 patients (52%), while TPUS confirmed them in 62 patients (57%). The final consensus agreed on the diagnosis of 63 (58%) muscular defects and 45 (42%) normal exams. The Cohen's kappa coefficient of agreement between the results of the 3D EAUS and the final consensus was 0.63. CONCLUSIONS The combination of 3D EAUS and TPUS improved the detection of anal muscular defects. The application of both techniques for the assessment of the anal integrity should be considered in every patient going through ultrasonographic assessment for anal muscular injury.
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Affiliation(s)
- Dan Carter
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hasomer, Ramat Gan 5266202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-35307729
| | - Edward Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department Surgery B, Chaim Sheba Medical Center, Ramat Gan 5266202, Israel
| | - Tal Engel
- Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hasomer, Ramat Gan 5266202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Hubka P, Dvorak J, Lincova M, Masata J, Martan A, Svabik K. When to assess residual anal sphincter defect after OASI by ultrasound. Eur J Obstet Gynecol Reprod Biol 2022; 277:8-11. [PMID: 35964398 DOI: 10.1016/j.ejogrb.2022.08.004] [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: 05/11/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months. STUDY DESIGN This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation. RESULTS Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination. CONCLUSIONS In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.
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Affiliation(s)
- Petr Hubka
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and Na Bulovce Faculty Hospital, Charles University, Prague, Czech Republic.
| | - Jan Dvorak
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Marcela Lincova
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and Na Bulovce Faculty Hospital, Charles University, Prague, Czech Republic.
| | - Jaromir Masata
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Alois Martan
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Kamil Svabik
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
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Mittal RK, Tuttle LJ. Anorectal Anatomy and Function. Gastroenterol Clin North Am 2022; 51:1-23. [PMID: 35135656 DOI: 10.1016/j.gtc.2021.10.001] [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: 02/21/2023]
Abstract
Anatomy of pelvic floor muscles has long been controversial. Novel imaging modalities, such as three-dimensional transperineal ultrasound imaging, MRI, and diffusion tensor imaging, have revealed unique myoarchitecture of the external anal sphincter and puborectalis muscle. High-resolution anal manometry, high-definition anal manometry, and functional luminal imaging probe are important new tools to assess anal sphincter and puborectalis muscle function. Increased understanding of the structure and function of anal sphincter complex/pelvic floor muscle has improved the ability to diagnose patients with pelvic floor disorders. New therapeutic modalities to treat anal/fecal incontinence and other pelvic floor disorders will emerge in the near future.
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Affiliation(s)
- Ravinder K Mittal
- Department of Medicine/Gastroenterology, University of California, San Diego, ACTRI, 9500 Gilman Drive, MC 0061, La Jolla, CA 92093-0990, USA.
| | - Lori J Tuttle
- Department of Medicine/Gastroenterology, University of California, San Diego, USA; San Diego State University, San Diego, CA, USA
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Roupakias S, Sinopidis X. Pelvic Floor Muscles Contribution in Surgical Outcome of Children with High-type Anorectal Malformations. Prague Med Rep 2021; 122:191-200. [PMID: 34606431 DOI: 10.14712/23362936.2021.16] [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: 10/20/2022] Open
Abstract
As a consequence of high-type anorectal malformations (ARMs) pathogenesis, the pelvic floor muscles remain severely underdeveloped or hypoplastic, the rectal pouch is located at the level or above the puborectalis sling, and the bowel terminates outside the sphincter muscle complex support. For children with high-type ARMs the ultimate objective of therapy is mainly to grow up having bowel continence function that is compatible with a good quality of life, and the final prognosis depends significantly on the grade of development of pelvic floor muscles and the successful entering of the anorectum fully within the support of the external anal sphincter due to intraoperative conservation of the puborectalis sling. Pelvic magnetic resonance imaging (MRI) has recently become the preferred imaging study for prediction of functional outcomes, since it can define the anatomy and evaluate the development of the sphincteric muscles before and after surgical correction. Based on recent literature and our clinical experience, we will discuss the relevance of pelvic floor muscles MRI to the clinical outcome of children with high type ARMs.
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Abstract
This article discusses various pelvic floor ultrasonographic modalities and the clinical applications of ultrasonography of the pelvic floor. Ultrasonography provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variabilities and pathologic conditions, such as prolapse, fecal incontinence, urinary symptoms, vaginal wall cysts, synthetic implanted material, and pelvic pain, are assessed with pelvic floor ultrasonography. This imaging modality is an important adjunct to the evaluation and diagnosis of pelvic floor disorders.
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Affiliation(s)
- Trang X Pham
- Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, 800 Stanton L. Young Boulevard, Suite 2400, Oklahoma City, OK 73104, USA
| | - Lieschen H Quiroz
- Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, 800 Stanton L. Young Boulevard, Suite 2400, Oklahoma City, OK 73104, USA.
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Volløyhaug I, Taithongchai A, Arendsen L, van Gruting I, Sultan AH, Thakar R. Author reply to the commentary on: Is endoanal, introital or transperineal ultrasound diagnosis of sphincter defects more strongly associated with anal incontinence? Int Urogynecol J 2020; 31:1491-1492. [DOI: 10.1007/s00192-020-04370-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 11/30/2022]
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Capanna F, Haslinger C, Wisser J. Accuracy of clinical diagnosis of anal sphincter defect: clinical evaluation versus 3D-transperineal ultrasound. MINERVA GINECOLOGICA 2020; 72:187-194. [PMID: 32403913 DOI: 10.23736/s0026-4784.20.04562-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are common and an important factor in the etiology of anal incontinence. The objective of this study was to evaluate, classify and compare the agreement of clinically diagnosed third-degree sphincter tears with 3D-transperineal ultrasound (3D-TPUS) realized within 3-7 days post-delivery. METHODS This is a retrospective observational study were 119 patients with third-degree obstetric anal sphincter tears were diagnosed and treated, 85 of those underwent a 3D-TPUS examination 3-7 days postpartum. We compared the proportion of third-degree perineal tears, classified with the clinical examination as grade 3a+b and grade 3c, with the 3D-TPUS. RESULTS In 16 patients with clinically diagnosed third-degree perineal tears grade a and b, the ultrasound examination confirmed the lesion of the external anal sphincter (EAS) muscle, but in nine patients (56% of the cases) we found a lesion of the internal anal sphincter (IAS) muscle, missed by clinical examination. In the remaining 69 patients with the third-degree perineal tears grade c, the ultrasound examination confirmed both lesions (EAS and IAS muscles) in 56 women, but in 13 patients (19% of the cases) defects of the IAS muscle could not be confirmed by the ultrasound. CONCLUSIONS There was moderate agreement regarding diagnosis of grade 3a+b and grade c perineal tears between ultrasound and clinical examination, so a combined use of clinical and ultrasound knowledge can improve the possibility to find a gold standard in the diagnosis of OASIS.
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Affiliation(s)
- Federica Capanna
- Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland - .,Department of Obstetrics, Geneva University Hospitals, Geneva, Switzerland -
| | | | - Josef Wisser
- Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland
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Is endoanal, introital or transperineal ultrasound diagnosis of sphincter defects more strongly associated with anal incontinence? Int Urogynecol J 2020; 31:1471-1478. [PMID: 32198534 PMCID: PMC7306045 DOI: 10.1007/s00192-020-04274-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/24/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to explore the association between anal incontinence (AI) and persistent anal sphincter defects diagnosed with 3D endoanal (EAUS), introital (IUS) and transperineal ultrasound (TPUS) in women after obstetric anal sphincter injury (OASI) and study the association between sphincter defects and anal pressure. METHODS We carried out a cross-sectional study of 250 women with OASI recruited during the period 2013-2015. They were examined 6-12 weeks postpartum or in a subsequent pregnancy with 3D EAUS, IUS and TPUS and measurement of anal pressure. Prevalence of urgency/solid/liquid AI or flatal AI and anal pressure were compared in women with a defect and those with an intact sphincter (diagnosed off-line) using Chi-squared and Mann-Whitney U test. RESULTS At a mean of 23.6 (SD 30.1) months after OASI, more women with defect than those with intact sphincters on EAUS had AI; urgency/solid/liquid AI vs external defect: 36% vs 13% and flatal AI vs internal defect: 27% vs 13%, p < 0.05. On TPUS, more women with defect sphincters had flatal AI: 32% vs 13%, p = 0.03. No difference was found on IUS. Difference between defect and intact sphincters on EAUS, IUS and TPUS respectively was found for mean [SD] maximum anal resting pressure (48 [13] vs 55 [14] mmHg; 48 [12] vs 56 [13] mmHg; 50 [13] vs 54 [14] mmHg) and squeeze incremental pressure (33 [17] vs 49 [28] mmHg; 37 [23] vs 50 [28] mmHg; 36 [18] vs 50 [30] mmHg; p < 0.01). CONCLUSIONS Endoanal ultrasound had the strongest association with AI symptoms 2 years after OASI. Sphincter defects detected using all ultrasound methods were associated with lower anal pressure.
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Subramaniam N, Dietz HP. What is a significant defect of the anal sphincter on translabial ultrasound? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:411-415. [PMID: 31271480 DOI: 10.1002/uog.20390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two-thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound. METHODS This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed. RESULTS There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single-slice defect angle on TUI was low, and areas under the receiver-operating-characteristics curves were too low to determine a distinct cut-off value for defect angle. CONCLUSIONS Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single-slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut-off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Subramaniam
- Sydney Medical School Nepean, The University of Sydney, Penrith, Australia
| | - H P Dietz
- Sydney Medical School Nepean, The University of Sydney, Penrith, Australia
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Zifan A, Mittal RK, Kunkel DC, Swartz J, Barr G, Tuttle LJ. Loop analysis of the anal sphincter complex in fecal incontinent patients using functional luminal imaging probe. Am J Physiol Gastrointest Liver Physiol 2020; 318:G66-G76. [PMID: 31736339 PMCID: PMC6985842 DOI: 10.1152/ajpgi.00164.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cardiac loops have been used extensively to study myocardial function. With changes in cardiac pump function, loops are shifted to the right or left. Functional luminal imaging probe (FLIP) recordings allow for loop analysis of the anal sphincter and puborectalis muscle (PRM) function. The goal was to characterize anal sphincter area-pressure/tension loop changes in fecal incontinence (FI) patients. Fourteen healthy subjects and 14 patients with FI were studied. A custom-designed FLIP was placed in the vagina and then in the anal canal, and deflated in 20-ml steps, from 90 to 30 ml. At each volume, subjects performed maximal voluntary squeezes. Area-pressure (AP) and area-tension (AT) loops were generated for each squeeze cycle. Three-dimensional ultrasound imaging of the anal sphincter and PRM were obtained to determine the relationship between anal sphincter muscle damage and loop movements. With the increase in bag volume, AP loops and AT loops shifted to the right and upward in normal subjects (both anal and vaginal). The shift to the right was greater, and the upward movement was less in FI patients. The difference in the location of AP loops and AT loops was statistically significant at volumes of 50 ml to 90 ml (P < 0.05). A similar pattern was found in the vaginal loops. There is a significant relationship between the damage to the anal sphincter and PRM, and loop location of FI patients. We propose AP and AT loops as novel ways to assess the anal sphincter and PRM function. Such loops can be generated by real-time measurement of pressure and area within the anal canal.NEW & NOTEWORTHY We describe the use of area-pressure (AP) and area-tension (AT)-loop analysis of the anal sphincters and puborectalis muscles in normal subjects and fecal incontinent patients using the functional luminal imaging probe (FLIP). There are differences in the magnitude of the displacement of the loops with increase in the FLIP bag volume between normal subjects and patients with fecal incontinence. The latter group shifts more to the right in AP and AT space.
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Affiliation(s)
- Ali Zifan
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - Ravinder K. Mittal
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - David C. Kunkel
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, California
| | - Jessica Swartz
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| | - Garrett Barr
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
| | - Lori J. Tuttle
- 2Doctor of Physical Therapy Program, School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California
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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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Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries. Am J Obstet Gynecol 2019; 221:134.e1-134.e9. [PMID: 30981717 DOI: 10.1016/j.ajog.2019.04.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/18/2019] [Accepted: 04/08/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The optimal imaging modality of obstetric anal sphincter injuries needs to take into consideration convenience, availability, and ability to assess the sphincter morphologic condition. Endoanal ultrasound imaging currently is regarded as the reference standard, but it is not widely available in obstetric units. Exoanal alternatives exist, such as 3-dimensional introital or transperineal ultrasound imaging, which are already readily available in most obstetrics and gynecology units. OBJECTIVE The primary objective was to evaluate the diagnostic accuracy of 3-dimensional introital and 3-dimensional transperineal ultrasound imaging compared with 3-dimensional endoanal ultrasound imaging as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate a diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort that is experienced for each imaging modality. STUDY DESIGN A cross-sectional study was conducted of 250 women who sustained obstetric anal sphincter injuries, all of whom underwent 3-dimensional introital, transperineal, and endoanal ultrasound imaging. Introital and transperineal ultrasound imaging were assessed with tomographic ultrasound imaging. All of the women completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on receiver operating characteristic curves with endoanal ultrasound imaging as the reference standard. Diagnostic test characteristics of introital and transperineal ultrasound imaging were calculated with the use of these optimal cut-offs. RESULTS Optimal cut-off for a significant external anal sphincter defect was ≥3 of 7 slices; sensitivity and specificity were 0.65 and 0.75 on introital imaging and 0.70 and 0.69 on transperineal ultrasound imaging. Optimal cut-off for a significant internal anal sphincter defect was ≥2 of 5 slices; sensitivity and specificity were 0.59 and 0.84 on introital imaging and 0.43 and 0.97 on transperineal ultrasound imaging. The area under the curve for the diagnosis of external and internal anal sphincter defects ranged from 0.70-0.74 (P<.001) for introital and transperineal imaging. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63, and negative predictive value ranged from 0.85-0.93 for introital and transperineal ultrasound imaging. Endoanal ultrasound imaging was the only modality for a defect to correlate with symptoms; mean modified St. Mark's score for a defect sphincter was 2.4 (standard deviation, 4.1) and for an intact sphincter was 0.9 (standard deviation, 2.7; P<.01). Introital and transperineal ultrasound imaging were associated with less discomfort than endoanal ultrasound imaging. CONCLUSION Endoanal ultrasound imaging remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound imaging are not suitable for the identification of sphincter defects; however, high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardization of a significant defect. In women with a history of obstetric anal sphincter injuries, introital and transperineal ultrasound imagings are suitable to screen for an intact sphincter if endoanal ultrasound imaging is not available. When defects are found, women should then have endoanal ultrasound imaging to verify the diagnosis.
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Turel Fatakia F, Subramaniam N, Bienkiewicz J, Friedman T, Dietz HP. How repeatable is assessment of external anal sphincter trauma by exoanal 4D ultrasound? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:836-840. [PMID: 30426575 DOI: 10.1002/uog.20175] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/31/2018] [Accepted: 11/01/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Three-/four-dimensional translabial ultrasound (TLUS) is gaining popularity for the assessment of anal sphincter trauma, although repeatability data are lacking. This study aimed to determine the repeatability of tomographic ultrasound imaging (TUI) on TLUS for the diagnosis of external anal sphincter (EAS) trauma and compare the performance of a novice with that of an experienced investigator. METHODS This was a retrospective study of archived ultrasound datasets of patients who presented with symptoms of pelvic floor dysfunction and were examined twice between 2012 and 2016 at an average interval of 260 (range, 1-1100) days. All volumes were obtained using a GE Medical Systems Voluson 730 Expert or E8 ultrasound system. Post-processing of volumes was performed independently by two investigators, one with over 1 year's experience and another with no prior experience in using TUI, who were blinded to clinical data, each other's results and the results obtained at the first timepoint. Significant trauma on EAS was diagnosed if four of the six TUI slices showed a defect of ≥ 30°. Intra- and interobserver agreement were determined using Cohen's kappa (κ) and intraclass correlation coefficients. RESULTS During the study period, 105 women underwent two TLUS assessments of the anal sphincter. Of these, 103 patients with ultrasound volumes available for both timepoints were included in the analysis. The novice investigator demonstrated average repeatability for assessment of significant EAS trauma and single-slice defect (κ, 0.30 and 0.22, respectively) despite relatively high agreement between measurements obtained at the two timepoints (84.5% and 79.3%, respectively). The experienced investigator demonstrated good to very good repeatability for significant EAS trauma and single-slice defect (κ, 0.91 and 0.78, respectively) between the two assessments, which equates to 98.1% and 94.7% agreement, respectively. CONCLUSION The repeatability of TLUS measurements for diagnosis of EAS trauma seems to be very good when imaging is undertaken with state-of-the-art equipment and the analysis is performed by an experienced observer; however, the performance of a novice investigator is much poorer. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Turel Fatakia
- Sydney Medical School Nepean, The University of Sydney, Sydney, Australia
| | - N Subramaniam
- Sydney Medical School Nepean, The University of Sydney, Sydney, Australia
| | - J Bienkiewicz
- Department of Surgical & Endoscopic Gynecology and Gynecologic Oncology, Polish Mothers' Memorial Hospital-Research Institute, Lodz, Poland
| | - T Friedman
- Sydney Medical School Nepean, The University of Sydney, Sydney, Australia
| | - H P Dietz
- Sydney Medical School Nepean, The University of Sydney, Sydney, Australia
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Meriwether KV, Lockhart ME, Meyer I, Richter HE. Anal Sphincter Anatomy Prepregnancy to Postdelivery Among the Same Primiparous Women on Dynamic Magnetic Resonance Imaging. Female Pelvic Med Reconstr Surg 2019; 25:8-14. [PMID: 29068801 PMCID: PMC5916743 DOI: 10.1097/spv.0000000000000504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The authors used 2-dimensional images from pelvic 3 T magnetic resonance imaging (MRI) to characterize changes in the internal anal sphincter (IAS) and external anal sphincter (EAS) from prepregnancy to postdelivery in the same cohort. METHODS This secondary analysis studied a prospective cohort of women undergoing 3 T MRI before their first pregnancy and 6 or more months after delivery. Radial thickness was measured at 12, 3, 9, and 6 o'clock from axial proximal and mid views and oblique distal views of the IAS, and at 3 and 9 o'clock from oblique views of the EAS. Measurements were compared prepregnancy to postdelivery; 10 women had 80% power (α = 0.05) to detect a 0.85-mm change. RESULTS Nineteen women completed initial 3 T MRI, 15 achieved pregnancy and birth, and 10 completed postdelivery MRI (4 vaginal birth and 6 Cesarean delivery). Mean change in measurement from prepregnancy to postdelivery was -0.01 mm ± 1.03 mm for the distal 12 o'clock IAS (P = 0.98) and +0.19 ± 0.64 mm for the lateral EAS (P = 0.32). All prepregnancy and postdelivery women had discontinuous EA sphincters at 6 and 12 o'clock. There were no statistically significant changes from prepregnancy to postdelivery in any IAS or EAS location (all >0.05) for the entire cohort, those with vaginal birth, or after Cesarean. CONCLUSIONS Anal sphincter measurements on MRI did not change significantly in nulliparous women prepregnancy to postdelivery at any location, and the EAS was not measurable at 12 o'clock in any women at either time point, challenging classic concepts of EAS anatomy.
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Affiliation(s)
| | | | - Isuzu Meyer
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
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Ledgerwood‐Lee M, Zifan A, Kunkel DC, Sah R, Mittal RK. High-frequency ultrasound imaging of the anal sphincter muscles in normal subjects and patients with fecal incontinence. Neurogastroenterol Motil 2019; 31:e13537. [PMID: 30680849 PMCID: PMC6405312 DOI: 10.1111/nmo.13537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/15/2018] [Accepted: 12/05/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The current "gold standard" to diagnose anal sphincter morphology and disruptions utilizes low-frequency (3-9 MHz) ultrasound (US) imaging techniques that provide a general outline of the sphincter muscles, but not their microstructural details. High-frequency US transducers (7-15 MHz) have been used to study the muscle architecture (direction of muscle fascicles) in the limb muscle. AIMS The goal of our study was to visualize the microstructural anatomy of the anal sphincters, specifically the external anal sphincter (EAS), using high-frequency US imaging. METHODS Studies were conducted in asymptomatic female and male subjects and patients with fecal incontinence. US images were acquired using a low-frequency US (3-9 MHz) and high-frequency (7-15 MHz) US transducer. The latter was placed intra-anally to image the anal canal at 12, 9, 3, and 6 o'clock positions. RESULTS The low-frequency US images revealed the general outline of the anal sphincter muscles. On the other hand, high-frequency imaging visualized muscle fascicles and connective tissue inside the external anal sphincter (EAS). In FI patients, there was loss of muscle fascicles and alteration in the echo-intensity pattern in the region of damaged EAS suggestive of muscle fibrosis. CONCLUSION High-frequency ultrasound imaging is a powerful tool to visualize the microstructural details of the EAS. Our studies show that damage to the EAS muscle results in the alteration of its myoarchitecture, that is, loss of muscle fascicles and increase in the muscle connective tissue.
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Affiliation(s)
- Melissa Ledgerwood‐Lee
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - Ali Zifan
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - David C. Kunkel
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - Robert Sah
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
| | - Ravinder K. Mittal
- Division of Gastroenterology, Department of Medicine and Department of Biomedical EngineeringUniversity of California San Diego ACTRI La Jolla California
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Turel F, Shek KL, Dietz HP. How Valid Is Tomographic Ultrasound Imaging in Diagnosing Levator and Anal Sphincter Trauma? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:889-894. [PMID: 30203420 DOI: 10.1002/jum.14767] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Three-/four-dimensional translabial ultrasound (US) is increasingly used to image the levator ani and anal sphincters, especially in the form of tomographic US. The aim of the study was to evaluate the validity of these published methods. METHODS This work was a retrospective analysis of datasets of 172 nulliparous women who attended 2 tertiary urogynecologic centers for symptoms of pelvic floor dysfunction between June 2012 and September 2016. All patients had a standardized interview, clinical examination, and 4-dimensional translabial US examination. An evaluation of volume data was performed by the first author, who was blinded against all clinical data, including parity. An assessment for levator avulsion and anal sphincter defects was performed using stored US volume data. RESULTS Data sets of 162 and 153 nulliparous women were available for levator and anal sphincter assessments, respectively. On the assessment by the first author, a complete avulsion was diagnosed in 3 nulliparas. On a review by 2 senior authors, 1 was judged as positive and the other 2 as normal. On the sphincter assessment, 2 significant external anal sphincter defects were detected. On the review, 1 was judged as false-positive. The second was judged as highly abnormal by all authors. Therefore, 1 nullipara each was diagnosed with avulsion and a significant external anal sphincter defect. CONCLUSIONS Published diagnostic criteria for levator avulsion and external anal sphincter trauma on tomographic US imaging are highly unlikely to result in false-positive findings. This finding supports the clinical validity of this method.
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Affiliation(s)
- Friyan Turel
- Department of Obstetrics, Gynecology, and Neonatology, Sydney Medical School Nepean, University of Sydney, Kingswood, New South Wales, Australia
| | - Ka Lai Shek
- Department of Obstetrics, Gynecology, and Neonatology, Sydney Medical School Nepean, University of Sydney, Kingswood, New South Wales, Australia
- Liverpool Clinical School, Western Sydney University, Sydney, New South Wales, Australia
| | - Hans Peter Dietz
- Department of Obstetrics, Gynecology, and Neonatology, Sydney Medical School Nepean, University of Sydney, Kingswood, New South Wales, Australia
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Santoso BI, Djusad S, Hakim S, Moegni F, Meutia AP, Priyantini T. Use of 2D and multislice transperineal ultrasonography to describe the degree of perineal laceration following vaginal delivery. MEDICAL JOURNAL OF INDONESIA 2018. [DOI: 10.13181/mji.v27i2.1908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background: Perineal tear is the most common complication after vaginal delivery. Pill-rolling test is a widely used clinical evaluation method to determine the degree of perineal tear. However, the evaluation results of anal sphincter complex (ASC) differ between clinical examination and 2D/multislice transperineal ultrasonography (TPUS). This study aims to describe measurement variation between these modalities.Methods: This cross-sectional study was conducted at Cipto Mangunkusumo Hospital from November 2015 to May 2016. Subjects were primiparous women after vaginal delivery. Clinical examination using pill-rolling test was performed to determine the degree of perineal laceration. Suture was conducted accordingly. The subjects were subjected to 2D/multislice TPUS 72 hours after delivery to evaluate the integrity of internal and external anal sphincters. Data were collected and analyzed to determine compatibility between these examinations.Results: Among 70 prospective primiparous women, five were excluded due to unavailability to undergo 2D/multislice TPUS 72 hours after delivery. The mean duration to perform 2D/multislice TPUS was 4.5 minutes, and pain was tolerable during the examination. The compatibility values of clinical examination with 2D and multislice TPUS were 0.98 and 0.93, respectively, with Cohen’s kappa of 0.92 (95% CI 0.81–1.00) and 0.79 (95% CI 0.58–0.99), respectively.Conclusion: Clinical examination is compatible with 2D/multislice TPUS for determining the degree of perineal tear after vaginal delivery.
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González MS, Garriga JC, Capel CD, Roda OP, Capó JP, Saladich IG. Is obstetric anal sphincter injury a risk factor for levator ani muscle avulsion in vaginal delivery? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:257-262. [PMID: 26701063 DOI: 10.1002/uog.15847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 12/17/2015] [Accepted: 12/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To analyze whether women who sustain obstetric anal sphincter injury (OASI) in their first vaginal delivery have a higher incidence of levator ani muscle (LAM) avulsion than do women without OASI. METHODS We conducted a prospective observational cohort study of 80 primiparous women who gave birth at our tertiary obstetric unit between September 2011 and July 2013. The women were divided into two groups: women diagnosed with OASI during vaginal delivery (n = 40) and women without OASI (n = 40), matched by mode of delivery and newborn birth weight. Four-dimensional (4D) transperineal ultrasound was performed in all participants at 6-12 months after delivery to assess for integrity or avulsion of the LAM. Ultrasound images were evaluated by two observers who were blinded to group assignment and clinical data. Interobserver agreement was assessed to determine the reproducibility of 4D transperineal ultrasound for diagnosing LAM avulsion. RESULTS We found no statistically significant differences between the two groups. The incidence of LAM avulsion was 24.3% in the OASI group and 34.2% in the control group (P = 0.448). Interobserver agreement in the diagnosis of LAM avulsion in the study population using 4D transperineal ultrasound was 89.5%, with a kappa index of 0.76. CONCLUSIONS Our findings do not support OASI as a risk factor for LAM avulsion. Prospective studies in larger populations are needed to establish the biomechanical relationships of the pelvic floor structures involved in vaginal delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Simó González
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - J Cassadó Garriga
- Department of Gynecology and Obstetrics, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - C Dosouto Capel
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - O Porta Roda
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - J Perelló Capó
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - I Gich Saladich
- Clinical Epidemiology Unit, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
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Abstract
This article discusses the background and appraisal of endoluminal ultrasound of the pelvic floor. It provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variability and pathology, such as prolapse, fecal incontinence, urinary incontinence, vaginal wall cysts, synthetic implanted material, and pelvic pain, are easily assessed with endoluminal vaginal ultrasound. With pelvic organ prolapse in particular, not only is the prolapse itself seen but the underlying cause related to the anatomic and functional abnormalities of the pelvic floor muscle structures are also visualized.
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Affiliation(s)
- Daniel E Stone
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, 920 Stanton L. Young, WP2430, Oklahoma City, OK 73104, USA
| | - Lieschen H Quiroz
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, 920 Stanton L. Young, WP2430, Oklahoma City, OK 73104, USA.
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Shek KL, Zazzera VD, Atan IK, Rojas RG, Langer S, Dietz HP. The evolution of transperineal ultrasound findings of the external anal sphincter during the first years after childbirth. Int Urogynecol J 2016; 27:1899-1903. [DOI: 10.1007/s00192-016-3055-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/12/2016] [Indexed: 12/31/2022]
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Albuquerque A, Pereira E. Current applications of transperineal ultrasound in gastroenterology. World J Radiol 2016; 8:370-377. [PMID: 27158423 PMCID: PMC4840194 DOI: 10.4329/wjr.v8.i4.370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 09/04/2015] [Accepted: 03/09/2016] [Indexed: 02/06/2023] Open
Abstract
Transperineal ultrasound is an inexpensive, safe and painless technique that dynamically and non-invasively evaluates the anorectal area. It has multiple indications, mainly in urology, gynaecology, surgery and gastroenterology, with increased use in the last decade. It is performed with conventional probes, positioned directly above the anus, and may capture images of the anal canal, rectum, puborectalis muscle (posterior compartment), vagina, uterus, (central compartment), urethra and urinary bladder (anterior compartment). Evacuatory disorders and pelvic floor dysfunction, like rectoceles, enteroceles, rectoanal intussusception, pelvic floor dyssynergy can be diagnosed using this technique. It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature, with images obtained at rest, straining and sustained squeezing. This technique is an accurate examination for detecting, classifying and following of perianal inflammatory disease. It can also be used to sonographically guide drainage of deep pelvic abscesses, mainly in patients who cannot undergo conventional drainage. Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence, postpartum and also following surgical repair of obstetric tears. There are also some studies referring to its role in anal stenosis, for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.
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Durnea CM, O'Reilly BA, Khashan AS, Kenny LC, Durnea UA, Smyth MM, Dietz HP. Status of the pelvic floor in young primiparous women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:356-362. [PMID: 25359670 DOI: 10.1002/uog.14711] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 10/16/2014] [Accepted: 10/21/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To investigate the postnatal prevalence of sonographically diagnosed pelvic floor trauma, and the correlations with various antenatal/intrapartum predictors in primiparous women. METHODS This was a prospective cohort study performed in a tertiary hospital with 9000 deliveries per annum. Of those invited, 202 (23.2%) primiparous participants were assessed clinically at least 1 year after delivery by Pelvic Organ Prolapse Quantification (POP-Q), two/three-dimensional transperineal sonography and quantification of serum collagen type III levels. RESULTS There was a high prevalence of clinically significant pelvic organ prolapse (POP) on POP-Q staging: uterine prolapse, 63%; cystocele, 42%; and rectocele, 23%. Ballooning of the levator ani muscle (LAM) hiatus was detected in 33% and LAM avulsion in 29% of participants, with partial LAM avulsion occurring in 15% and complete avulsion in 14%. Postnatal POP symptoms (odds ratios (ORs) given here for presence of multiple prolapse symptoms) were positively associated with similar prepregnancy symptoms (OR, 7.2 (95% CI, 1.19-44.33)), LAM avulsion (OR, 4.8 (95% CI, 1.99-11.34)) and forceps delivery (borderline significance; OR, 1.8 (95% CI, 0.96-3.25)) and negatively associated with elective (OR, 0.2 (95% CI, 0.09-0.63)) and emergency (OR, 0.3 (95% CI, 0.12-0.83)) Cesarean section. LAM abnormality was associated with forceps delivery (OR, 4.9 (95% CI, 1.44-16.97)) and prolapse (OR, 6.8-11.7 (95% CI, 2.34-78.51)), whereas collagen levels did not play a role (OR, 1.001 (95% CI, 0.99-1.02)). CONCLUSIONS Clinically significant POP was common in relatively young premenopausal primiparous women. Partial or full levator avulsion was seen in 29% of participants and was associated with POP and related symptoms. Congenital factors seem to play little role in the etiology of LAM trauma, and the main risk factor seems to be forceps delivery. Avoidance of difficult vaginal deliveries may prevent severe pelvic floor trauma.
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Affiliation(s)
- C M Durnea
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Urogynaecology, Cork University Maternity Hospital (CUMH), Cork, Ireland
| | - B A O'Reilly
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Urogynaecology, Cork University Maternity Hospital (CUMH), Cork, Ireland
| | - A S Khashan
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - L C Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - U A Durnea
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - M M Smyth
- School of Medicine, University College Cork, Cork, Ireland
| | - H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, Australia
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The relationship of 3-D translabial ultrasound anal sphincter complex measurements to postpartum anal and fecal incontinence. Int Urogynecol J 2015; 26:1191-9. [PMID: 26085463 DOI: 10.1007/s00192-015-2676-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/24/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to determine whether anal sphincter complex (ASC) measurements on translabial ultrasound (TL-US) were related to anal incontinence (AI) or fecal incontinence (FI) symptoms 6 months postpartum. METHODS A prospective cohort of primiparous women underwent TL-US 6 months after a vaginal birth (VB) or cesarean delivery (CD). Muscle thickness was measured at 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS), the same four quadrants of the internal anal sphincter (IAS) at proximal, mid, and distal levels, and at the bilateral pubovisceralis muscle (PVM). Measurements were correlated to AI and FI on the Wexner Fecal Incontinence Scale, with sub-analyses by mode of delivery. The odds ratio (OR) of symptoms was calculated for every 1 mm increase in muscle thickness (E1MIT). RESULTS A total of 423 women (299 VB, 124 CD) had TL-US 6 months postpartum. Decreased AI risk was associated with thicker measurements at the 6 o'clock (OR 0.74 E1MIT) and 9 o'clock proximal IAS (OR 0.71 E1MIT) in the entire cohort. For CD women, thicker measurements of the 9 o'clock proximal IAS were associated with decreased risk of AI (OR 0.56 E1MIT) and thicker distal 6 o'clock IAS measurements were related to a decreased risk of FI (OR 0.37 E1MIT). For VB women, no sphincter measurements were significantly related to symptoms, but thicker PVM measurements were associated with increased risk of AI (right side OR 1.32 E1MIT; left side OR 1.21 E1MIT). CONCLUSIONS ASC anatomy is associated with AI and FI in certain locations; these locations vary based on the patient's mode of delivery.
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Steele SR, Varma MG, Prichard D, Bharucha AE, Vogler SA, Erdogan A, Rao SSC, Lowry AC, Lange EO, Hall GM, Bleier JIS, Senagore AJ, Maykel J, Chan SY, Paquette IM, Audett MC, Bastawrous A, Umamaheswaran P, Fleshman JW, Caton G, O'Brien BS, Nelson JM, Steiner A, Garely A, Noor N, Desrosiers L, Kelley R, Jacobson NS. The evolution of evaluation and management of urinary or fecal incontinence and pelvic organ prolapse. Curr Probl Surg 2015; 52:17-75. [PMID: 25919203 DOI: 10.1067/j.cpsurg.2015.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
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Alteration of anal sphincter function in patients with levator avulsion: observational study. Int Urogynecol J 2015; 26:985-90. [DOI: 10.1007/s00192-014-2623-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
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Shek KL, Guzman-Rojas R, Dietz HP. Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:704-709. [PMID: 24652810 DOI: 10.1002/uog.13368] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/08/2014] [Accepted: 03/12/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Obstetric anal sphincter tears are common and an important factor in the etiology of anal incontinence. The objective of the study was to evaluate the prevalence of residual defects of the external anal sphincter (EAS) after primary repair of obstetric anal sphincter injury using four-dimensional (4D) transperineal ultrasound and to correlate sonographic findings of residual defects and levator avulsion with significant symptoms of anal incontinence, defined as St Mark's fecal incontinence score (SMIS) of ≥ 5. METHODS This was a retrospective observational study. One-hundred and forty women were seen after primary repair of obstetric anal sphincter tears in a dedicated perineal clinic at a tertiary hospital in Australia. They all underwent a standardized interview, and physical and 4D transperineal ultrasound examination. RESULTS Mean follow-up interval was 1.9 months after delivery. Eighty-nine (64%) women had a 3a/3b tear, 28 (20%) a 3c/4(th) degree tear and 23 (16%) an unclassified 3(rd) degree tear. Thirty-five (25%) patients reported symptoms of anal incontinence. Nine had an SMIS of ≥ 5. A residual defect was found in 56 (40%) cases and levator avulsion in 27 (19%). On multivariate logistic regression, residual defects (P = 0.03; odds ratio (OR) = 6.38; 95% CI, 1.23-33.0) and levator avulsion (P = 0.047; OR = 4.38; 95% CI, 1.02-18.77) were found to be independent risk factors for anal incontinence. CONCLUSIONS Residual defects of the EAS were found on transperineal ultrasound in 40% of women after primary repair of obstetric anal sphincter injuries. Although most were asymptomatic, residual anal sphincter defects and levator avulsion were associated with significant symptoms of anal incontinence as quantified using the SMIS.
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Affiliation(s)
- K L Shek
- Nepean Clinical School, University of Sydney, Penrith, Australia
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Anal sphincter complex: 2D and 3D endoanal and translabial ultrasound measurement variation in normal postpartum measurements. Int Urogynecol J 2014; 26:511-7. [PMID: 25344221 DOI: 10.1007/s00192-014-2524-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Women may experience anal sphincter anatomy changes after vaginal birth (VB) or Cesarean delivery (CD). Therefore, accurate and acceptable imaging options to evaluate the anal sphincter complex (ASC) are needed. ASC measurements may differ between translabial (TLUS) and endoanal (EAUS) ultrasound imaging and between 2D and 3D US. The objective of this analysis was to describe measurement variation between these modalities. METHODS Primiparous women underwent 2D and 3D TLUS imaging of the ASC 6 months after VB or CD. A subset of women also underwent EAUS measurements. Measurements included internal anal sphincter (IAS) thickness at proximal, mid, and distal levels and the external anal sphincter (EAS) at 3, 6, 9, and 12 o'clock positions, as well as bilateral thickness of the pubovisceralis muscle (PVM). RESULTS There were 433 women presenting for US: 423 had TLUS and 64 had both TLUS and EAUS of the ASC. All IAS measurements were significantly thicker on TLUS than EAUS (all p < 0.01), while EAS measurements were significantly thicker on EAUS (p < 0.01). PVM measurements with 3D or 2D imaging were similar (p > 0.20). On both TLUS and EAUS, there were multiple sites where significant asymmetry existed in left versus right measurements. CONCLUSIONS US modality used to image the ASC introduces small but significant changes in measurements, and the direction of the bias depends on the muscle and location being imaged.
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Mittal RK, Bhargava V, Sheean G, Ledgerwood M, Sinha S. Purse-string morphology of external anal sphincter revealed by novel imaging techniques. Am J Physiol Gastrointest Liver Physiol 2014; 306:G505-14. [PMID: 24458022 PMCID: PMC3949029 DOI: 10.1152/ajpgi.00338.2013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The external anal sphincter (EAS) may be injured in 25-35% of women during the first and subsequent vaginal childbirths and is likely the most common cause of anal incontinence. Since its first description almost 300 years ago, the EAS was believed to be a circular or a "donut-shaped" structure. Using three-dimensional transperineal ultrasound imaging, MRI, diffusion tensor imaging, and muscle fiber tracking, we delineated various components of the EAS and their muscle fiber directions. These novel imaging techniques suggest "purse-string" morphology, with "EAS muscles" crossing contralaterally in the perineal body to the contralateral transverse perineal (TP) and bulbospongiosus (BS) muscles, thus attaching the EAS to the pubic rami. Spin-tag MRI demonstrated purse-string action of the EAS muscle. Electromyography of TP/BS and EAS muscles revealed their simultaneous contraction and relaxation. Lidocaine injection into the TP/BS muscle significantly reduced anal canal pressure. These studies support purse-string morphology of the EAS to constrict/close the anal canal opening. Our findings have implications for the effect of episiotomy on anal closure function and the currently used surgical technique (overlapping sphincteroplasty) for EAS reconstructive surgery to treat anal incontinence.
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Affiliation(s)
- Ravinder K. Mittal
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California; ,4San Diego Veterans Affairs Healthcare System, San Diego, California
| | - Valmik Bhargava
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California; ,4San Diego Veterans Affairs Healthcare System, San Diego, California
| | - Geoff Sheean
- 2Department of Neurology, University of California San Diego, San Diego, California;
| | - Melissa Ledgerwood
- 1Division of Gastroenterology, Department of Medicine, University of California San Diego, San Diego, California;
| | - Shantanu Sinha
- 3Department of Radiology, University of California San Diego, San Diego, California; and
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van Delft K, Sultan AH, Thakar R, Schwertner-Tiepelmann N, Kluivers K. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014; 121:1164-71; discussion 1172. [DOI: 10.1111/1471-0528.12666] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 01/05/2023]
Affiliation(s)
- K van Delft
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - AH Sultan
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - R Thakar
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - N Schwertner-Tiepelmann
- Department of Obstetrics and Gynaecology, Urogynaecology; Croydon University Hospital; Croydon UK
| | - K Kluivers
- Department of Obstetrics and Gynaecology (791); Radboud University Medical Centre; Nijmegen The Netherlands
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Bharucha AE, Rao SSC. An update on anorectal disorders for gastroenterologists. Gastroenterology 2014; 146:37-45.e2. [PMID: 24211860 PMCID: PMC3913170 DOI: 10.1053/j.gastro.2013.10.062] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 01/13/2023]
Abstract
Gastroenterologists frequently encounter pelvic floor disorders, which affect 10% to 15% of the population. The anorectum is a complex organ that collaborates with the pelvic floor muscles to preserve fecal continence and enable defecation. A careful clinical assessment is critical for the diagnosis and management of defecatory disorders and fecal incontinence. Newer diagnostic tools (eg, high-resolution manometry and magnetic resonance defecography) provide a refined understanding of anorectal dysfunctions and identify phenotypes in defecatory disorders and fecal incontinence. Conservative approaches, including biofeedback therapy, are the mainstay for managing these disorders; new minimally invasive approaches may benefit a subset of patients with fecal incontinence, but more controlled studies are needed. This mini-review highlights advances, current concepts, and controversies in the area.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Satish S C Rao
- Section of Gastroenterology/Hepatology, Department of Internal Medicine, Medical College of Georgia, Georgia Regents University, Augusta, Georgia.
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Longitudinal and radial characteristics of intra-anal pressures in children using 3D high-definition anorectal manometry: new observations. Am J Gastroenterol 2013; 108:1918-28. [PMID: 24169274 DOI: 10.1038/ajg.2013.361] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/14/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The pathophysiology of fecal incontinence is not well understood. Standard or high-resolution anorectal manometry (ARM) provides simple two-dimensional (2D) intra-anal pressure measurements and do not identify radial asymmetry or localize abnormal sphincter function. 3D high-definition ARM (HDARM) has 256 pressure sensors distributed circumferentially and provides a detailed topographical and 3D pressure gradient representation of the anal canal. The objective of this study was to use HDARM to characterize intra-anal pressure profiles in children during rest and squeeze. METHODS HDARM manometric tracings of 30 children with constipation referred for ARM were reviewed. 2D pressure profiles using high-resolution manometry were used to measure the length of the high-pressure zone (HPZ). The HPZ was divided into four equal segments from the anal verge to adjust for the variable sphincter length. Longitudinal and radial measurements of the HPZ during rest and squeeze (anterior, left, posterior, right quadrants of the HPZ) were taken along each segment in 2D and 3D topographical views. A 3D reconstruction combining all patients was then constructed. RESULTS Mean age was 149.3±1.8 months and mean HPZ length was 3.0±0.1 cm. Using 2D manometry, the mean peak HPZ pressure at rest was 72.0±2.5 mm Hg, and was located in the second segment of the HPZ. The mean peak HPZ pressure at squeeze was 202.9±13.1, and was located in the second segment. 3D measurement demonstrated both longitudinal and radial asymmetry along the anterior, left, posterior, and right quadrants of the HPZ. Left and right quadrant pressures were higher than anterior and posterior pressures at the anal verge and segment 1 during rest and squeeze. Anterior pressures were lower than posterior pressures longitudinally and radially in segments 2, 3, and 4 both during rest and squeeze. Our findings also suggest that in pediatrics it may be necessary to adjust pressure measurement to the anal canal length to get a more accurate picture. CONCLUSIONS 3D HDARM allows for a detailed characterization of intra-anal pressures. 3D topographic pressure measurements demonstrate longitudinal and radial asymmetry of the anal canal at rest and during squeeze. This is the first time longitudinal and radial asymmetry of the anal canal has been described in children. 3D HDARM may allow for a better understanding of the mechanisms of fecal continence in children.
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Kim YS, Weinstein M, Raizada V, Jiang Y, Bhargava V, Rajasekaran MR, Mittal RK. Anatomical disruption and length-tension dysfunction of anal sphincter complex muscles in women with fecal incontinence. Dis Colon Rectum 2013; 56:1282-9. [PMID: 24105004 PMCID: PMC3802525 DOI: 10.1097/dcr.0b013e3182a18e87] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anal sphincter complex muscles, the internal anal sphincter, external anal sphincter, and puborectalis muscles, play an 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 This study aimed to assess the anatomy of the anal sphincter complex muscles with the use of a 3-dimensional ultrasound imaging system and to determine the relationship between the anatomical defects and the length-tension property of external anal sphincter and puborectalis muscles in women with incontinence symptoms and in control subjects. DESIGN Severity of anal sphincter muscle damage was determined by static and dynamic 3-dimensional ultrasound imaging. The length-tension property was determined by anal and vaginal pressure with the use of custom-designed probes. PATIENTS Forty-four asymptomatic controls and 24 incontinent patients participated in this study. MAIN OUTCOME MEASURES The anatomical defects and length-tension dysfunction of anal sphincter complex muscles in patients with fecal incontinence were evaluated. RESULTS The prevalence of injury to sphincter muscles is significantly greater in the incontinent patients than in the controls. Eighty-five percent of patients but only 9% controls reveal damage to ≥2 of the 3 muscles of the anal sphincter complex. Anal and vaginal squeeze pressures increased with the increase in the probe size (length-tension curve) in the majority of controls. In patients, the increase in anal and vaginal squeeze pressures was either significantly smaller than in controls or it decreased with the increasing probe size (abnormal length-tension). LIMITATIONS We studied patients with severe symptoms. Whether our findings are applicable to patients with mild to moderate symptoms remains to be determined. CONCLUSIONS The length-tension property of the external anal sphincter and puborectalis muscles is significantly impaired in incontinent patients. Our findings have therapeutic implications for the treatment of anal incontinence.
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Affiliation(s)
- Young Sun Kim
- 1 Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, California 2 Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
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Postpartum translabial 2D and 3D ultrasound measurements of the anal sphincter complex in primiparous women delivering by vaginal birth versus Cesarean delivery. Int Urogynecol J 2013; 25:329-36. [PMID: 24105408 DOI: 10.1007/s00192-013-2215-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/17/2013] [Indexed: 02/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Consensus on normal translabial ultrasound (TL-US) anal sphincter complex measurements for postpartum women is lacking. We aimed to evaluate normative measurements in 2D and 3D TL-US for the anal sphincter complex (ASC) at 6 months postpartum and compare these measurements in women who had a vaginal birth (VB) and in those who had a Cesarean delivery (CD). METHODS A large, prospective cohort of primiparous women underwent 2D and 3D TL-US 6 months after their first delivery. For normative sphincter measurements, we excluded women with third- or fourth-degree lacerations or with sphincter interruption on TL-US. Measurements included the sphincter thickness at the 3, 6, 9, and 12 o'clock positions of the external anal sphincter (EAS) and the internal anal sphincter (IAS) at proximal, mid, and distal levels. We also measured the mean coronal diameter of the pubovisceralis muscle (PVM). RESULTS 696 women consented to participate, and 433 women presented for ultrasound imaging 6 months later. Women who sustained a third- or fourth-degree laceration had significantly thicker EAS measurements at 12 o'clock. Sphincter asymmetry was common (69 %), but was not related to mode of delivery. Only IAS measurements at the proximal and distal 12 o'clock position were significantly thicker for CD patients. There were no significant differences in the EAS or PVM measurements between VB and CD women. CONCLUSIONS There appear to be few differences in normative sphincter ultrasound measurements between primiparous patients who had VB or CD.
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Diagnosis of anal sphincter defects by three-dimensional transperineal ultrasound in women with anal incontinence. J Med Ultrason (2001) 2012; 39:241-7. [DOI: 10.1007/s10396-012-0369-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
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Detection of anal sphincter defects in female patients with fecal incontinence: a comparison of 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound. Dis Colon Rectum 2012; 55:646-52. [PMID: 22595843 DOI: 10.1097/dcr.0b013e318251dca1] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoanal ultrasound is widely used for the detection of external and internal anal sphincter defects in patients with fecal incontinence. Recently, 3-dimensional transperineal ultrasound has been introduced as a noninvasive imaging method for the detection of these sphincter defects. OBJECTIVE This study was designed to assess agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects in women with fecal incontinence. DESIGN This study was designed as a prospective observational study. SETTINGS The study took place in a university hospital. PATIENTS Between October 2008 and June 2009, all women with concerns of fecal incontinence underwent 2-dimensional endoanal ultrasound as well as 3-dimensional transperineal ultrasound. MAIN OUTCOME MEASURES The main outcome measures are the presence of external and internal anal sphincter defects. RESULTS Fifty-five patients were included. External and internal anal sphincter defects were observed with 2-dimensional endoanal ultrasound in 27 (49%) and 15 (27%) patients. Three-dimensional transperineal ultrasound detected an external and internal sphincter defect in 19 (35%) and 16 (29%) patients. The Cohen κ coefficient for the detection of external (κ = 0.63) and internal (κ = 0.78) anal sphincter defects was good. LIMITATIONS This study's limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. CONCLUSION This study shows good agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects. Based on these data, 3-dimensional transperineal ultrasound might be considered as a valuable alternative noninvasive investigation method.
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Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R. Obstetric levator ani muscle injuries: current status. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:372-383. [PMID: 22190408 DOI: 10.1002/uog.11080] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.
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Abstract
Pelvic floor ultrasound is a valuable adjunct in elucidation of cause, diagnosis, and treatment of pelvic floor disorders. Three-dimensional ultrasound specifically has been shown to have many advantages over conventional imaging modalities. Proper evaluation of pelvic floor muscle function, strength, and integrity is an important component of diagnosis and treatment of pelvic floor disorders. The pelvic floor muscle training used to change the structural support and strength of muscle contraction requires clinicians to be able to conduct high-quality measurements of pelvic floor muscle function and strength. Ultrasound is a useful modality to assess the pelvic floor and its function. As practitioners become more familiar with the advantages and capabilities of ultrasound, this tool should become part of routine clinical practice in evaluation and management of pelvic floor disorders.
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Mittal RK, Sheean G, Padda BS, Lieber R, Raj Rajasekaran M. The external anal sphincter operates at short sarcomere length in humans. Neurogastroenterol Motil 2011; 23:643-e258. [PMID: 21418426 DOI: 10.1111/j.1365-2982.2011.01700.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The length at which a muscle/sarcomere operates in vivo (operational length) and the length at which it generates maximal stress (optimal length) can be quite different. In a previous study, we found that the rabbit external anal sphincter (EAS) operates on the ascending limb of the length-tension curve, in other words at lengths shorter than its optimal length (short sarcomere length). In this study, we tested whether the human EAS muscle also operates at a short sarcomere length. METHODS The length-tension relationship of the EAS muscle was studied in vivo in 10 healthy nullipara women. EAS muscle length was altered by anal distension using custom-designed probes of 5, 10, 15, and 20mm diameter. Probes were equipped with a sleeve sensor to measure anal canal pressure. The EAS muscle electromyograph (EMG) was recorded using wire electrodes. Ultrasound images of anal canal were obtained to measure EAS muscle thickness and anal canal diameter. EAS muscle stress was calculated from the anal canal pressure, inner radius, and thickness of the EAS muscle. KEY RESULTS Rest and squeeze stress of the anal canal increased with the increase in probe size. Similarly, the change in anal canal stress, i.e. the difference between the rest and the squeeze, which represents the active contribution of EAS to the anal canal stress, increased with the increase in probe size. However, increase in probe size was not associated with an increase in the external anal sphincter EMG activity. CONCLUSIONS & INFERENCES Increase in EAS muscle stress with the increase in probe size, in the presence of constant EMG (neural input), demonstrates that the human EAS muscle operates on the ascending limb of the length-tension curve or at low sarcomere lengths. We propose that surgically adjusting EAS sarcomere length may represent a novel strategy to treat fecal incontinence in humans.
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Affiliation(s)
- R K Mittal
- The Pelvic Floor Function and Diseases Group, University of California, San Diego, CA 92161, USA.
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Weinstein MM, Pretorius DH, Jung SA, Wan JJ, Nager CW, Mittal RK. Anal sphincter complex muscles defects and dysfunction in asymptomatic parous women. Int Urogynecol J 2011; 22:1143-50. [PMID: 21604060 DOI: 10.1007/s00192-011-1446-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 04/26/2011] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to determine anatomy and function of anal sphincter complex using three-dimensional ultrasound (3D-US) and manometry in asymptomatic parous women. METHODS 3D-US of puborectalis muscle (PRM), external (EAS), and internal anal sphincters (IAS) anatomy was performed in 45 women without pelvic floor dysfunction. To assess function, rest and squeeze vaginal and anal pressures were measured. Based on 3D-US, subjects were divided into injured and uninjured groups. RESULTS Forty-four of 45 subjects had adequate PRM images. The injured PRM (N = 14) group had significantly lower vaginal pressures as compared with uninjured PRM group (N = 30; p = 0.001). Four of 45 subjects with IAS and EAS defects had lower resting and squeeze anal canal pressure. Muscle injury to IAS, EAS and PRM in the same individual was uncommon. CONCLUSIONS In asymptomatic parous women, PRM defects were more common than the EAS/IAS defects but defects in more than one muscle were infrequent. Subjects with injured PRM had low vaginal pressure than the ones without.
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Affiliation(s)
- Milena M Weinstein
- The Pelvic Floor Function and Disorder Group, University of California, San Diego, CA, USA
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Santoro GA, Wieczorek AP, Dietz HP, Mellgren A, Sultan AH, Shobeiri SA, Stankiewicz A, Bartram C. State of the art: an integrated approach to pelvic floor ultrasonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:381-396. [PMID: 20814874 DOI: 10.1002/uog.8816] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available. In this review, pelvic floor ultrasonography, including two-dimensional (2D), three-dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor-urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome-is evaluated critically.
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Affiliation(s)
- G A Santoro
- Pelvic Floor Unit, I°Department of Surgery, Regional Hospital, Treviso, Italy.
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CHANTARASORN V, SHEK KL, DIETZ HP. Sonographic detection of puborectalis muscle avulsion is not associated with anal incontinence. Aust N Z J Obstet Gynaecol 2011; 51:130-5. [DOI: 10.1111/j.1479-828x.2010.01273.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rao SS. Advances in diagnostic assessment of fecal incontinence and dyssynergic defecation. Clin Gastroenterol Hepatol 2010; 8:910-9. [PMID: 20601142 PMCID: PMC2964406 DOI: 10.1016/j.cgh.2010.06.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 05/12/2010] [Accepted: 06/05/2010] [Indexed: 02/07/2023]
Abstract
Disorders of the anorectum and pelvic floor affect approximately 25% of the population. Their evaluation and treatment have been hindered by a lack of understanding of underlying mechanism(s) and a working knowledge of the diagnostic advances in this field. A meticulous evaluation of anorectal structure and its function can provide invaluable insights to the practicing gastroenterologist regarding the pathogenic mechanism(s) of these disorders. Also, significant new knowledge has emerged over the past decade that includes the development of newer diagnostic tools such as high-resolution manometry and magnetic resonance defecography as well as a better delineation of the clinical and pathophysiologic subtypes of constipation and incontinence. This article provides an up-to-date review on the role of diagnostic tests in the evaluation of fecal incontinence and constipation with dyssynergic defecation.
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Affiliation(s)
- Satish S.C. Rao
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Whitehead WE, Bharucha AE. Diagnosis and treatment of pelvic floor disorders: what's new and what to do. Gastroenterology 2010; 138:1231-5, 1235.e1-4. [PMID: 20176023 PMCID: PMC3924316 DOI: 10.1053/j.gastro.2010.02.036] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- William E. Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology and Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Adil E. Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
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Is sacral neuromodulation for fecal incontinence worthwhile in patients with associated pelvic floor injury? Dis Colon Rectum 2010; 53:422-7. [PMID: 20305441 DOI: 10.1007/dcr.0b013e3181c38365] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE It has been shown that vaginal delivery may result in pelvic floor injury. Until now it is unknown whether this type of injury plays a role in the etiology of fecal incontinence and whether it affects the outcome of treatment. The aim of the present study was to assess the prevalence of pelvic floor injury in patients with fecal incontinence who were eligible for sacral neuromodulation and to determine whether sacral neuromodulation is worthwhile in patients with pelvic floor injury. METHODS All women with fecal incontinence who were eligible for sacral neuromodulation in the past were invited to participate in the present study. With transperineal ultrasound, which has been developed recently, pelvic floor integrity was examined in 46 of the 66 patients (70%). Follow-up was obtained from a standardized questionnaire. RESULTS Pelvic floor injury was found in 29 of the 46 participants (63%). No differences regarding the efficacy of sacral neuromodulation were found between patients with and those without pelvic floor injury. Successful test stimulation was obtained in 86% of the patients with pelvic floor injury and in 71% of the patients without pelvic type injury. After implantation of a definitive pulse generator, a successful outcome was found in 84% of the patients with pelvic floor injury and in 75% of the patients with an intact pelvic floor. CONCLUSION Pelvic floor injury is present in the majority of incontinent patients who were eligible for sacral neuromodulation. This type of injury seems to have no detrimental effect on the treatment outcome.
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