Factors predictive of outcome after surgery for faecal incontinence

Gatekeeper™ Prostheses Implants in the Anal Canal for Gas Incontinence and Soiling: Long-Term Follow-Up

Introduction: Although several treatments for faecal incontinence are available, gas incontinence (GI) and soiling are difficult to manage. The aim of this study is to evaluate Gatekeeper™ for this subtype of faecal incontinence. Methods: Prospective single-centre case series. Patients with mainly soiling and/or GI were treated with polyacrylonitrile prostheses. An evaluation was performed with a 3-week continence diary. St. Mark's score and a Visual Analogue Scale (VAS) were used to study the patient's continence perception and surgical satisfaction, at baseline and 1, 3, 6, 12, and 24 months postoperatively. 3D-Endoanal Ultrasound and Anorectal Manometry were performed at baseline and postoperatively. Results: A total of 13 patients were enrolled (11 women), aged (median (IQR)) 62 (13) years, and all implants were uneventful. A significant reduction in soiling and GI episodes was documented at 1 year, 7 (18) baseline days of soiling/3 weeks vs. 2 (4) (p = 0.002); 13 (13) baseline episodes of GI/3 weeks vs. 4 (10) (p = 0.01). This improvement was correlated with a significant increase in VAS (0-10), 3 (2, 5) baseline vs. 7 (1, 5) (p = 0.03), and maintained throughout the follow-up. There was complete remission or significant improvement defined as >70% reduction in gas and soiling days in 6 patients at 2 years follow-up. Soiling episodes were reduced ≥70% in 8/11 patients (72.7%). Nine (70%) patients would repeat the treatment. Conclusions: Gatekeeper™ is a safe, minimally invasive treatment for soiling and GI. A significant reduction in soiling and GI was observed in our series, with a better response to soiling. Most of the patients would repeat the treatment. Other studies are needed to confirm these findings in this subgroup of FI patients.

[Postpartum fecal incontinence. State of the problem]

A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.

Clinical relevance of neurological evaluation in patients suffering urinary retention in the absence of subvesical obstruction

PURPOSE

Clinical relevance of neurological evaluation in patients suffered urinary retention in the absence of subvesical obstruction. Determining whether (1) women complaining residual bladder volume without prolapse and obstruction always suffer pudendal nerve damage; (2) neurogenic damage can be linked to patients history/clinical examination; (3) therapy alters regarding to neurological findings; and (4) electromyography (EMG) of musculus sphincter ani externus (MSAE) can be omitted with electronically stimulated pudendal nerve latency (ESPL) as the standard investigation.

METHODS

Women with urinary retention without ≥stage 2 prolapse or obstruction have neurological investigation including vaginally and anally pudendal terminal nerve latency (PTNL) (>2.4 ms considered abnormal) and EMG seen 7/2005-04/2010.

RESULTS

(1) 148/180 (82.2%) suffered at least moderate neurogenic damage and (2) severe neurogenic damage occurs with urge odds ratio (OR) = 3.1 or age (OR = 3.2). Correlations: spasticity with therapy changes (OR = 11.1), latencies. (a) Anally: (i) right and peripheral neuropathy (PNP) (OR = 2.5), chemotherapy (OR = 5.0); (ii) left and PNP (OR = 3.9), chemotherapy (OR = 4.8); (iii) left or right with PNP (OR = 3.9), chemotherapy (OR = 6.8); and (iv) left and right with chemotherapy (OR = 5.0). (b) Vaginally: (i) right with age >60 (OR = 3.2), radical operation (OR = 10.6); (ii) left with diabetes mellitus (OR = 2.5); and (iii) left or right with age (OR = 3.3), radical operation (OR = 8.7). (3) 19.6% therapy changes (36 patients). (4) Neither EMG nor ESPL can be replaced one by another (p = 0.12 anal, p = 0.05 vaginal).

CONCLUSION

Red flags are neurogenic damage, age >60, chemotherapy, PNP, radical operation or diabetes. In unclear situations, EMG and ESPL need to be performed to gain relevant information.

Challenges faced in the clinical application of artificial anal sphincters

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

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Anorectal incontinence: a challenge in diagnostic and therapeutic approach

Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ~2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.

Sacral neuromodulation: long-term outcome and quality of life in patients with faecal incontinence

AIM

Since 1994 sacral neuromodulation (SNM) has increasingly been used for the treatment of faecal incontinence, but no long-term data in a large group of patients have so far been published. We report long-term outcome and quality of life in the first 50 patients treated by permanent SNM for faecal incontinence.

METHOD

We began to use SNM in 2000. Data from the first 50 patients with faecal incontinence who underwent permanent SNM are presented. Efficacy was assessed using a bowel diary and the Quality of Life score was assessed by the Faecal Incontinence Quality of Life questionnaire (FIQOL) and the standard short form health survey questionnaire (SF-36).

RESULTS

Over a median follow up of 7.1 (5.6-8.7) years, forty-two (84%) patients had an improvement in continence of over 50%. Median incontinent episodes and days of incontinence per week decreased significantly during follow up (P<0.002). Improvement was seen in all four categories of the FIQOL scale and in some domains of the SF-36 QOL questionnaire. There were no statistically significant changes in the median resting and squeeze anal canal pressures.

CONCLUSION

Initial improvement in continence with SNM was sustained in the majority of patients, with an overall success rate of 80% after a permanent implant at 7 years.

Accuracy of measurement of puborectal contraction by perineal ultrasound in patients with faecal incontinence

AIM

The study aimed to determine the accuracy of measurement of puborectal contraction, measured by perineal ultrasound during anal voluntary contraction in patients with incontinence.

METHOD

Puborectalis sling contraction in 32 consecutive patients investigated for faecal incontinence was determined by two examiners on two occasions (four measurements per patient). The examiners were blinded to each other's results.

RESULTS

The mean anterior movement of the puborectalis sling was between 11 and 12 mm for both examiners on both occasions. The global intraclass correlation coefficient for examiners and occasions together was 0.92. The absolute agreement on the movement exceeding or not 8 mm was 87.5% (28 of 32), and the corresponding κ statistic was 0.84. The differences between the two experts were minimal.

CONCLUSION

The study confirms the reliability of puborectalis sling contraction measurement and its value as a preoperative predictive tool to assess the prognosis of sphincter repair for postdelivery faecal incontinence.

Sacral nerve stimulation induces changes in the pelvic floor and rectum that improve continence and quality of life

PURPOSE

Sacral nerve stimulation (SNS) can improve fecal incontinence, though the exact mechanism is not known. This study examines the following hypotheses: SNS leads to contraction of the pelvic floor, influences rectal perception, and improves continence and quality of life.

METHODS

Fourteen patients with sacral nerve stimulators implanted for fecal incontinence were examined prospectively. Morphological and functional assessment was done by endosonography, manometry, and volumetry with the stimulator turned on and off in direct succession. Questionnaires were used to determine incontinence and quality of life.

RESULTS

With the stimulator turned on, rectal filling conditions were perceived only at higher volumes; in particular, the defecation urge was sensed only at higher volumes. There was also a reduction in the diameters of the external and internal anal sphincters and a decrease in the distance between the anal mucosa and the symphysis as a sign of pelvic floor elevation. Six months after surgery, continence and quality of life were markedly better than before the operation.

CONCLUSIONS

We were able to confirm the hypotheses given above. The improvements of pelvic floor contraction and rectal perception are rapid adjustment processes in response to stimulation of sacral nerves S3/S4 when turning on the stimulator.

Sacral nerve stimulation is a valid approach in fecal incontinence due to sphincter lesions when compared to sphincter repair

PURPOSE

Anal sphincter lesions represent the major cause of fecal incontinence, particularly in women. Sphincteroplasty with overlap is the traditional treatment, but a significant reduction in benefits within 5 years of surgery has been reported. More recently, sacral nerve stimulation has been suggested following sphincteroplasty or as primary treatment.

METHODS

Overall, 24 women with fecal incontinence in the presence of anal sphincter lesions underwent sphincteroplasty (14 patients, mean age 47.6 +/- 15.6 years, range 26-70) or definitive implant of sacral nerve stimulation (10 patients, mean age 60.7 +/- 17.6 years, range 26-73), using identical selection criteria. At baseline, patients were studied with clinical evaluation, 3-dimensional endoanal ultrasound, and anorectal manometry (ARM), repeated at follow-up (median 60.0 months, range 6-96 in sphincteroplasty group; median 33.0 months, range 6-84 in sacral nerve stimulation group).

RESULTS

At baseline, both groups presented similar characteristics. Two sphincteroplasty patients (14.3%) experienced relapse of fecal incontinence at 6 and 19 months after treatment, whereas good to excellent continence was observed in all of the sacral nerve stimulation patients. Compared to baseline, both groups showed a significant improvement in clinical parameters, and ARM data remained unchanged. In 12 of 14 sphincteroplasty patients, the repaired sphincter at endoanal ultrasound was found to overlap. At follow-up, comparison between sphincteroplasty and sacral nerve stimulation showed no significant differences in clinical and ARM parameters, if related to lesion of internal, external, or both sphincters.

CONCLUSIONS

These data appear to confirm that sacral nerve stimulation could represent a valid alternative in the treatment of fecal incontinence patients presenting with sphincter lesion that was not preceded by sphincteroplasty.

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

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

Measure of the voluntary contraction of the puborectal sling as a predictor of successful sphincter repair in the treatment of anal incontinence

PURPOSE

Overlapping sphincteroplasty is the surgery of choice for incontinent patients with an anterior defect after childbirth. Numerous predictive factors have been proposed, but no preoperative variables have been successfully shown to be reproducible. The purpose of this study was to assess the prognostic value of voluntary contraction of the puborectal sling before sphincter repair for anal incontinence.

METHODS

This prospective study evaluated 109 consecutive women who underwent surgery for postobstetric anal incontinence. Voluntary contraction of the puborectal sling was measured by perineal ultrasound before the surgery. Severity of anal incontinence was evaluated preoperatively and postoperatively with the Miller Incontinence Score (total incontinence = 18, complete continence = 0).

RESULTS

The proportion of patients with scores <or=3 was 16.7 percent when the preoperative voluntary contraction of the puborectal sling was <or=4 mm, 48.1 percent when it was 4.1 to 8 mm, and 98.7 percent when it was >8 mm (P < 0.001). Using <or=8 mm to define abnormal shortening, the sensitivity of the test was 0.95 (95 percent confidence interval, 0.75-1.00) and specificity was 0.84 (95 percent confidence interval, 0.75-0.91).

CONCLUSION

A preoperative voluntary contraction of the puborectal sling >8 mm convincingly discriminates between patients with a good functional outcome and those with an unsatisfactory outcome after sphincter repair for postobstetric anal incontinence.

A cost-effectiveness analysis of delayed sphincteroplasty for anal sphincter injury

OBJECTIVE

Anal-sphincter injury may result in faecal incontinence. Sphincteroplasty is usually performed as a primary (immediate) procedure. Delayed sphincteroplasty (DS) can be performed if there is significant trauma or soiling, if the primary procedure has failed, and if the injury was not recognized initially. This study aimed to determine the cost to patient and health service in the event a DS is performed.

METHOD

Patients with anal-sphincter-injury who underwent primary sphincteroplasty (PS)/DS were identified from the published literature (primary, n = 103; delayed, n = 777) using Medline, Embase, Ovid and Cochrane databases for studies published between 1976 and 2006. Studies included described at least one of the measured outcomes--probability of functional success/failure and quality of life (QOL). An economic model was constructed and decision analysis performed using a decision tree based on a Markov process. Main outcomes were quality-adjusted-life-years (QALYs) gained from each strategy, costs incurred and incremental cost-effectiveness ratio (ICER) over a 10- and 15-year time horizon.

RESULTS

Over 10 years, primary sphincteroplasty (PS) produced a gain of 5.72 QALYs for an estimated 2750 pounds, giving an ICER of 487 pounds per QALY. DS produced a gain of 3.73 QALYs for a cost of 2667 pounds, giving an ICER of 719 pounds per QALY. Both procedures fell below the 10,000 pounds per QALY willingness-to-pay threshold, but PS produced the highest QALYs. Both procedures performed poorly beyond the 10-year mark.

CONCLUSION

If DS has to be performed, the resultant cost is greater with concurrently lower QALYs gained. Successful PS substantially improves QOL and reduces overall cost-of-treatment.

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

BACKGROUND AND AIMS

Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management.

METHOD

This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists.

RESULTS

A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality.

CONCLUSIONS

Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?

OBJECTIVE

Sacral nerve modulation (SNM) for the treatment of faecal incontinence was originally performed in patients with an intact anal sphincter or after repair of a sphincter defect. There is evidence that SNM can be performed in patients with faecal incontinence and an anal sphincter defect.

METHOD

Two groups of patients were analysed retrospectively to determine whether SNM is as effective in patients with faecal incontinence associated with an anal sphincter defect as in those with a morphologically intact anal sphincter following anal repair (AR). Patients in group A had had an AR resulting in an intact anal sphincter ring. Group B included patients with a sphincter defect which was not primarily repaired. Both groups underwent SNM. All patients had undergone a test stimulation percutaneous nerve evaluation (PNE) followed by a subchronic test over 3 weeks. If the PNE was successful, a permanent SNM electrode was implanted. Follow-up visits for the successfully permanent implanted patients were scheduled at 1, 3, 6 and 12 months and annually thereafter.

RESULTS

Group A consisted of 20 (19 women) patients. Eighteen (90%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. Group B consisted of 20 women. The size of the defect in the anal sphincter varied between 17% and 33% of the anal circumference. Fourteen (70%) had a positive subchronic test stimulation. Twelve patients had a successful SNM implant during middle-term follow-up. In both groups, the mean number of incontinence episodes decreased significantly with SNM (test vs baseline: P = 0.0001, P = 0.0002). There was no significant difference in resting and squeeze pressures during SNM in group A, but in group B squeeze pressure had increased significantly at 24 months. Comparison of patient characteristics and outcome between groups A and B revealed no statistical differences.

CONCLUSION

A morphologically intact anal sphincter is not a prerequisite for success in the treatment of faecal incontinence with SNM. An anal sphincter defect of <33% of the circumference can be effectively treated primarily with SNM without repair.

The artificial bowel sphincter for faecal incontinence: a single centre study

BACKGROUND AND AIMS

Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS).

MATERIALS AND METHODS

Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed.

RESULTS

Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8-106.3) months. The Williams score improved significantly after placement of the ABS (p<0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p=0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p=0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted.

CONCLUSION

The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.

The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence

OBJECTIVE

Anterior sphincter repair has become the operation of choice in patients with fecal incontinence who have defects of the external anal sphincter (EAS), but not all patients benefit from surgery. The aim of this study was to investigate whether endoluminal imaging can identify determinants that play a role in the outcome of sphincter repair.

SUBJECTS AND METHODS

Thirty fecal incontinent patients with an EAS defect were included. The severity of incontinence was evaluated pre- and postoperatively using the Vaizey incontinence score. Patients underwent endoanal MRI and endoanal sonography before and after sphincter repair. We evaluated the association between preoperatively assessed EAS measurements with outcome and postoperatively depicted residual defects, atrophy, tissue at overlap, and sphincter overlap with clinical outcome.

RESULTS

After surgery, the mean Vaizey score in 30 patients (97% females; mean age, 50 years) had improved from 18 to 13 (p < 0.001). MRI showed that baseline measurement of preserved EAS thickness correlated with a better outcome (r = 0.42; p = 0.03). Clinical outcome did not differ between patients with and those without a persistent EAS defect (p = 0.54) or EAS atrophy (p = 0.26) depicted on MRI. Patients with a visible overlap and less than 20% fat tissue had a better outcome than patients with nonvisible, fatty overlap (decrease in Vaizey score, 7 vs 2 points, respectively; p = 0.04). Sonography showed that patients with a persistent EAS defect had a worse outcome than those without an EAS defect (17 vs 10 points, respectively; p = 0.003).

CONCLUSION

Endoanal MRI was useful in determining EAS thickness and structure, and endoanal sonography was effective in depicting residual EAS defects.

Early results of immediate repair of obstetric third-degree tears: 65% are completely asymptomatic despite persistent sphincter defects in 61%

OBJECTIVE

The outcome of immediate repair of obstetric third-degree tears is poorly documented. Immediate repair may give better functional results than delayed repair because scarring is reduced. This aim of this prospective study was to examine the early outcome of immediate repair of third-degree tears.

METHOD

A total of 121 women who had immediate repair of obstetric third-degree tears underwent interview, anal ultrasonography and anorectal physiology.

RESULTS

At review, 79 (65%) were completely asymptomatic (score = 0), 23 (19%), had minor flatus incontinence or mild urgency causing no compromise to their quality of life (score 1-4), and 19 (16%) had clinically embarrassing faecal incontinence (score 5-24). Thirty-nine (32%) had an intact internal anal sphincter (IAS) and external anal sphincter (EAS) (i.e. a successful repair), eight (7%) had a defect in the IAS alone but the EAS was intact (i.e. a successful repair but a residual IAS defect), 43 (35%) had a residual defect in the EAS alone (IAS intact) and 31 (26%) had a persistent defect in the IAS and EAS. Residual defects in either or both of the sphincters were associated with a significantly higher incidence of abnormal resting and squeeze anal pressures. Anal manometry had no correlation with symptoms. The highest proportion of severe incontinence was in those with an IAS defect alone (37%) and when there was a residual IAS and EAS defect (24%). Only 2 of 39 (5%) with an intact IAS and EAS had severe incontinence and only 8 of 43 (18%) with a residual EAS defect alone had severe faecal incontinence.

CONCLUSION

These results indicate a good outcome following immediate repair of third-degree obstetric tears and emphasize the role of the IAS in providing continence.

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

PURPOSE

To prospectively compare in a multicenter study the agreement between endoanal magnetic resonance (MR) imaging and endoanal ultrasonography (US) in depicting external anal sphincter (EAS) defects in patients with fecal incontinence.

MATERIALS AND METHODS

The study was approved by the medical ethics committee of all participating centers. A total of 237 consenting patients (214 women, 23 men; mean age, 58.6 years +/- 13 [standard deviation]) with fecal incontinence were examined from 13 different hospitals by using endoanal MR imaging and endoanal US. Patients with an anterior EAS defect depicted on endoanal MR images and/or endoanal US scans underwent anal sphincter repair. Surgical findings were used as the reference standard in the determination of anterior EAS defects. The Cohen kappa statistic and McNemar test were used to calculate agreement and differences between diagnostic techniques.

RESULTS

Agreement between endoanal MR imaging and endoanal US was fair for the depiction of sphincter defects (kappa = 0.24 [95% confidence interval: 0.12, 0.36]). At surgery, EAS defects were found in 31 (86%) of 36 patients. There was no significant difference between MR imaging and US in the depiction of sphincter defects (P = .23). Sensitivity and positive predictive value were 81% and 89%, respectively, for endoanal MR imaging and 90% and 85%, respectively, for endoanal US.

CONCLUSION

In the selection of patients for anal sphincter repair, both endoanal MR imaging and endoanal US are sensitive tools for preoperative assessment, and both techniques can be used to depict surgically repairable anterior EAS defects.

The corner of the coloproctologist: what to ask to radiologist

Defecation disorders, fecal incontinence, often associated to urinary and genital dysfunction, represent symptoms of a large number of functional and structural alterations of pelvic floor. They can be evaluated by functional and morphologic tests. A perfect anatomic and functional knowledge of the anorectum and pelvic floor is indispensable for a correct diagnostic and therapeutic path. Incontinence due to sphincter lesions can be diagnosed only by imaging techniques. In defecation disorders the issue is complex because functional and anatomic alterations can coexist. The radiological diagnosis of dyssynergic defecation is a diagnosis of confidence that enhances its value when manometric and electromyographic evidence of pelvic dyssynergia are detected. When anatomical alterations are detected the aim is to understand their physiopathology, to make a more precise diagnosis and treatment, and to minimize the errors of an inappropriate therapy. Our attention is focused on the information provided by imaging techniques about anorectum and pelvic floor abnormalities for optimal therapeutic planning.

Is there a role for concomitant pelvic floor repair in patients with sphincter defects in the treatment of fecal incontinence?

BACKGROUND AND AIMS

More than half of all patients who undergo overlapping anal sphincter repair for fecal incontinence develop recurrent symptoms. Many have associated pelvic floor disorders that are not surgically addressed during sphincter repair. We evaluate the outcomes of combined overlapping anal sphincteroplasty and pelvic floor repair (PFR) vs. anterior sphincteroplasty alone in patients with concomitant sphincter and pelvic floor defects.

PATIENTS AND METHODS

We reviewed all patients with concomitant defects who underwent surgery between February 1998 and August 2001. Patients were assessed preoperatively by anorectal manometry, pudendal nerve terminal motor latency, and endoanal ultrasound. The degree of continence was assessed both preoperatively and postoperatively using the Cleveland Clinic Florida fecal incontinence score. Postoperative success was defined as a score of <or=5, whereas postoperative quality of life was assessed by a standardized questionnaire.

RESULTS

Twenty-eight patients (mean age 52.3 years) underwent overlapping anal sphincteroplasty. The mean follow-up was 33.8 months. Cleveland Clinic Florida scores postoperatively showed a significant improvement from preoperative values (14.2 vs 5.1, p<0.001). Seventeen patients (61%) underwent concomitant PFR with sphincteroplasty. Three patients (27%) without PFR and one patient (6%) with PFR underwent repeat sphincter repair due to worsening symptoms (p=0.15). Two patients with PFR and one patient without PFR ultimately had an ostomy due to a failed repair (p=0.66). Comparing patients with and without PFR, there was a trend toward higher success rates (71 vs. 45%) when pelvic prolapse issues were addressed during sphincter repair.

CONCLUSION

Concomitant evaluation and repair of pelvic floor prolapse may be a clinically significant component of a successful anal sphincteroplasty for fecal incontinence but warrant further prospective evaluation.

Sacral neuromodulation in the treatment of severe anal incontinence

INTRODUCTION

Sacral neuromodulation is a recognized therapeutic option in severe anal incontinence from neurogenic origins, when medical treatment has failed.

METHODS

We report the results of this procedure applied in 40 consecutive patients operated on by a single surgeon from August 2001 to June 2004. Mean duration of incontinence was 5 years. There were 33 women and 7 men of mean age 59 (range 29-89). All patients had had medical treatment, 26 had had physiotherapy and 9 had been previously operated on for that problem. Neuromodulation consisted in a temporary electrical stimulation test followed by implantation of a stimulator in case of efficacy.

RESULTS

Twenty nine patients had a positive test and were implanted. Ten had a negative test and one is waiting for implantation. From the 29 patients, 23 had uneventful postoperative course. Incontinence score varied from 17 before neuromodulation to 6 after in the 24 patients who were improved. Mean resting pressure, mean maximum squeeze pressure and mean duration of squeeze pressure did not change from pre to postoperative period.

CONCLUSION

Sacral neuromodulation is a safe and efficacious procedure in properly selected anal incontinent patients. However, we observed no correlation between clinical and manometric data.

Single-fiber electromyography correlates more closely with incontinence scores than pudendal nerve terminal motor latency

BACKGROUND

The investigation of fecal incontinence is important in deciding the most appropriate treatment. The presence of neuropathy has been shown to affect surgical outcomes adversely. Latency studies are of dubious value in assessing neuropathy; needle electromyography is the gold standard test. The relationship between these two tests and the symptoms of fecal incontinence has not been studied.

METHOD

A cohort of 57 patients underwent neurologic and symptom assessment using latency studies, concentric and single-fiber electromyography, and symptom assessment using the Cleveland Clinic Scoring System.

RESULTS

There was a significant correlation between left mean fiber density and Cleveland Clinic Scoring (correlation: 0.32, P = 0.02) but not between right or left latency studies.

CONCLUSION

Single-fiber electromyography gave relevant results that could be obtained easily on modern equipment. Latency values were not reliable.

Long-term outcome of postanal repair in the treatment of faecal incontinence

BACKGROUND

Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence.

OBJECTIVES

The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence.

PATIENTS AND METHODS

Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated.

RESULTS

Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively (P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse.

CONCLUSIONS

Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.

Quality of life measures for fecal incontinence and their use in children

BACKGROUND

Fecal incontinence is a common problem within society from childhood through to the elderly. Its clinical assessment has focussed on severity and frequency of soiling episodes but it is increasingly recognized to have an impact on physical, psychological and social well-being (quality of life [QOL]). This is likely to be particularly important in childhood. The aim of the present study was to critically evaluate the development and application of disease-specific QOL measures, focusing particularly on their use in children.

METHODS

Generally recognized disease-specific QOL measures for fecal incontinence were identified and their generation and validation were critically evaluated.

RESULTS

Six instruments were identified: Ditesheim and Templeton QOL Scoring System, Manchester Health Questionnaire, Hirschsprung's Disease/Anorectal Malformation Quality of Life Questionnaire (HAQL), Gastrointestinal Quality of Life Index (GIQLI), Fecal Incontinence TyPE Specification, and the Fecal Incontinence Quality of Life Scale (FIQL). Although the FIQL appeared to be the better tool for adults with fecal incontinence because it was brief and had the best validity and reliability, it needed further modification to become appropriate for use in children. In particular, items relating to sexual activity were inappropriate.

CONCLUSION

Neither the FIQL nor other disease-specific instruments met basic psychometric standards for use in children with fecal incontinence. Substantial revision of currently available instruments will be required to meet the needs of this population.

Sacral nerve stimulation: an emerging treatment for faecal incontinence

Faecal incontinence is common, distressing to the patient and socially incapacitating. The treatment options depend on the severity and aetiology of incontinence. For mild cases of faecal incontinence, medical management and pelvic floor physiotherapy may be adequate. For more severe cases, surgery is often required. Patients who have a distinct sphincter defect are amenable to surgical repair. In many cases, there is a combination of diffuse structural damage of the anal sphincters with pudendal neuropathy. Conventional surgical repairs have a modest degree of success and the results tend to deteriorate with time. Neosphincter procedures such as artificial bowel sphincter and dynamic graciloplasty are potentially morbid and technically complex. Sacral nerve stimulation is innovative and has had a medium-term success with improvement of quality of life in over 80% of patients treated for faecal incontinence. These results are superior to other techniques in treating patients with severe refractory faecal incontinence, where current maximal therapy has failed. The technique is unique because there is a screening phase, which has a high predictive value. It is also associated with minimal complications that are usually minor. However, most published reports of sacral nerve stimulation for treatment of faecal incontinence were case studies and methods of assessing outcome were variable. Criteria for patient selection are evolving and are yet to be defined. The present paper critically reviews the publications to date on sacral nerve stimulation for treatment of faecal incontinence. This will form the basis for future evaluation of this emerging treatment of severe, intractable faecal incontinence. Randomized clinical trials like that of the Melbourne trial will further clarify the role and indications of sacral nerve stimulation for faecal incontinence.

Anal manometric parameters: predictors of outcome following anal sphincter repair?

Controversy exists over the utility of manometry in the management of fecal incontinence. In light of newer methods for the management of fecal incontinence demonstrating favorable results, this study was designed to evaluate manometric parameters relative to functional outcome following overlapping sphincteroplasty. Twenty women, 29 to 84 years of age (mean age 50 years), with severe fecal incontinence and large (>or=50%) sphincter defects on ultrasound were studied. All participants underwent anal manometry (mean resting pressure, mean squeeze pressure, anal canal length, compliance), pudendal nerve terminal motor latency (PNTML) testing, and completed the American Society of Colon and Rectal Surgeons fecal incontinence severity index (FISI) survey before and 6 weeks after sphincter repair. Statistical analysis for all data included the Wilcoxon rank-sum test, Mann-Whitney test, and Spearman's correlation. Significant perioperative improvement was seen in the absolute resting and squeeze pressures and anal canal length. Overlapping sphincteroplasty was also associated with significant improvement in fecal incontinence scores (FISI 36 vs. 16.4; P=0.0001). Although no single preoperative manometric parameter was able to predict outcome following sphincteroplasty, preoperative mean resting and squeeze pressures as well as anal canal length inversely correlated with the relative changes in these parameters achieved postoperatively. These findings suggest that either the physiologic parameters studied are not predictive of functional outcome or the scoring system used is ineffective in determining function. The perioperative paradoxical changes in resting pressure, squeeze pressure, and anal canal length would support the use of overlapping sphincteroplasty in patients with significant sphincter defects and poor anal tone.

A review of contemporary surgical alternatives to permanent colostomy

OBJECTIVES

To review the options available to patients with faecal incontinence with failed conservative treatment and/or failed anal sphincter repair and assessing the current indications and results of these options.

METHODS

A literature search of MEDLINE, EMBASE and Cochrane databases was performed using the relevant search terms.

RESULTS

Continent options for patients with severe or end stage faecal incontinence include the creation of a form of an anal neosphincter and more recently sacral nerve stimulation. Over half the patients, who are candidates, may benefit from these procedures, although long term results of sacral nerve stimulation are unknown. Dynamic graciloplasty improves the continence in 44-79% of the patients. The complications include frequent reoperations, high incidence of infection and obstructive defaecation. The success rates of artificial bowel sphincter vary between 24% and 79%. Once functional, the artificial bowel sphincter seems to improve the continence in the majority of the patients. Device removal due to infection, obstructive defaecation and pain is a frequent problem. Sacral nerve stimulation is claimed to result in improvement in continence in 35-100% of patients. The main risks in this procedure are infection, electrode displacement and pain.

CONCLUSIONS

All these procedures have high complication rates and have moderate success rates only. A major proportion of patients will need reoperations and hence high motivation is necessary for patients who undergo these procedures. A uniform standard for measurement of success is also necessary so that these procedures can be compared with each other.

A prospective, randomized, controlled clinical trial of placement of the artificial bowel sphincter (Acticon Neosphincter) for the control of fecal incontinence

BACKGROUND

Severe fecal incontinence remains a disabling condition for the patient and a major therapeutic challenge for the physician. A series of observational studies have indicated that placement of an artificial bowel sphincter is associated with marked improvement of continence and quality of life. We have performed a prospective, randomized, controlled trial to evaluate the effect of placement of an artificial bowel sphincter (Acticon Neosphincter) on continence and quality of life in a group of severely incontinent adults.

METHODS

Fourteen adults (male:female, 1:13; age range, 44-75 years) were randomized to placement of the artificial bowel sphincter or to a program of supportive care and were followed for six months from operation or entry into the study. The principal outcome measure was the level of continence, measured with the Cleveland Continence Score, which provides a scale from 0 to 20, representing perfect control through to total incontinence. Secondary outcome measures were perioperative and late complications in the artificial bowel sphincter group, and the changes in quality of life in both groups.

RESULTS

In the control group, the Cleveland Continence Score was not significantly altered, with an initial value of 17.1 +/- 2.3 and a final value of 14.3 +/- 4.6 at six months. The artificial bowel sphincter group showed a highly significant improvement, changing from 19.0 +/- 1.2 before placement to 4.8 +/- 4.0 at six months after placement. One patient in the artificial bowel sphincter group had failure of healing of the perineal wound and explantation of the device (14 percent explantation rate). There were two other significant perioperative events of recurring fecal impaction initially after placement in one patient and additional suturing of the perineal wound in another. There were major improvements in the quality of life for all measures in the artificial bowel sphincter group. There was significant improvement in all eight subscales of the Medical Outcome Study Short Form-36 measures. The American Medical Systems Quality of Life score was raised from 39 +/- 6 to 83 +/- 14 and the Beck Depression Inventory showed reduction from a level of mild depression (10.8 +/- 9.3) to a normal value (6.8 +/- 8.7). No significant changes in any of the quality of life measures occurred for the control group.

CONCLUSIONS

Through a prospective, randomized trial format, we have shown that placement of an artificial bowel sphincter is safe and effective when compared with supportive care alone. Perioperative and late problems are likely to continue to occur and between 15 percent and 30 percent of patients may require permanent explantation. For the remainder, the device is easy and discrete to use, highly effective in achieving continence, and able to generate a major improvement in the quality of life.

Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county

BACKGROUND

Anal sphincter tears during vaginal delivery are a major cause of anal incontinence. We wanted to assess the incidence in a Norwegian county where primary repairs are performed in four hospitals using similar per- and postoperative protocol for the treatment of such injuries.

METHODS

A postal questionnaire was distributed to all women who underwent primary repair of obstetric sphincter tears in the years 1999 and 2000 in the county of Möre and Romsdal. Symptoms of incontinence and fecal urgency were recorded. Incontinence was assessed using the Pescatori score system.

RESULTS

Clinically detected sphincter tears occurred in 180 of 5123 vaginal deliveries (3.5%). The questionnaire was returned by 156 women (87%). Six women were excluded. Median follow-up was 25 months (range 4-39). Incontinence was reported by 88 women (59%), restricted to flatus incontinence in 53 cases (35%). Fecal urgency without incontinence was reported by 14 women (9%). Sixty-three women (42%) reported de novo moderate to severe symptoms. There was no difference in outcome whether the sphincter injury was partial or complete. Mean Pescatori score was 3.7 in women who felt disabled compared with 2.9 in women who did not feel disabled by their incontinence (P < 0.001). Of 29 women who felt disabled, only three had sought medical attention. Fifty-eight women (39%) had received no information about the sphincter tear before discharge.

CONCLUSION

Anal incontinence is common after both partial and complete obstetric sphincter tears. Information before discharge is deficient, and women avoid seeking medical attention when incontinence develops.

Physiologic variables that predict the outcome of treatment for fecal incontinence

Identification of physiologic factors that predict response to fecal incontinence therapy would be helpful in choosing the optimal treatment and advising patients on the likelihood of a successful outcome. However, few physiologic parameters have been consistently identified as important in predicting response to either biofeedback or surgery. The process of isolating these factors has been hampered by heterogeneity in the definition of fecal incontinence, lack of consensus on what constitutes a successful outcome, lack of follow-up data, variations in the way "standard" treatments are implemented, and lack of properly powered randomized controlled trials. Among the physiologic variables that studies have generally found to be predictive of successful outcomes in biofeedback treatment are the threshold for external anal sphincter contraction after treatment, the inclusion of sensory training in treatment, and a reduction in volume for the first sensation after treatment. Factors that have not been found to be important in predicting outcome following biofeedback retraining include the duration of fecal incontinence, pudendal nerve damage, patient age, symptom severity, pretreatment anal canal pressures, and results of anal ultrasonography. The presence of some degree of anorectal sensation is the only preoperative assessment that has been found to be predictive of response to surgical therapy. It is recommended that outcome measures for fecal incontinence be more clearly defined, that future biofeedback studies elaborate the predictive value of pretreatment anorectal sensation and the response to sensory retraining, and that postsurgical measurements such as anal squeeze pressure and sphincter length be taken into account.

Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence

OBJECTIVE

The purpose of this study was to assess patterns of abnormal pudendal nerve function in women who complain of postpartum fecal incontinence.

STUDY DESIGN

During a 12-month period, a cohort of 83 women underwent neurophysiologic assessment as part of an evaluation of fecal incontinence after vaginal delivery. Pudendal nerve assessment consisted of the measurement of the clitoral-anal reflex and quantitative electromyography of the external anal sphincter. Endoanal ultrasound examination and anal manometry were also performed in each patient.

RESULTS

Thirty of 83 women (38%) with fecal incontinence were found to have abnormal neurophysiologic condition, among whom four identifiable patterns of abnormality emerged. Five women (17%) had evidence of pudendal nerve demylenation with a prolonged sensory threshold of the clitoral-anal reflex (>5.2 mA), although electromyography studies were normal. Eight women (27%) had abnormal electromyography results that were consistent with axonal neuropathy with or without reinervation, in whom the clitoral-anal reflex was normal. Thirteen women (43%) demonstrated a mixed demyelinating and axonal pudendal neuropathy, with evidence of reinervation. Four women (13%) had abnormal patterns of neurophysiologic condition that was not attributable directly to past obstetric trauma but to coincident medical problems.

CONCLUSION

Four abnormal patterns of pudendal nerve function may be identified, three of which (demyelinating, axonal, and mixed demyelinating/axonal) can be attributed to specific past obstetric events, although a fourth radicular pattern is due to coincident medical or orthopedic problems. Assessment of pudendal nerve function is important in women with postpartum fecal incontinence because particular patterns of abnormality correlate with different symptoms and can influence treatment options.

Fecal incontinence: evaluation and treatment

Fecal incontinence affects men and women of all ages, leading to personal disability and high financial costs. The evaluation of the patient should clarify the pathophysiology of the symptoms and provide guidance in choosing the appropriate treatment. A comprehensive history and physical examination including endoscopic assessment is able to identify the cause of most cases of fecal incontinence. If necessary, functional methods can be used to confirm the diagnosis. Patient selection for suitable treatment is most important and should be based on clinical and physiologic findings. Conservative dietary or medical treatment is often effective, when the symptoms are mild. Biofeedback therapy is effective in most patients. It has no side effects and is well tolerated. Structural damage to the anus may be repaired by surgery, like sphincter repair, the best treatment of selective sphincter defects. Neoanal sphincters and artificial sphincters are the last possibility after failed surgery and before colostomy. They are less attractive because of technical difficulties and low success rate. A multidisciplinary approach to treatment has the potential to improve the outcome for patients with fecal incontinence.

Second-line treatment for faecal incontinence

BACKGROUND

In the treatment of faecal incontinence, more than 30% of patients experience continuation of their problem. We discuss new therapeutic procedures for dealing with faecal incontinence.

METHODS

Discussion of authors' own work in relation to the literature.

RESULTS

First-line care includes diets, constipating drugs, biofeedback therapy, anal repair and operations for prolapse and fistulas. For the failures of these first-line treatments there is hope with second-line therapies. Creation of a neosphincter is possible with a dynamic graciloplasty (DGP) or an artificial bowel sphincter (ABS). A DGP is a conventional graciloplasty with the addition of implanted electrodes and a stimulator that transforms the muscle into an automatic contracting sphincter. ABS comprises an inflatable cuff around the anus that is filled from a pressure-regulating balloon. The cuff can be emptied with an implanted pump.

CONCLUSIONS

DGP and ABS give good results in 56%-88% of cases. For patients with an anatomical intact but nonfunctioning sphincter there is a new treatment: sacral nerve stimulation. This gives continence in a high percentage of cases, but experience is rather limited. Second-line treatment for faecal incontinence is successful and should be considered in cases where initial therapies fail.

The procon incontinence device: a new nonsurgical approach to preventing episodes of fecal incontinence

OBJECTIVES

Treatment of severe fecal incontinence (FI) is essentially surgical. However, patients in whom surgery has failed, those who have high operative risks, and those who refuse to undergo surgery are often condemned to living with this embarrassing condition. The Procon incontinence device, a relatively simple, nonsurgical device, may represent a good solution in preventing episodes of FI, thus improving quality of life in these individuals. This device consists of a disposable, pliable rubber catheter with an infrared photo-interrupter sensor and flatus vent holes on the distal tip that is connected to a pager (or "beeper"). The catheter is inserted in the rectum and held in place by a 20-cc capacity cuff, which acts as a temporary mechanical barrier to stool leakage. Stool entering the rectum is sensed by the photo-interrupter sensor, which then alerts the patient to an imminent bowel movement. Voluntary evacuation is accomplished by deflating the balloon and removing the catheter. The aim of this study was to evaluate the efficacy, reliability, and safety of the Procon device in a group of patients with FI.

METHODS

Patients with significant FI who had undergone anorectal manometry, ultrasound, and electromyography with pudendal nerve terminal motor latency assessment were prospectively entered into this study. The Procon device was used for 14 consecutive days. A quality of life diary and daily log of bowel activity and incontinent episodes were completed before and after the end of the study.

RESULTS

Seven patients (five female and two male) with a mean age of 72.7 yr (range 39-81 yr) were evaluated. Etiology of incontinence included idiopathic in four patients, sphincter defect in two, and neurological disorder in one patient. There was an overall significant improvement in the quality of life (p < 0.05) and a significant reduction in incontinence scores with the Procon device (p < 0.05).

CONCLUSION

The Procon is a unique, safe, and promising device that is able to prevent episodes of FI without the need for surgery, thereby improving quality of life. Its role includes use in patients with severe FI who are unfit to undergo surgery, those in whom previous surgical treatments have failed, or those who do not wish to undergo surgery.

Experience with an obstetric perineal clinic

OBJECTIVE

To review the characteristics of patients attending a dedicated perineal clinic in a maternity hospital.

METHODS

Case-note review of all new referrals over 2 years 1998 and 1999.

RESULTS

A total of 399 women were referred with mean age of 34 years (range 18-77), parity of 1.7 (range 1-13) and duration of symptoms of 14 (range 1-156) months. A total of 213 (53%) women were assessed following a recognized third degree perineal tear, 78 (20%) because of fecal incontinence, 45 (11%) for determination of future mode of delivery following a previous perineal injury, 37 (9%) women for treatment of perineal pain and 26 (7%) for other miscellaneous complaints. A total of 83 (21%) required physiotherapy, 42 (11%) received dietetic manipulation, 29 (7%) were treated for perineal pain and 12 (3%) underwent vaginal surgery. A total of 24 (6%) women were referred for consideration of secondary anal sphincter repair and 11 (3%) for specialist gastroenterological investigation.

CONCLUSIONS

The perineal clinic provides a valuable resource for investigation and treatment of postpartum perineal injury.

Advantages of a posterior fourchette incision in anal sphincter repair

PURPOSE

Delayed repair of obstetric-related anal sphincter injury remains problematic, and perineal wound breakdown is common. The aim of this study was to assess the outcome after overlap anal sphincter repair and to determine the advantages, if any, of a posterior fourchette incision (n = 18) compared with a conventional perineal incision (n = 32).

METHODS

Fifty females of mean parity 2.8 (standard deviation, 1.6) underwent repair in a five-year period. The mean follow-up was 23 months. Assessment was by anal vector manometry, endoanal ultrasound, and continence scoring.

RESULTS

Functional outcomes were similar in the two groups. Repair increased squeeze-pressure increment and improved continence scores in both groups. Postoperative wound complications were fewer when a posterior fourchette incision was used compared with a perineal incision (11 vs. 44 percent, respectively; P < 0.05).

CONCLUSIONS

Delayed anal sphincter repair improves continence. A posterior fourchette approach is associated with fewer postoperative wound complications without compromising the quality of repair and the functional outcome.