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Desprez C, Gourcerol G, Savoye‐Collet C, Bridoux V, Duflot T, Leroi A. Relationship between anal functional lumen imaging probe (EndoFLIP®) results and the clinical presentation of faecal incontinence. Colorectal Dis 2022; 24:1379-1389. [PMID: 35717676 PMCID: PMC9795963 DOI: 10.1111/codi.16225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/23/2022] [Accepted: 06/09/2022] [Indexed: 12/30/2022]
Abstract
AIM Faecal incontinence (FI) subtypes (urge, passive, mixed) are linked to the physiopathological mechanism of FI. Previous studies have failed to demonstrate a consistent relationship between FI subtype and anal sphincter dysfunction. Our aim was to evaluate the relationship between anal sphincter function, assessed using the new EndoFLIP® technology, and FI subtype. METHOD Patients referred for FI were prospectively enrolled between October 2015 and May 2021 in a registry, and data were retrospectively examined. Each patient underwent a clinical assessment as well as three-dimensional high-resolution or water-perfused anorectal manometry, anal EndoFLIP®, and anorectal electrophysiological and endoanal ultrasound tests. The results of the investigations were compared across FI subtypes. RESULTS The cohort included 133 patients, 54 (41%) of whom met the criteria for urge FI, 40 (30%) for passive FI and 39 (29%) for mixed FI. The resting anal distensibility index (DI) at 50 ml of distension was significantly lower in patients with urge FI than in patients with passive FI (p = 0.04). At rest, a DI at 50 ml of distension ≥7.3 mm2 mmHg-1 and a DI at 40 ml of distension <1.3 mm2 mmHg-1 were associated with the passive and urge FI subtypes, respectively, with poor discriminatory power (an accuracy of 0.49 compared with 0.33 for random assignment). There were no differences in anorectal manometry, endoanal ultrasound or electrophysiological test results among the urge, passive and mixed FI subgroups (all p > 0.05). CONCLUSION The anal sphincter DI using the EndoFLIP® system displayed poor predictive performance in distinguishing among FI subtypes.
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Affiliation(s)
- Charlotte Desprez
- Department of Digestive PhysiologyRouen University HospitalRouenFrance
| | - Guillaume Gourcerol
- Department of Digestive Physiology, CIC‐CRB 1404, Inserm U1073, CHU Rouen'Normandie Université, UNIROUENRouenFrance
| | | | - Valérie Bridoux
- Department of Digestive Surgery, Inserm U1073'Normandie Université, UNIROUEN, CHU RouenRouenFrance
| | - Thomas Duflot
- Department of Pharmacology'Normandie Université, UNIROUEN, Inserm U1096, CHU RouenRouenFrance
| | - Anne‐Marie Leroi
- Department of Digestive Physiology, CIC‐CRB 1404, Inserm U1073, CHU Rouen'Normandie Université, UNIROUENRouenFrance
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Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:303-312. [PMID: 32653603 DOI: 10.1016/j.ejogrb.2020.06.048] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. METHODS We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. RESULTS We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I2 = 95 %). Following primary repair of OASIS, 55 % (46-63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I2 = 98 %). INTERPRETATION Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.
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Affiliation(s)
- Michail Sideris
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.
| | - Tristan McCaughey
- Department of Surgery, School of Clinical Science at Monash Health, Monash University, 3800, VIC, Australia
| | | | - David Arroyo-Manzano
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Javier Zamora
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Swati Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Charles H Knowles
- National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Charlotte Chaliha
- Department of Obstetrics and Gynaecology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Multidisciplinary Evidence Synthesis Hub (MEsH), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
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Leroi AM, Melchior C, Charpentier C, Bridoux V, Savoye-Collet C, Houivet E, Ducrotté P, Gourcerol G. The diagnostic value of the functional lumen imaging probe versus high-resolution anorectal manometry in patients with fecal incontinence. Neurogastroenterol Motil 2018; 30:e13291. [PMID: 29345097 DOI: 10.1111/nmo.13291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 12/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The functional lumen imaging probe (EndoFLIP® ) is a new technology that measures the distensibility of the anal canal represented by the anal distensibility index. The aims of this study were (i) to compare the anal distensibility index to anal pressure in a cohort of patients with fecal incontinence (FI) and (ii) to compare the diagnostic value of the EndoFLIP® to that of high-resolution anorectal manometry (HRAM) in the same cohort of patients. METHODS Eighty-three consecutive patients with FI who underwent EndoFLIP® and HRAM assessments were enrolled. The diagnostic value of the EndoFLIP® was compared to that of HRAM and agreement between EndoFLIP® and HRAM data was assessed. KEY RESULTS More than 70% of the patients diagnosed with anal deficiency at rest and/or during voluntary contractions by HRAM had the same diagnosis using the EndoFLIP® . Two patients with higher distensibility indexes at rest had normal anal resting pressures. Sixteen patients with a normal EndoFLIP® index (ie, normal distensibility index at rest and during voluntary contractions) had an abnormal HRAM result. Seven of these 16 patients (44%) had no sphincter lesion or neuropathic disorder that could explain an abnormal anal sphincter function. CONCLUSIONS & INFERENCES We demonstrated that the anal distensibility index and HRAM results are largely in agreement. We did, however, identify several discrepancies between the two techniques, indicating that they may be complementary.
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Affiliation(s)
- A M Leroi
- INSERM U1073, Service de Physiologie Digestive, INSERM CIC 1404, Rouen, F-76000, France
| | - C Melchior
- INSERM U1073, Service d'Hépato-Gastroentérologie, CHU Rouen, Rouen, France
| | | | - V Bridoux
- INSERM U1073, Service de Chirurgie Digestive, CHU Rouen, Rouen, France
| | | | - E Houivet
- Unité de Biostatistiques, Rouen, INSERM CIC 1404, Rouen, F-76000, France
| | - P Ducrotté
- INSERM U1073, Service d'Hépato-Gastroentérologie, CHU Rouen, Rouen, France
| | - G Gourcerol
- INSERM U1073, Service de Physiologie Digestive, INSERM CIC 1404, Rouen, F-76000, France
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Thomas GP, Gould LE, Casunuran F, Kumar DA. A retrospective review of 1495 patients with obstetric anal sphincter injuries referred for assessment of function and endoanal ultrasonography. Int J Colorectal Dis 2017; 32:1321-1325. [PMID: 28685224 DOI: 10.1007/s00384-017-2851-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2017] [Indexed: 02/04/2023]
Abstract
AIM Obstetric anal sphincter injuries are a significant risk factor for faecal incontinence. Correct identification and successful primary repair are important. The aim of this study was to review the outcome of all patients, with an obstetric anal sphincter injury, referred to our unit. METHOD This is a retrospective review of 1495 patients over a 12-year period. All had a third or fourth degree tear and were referred at 4-months postpartum. RESULTS Endoanal ultrasonography demonstrated residual sphincter defect in 792 (53%) and normal sphincters, with no evidence of repair, in 661 (44%). The majority of injuries involved both the external and internal sphincters (n = 501). Significant reductions in resting pressure and voluntary squeeze pressures were seen when those with a sphincter defect were compared to those with intact sphincters. However, there was no significant difference in the mean (SD) Cleveland Clinic faecal incontinence scores (5.8 (5.8) and 4.3 (5.5), p = 0.8). CONCLUSION Third and fourth degree tears appear to be over diagnosed. Primary repair appears to be unsuccessful in the majority of cases. There appears to be poor correlation between objective and subjective assessment of sphincter function.
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Affiliation(s)
- G P Thomas
- Department of Colorectal Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - L E Gould
- Department of Colorectal Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - F Casunuran
- Department of Colorectal Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - D A Kumar
- Department of Colorectal Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK.
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Gourcerol G, Granier S, Bridoux V, Menard JF, Ducrotté P, Leroi AM. Do endoflip assessments of anal sphincter distensibility provide more information on patients with fecal incontinence than high-resolution anal manometry? Neurogastroenterol Motil 2016; 28:399-409. [PMID: 26670599 DOI: 10.1111/nmo.12740] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 10/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anal manometry is the standard technique for evaluating anal sphincter function. However, the functional lumen imaging probe (EndoFLIP(®) ) can be used to measure sphincter distensibility during volume-controlled distensions. Our aims were (i) to assess anal distensibility in patients with fecal incontinence (FI) and in healthy subjects using the EndoFLIP(®) and (ii) to compare the results with anal pressures measured by 3D high-resolution manometry (3D-HRM) to determine whether the EndoFLIP(®) was more sensitive and specific for diagnosing FI than 3D-HRM. METHODS EndoFLIP(®) and 3D-HRM assessments of 34 female FI patients and 40 healthy female subjects were performed. Anal distensibility was measured as the median cross-sectional area at the narrowest point divided by the corresponding intra-bag pressure at rest and during peak voluntary contraction and was expressed in mm(2) /mmHg. KEY RESULTS A 40-mL anal distensibility index was selected for further comparisons as it provided the best discrimination between the FI patients and the healthy subjects. The index was significantly higher in the FI patients than in the healthy subjects at rest (p = 1.10(-4) ) and during voluntary contraction (p = 1.10(-4) ). The index at rest and during voluntary contraction appeared to be more appropriate than anal pressures for discriminating between FI patients and healthy subjects. CONCLUSIONS & INFERENCES The present study confirmed that FI is associated with an abnormally high distensibility index at rest and during voluntary contraction. The ability of the distensibility index to discriminate between FI patients and healthy subjects was significantly better than anal pressure.
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Affiliation(s)
- G Gourcerol
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
| | - S Granier
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
| | - V Bridoux
- INSERM U1073, Service de Chirurgie Digestive, CHU Rouen, Rouen, France
| | | | - P Ducrotté
- INSERM U1073, Service d'Hépato-Gastroentérologie, CHU Rouen, Rouen, France
| | - A M Leroi
- INSERM U1073, Service de Physiologie Digestive, CHU Rouen, INSERM CIC 0204 Rouen, Rouen, France
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Melchior C, Bridoux V, Touchais O, Savoye-Collet C, Leroi AM. MRI defaecography in patients with faecal incontinence. Colorectal Dis 2015; 17:O62-9. [PMID: 25641440 DOI: 10.1111/codi.12889] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/09/2014] [Indexed: 12/13/2022]
Abstract
AIM Faecal incontinence (FI) requires careful assessment of its aetiology to determine the most effective treatment. The aims of this study were to evaluate MRI defaecography in FI and to compare it with clinical examination combined with rigid rectoscopy in assessing the pelvic floor in patients with FI. METHOD Consecutive patients with FI referred over a 3-year period to our tertiary centre for MRI defaecography were retrospectively studied. MRI images of the pelvic floor were compared with clinical examination and anuscopy and rectoscopy. RESULTS Seventy-four female patients [mean age 60.5 (30.0-81.0) years] were recruited. MRI defaecography showed conditions which often overlapped, including internal intussusception in 19 (25.7%) and pelvic floor descent in 24 (32.4%). There was average agreement between MRI and clinical examination for a significant anterior rectocoele (κ = 0.40) and poor agreement between MRI and anuscopy/rectoscopy for intra-rectal (κ = 0.06) and intra-anal intussusception (κ = 0.11). CONCLUSION Other than for anterior rectocoele, there is poor correlation between MRI defaecography and clinical examination with rigid rectoscopy. MRI can detect a variety of abnormal static and dynamic pelvic disorders. This includes enterocoele, which could result in a modification of the surgical approach to intussusception and anterior rectocoele.
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Affiliation(s)
- C Melchior
- INSERM U1073, Service de Physiologie Digestive, Hôpital Charles Nicolle, Rouen, France
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Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms. Int J Gynaecol Obstet 2014; 126:70-3. [DOI: 10.1016/j.ijgo.2014.01.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 12/31/2013] [Accepted: 03/27/2014] [Indexed: 11/20/2022]
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Savoye-Collet C, Koning E, Dacher JN. Radiologic evaluation of pelvic floor disorders. Gastroenterol Clin North Am 2008; 37:553-67, viii. [PMID: 18793996 DOI: 10.1016/j.gtc.2008.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Several imaging modalities are available ranging from fluoroscopic techniques to ultrasonography and MRI for the evaluation of patients with pelvic floors disorders. High-resolution ultrasonography and MRI not only provide superior delineation of the pelvic floor anatomy but also reveal pathology and functional changes. This article focuses on standard imaging procedures including defecography, ultrasonography, and MRI and discusses its use in clinical practice by illustrating both normal and abnormal patterns.
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Affiliation(s)
- Celine Savoye-Collet
- Radiology Department, Rouen University Hospital Charles Nicolle, 1 Rue de Germont, F-76031 Rouen, France.
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Abstract
Fecal incontinence (FI) has a significant social and economic impact on the patient and the community. In women, obstetric injury is commonly associated with the development of FI. Understanding FI is aided by a good knowledge of the pelvic floor anatomy and continence mechanisms. This same knowledge along with a good history and physical can guide the physician in selecting appropriate studies and treatment options. Surgical treatment of FI is currently the best option when a sphincter defect exists. The long-term prognosis of the repair is disappointing, however. Ongoing investigations continue in the hopes of getting closer to a cure and to reclaiming the patient's former quality of life.
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Abstract
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.
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Norderval S, Markskog A, Røssaak K, Vonen B. Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:78-84. [PMID: 18059077 DOI: 10.1002/uog.5155] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To determine if there is a correlation between the sonographic extent of anal sphincter defects revealed by three-dimensional endoanal sonography (EAUS) and the degree of anal incontinence following primary repair of obstetric sphincter tears. METHODS This was a follow-up study of women who had suffered anal sphincter tearing during vaginal delivery at Aalesund Hospital between January 2002 and July 2004. Incontinence was assessed by St Mark's score. The anal canal was assessed with three-dimensional endoanal sonography (EAUS). Sphincter defects were classified according to the Starck score and our new EAUS defect score. The EAUS images were interpreted by an observer blinded to other patient data. RESULTS Sixty-one women were included in this study. Incontinence was reported by 32 (52%) women at a median of 21 (range, 9-35) months after delivery. Three-dimensional EAUS datasets were obtained in 55 women. There was a significant correlation between St Mark's score and our EAUS defect score (P = 0.034), and correlation approached but did not reach significance between St Mark's score and the Starck score (P = 0.053). There was a strong correlation between our EAUS defect score and the Starck score (P < 0.001). CONCLUSIONS There is a positive correlation between the extent of sphincter defects and the degree of anal incontinence following primary repair of obstetric sphincter tears. Our findings highlight the importance of adequate reconstruction of the anal sphincters during primary repair.
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Affiliation(s)
- S Norderval
- Department of Gynaecology and Obstetrics, Aalesund Hospital,Tromsø, Norway.
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