The effects of age and childbirth on anal sphincter function and morphology in 999 symptomatic female patients with colorectal dysfunction

Effectiveness of pudendal nerve block in the management of acute post-haemorrhoidectomy pain in Asian individuals using inverse probability of treatment weighting (IPTW)

BACKGROUND

Inadequate management of acute post-haemorrhoidectomy pain is a major concern. Optimal pain management is necessary to reduce acute postoperative pain and improve care quality. Therefore, we investigated the efficacy of postoperative pudendal nerve block (PNB) in reducing acute post-haemorrhoidectomy pain in Asian individuals.

METHODS

This retrospective cohort study analysed 108 adult patients with grade 3 haemorrhoids. Patients with anorectal cancer were excluded from this study. Among the 108 patients, 79 and 29 received spinal anaesthesia (SA) with PNB (SAPNB) and SA alone, respectively. Propensity score matching and inverse probability of treatment weighting were performed to adjust for the effects of confounders.

RESULTS

Patients receiving SAPNB had significantly lower postoperative pain scores 6, 12, and 18 h after haemorrhoidectomy but significantly higher postoperative pain scores 24 and 48 h after haemorrhoidectomy than did patients receiving SA alone. PNB, older age, female sex, reduced operation time, and absence of cardiovascular disease reduced the risk of moderate to severe postoperative pain. Only the addition of PNB was consistently associated with a reduced risk of moderate to severe pain 6, 12, and 18 h after haemorrhoidectomy. Patients receiving SAPNB had significantly lower risks of perianal swelling and urinary retention but a significantly higher risk of nausea than did those receiving SA alone. The two groups exhibited similarity in their rates of postoperative readmission because of poor pain management and their lengths of stay upon readmission.

CONCLUSION

The addition of PNB to SA may effectively reduce acute post-haemorrhoidectomy pain.

A systematic review and a meta-analysis on the incidence of obstetric anal sphincter injuries during vaginal delivery

AIM

The incidence of obstetric anal sphincter injuries (OASIS) has increased in the past two decades despite improved awareness of the risk factors. This study aimed to define the incidence of OASIS in women with different features (instrumental delivery or other variables).

METHODS

A systematic review was conducted on articles reporting the incidence of OASIS. This review aims to examine the association of instrumentation and OASIS by performing a formal systematic review of the published literature. Databases used for the research were MEDLINE, Embase, CINAHL and 'Maternity and infant care' databases.

RESULTS

Two independent reviewers screened the selected articles. 2326 duplicates were removed from the total of 4907 articles. The remaining 2581 articles were screened for title and abstract. 1913 articles were excluded due to irrelevance. The remaining 300 were screened as full text. Primiparity associated with the use of forceps were the features associated with the highest incidence of OASIS in the selected articles (19.4%). OASIS in all women had an overall incidence of 3.8%. The incidence of OASIS in all women by geographical region was the highest (6.5%) in North America.

CONCLUSIONS

There are various factors that impact on the incidence of OASIS and the combination of some of these, such as the use of forceps in primiparas, resulted in the highest incidence of OASIS. The lack of international consensus is limiting the improvements that can be done to reduce OASIS rates and improve best clinical practice.

Understanding the physiology of human defaecation and disorders of continence and evacuation

The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.

Fecal Urgency: Clinical and Manometric Characteristics in Patients With and Without Diarrhea

BACKGROUND

Fecal urgency is classically associated with diarrhea, but is also common in individuals with normal bowel habits or constipation. Its etiology, particularly in non-diarrhea individuals, is unclear.

METHODS

We examined data from 368 individuals with and without diarrhea who underwent three-dimensional high-resolution anorectal manometry and balloon expulsion test. All patients completed the Rome III constipation module and the pelvic floor distress inventory (PDFI-20) survey. Patients were considered to have fecal urgency if they reported being bothered "moderately" or "quite a bit" by it in the past 3 months.

RESULTS

A total of 103 patients (28.0%) met our definition of fecal urgency. These patients were significantly more likely to meet criteria for irritable bowel syndrome and to report fecal incontinence, urinary incontinence, and diarrhea. Fecal urgency was associated with rectal hypersensitivity in those with diarrhea, but not in those without diarrhea. Fecal urgency was associated with urinary urge incontinence in those without diarrhea, but not those with diarrhea.

CONCLUSIONS

In patients with diarrhea, fecal urgency is associated with rectal hypersensitivity, whereas in patients without diarrhea, fecal urgency is associated with urinary urge incontinence. This suggests that fecal urgency has different pathophysiological mechanisms in patients with different underlying bowel habits.

Effect of gender on the etiology of fecal incontinence: Retrospective analysis of a tertiary referral center in Turkey

BACKGROUND/AIMS

Anorectal diseases, including fecal incontinence, are prevalent and have an enormous impact on the quality of life. Therefore, investigating their etiological factors may help to reduce the incidence and/or the severity of the underlying diseases.

MATERIALS AND METHODS

Referral complaints (constipation, strained defecation, and incontinence) and medical and anorectal manometry records of 883 (562 female/321 male, ages 45.17±1.00 and 48.41±0.63 years, respectively) patients were evaluated retrospectively. Maximal resting pressure (MRP) and maximal squeeze pressure (MSP) measured by stationary pull-through technique, volume of rectoanal inhibitory reflex, and sensory threshold to rectal balloon distention (ST) were obtained by water perfusion system. Data were compared according to referral complaints, age, gender, parity, and underlying diseases.

RESULTS

Incontinence was the most frequent referral complaint in 61.2% of females and 67.6% of males. MRP and MSP were significantly lower in incontinent females than in the other groups. In incontinent males, MSP was lower than the strained defecation group, and ST was higher than the constipation group. Age was negatively correlated with MRP for both of the genders and in all groups. Obstetric trauma (85%) and number of parity (3.40±2.59) were significantly higher in incontinent females. Moreover, the most prevalent underlying disease was diabetes in incontinent females (13.7%) and neurological diseases, including traumas, in incontinent males (41.5%).

CONCLUSION

Increasing awareness of labor safety, controlling diabetes mellitus, and preventing obstetric traumas may reduce the prevalence of fecal incontinence.

Functional anal canal length measurement using high-resolution anorectal manometry to investigate anal sphincter dysfunction in patients with fecal incontinence or constipation

BACKGROUND

Using high-resolution anorectal manometry, we aimed to evaluate the: (a) optimal threshold to measure functional anal canal length (FACL) with intra- and inter-observer variability; (b) relationship between abnormal FACL and other phenotypic findings; and (c) utility of FACL measurement to discriminate between healthy volunteers (HV) and patients with fecal incontinence (FI) or chronic constipation (CC).

METHODS

Consecutive patients referred for investigation of FI or CC in isolation were included. FACL was calculated at 5, 10, 20, 30, and 50 mm Hg above rectal pressure. 5th-95th percentile in HV defined limits of normality.

KEY RESULTS

FACL was analyzed in 192 patients with FI (154 females), 204 patients with CC (175 females), and 134 HV (101 females). The optimal threshold for measurement of FACL was 20 mm Hg. Using this threshold, observer reproducibility was very high (ICC 0.99, P < 0.0001). FACL was shorter in females with FI and longer in females with CC compared to HV (2.3 vs 2.9 cm; and 3.4 cm vs 2.9 cm; both P < 0.0001). Twenty percent of females and 13% males with FI had a short FACL, associated with older age, anal hypotonia or hypocontractility, and a atrophic internal anal sphincter. However, abnormal FACL in isolation was only found in 1/190 FI (0.5%) and 2/201 CC (1%) patients; all other patients had other abnormal manometric findings.

CONCLUSIONS AND INFERENCES

Considering overlap with other routinely evaluated manometric parameters, FACL measurement does not provide additional information in the diagnostic assessment of FI or CC.

Normal values for assessment of anal sphincter morphology, anorectal motion, and pelvic organ prolapse with MRI in healthy women

BACKGROUND

Endoanal MRI and MR defecography are used to identify anal sphincter injury and disordered defecation. However, few studies have evaluated findings in asymptomatic healthy people. The effects of BMI and parity on rectoanal motion and evacuation are unknown.

METHODS

In 113 asymptomatic females (age 50 ± 17 years, Mean ± SD) without risk factors for anorectal trauma, anal sphincter appearance, anorectal motion, and pelvic organ prolapse were evaluated with MRI. The relationship between age, BMI, and parity and structural findings were evaluated with parametric and non-parametric tests.

RESULTS

The anal sphincters and puborectalis appeared normal in over 90% of women. During dynamic MRI, the anorectal angle was 100 ± 1º (Mean ± SEM) at rest, 70 ± 2° at squeeze, and 120 ± 2° during defecation. The change in anorectal angle during squeeze (r = -.25, P < .005), but not during evacuation (r = .13, P = .25) was associated with age. In the multivariable models, BMI (P < .01) and parity (P < .01) were, respectively, independently associated with the intersubject variation in the anorectal angle at rest and the angle change during squeeze. Ten percent or fewer women had had descent of the bladder base or uterus 4 cm or more below the pubococcygeal line or a rectocele measuring 4 cm or larger. Only 5% had a patulous anal canal.

CONCLUSIONS

In addition to age, BMI and parity also affect anorectal motion in asymptomatic women. These findings provide age-adjusted normal values for rectoanal anatomy and pelvic floor motion.

MRI of anal canal: common anal and perianal disorders beyond fistulas: Part 2

A broad spectrum of disease, from benign processes to life-threatening pathologies, can cause anal pain. MR imaging (MRI) has become increasingly widely used method over the past two decades for the evaluation of individuals with anorectal symptoms. Although imaging is rarely necessary to determine the etiology of the majority of cases, MRI is particularly useful as a noninvasive method of excluding severe neoplastic conditions. In this article, MRI findings of a number of pathologies such as anal and perianal neoplasms, hemorrhoidal disease, arteriovenous malformation of the perianal region, and anal sphincter lesions (defects, scarring, atrophy) which may lead to fecal incontinence are presented.

Age-related external anal sphincter muscle dysfunction and fibrosis: possible role of Wnt/β-catenin signaling pathways

Studies show an age-related increase in the prevalence of anal incontinence and sphincter muscle atrophy. The Wnt/β-catenin signaling pathway has been recently recognized as the major molecular pathway involved in age-related skeletal muscle atrophy and fibrosis. The goals of our study were to 1) evaluate the impact of normal aging on external anal sphincter (EAS) muscle length-tension (L-T) function and morphology and 2) specifically examine the role of Wnt signaling pathways in anal sphincter muscle fibrosis. New Zealand White female rabbits [6 young (6 mo of age) and 6 old (36 mo of age)] were anesthetized, and anal canal pressure was measured to determine the L-T function of EAS. Animals were killed at the end of the study, and the anal canal was harvested and processed for histochemical studies (Masson trichrome stain for muscle/connective tissue) as well as for molecular markers for fibrosis and atrophy [collagen I, β-catenin, transforming growth factor-β (TGF-β), atrogin-1, and muscle-specific RING finger protein-1 (MuRF-1)]. The L-T was significantly impaired in older animals compared with young animals. Anal canal sections stained with trichrome showed a significant decrease in the muscle content (52% in old compared with 70% in young) and an increase in the connective tissue/collagen content in the old animals. An increased protein and mRNA expression of all the fibrosis markers was seen in the older animals. Aging EAS muscle exhibits impairment of function and increase in connective tissue. Upregulation of atrophy and profibrogenic proteins with aging may be the reason for the age-related decrease in anal sphincter muscle thickness and function.NEW & NOTEWORTHY Our studies using a female rabbit model show age-related alterations in the structure and function of the external anal sphincter (EAS) muscle. We used endoluminal ultrasound to measure age-related changes in EAS muscle thickness. We employed Western blot and quantitative PCR to demonstrate age-related changes in the levels of important fibrogenic as well as atrophy markers. Our findings may have significant clinical implications, i.e., use of specific antagonists to prevent age-related EAS muscle dysfunction.

Factors Associated with Fecal Incontinence in Women of Childbearing Age with Crohn's Disease

BACKGROUND

Fecal incontinence is common in women with Crohn's disease, but little is known about the impact of childbirth, perianal Crohn's disease, and past surgical history on fecal incontinence.

METHODS

Self-administered questionnaires were mailed to consecutive women referred to a tertiary gastroenterology centre with a focus on fecal incontinence and childbirth. These data were cross-referenced with a prospective database of the same patients' own Crohn's disease histories. Fecal incontinence was defined as a Cleveland Clinic Incontinence Score ≥5. Factors associated with fecal incontinence were analyzed.

RESULTS

A total of 173 patients were assessed, including 113 parous women. The prevalence of fecal incontinence was 37.5% (95% CI, 30.7-45.0). The disease duration, a history of anal surgery for fistula, the number of childbirths per woman and Crohn's activity were all independently associated with fecal incontinence in a multivariate analysis model. Specifically, among the group of parous women, fecal incontinence was associated with prior abdominal surgery, prior anal surgery, and Crohn's activity. The mode of delivery was not statistically associated with fecal incontinence.

CONCLUSIONS

Fecal incontinence is a significant complaint in at least one-third of women of childbearing age with Crohn's disease. Patients'disease and treatment histories seem to have a comparable effect to their childbirth history concerning the presence of fecal incontinence. Both physicians and surgeons who are involved in the management of Crohn's disease need to keep this in mind.

Gender differences in chronic constipation on anorectal motility

BACKGROUND

The epidemiology of chronic constipation (CC) skews toward female predominance, yet men make up an important component of those suffering from CC. We sought to determine whether there are sex-specific differences in symptoms and physiologic parameters on anorectal manometry (ARM).

METHODS

We performed a case-control analysis of sequential men and age-matched women (2:1 ratio) presenting for ARM as part of the evaluation of CC. We collected physiologic parameters derived from 3D high-resolution ARM in addition to the ROME III constipation module and the Pelvic Floor Distress Inventory 20 (PFDI-20) questionnaires. We analyzed univariate, sex-specific differences in ARM physiologic parameters and PFDI-20 parameters and adjusted for putative confounders using multivariate logistic regression.

KEY RESULTS

Our study enrolled 80 men and 165 age-matched women. Men had a higher median sphincter resting pressure (81.2 vs 75.2 mm Hg, P=.01) and mean squeeze pressure (257.0 vs 170.5 mm Hg, P<.0001) than women. Although men reported significantly less severe straining and incomplete evacuation, they had greater mean rectoanal pressure differential (-106.7 vs -71.1 mm Hg, P<.0001), smaller mean defecation index (0.17 vs 0.27, P=.03) and higher volume threshold for urgency (115.2 v. 103.4 mL, P=.03). However, women were more likely to have abnormal balloon expulsion time (BET) than men (52.7% vs 35.0%, P=.01). After multivariate analysis, male gender was the only independent predictor of a normal BET (OR: 0.48, 95% CI: 0.27-0.86, P=.01).

CONCLUSIONS & INFERENCES

Men and women with CC differ with regard to symptom severity and physiologic parameters derived from ARM suggesting differences in their pathophysiology.

Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer

BACKGROUND

An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer.

AIM

The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry.

METHODS

Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2).

RESULTS

Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p=0.007). Surgery determined a significantly decrease of the resting pressure (p=0.001), of the maximum squeeze pressure (p=0.001) and of the volume threshold for urgency (p=0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively.

CONCLUSIONS

CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.

Drug Management in the Elderly IBD Patient

OPINION STATEMENT

Managing inflammatory bowel disease (IBD) in a world of immunomodulators and biologics is complex enough, but managing the elderly IBD patient is further confounded by multiple comorbidities, polypharmacy with drug-drug interactions, and cognitive mobility/motility disturbances. Social and insurance coverage issues also always lurk in the background. All of these factors summate into a daunting challenge for the clinician. In this review, we aim to describe important considerations when prescribing to an elderly patient with IBD, taking into account costs of medications, drug interactions, the aging body's effect on pharmacokinetics, and the effect of aging on the immune system. Adverse effects and drug-drug interactions are expounded upon in detail specific for the aging adult with IBD in an effort to assist the clinician in the decision-making process.

Development and validation of a practical score to predict pain after excisional hemorrhoidectomy

PURPOSE

Excisional hemorrhoidectomy (EH) can be complicated by high early (EP) and prolonged pain (PP). This study aimed to determine predictors of high postoperative pain and to develop a risk score suitable to identify patient candidates to a more active analgesic treatment.

METHODS

We collected data of patients undergoing EH between January 2005 and September 2012 (development group). Patient-, disease-, surgery-, and surgeon-related characteristics were gathered. Anxiety was evaluated by means of STAI-Y. EP was assessed at 1-day, while PP at 15-day follow-up by means of a 10-cm VAS (cutoff, EP ≥ 5; PP ≥ 3 cm). On the basis of the odds ratio from a logistic regression, independent risk factors were assigned a weighted integer. The sum comprised the risk score, which was validated on a prospective cohort of patients undergoing EH between September 2012 and January 2014.

RESULTS

Five hundred fourteen patients were included in development group. Incidence of EP was 18.3 %, with 40.4 % developing PP. Younger age, male gender, advanced education, constipation, external component, anxious state and trait, and high anal resting tone were independent predictors of EP. Previous pain exerted a protective effect. Incomplete postoperative evacuation, advanced education level, high anal resting tone, and anxious trait were predictors of PP. In the development group, the risk of EP ranged between 1 % (low risk) and 21 % (high risk). Receiver operating curve (ROC) analysis of validation group (n = 130) confirmed the discriminatory power of this model (area under the ROC = 0.69).

CONCLUSION

The score can stratify the risk of EP following EH, identifying high-risk patient candidates to active analgesic administration or alternative surgical procedures.

Medical management of inflammatory bowel disease in the elderly: balancing safety and efficacy

The medical management of inflammatory bowel disease (IBD) in the older patient extends beyond luminal disease activity. Factors such as comorbidity, functional status, polypharmacy, and age-related changes in physical reserve and drug metabolism may affect therapeutic decision making. The older patient with IBD is more susceptible to disease-related complications and also to adverse events with therapy, particularly immunosuppression. Appropriate medication selection along with multidisciplinary care, factoring not only disease activity but also these age-related risk factors, may improve therapeutic outcomes and decrease adverse events to therapy.

Traditional measures of normal anal sphincter function using high-resolution anorectal manometry (HRAM) in 115 healthy volunteers

BACKGROUND

High-resolution anorectal manometry (HRAM) is a relatively new method for collection and interpretation of data relevant to sphincteric function, and for the first time allows a global appreciation of the anorectum as a functional unit. Historically, traditional anal manometry has been plagued by lack of standardization and healthy volunteer data of variable quality. The aims of this study were: (i) to obtain normative data sets for traditional measures of anorectal function using HRAM in healthy subjects and; (ii) to qualitatively describe novel physiological phenomena, which may be of future relevance when this method is applied to patients.

METHODS

115 healthy subjects (96 female) underwent HRAM using a 10 channel, 12F solid-state catheter. Measurements were performed during rest, squeeze, cough, and simulated defecation (push). Data were displayed as color contour plots and analysed using a commercially available manometric system (Solar GI HRM v9.1, Medical Measurement Systems). Associations between age, gender and parity were subsequently explored.

KEY RESULTS

HRAM color contour plots provided clear delineation of the high-pressure zone within the anal canal and showed recruitment during maneuvers that altered intra-anal pressures. Automated analysis produced quantitative data, which have been presented on the basis of gender and parity due to the effect of these covariates on some sphincter functions. In line with traditional manometry, some age and gender differences were seen. Males had a greater functional anal canal length and anal pressures during the cough maneuver. Parity in females was associated with reduced squeeze increments.

CONCLUSIONS & INFERENCES

The study provides a large healthy volunteer dataset and parameters of traditional measures of anorectal function. A number of novel phenomena are appreciated, the significance of which will require further analysis and comparisons with patient populations.

Electrically stimulated gracilis neosphincter for end-stage fecal incontinence: the long-term outcome

BACKGROUND

Electrically stimulated gracilis neosphincter is an established treatment for patients with end-stage fecal incontinence. Few data, however, describe its long-term efficacy.

OBJECTIVE

This study aimed to assess the long-term functional outcome associated with this procedure.

DESIGN

Patients who underwent gracilis neosphincter construction between1989 and 2001 were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiologic data were available for all patients.

SETTINGS

This study was conducted at an academic colorectal unit in a tertiary center.

PATIENTS

Sixty patients (median age, 42 years; 46 females) with fecal incontinence and a Williams continence score ≥5 were recruited to the study. The causes of incontinence included obstetric injury (n = 22), anal surgery (n = 17), atresia (n = 7), idiopathic incontinence (n = 6), anorectal excision (n = 4), and ileoanal pouch incontinence (n = 4).

MAIN OUTCOME MEASURE

The primary outcomes measured were the Williams continence score and the proportion of patients with a Williams score ≤3 who avoided permanent stoma formation.

RESULTS

Continence improved for the cohort postoperatively at 2 years (2(2-5); p < 0.001) but no significant difference was found between continence scores preoperatively and at 13 years (5(3-6); p = not significant). However, a sustained improvement at 13 years was noted for patients in the anal surgery (3(2-5);p < 0.001) and obstetric injury groups (4.5(3-6); p = 0.001). Twenty-six patients (43%) had a Williams score ≤3 and avoided permanent stoma after 13 years. Eighteen patients developed postoperative rectal evacuatory disorder; 10 of them required a conduit to facilitate colonic irrigation. Postoperative evacuatory disorder was more frequent in patients with a history of obstetric injury (p = 0.008).

LIMITATIONS

This study was limited by the lack of bowel diaries and quality-of-life scores.

CONCLUSION

Gracilis neosphincter is associated with clinically significant and sustained symptom improvement in patients with end-stage fecal incontinence secondary to obstetric injury or anal surgery. These data support the continued use of this procedure in highly selected patients.

Operative strategy for fistula-in-ano without division of the anal sphincter

INTRODUCTION

The treatment of perianal fistulas is diverse because no single technique is universally effective. Fistulotomy remains the most effective way of eradicating the pathology but it renders the patient at some risk of faecal incontinence, which many patients are reluctant to take. There are no data in the literature to indicate the healing rate of perianal fistulas when using an operative strategy that routinely avoids division of any part of the anal sphincter. The aim of this paper is to present the long-term results with an operative strategy that aims to avoid division of any part of the anal sphincter complex when treating all types of perianal fistulas, thereby minimising/eliminating the risk of postoperative incontinence.

METHODS

We report 54 consecutive cases of anal fistula that presented electively and as an emergency. Patients with known or subsequently diagnosed inflammatory bowel disease or malignancy were excluded from the study.

RESULT

Overall, 46 patients (37 male and 9 female) with a median age at presentation of 42 years (range: 19-73 years) were treated by lay-open of the subcutaneous tract of the perianal fistula and insertion of a loose seton for the part of the fistula tract related to the sphincter complex. The types of fistula treated were intersphincteric (89%), transsphincteric (4%) and high suprasphincteric (7%). The median length of time that the seton was left in place was 7 months (range: 1.5-24 months). The healing rate was 86% with a recurrence rate of 19% and a median follow-up duration of 42 months.

CONCLUSIONS

Patients who are reluctant to take any risk of faecal incontinence could be treated using an operative strategy that routinely avoids division of any part of the anal sphincter complex as this has a recurrence rate that compares well with other treatment modalities.

Factors affecting reflex pelvic floor muscle contraction patterns in women with pelvic floor disorders

OBJECTIVE

To explore factors affecting the presence of two reflex pelvic floor muscle contraction (PFMC) patterns in women with pelvic floor disorders.

METHODS

This was a retrospective analysis of pelvic floor ultrasonography and urodynamic data for 667 consecutive symptomatic women with pelvic floor disorders. We identified on ultrasonography the presence or absence of two reflex PFMC patterns, anorectal lift (ARL) and inward clitoral motion (ICM), preceding or occurring during coughing, and evaluated their associations with possible factors affecting reflex PFMC reactivity, including patient demographics, pelvic organ prolapse stages, ultrasonography findings and urodynamic data.

RESULTS

Of the 667 women, 560 (84.0%) clearly demonstrated reflex ARL and 536 (80.4%) demonstrated ICM. There were significant differences in age (P < 0.001), parity (P = 0.033) and menopausal status (P = 0.005) between women with and those without reflex ICM before or during coughing. The multivariable logistic regression model showed that age was the only independent factor associated with presence of reflex ICM (odds ratio, 0.93 (95% CI, 0.88-0.99), P = 0.017). In contrast, no significant differences were noted between women with and without reflex ARL.

CONCLUSIONS

Increasing age is negatively associated with the presence of reflex ICM during coughing in symptomatic women with pelvic floor disorders.

Interpretation of overall colonic transit in defecation disorders in males and females

BACKGROUND

There is little information regarding gender-specific measurements of colonic transit and anorectal function in patients with defecation disorders (DD). To compare overall colonic transit by gender in DD.

METHODS

In 407 patients with constipation due to DD diagnosed by a single gastroenterologist (1994-2012), DD was characterized by anorectal manometry, balloon expulsion test, and colonic transit by scintigraphy. The primary endpoint was overall colonic transit (geometric center, GC) at 24 h (GC24). Effects of gender in DD on colonic transit, and comparison with transit in 208 healthy controls were assessed by Mann-Whitney rank sum test. Secondary endpoints were maximum anal resting (ARP) and squeeze (ASP) pressures. We also tested association of the physiological endpoints among DD females by pregnancy history and among DD patients by colectomy history.

KEY RESULTS

The DD patients were 67 males (M) and 340 females (F). Significant differences by gender in DD patients were observed in GC24 (median: M: 2.2; F: 1.8; P = 0.01), ARP (median: M: 87.8 mmHg; F: 82.4 mmHg; P = 0.04), and ASP (median: M: 182.4 mmHg; F: 128.7 mmHg; P < 0.001). GC24 was slower in DD compared with same-gender healthy controls. GC24 did not differ among DD females by pregnancy history. Anorectal functions and upper GI transit did not differ among DD patients by colectomy history.

CONCLUSIONS & INFERENCES

Patients with DD have slower colonic transit compared with gender-matched controls. Among DD patients, males have higher ARP and ASP, and females have slower colonic transit. Although the clinical significance of these differences may be unclear, findings suggest that interpretation of these tests in suspected DD should be based on same-gender control data.