Ali A. Shafik

Percutaneous Peripheral Neuromodulation in the Treatment of Fecal Incontinence

Background/Aims: To assess the results of peripheral neuromodulation for the treatment of fecal incontinence (FI) resulting from uninhibited rectal contraction (URC) or uninhibited anal sphincter relaxation (UASR). Methods: The work comprised 32 patients (age 38.2 ± 6.7 years; 22 women) with FI in whom conventional therapy had failed before enrollment in the study. Twenty-six had URC and 6 UASR. Peripheral neurostimulation was effected by posterior tibial nerve stimulation using a Stoller Afferent Nerve Stimulator (UroSurge, Coralville, lowa, USA). The needle was introduced into the skin cephalad to the medial malleolus. Stimulation (parameters: 0.5–10 mA, 200 µs, 20 Hz) was performed every other day for 4 weeks. Functional assessment was done by a questionnaire (incontinence score: 0–20) and physiologic studies. Results: Group 1: 17 patients (13 URC, 4 UASR) had FI improvement, recording a mean score of 1.7 of 20. Group 2: 10 patients (8 URC, 2 UASR) had fair improvement (score 8.6). Group 3: 5 patients had poor results (score 14.8). Rectometric recording showed improvement in groups 1 and 2. Recurrence of symptoms occurred in 8 patients; 6 improved after retreatment. Conclusions: A percutaneous access to the S3 spinal region was achieved through the posterior tibial nerve. Improvement of FI was achieved in 78.2%. The technique is simple, easy, without complications and cost-effective. It can be done as an outpatient procedure or by the patient at home. The results need to be reproduced on a large number of patients.

The Role of the Levator Ani Muscle in Evacuation, Sexual Performance and Pelvic Floor Disorders

This paper reviews the role of the levator ani muscle (LAM) in evacuation, sexual performance and pelvic floor disorders. The LAM fixes the vesical neck, anorectal junction and vaginal fornices to the side wall of the pelvis by means of the suspensory sling and hiatal ligament. On contraction it shares in the mechanism of evacuation (urination, defecation). During the sexual act vaginal distension by the erect penis evokes the vaginolevator and vaginopuborectalis reflexes, with a resulting LAM contraction. The LAM also contracts upon stimulation of the clitoris or cervix uteri, an action mediated through clitoromotor and cervicomotor reflexes. LAM contraction leads to upper vagina ballooning, which acts as receptacle for semen collection, to uterine elevation and straightening and to elongation and narrowing of the vagina. These actions enhance the sexual response and prepare the uterus and vagina for the reproductive process. During ejaculation LAM contraction facilitates semen ejection. Levator subluxation and sagging leads to levator dysfunction syndrome, which may present as pudendal canal syndrome.

Study of the Electrical and Mechanical Activity of the Rectum: An Experimental Study

The electrical activity of the rectal detrusor was studied in 13 dogs. 10 electrodes were sutured serially to the rectal and lower sigmoid colon serosa. Electrical activity was recorded for 30 min/day for 10 days. Simultaneous electric and mechanical activity (recorded by a 6-French catheter connected to a pressure transducer) was also recorded with and without rectal distension by a condom balloon. Electrical activity was further determined after annular myotomy performed at different levels in the rectum and lower sigmoid colon. Pacesetter potentials (PP) were recorded from electrodes 3-10. They were triphasic, propagated caudally and had the same frequency and regular rhythm by all electrodes distal to the 3rd one. Frequency was constant in each dog from day to day. PP were accompanied by action potentials (AP) which had inconsistent frequencies and were accompanied by increased rectal pressure. Rectal distension led to an increase in both the frequency and amplitude of PP and AP. Rectal myotomy below the 3rd electrode resulted in PP and AP disappearing distal but not proximal to the cut, excluding the 1st and 2nd electrodes, which did not show activity. The results suggest that PP start at the 3rd electrode, which corresponds anatomically to the rectosigmoid junction (RSJ). AP cause contractile activity along the rectum. It seems that the RSJ is the site of a pacemaker triggering the PP that pace the AP which initiate the rectal contractile activity.

Pudendal Canal Decompression in the Treatment of Erectile Dysfunction

The results of the treatment of 7 patients with neurogenic erectile dysfunction (ED) by pudendal canal decompression are presented. Ages ranged from 46 to 56 years. Patients had penile, perineal, and scrotal hypoesthesia or anesthesia. EMG of the external urethral sphincter and levator ani muscle revealed diminished activity. There were increased bulbocavernosus and pudendal nerve terminal motor (PNTML) latencies. Patients tested normal for endocrine assays, Doppler examination of the penile arteries penobrachial pressure index, and cavernosometry. Nocturnal penile tumescence activity was absent. These findings pointed to neurogenic ED due to pudendal canal syndrome (PCS). Pudendal canal decompression was done through a para-anal incision. The inferior rectal nerve was followed to the pudendal nerve in the pudendal canal, which was slit open. Mean followup was 19.6 months. No complications were encountered. ED improved in 6 of the 7 patients 2-6 months postoperatively. Sensory and motor changes also improved. It is suggested that chronic straining at stool in these patients led to levator subluxation and sagging, and to pulling on the pudendal nerve with a resulting entrapment in the pudendal canal, pudendal neuropathy, and PCS. ED results from involvement of the penile and perineal branches of the pudendal nerve. To conclude, PCS may cause ED, which improves with pudendal canal decompression.

IDENTIFICATION OF C-KIT-POSITIVE CELLS IN THE HUMAN PROSTATE: THE INTERSTITIAL CELLS OF CAJAL

The prostate exhibits electric activity in the form of slow waves (SWs) and action potentials (APs). As the interstitial cells of Cajal (ICCs) are considered the pacemaker cells which generate the electric waves, we investigated the hypothesis that the prostate contains ICC. Prostatic biopsies were obtained from 15 healthy volunteers (mean age 36 ± 3.8 SD years). They were subjected to c-kit immunohistochemistry. Controls for the specificity of the antisera consisted of tissue incubated with normal rabbit serum substituted for the primary antiserum. C-kit-positive cells were identified as fusiform with dendritic processes. The cytoplasm was granular and the nucleus large and oval. Mast cells, also c-kit-positive, were round and lacked the dendritic processes. Immunoreactivity was absent in the negative controls. There were cells in the prostate with morphological and immunological phenotypes similar to ICCs of the gut. We predict an abnormal distribution of these cells in prostatic diseases. The study of the integrity of these cells may prove to be a useful investigative tool in the diagnosis of prostatic diseases and in the planning of an appropriate treatment.

A Novel Concept for the Surgical Anatomy of the Perineal Body

PurposePerineal body is considered by investigators as a fibromuscular structure that is the site of insertion of perineal muscles. We investigated the hypothesis that perineal body is the site across which perineal muscles pass uninterrupted from one side to the other.MethodsPerineal body was studied in 56 cadaveric specimens (46 adults, 10 neonatal deaths) by direct dissection with the help of magnifying loupe, fine surgical instruments, and bright light.ResultsPerineal body consisted of three layers: 1) superficial layer, which consisted of fleshy fibers of the external anal sphincter extending across perineal body to become the bulbospongiosus muscle; 2) tendinous extension of superficial transverse perineal muscle crossing perineal body to contralateral superficial transverse perineal muscle, with which it formed a criss-cross pattern; and 3) tendinous fibers of the deep transverse perineal muscle; the fibers crossing perineal body decussated in criss-cross pattern with the contralateral deep transverse perineal muscle. A relation of levator ani or puborectalis muscles to perineal body could not be identified.ConclusionsPerineal body (central perineal tendon) is not the site of insertion of perineal muscles but the site along which muscle fibers of these muscles and the external anal sphincter pass uninterrupted from one side to the other. Such a free passage from one muscle to the other seems to denote a “digastric pattern” for the perineal muscles. Perineal body is subjected to injury or continuous intra-abdominal pressure variations, which may eventually result in perineocele, enterocele, or sigmoidocele.

SPERM DNA FRAGMENTATION

Several techniques have been developed to measure the amount of sperm DNA damage in an effort to identify more objective parameters for evaluation of infertile men. The integrity of sperm DNA influences a couples fertility and helps predict the chances of pregnancy and its successful outcome. The available tests of sperm DNA damage require additional large-scale clinical trails before their integration into routine clinical practice. The physiological/molecular integrity of sperm DNA is a novel parameter of semen quality and a potential fertility predictor. Although DNA integrity assessment appears to be a logical biomarker of sperm quality, it is not being assessed as a routine part of semen analysis by clinical andrologists [26]. Extensive investigation has been conducted for the comparative evolution of these techniques. However, some of these techniques require expensive instrumentation for optimal and unbiased analysis, are labor intensive, or require the use of enzymes whose activity and accessibility to DNA breaks may be irregular. Thus, these techniques are recommended for basic research rather than for routine andrology laboratories. Sperm chromatin structure evaluation is applied to detect male factors that may affect the chance of success with IVF as well as natural fertility. Further research is needed to define the optimal test of sperm chromatin structure. The clinical application of this test will evolve as well.

Rectosigmoid junction: anatomical, histological, and radiological studies with special reference to a sphincteric function

Abstract The existence of a sphincter at the rectosigmoid junction (RSJ) is controversial. Recent studies have demonstrated a high-pressure zone within the RSJ which responds to sigmoid colon or rectal contractions by relaxation or contraction, respectively. These findings suggest the presence of a ”physiological” sphincter at the RSJ. The current study investigated the anatomical and histological structure and the radiological picture of the RSJ in view of the possible existence of an anatomical sphincter at the RSJ and elucidating its function. The RSJ was studied in 28 cadavers (18 adults and 10 fully mature neonates) by dissection. A histological study of the RSJ was performed in 5 cadavers. Radiological examination using double-contrast barium enema was carried out in 50 healthy volunteers (mean age 44.2±14.4 years; 32 men, 18 women). The mucous membrane of the RSJ was found in folds forming a ”mucosal rosette” of a mean length of 2.8±0.9 cm in adult specimens and 0.7±0.2 cm in neonates. The distal end of the mucosal rosette was sharply delineated and in some specimens protruded into the rectal lumen as a small nipple, which was surrounded by a ”rectal fornix” on either side. The histological examination of the RSJ showed mucosal foldings with deep crypts surrounded by lymphocytic aggregates and marginated by muscularis mucosa. The circular muscle coat showed gradually increasing thickness towards the rectum. Nerve cells in the submucosa were located at three levels: in the vicinity of the muscularis mucosa, in the middle of the submucosa, and in the proximity of the circular muscle. Radiologically the opening of the sigmoid colon into the RSJ presented as a ring or crescent. Radiological striations representing the mucosal rosette were demonstrated. The RSJ appeared as a narrow contractile segment. The anatomical, histological, and radiological findings thus indicate that the RSJ is a segment which can be identified by its interior rather than outer aspect. The study suggests the presence of an anatomical sphincter at the RSJ which seems to regulate the passage of stools from the sigmoid colon to the rectum.

Study of the electromechanical activity of the urinary bladder

SummaryThe electromechanical activity of the urinary bladder (UB) was studied in 16 dogs. With the animals under anesthesia, the UB was exposed and four electrodes were sutured serially to its anterior wall. Electric activity simultaneously with vesical pressure was recorded for periods of 30 min daily on 10 days. Triphasic pacesetter potentials (PP) were registered from electrodes 1–4, having identical frequency and regular rhythm by all electrodes and being consistent in the individual dog on all test days. Action potentials (AP) followed PP randomly and were accompanied by vesical pressure increase; they represented vesical contractile waves. Balloon distension of the UB effected increased PP and AP frequency. Annular vesical myotomy led to PP and AP disappearance distal but not proximal to the myotomy, which would suggest that (a) the waves spread caudally and (b) a “pacemaker” exists at the upper part of the UB and triggers the PP.

Effect of topical esophageal acidification on salivary secretion: Identification of the mechanism of action

Background:  In past studies, investigators have reported that the salivary glands respond to esophageal acidification by increased salivary secretion and termed this response the ‘esophago–salivary response’. The existence, however, of such a reflex was but a speculation because the verification of its mechanism could not be traced in the literature. In the current study, the hypothesis that the salivary glands’ response to esophageal acidification is a reflex was investigated.