Edward S. Kiff

History and examination in the assessment of patients with idiopathic fecal incontinence

AbstractPURPOSE: This study was undertaken to identify those factors from the history and examination which might predict the pathophysiologic basis of idiopathic fecal incontinence. METHODS: In a prospective study of 237 patients with idiopathic fecal incontinence (female to male, 7∶1.7; mean age, 54.8 years; median history, 3 years), history, examination, and anorectal physiology studies findings have been analyzed using contingency table analysis. RESULTS: In patients with idiopathic fecal incontinence, anorectal physiology studies have shown that a low maximum basal pressure (<45 cm H2O) is predominantly attributable to internal anal sphincter weakness, and low maximum squeezing pressure (<76 cm H2O) is indicative of voluntary sphincter deficiency. In this study, a low maximum basal pressure is correlated with leakage, gaping of the anus on traction of the anal verge, and decreased resting tone on digital examination (allP< 0.05). A low maximum squeezing pressure is correlated with incontinence en route to the lavatory, urgency, both stress and urge incontinence of urine, reduced voluntary contraction in the external anal sphincter and puborectalis on digital examination, and a reduced or absent anorectal angle (allP<0.05). CONCLUSION: This study has shown that an informed history and digital examination can predict the manometric findings of specialist anorectal physiology studies.

Anterior anal sphincter repair can be of long term benefit: a 12-year case cohort from a single surgeon

BackgroundEarly surgical results of anterior sphincter repair for faecal incontinence can be good, but in the longer term are often disappointing. This study aimed to determine the short and long term outcomes from anterior sphincter repair and identify factors predictive of long term success.MethodsPatients who underwent anterior sphincter repair between 1989 and 2001 in one institution were identified. Postal questionnaires were sent to patients, which included validated scoring systems for symptom severity and quality of life assessments for faecal incontinence. Patient demographics and risk factors were recorded as were the results of anorectal physiology studies and endoanal ultrasound.ResultsEighty-five patients underwent repair by one consultant. The length of follow up ranged from 1 to 12 years. Most patients (96%) had early symptom improvement postoperatively. Of the 47 patients assessed long term (≥ 5 years), 28 (60%) maintained this success. Significant improvements in quality of life were observed (P < 0.001). Neither patient, surgical nor anorectal physiology study parameters were predictive of outcome.ConclusionThere were no predictive factors of outcome success and no changes in anal manometry identified, however anterior sphincter repair remains worthwhile. Changes in compliance of the anorectum may be responsible for symptom improvement.

Fatigability of the External Anal Sphincter in Anal Incontinence

INTRODUCTIONAnal incontinence commonly results from external anal sphincter dysfunction. The muscle is routinely assessed by anorectal physiology studies. Fatigability is not routinely measured but should be an important factor in the maintenance of continence. The fatigue rate index has been developed to address this. The purpose of this study was to investigate the fatigability of the external anal sphincter in incontinent patients compared with that in controls and to determine its correlation with symptom severity and pudendal nerve terminal motor latency measurement.METHODSForty-two patients with anal incontinence (33 female, 9 male) and 20 control patients (17 female, 3 male) were studied. As part of anorectal physiology studies, manometry was measured by a station pull-through technique with a closed-system microballoon. After a rest period of one minute, fatigue was measured over a 20-second squeeze at 1.5 cm in the anal canal with two consecutive readings separated by a further one-minute rest period. The fatigue rate index was calculated from the maximum squeeze pressure and fatigue rate. A validated symptom severity scoring system was used to assess symptomatology in patients with anal incontinence.RESULTSNo difference was detected in demographic factors between the two groups. The fatigue rate index was significantly different between the control and incontinent groups (1.85 vs. 0.67 minutes, P = 0.001). No other factors were significantly different between the two groups (maximum squeeze pressure, 89.1 vs. 79 cm H2O, P = 0.42; fatigue rate, −85.8 vs. −101.2 cm H2O/min, P = 0.62). The fatigue rate index demonstrated a significant correlation with symptom score (r = −0.44, P = 0.005). The fatigue rate index did not correlate with latency measurement.CONCLUSIONsA significant difference was detected in the fatigue rate index between incontinent and control patients. The Fatigue Rate Index demonstrated a significant correlation with symptom severity score and it may be a useful discriminating measure of external anal sphincter function.

The appreciation of rectal distention in fecal incontinence

The subjective response to rectal balloon sensation was assessed with anorectal manometry and pudendal nerve terminal motor latency measurement (PNTML) in three groups of patients. There were 37 healthy subjects, 54 patients with idiopathic fecal incontinence (IFI), and 36 with complete rectal prolapse and incontinence (CRP). There was no significant difference for any parameter of rectal balloon sensation between patients with IFI and normals. Patients with CRP differed only in onset (P=.001). The results show that the appreciation of rectal distention is maintained in IFI.

Anal acoustic reflectometry: a new technique for assessing anal sphincter function.

Objective  Anal acoustic reflectometry (AAR) is a new technique that offers an assessment of anal sphincter function by the measurement of additional parameters not available with conventional manometry. The aim of this study is to describe the technique, methodology and initial pilot study results.

Insertion under local anaesthetic of temporary electrodes for sacral nerve stimulation testing is reliable and cost effective

Aim  The aim of this study was to determine whether temporary electrode implantation under local anaesthesia (LA), with reliance on sensory response rather than motor response, gives as good a result as implantation under general anaesthesia (GA).

The strength duration test: a novel tool in the identification of occult neuropathy in women with pelvic floor dysfunction.

Objective  The Strength‐duration test (SDT) is a simple minimally invasive measure of muscle innervation, recently adapted for the assessment of the external anal sphincter (EAS). This test can discriminate women with faecal incontinence from controls. The purpose of this study was to determine if the SDT could detect denervation of the EAS in women with weak but anatomically intact EAS and normal pudendal nerve terminal motor latency (PNTML).

Anal acoustic reflectometry: a new reproducible technique providing physiological assessment of anal sphincter function.

BACKGROUND: Anal acoustic reflectometry is a new technique of assessing anal sphincter function. Five new variables reflecting anal canal function are measured: the opening and closing pressure, the opening and closing elastance, and hysteresis. OBJECTIVE: This study aimed to compare the reproducibility of this new technique, in terms of test-retest and interrater reliability, with manometry, the current standard test of sphincter function. DESIGN: This is a comparative study of reproducibility between anal acoustic reflectometry and manometry. SETTINGS: This study was conducted at a university hospital (outpatient clinic and endoscopy unit). PATIENTS: Twenty-six (21 female) subjects were assessed with both anal acoustic reflectometry and manometry on 2 separate occasions (test-retest reliability) and 22 (16 female) subjects were assessed with both methods by 2 separate investigators (interrater reliability). MAIN OUTCOME MEASURES: Reproducibility was assessed according to the Bland-Altman method. RESULTS: All of the measured novel anal acoustic reflectometry parameters had acceptable mean differences and repeatability coefficients. Comparison of the 2 methods of sphincter assessment (anal acoustic reflectometry vs manometry) was made for measurements taken at rest and during voluntary contraction. There was no significant difference in terms of test-retest reliability between the manometry maximum resting pressure vs the reflectometry opening pressure (P = .57) or manometry maximum squeeze pressure vs the reflectometry squeeze opening pressure (P = .68). No significant difference between methods was found in interrater reliability during assessments at rest (P = .62) and voluntary contraction (P = .96). LIMITATIONS: Anal acoustic reflectometry is limited, as with all tests of anorectal function, in that the device is placed within the anal canal, causing stimulation of sensory and stretch receptors. CONCLUSIONS: Anal acoustic reflectometry has a reproducibility comparable to manometry in terms of both test-retest and interrater reliability. Anal acoustic reflectometry is a promising technique that allows an assessment of anal canal physiology that is not available with manometry.

Viscoelastic assessment of anal canal function using acoustic reflectometry: a clinically useful technique.

BACKGROUND: Anal acoustic reflectometry is a new reproducible technique that allows a viscoelastic assessment of anal canal function. Five new variables reflecting anal canal function are measured: the opening and closing pressure, opening and closing elastance, and hysteresis. OBJECTIVE: The aim of this study was to assess whether the parameters measured in anal acoustic reflectometry are clinically valid between continent and fecally incontinent subjects. DESIGN: This was an age- and sex-matched study of continent and incontinent women. SETTING: The study was conducted at a university teaching hospital. PATIENTS: One hundred women (50 with fecal incontinence and 50 with normal bowel control) were included in the study. Subjects were age matched to within 5 years. MAIN OUTCOME MEASURES: Parameters measured with anal acoustic reflectometry and manometry were compared between incontinent and continent groups using a paired t test. Diagnostic accuracy was assessed by the use of receiver operator characteristic curves. RESULTS: Four of the 5 anal acoustic reflectometry parameters at rest were significantly different between continent and incontinent women (eg, opening pressure in fecally incontinent subjects was 31.6 vs 51.5 cm H2O in continent subjects, p = 0.0001). Both anal acoustic reflectometry parameters of squeeze opening pressure and squeeze opening elastance were significantly reduced in the incontinent women compared with continent women (50 vs 99.1 cm H2O, p = 0.0001 and 1.48 vs 1.83 cm H2O/mm2, p = 0.012). In terms of diagnostic accuracy, opening pressure at rest measured by reflectometry was significantly superior in discriminating between continent and incontinent women in comparison with resting pressure measured with manometry (p = 0.009). CONCLUSIONS: Anal acoustic reflectometry is a new, clinically valid technique in the assessment of continent and incontinent subjects. This technique, which assesses the response of the anal canal to distension and relaxation, provides a detailed viscoelastic assessment of anal canal function. This technique may not only aid the investigation of fecally incontinent subjects, but it may also improve our understanding of anal canal physiology during both the process of defecation and maintenance of continence.

Assessment and Investigation of Fecal Incontinence and Constipation

Fecal incontinence and constipation are common conditions that have a significant impact upon a patient’s quality of life. The maintenance of continence and act of defecation result from the complex interaction of many factors that is reflected in the many different etiologies of fecal incontinence and constipation, and the many different investigations available. As with all medical practice, a thorough history and examination forms the solid foundation required to assessing such patients, with supplementary information from specialist tests being useful in some. The symptoms of both constipation and fecal incontinence may in a few be the presenting symptoms of a colorectal or anal neoplasm. Such a diagnosis should be excluded in the assessment and with appropriate investigations. The assessment of a patient with incontinence and constipation is described, followed by a detailed discussion of the most useful specialist tests of anorectal and colonic function.