Gordon L. Hosker

Pelvic floor damage and childbirth : a neurophysiological study

Summary. Ninety six nulliparous women were investigated to establish whether childbirth causes damage to the striated muscles and nerve supply of the pelvic floor. The techniques used were concentric needle electromyography (EMG), pudendal nerve conduction tests and assessment of pelvic floor contraction using a perineometer. There was EMG evidence of re‐innervation in the pelvic floor muscles after vaginal delivery in 80% of those studied. Women who had a long active second stage of labour and heavier babies showed the most EMG evidence of nerve damage. Forceps delivery and perineal tears did not affect the degree of nerve damage seen. We conclude that vaginal delivery causes partial denervation of the pelvic floor (with consequent re‐innervation) in most women having their first baby. In a few this is severe and is associated with urinary and faecal incontinence. For some it is likely to be the first step along a path leading to prolapse and/or stress incontinence.

Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery

Headline This is a longitudinal study of a cohort of primigravidae recruited between 1985 and 1987 and followed up 7 and 15 years later. Pelvic floor neurophysiology was performed and questionnaires were administered to determine the natural history of stress incontinence and to establish whether pelvic floor denervation after the first delivery is associated with symptoms of stress urinary incontinence in the future.

A new condition‐specific health‐related quality of life questionnaire for the assessment of women with anal incontinence

Objective To design and validate a condition‐specific health‐related quality of life questionnaire for the assessment of women with anal incontinence.

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.

A valsalvometer can be effective in standardising the Valsalva manoeuvre

A prospective randomised controlled study was performed in order to study the effectiveness of a device designed to reduce the variability in intra-abdominal pressures generated by individuals performing the Valsalva manoeuvre. One hundred women were recruited to take part in the project which compared a traditional Valsalva manoeuvre following standardised verbal instruction with forced expiration through a flow restriction device called a ‘valsalvometer’. The abdominal pressure was measured using an air-filled rectal balloon catheter linked to a pressure transducer. The use of the valsalvometer was associated with a reduction in variation of intra-abdominal pressure between women to 50% of the standard deviation. The new device has the capacity to reduce the variation in intra-abdominal pressure produced when performing the Valsalva manoeuvre. The rise in intra-abdominal pressure may act as a standard against which other measurements are made.

The effect of physical activity on pelvic organ prolapse

Objective  The objective of this study was to determine whether pelvic organ prolapse increases after physical activity.

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.

Executive summary: The International Consultation on incontinence 2008—committee on: “Dynamic Testing”; for Urinary or fecal incontinence. Part 3: Anorectal physiology studies

The members of ‘The International Consultation on Incontinence 2008 (Paris) Committee on Dynamic Testing’ provide an executive summary of the chapter ‘Dynamic Testing’ that discusses testing methods for patients with signs and or symptoms of incontinence. Testing of patients with signs and or symptoms of urinary as well as testing of patients with fecal incontinence is discussed.

Air filled, including "air-charged," catheters in urodynamic studies: Does the evidence justify their use?

Air filled catheters (AFCs) have been actively marketed for the past few years and in some geographic areas are widely used. However, as the scientific basis for introduction of this technology for pressure measurement in urodynamics was not clear, a study group examined the evidence.