Graziela Olivia da Silva Fernandes

Anatomical and functional characteristics of the pelvic floor in nulliparous women submitted to three-dimensional endovaginal ultrasonography: case control study and evaluation of interobserver agreement

PURPOSE To determine anatomical and functional pelvic floor measurements performed with three-dimensional (3-D) endovaginal ultrasonography in asymptomatic nulliparous women without dysfunctions detected in previous dynamic 3-D anorectal ultrasonography (echo defecography) and to demonstrate the interobserver reliability of these measurements. METHODS Asymptomatic nulliparous volunteers were submitted to echo defecography to identify dynamic dysfunctions, including anatomical (rectocele, intussusceptions, entero/sigmoidocele and perineal descent) and functional changes (non-relaxation or paradoxical contraction of the puborectalis muscle) in the posterior compartment and assessed with regard to the biometric index of levator hiatus, pubovisceral muscle thickness, urethral length, anorectal angle, anorectal junction position and bladder neck position with the 3-D endovaginal ultrasonography. All measurements were compared at rest and during the Valsalva maneuver, and perineal and bladder neck descent was determined. The level of interobserver agreement was evaluated for all measurements. RESULTS A total of 34 volunteers were assessed by echo defecography and by 3-D endovaginal ultrasonography. Out of these, 20 subjects met the inclusion criteria. The 14 excluded subjects were found to have posterior dynamic dysfunctions. During the Valsalva maneuver, the hiatal area was significantly larger, the urethra was significantly shorter and the anorectal angle was greater. Measurements at rest and during the Valsalva maneuver differed significantly with regard to anorectal junction and bladder neck position. The mean values for normal perineal descent and bladder neck descent were 0.6 cm and 0.5 cm above the symphysis pubis, respectively. The intraclass correlation coefficient ranged from 0.62-0.93. CONCLUSIONS Functional biometric indexes, normal perineal descent and bladder neck descent values were determined for young asymptomatic nulliparous women with the 3-D endovaginal ultrasonography. The method was found to be reliable to measure pelvic floor structures at rest and during Valsalva, and might therefore be suitable for identifying dysfunctions in symptomatic patients.

Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome

CONTEXT Management of patients with obstructed defecation syndrome is still controversial. OBJECTIVE To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. METHODS The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. RESULTS Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. CONCLUSIONS Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts.

Anatomic characteristics of anal fistula on three-dimensional anorectal ultrasonography.

BACKGROUND: Surgery for anal fistula is often associated with continence disorders due to the transection of sphincter muscles. Extensive knowledge of anal canal anatomy and anal fistula can help prevent this outcome. OBJECTIVE: This study aimed to correlate the anatomical conformation of the anal canal, the fistula track, and the internal opening according to sex and hemicircumference (anterior vs posterior) by use of 3-dimensional ultrasonography. METHODS: One hundred sixty-five patients with fistula were evaluated with 3-dimensional ultrasound and grouped according to sex, fistula type, internal opening, and track position. Fistulas were transsphincteric in 128 subjects and intersphincteric in 37 subjects. The study measured the external and internal anal sphincter, the puborectalis, the distance from the internal opening to the distal edge of the external and internal sphincter, the length of the internal and external sphincter compromised by the track, and the percentage of compromised muscle. RESULTS: The anal canal muscles were longer in males. The distance from the internal opening to the internal sphincter was greater for the posterior hemicircumference. The point where the fistulous track crossed the anterior external sphincter was similar for the 2 sexes, but the percentage of compromised muscle was greater in females. The point where the fistulous track crossed the internal sphincter was similar for the 2 sexes, but the percentage of compromised internal sphincter was greater in males for the posterior hemicircumference. The study was limited by the absence of testing for interobserver and intraobserver agreement. CONCLUSION: The anal canal muscles are longer in males and the pectinate line is asymmetrical. In females, the percentage of compromised external sphincter was greater in the anterior hemicircumference because of the shorter external sphincter, whereas in males the percentage of compromised internal sphincter was greater in the posterior hemicircumference.

Do changes in anal sphincter anatomy correlate with anal function in women with a history of vaginal delivery

OBJECTIVES To evaluate anal sphincter anatomy using three-dimensional ultrasonography (3-DAUS) in incontinent women with vaginal delivery, correlate anatomical findings with symptoms of fecal incontinence and determine the effect of vaginal delivery on anal canal anatomy and function. METHODS Female with fecal incontinence and vaginal delivery were assessed with Wexners score, manometry, and 3DAUS. A control group comprising asymptomatic nulliparous was included. Anal pressure, the angle of the defect and length of the external anal sphincter (EAS), the anterior and posterior internal anal sphincter (IAS), the EAS + puborectal and the gap were measured and correlated with score. RESULTS Of the 62, 49 had fecal incontinence and 13 were asymptomatic. Twenty five had EAS defects, 8 had combined EAS+IAS defects, 16 had intact sphincters and continence scores were similar. Subjects with sphincter defects had a shorter anterior EAS, IAS and longer gap than women without defects. Those with a vaginal delivery and intact sphincters had a shorter anterior EAS and longer gap than nulliparous. We found correlations between resting pressure and anterior EAS and IAS length in patients with defects. CONCLUSIONS Fecal incontinence symptoms did not correlate with anal pressures and anal sphincter anatomy changes, but women with sphincter defects have shorter anterior EAS and IAS and a longer gap.

AMPUTAÇÃO ABDOMINOPERINEAL DO RETO E RECONSTRUÇÃO VAGINAL COM RETALHO FASCIOCUTÂNEO GLÚTEO POR RECIDIVA DE CARCINOMA ESPINOCELULAR DE CANAL ANAL ‐ RELATO DE CASO

foram incluídos no estudo todos os pacientes submetidos a cirurgia de APE nesse período, após foi realizado um estudo do perfil epidemiológico desses fazendo revisão do prontuário. Foram analisados a idade, sexo, cor, o tipo histológico e grau de diferenciação celular, realização de tratamento neoadjuvante e o estadiamento clinico. Resultados: Foram incluídos no estudo 21 pacientes, 6 do sexo feminino e 15 do masculino, a média de idade é de 60 anos (27-84). Dois autodeclarados negros. Dois não realizaram neoadjuvância. No estadiamento, 8 pertenciam ao estágio II, 10 ao estágio III e 3 pertenciam ao estágio IV. Quanto ao tipo histológico e grau de diferenciação celular, 15 apresentavam adenocarcinoma moderadamente diferenciado, 2 bem diferenciado, 2 pouco diferenciado e 2 mucinoso. Discussão: Analisando os dados apresentados e comparando com a literatura, podemos observar que em nosso serviço a APE é mais frequente no sexo masculino, 72%, e a média de idade é 60 anos o que é compatível com a literatura. Foi verificado que a maioria dos pacientes realizou tratamento neoadjuvante. Provavelmente devido ao diagnóstico tardio, foi observado a maior prevalência do estágio III, o que evidencia a importância do rastreamento do CCR, no sistema público de saúde. Em relação ao tipo histológico e grau de diferenciação celular o adenocarcinoma moderadamente diferenciado, 72%, tem sido o mais prevalente. Conclusão: Os dados obtidos corroboram a literatura, com predomínio de homens. A média de idade foi de 60 anos, com maior incidência do adenocarcinoma moderadamente diferenciado e com seu diagnóstico tardio, o que reforça a necessidade de diagnóstico precoce.

Usefulness of anorectal and endovaginal 3D ultrasound in the evaluation of sphincter and pubovisceral muscle defects using a new scoring system in women with fecal incontinence after vaginal delivery

PurposeThis study aims to evaluate pubovisceral muscle and anal sphincter defects in women with previous vaginal delivery and fecal incontinence and to correlate the findings with the severity of symptoms using the combined anorectal and endovaginal 3D ultrasonography with a new ultrasound scoring system.MethodsConsecutive female patients with previous vaginal delivery and fecal incontinence symptoms were screened. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale, and the extent of defects was assessed by an ultrasound score based on results of anorectal and endovaginal 3D ultrasound. Fecal incontinence was assessed with the Cleveland Clinic Florida fecal incontinence scale.ResultsOf 84 women with previous vaginal delivery and fecal incontinence, 21 (25%) had intact pubovisceral muscles and anal sphincters; 63 (75%) had a pubovisceral muscle or anal sphincter defect, or both. Twenty-eight (33%) had a pubovisceral muscle defect [23% with an external anal sphincter (EAS) defect or combined EAS/internal anal sphincter defects; 11% with intact anal sphincters]. Thirty-five (42%) had intact pubovisceral muscles and an anal sphincter defect. Compared with women with intact pubovisceral muscles/anal sphincter defects, patients with pubovisceral muscle defects had significantly higher incontinence scores and significantly higher ultrasound scores indicating more extensive defects. Incontinence symptoms correlated positively with the ultrasound score, measurements of sphincter defects, and area of the levator hiatus.ConclusionsEvaluation of both pubovisceral muscles and anal sphincters is important to identify defects and determine treatment for women with fecal incontinence after vaginal delivery. The severity of fecal incontinence symptoms is significantly related to the extent of defects of the pubovisceral muscles and anal sphincters.