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Pang J, Gao Y, Yin N, Liu X. Diagnostic performance of different examination methods for detecting obstetric anal sphincter injuries: A meta-analysis comparing multiple diagnostic methods. Eur J Obstet Gynecol Reprod Biol 2025; 305:344-350. [PMID: 39742732 DOI: 10.1016/j.ejogrb.2024.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 12/19/2024] [Accepted: 12/20/2024] [Indexed: 01/04/2025]
Abstract
BACKGROUND There was limited evidence on the comparative value of various examination methods for women with obstetric anal sphincter injuries (OASIS). OBJECTIVES To evaluate diagnostic performance of different examination methods for detecting OASIS. METHODS We searched PubMed, EMBASE, Cochrane Library, and Web of Science to identify relevant studies from inception to December 2023. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to assess methodological quality of included studies. We extracted sufficient data to construct 2 × 2 tables and then used STATA version 12.0 to perform data pooling, heterogeneity testing, and subgroup analysis. RESULTS For external anal sphincter (EAS), 4 studies including 514 patients were included in analysis. The pooled sensitivity and specificity of endovaginal ultrasound (EVUS) were 0.59 (95 % CI: 0.33-0.85) and 0.71 (95 % CI: 0.50-0.92). The pooled sensitivity and specificity of transperineal ultrasound (TPUS) were 0.78 (95 % CI: 0.63-0.93) and 0.74 (95 % CI: 0.59-0.89). For internal anal sphincter (IAS), we analyzed 3 studies with 459 patients. The pooled sensitivity and specificity of EVUS were 0.54 (95 % CI: 0.44-0.65) and 0.90 (95 % CI: 0.87-0.94). The pooled sensitivity and specificity of TPUS were 0.47 (95 % CI: 0.29-0.65) and 0.93 (95 % CI: 0.89-0.97). Subgroup analysis showed that 3D images may have better sensitivity than that of 2D images when diagnosing EAS with either EVUS (0.74 vs 0.37) or TPUS (0.80 vs 0.74). CONCLUSION In evaluating OASIS, TPUS had better diagnostic value than EVUS in detecting EAS. For examining IAS, TPUS and EVUS are comparable in terms of diagnostic accuracy. Due to limited data available, more studies with rigorous methods are required to confirm our findings.
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Affiliation(s)
- Jian Pang
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ya Gao
- Department of Medical Data, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Nana Yin
- Department of Operating Room, Changde First People's Hospital, Changde, China
| | - Xiangyan Liu
- Department of Breast Surgery, General Surgery, Xiangya Hospital, Central South University, Changsha, China.
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Packet B, Page AS, Cattani L, Bosteels J, Deprest J, Richter J. Predictive factors for obstetric anal sphincter injury in primiparous women: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:486-496. [PMID: 37329513 DOI: 10.1002/uog.26292] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective. METHODS We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I2 = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I2 = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias. CONCLUSION Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B Packet
- Department of Development and Regeneration, Unit of Woman and Child, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - A-S Page
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - L Cattani
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - J Bosteels
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
- Department of Obstetrics and Gynaecology, Imelda Hospital, Bonheiden, Belgium
| | - J Deprest
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
- Research Department of Maternal-Fetal Medicine, Institute for Women's Health, University College London, London, UK
| | - J Richter
- Department of Development and Regeneration, Unit of Woman and Child, Catholic University of Leuven (KU Leuven), Leuven, Belgium
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Guo M, Zbar AP, Wu Y. Imaging the levator ani and the puborectalis muscle: implications in understanding regional anatomy, physiology and pathology. Scand J Gastroenterol 2023; 58:1295-1308. [PMID: 37309141 DOI: 10.1080/00365521.2023.2220458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 06/14/2023]
Abstract
Purpose:To review the findings of recent dynamic imaging of the levator ani muscle in order to explain its function during defecation. Historical anatomical studies have suggested that the levator ani initiates defecation by lifting the anal canal, with conventional dissections and static radiologic imagery having been equated with manometry and electromyography.Materials and methods:An analysis of the literature was made concerning the chronological development of imaging modalities specifically designed to assess pelvic floor dynamics. Comparisons are made between imaging and electromyographic data at rest and during provocative manoeuvres including squeeze and strain.Results:The puborectalis muscle is shown distinctly separate from the levator ani and the deep external anal sphincter. In contrast to conventional teaching that the levator ani initiates defecation by lifting the anus, dynamic illustration defecography (DID) has confirmed that the abdominal musculature and the diaphragm instigate defecation with the transverse and vertical component portions of the levator ani resulting in descent of the anus. Current imaging has shown a tendinous peripheral structure to the termination of the conjoint longitudinal muscle, clarifying the anatomy of the perianal spaces. Planar oXy defecography has established patterns of movement of the anorectal junction that separate controls from those presenting with descending perineum syndrome or with anismus (paradoxical puborectalis spasm).Conclusions:Dynamic imaging of the pelvic floor (now mostly with MR proctography) has clarified the integral role of the levator ani during defecation. Rather than lifting the rectum, the muscle ensures descent of the anal canal.
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Affiliation(s)
- Maolin Guo
- Department of Radiology, PLA 989 Hospital, Luoyang, P.R. China
| | - Andrew P Zbar
- Department of Neuroscience and Anatomy, University of Melbourne, Melbourne, Australia
| | - Yucen Wu
- Department of Neuroscience and Anatomy, University of Melbourne, Melbourne, Australia
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Hurni Y, Maes E, Avau F, Becu L, Buljubasic M, Danon A, Paquier L, Garofalo G, Albert V, Pastijn A. Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: An experimental study. Int Urogynecol J 2022; 33:1639-1647. [PMID: 35389056 DOI: 10.1007/s00192-022-05191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/10/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injuries are frequently missed and carry a significant risk for the development of anal incontinence. Immediate postpartum endoanal ultrasound increases identification of these injuries but is rarely employed. We hypothesize that endovaginal ultrasound could be a feasible and easily available alternative sonographic tool to improve early diagnosis of anal sphincter tears. METHODS We conducted a prospective experimental study including 160 primiparous women. Shortly after vaginal delivery, patients underwent clinical and sonographic perineal examinations. We analyzed the feasibility of anal sphincter assessment by endovaginal ultrasound and its potential contribution in the early diagnosis of anal sphincter injuries. RESULTS Sonographic assessment of the anal sphincter was analyzable for 136 patients (85.0%). Causes of non-analyzability included air artifacts (6.9%), lack of distinction between the external anal sphincter and surrounding tissues (9.4%) and distortion artifacts (9.4%). Patients in the non-analyzable ultrasound subgroup were less likely to have delivered in a dorsal lithotomy position (62.5% vs. 85.3 %) and more likely to have had an episiotomy (33.3% vs. 14.0%), and their risk of sphincter injury was more frequently classified as "improbable" on clinical examination (91.7% vs. 61.0%). Ultrasounds were analyzable for 96.4% of patients clinically reported as having "possible" or "certain" sphincter injuries. The incidence of anal sphincter injury was 16.9% for clinical observation and 20.0% with associated sonographic examination. CONCLUSIONS Endovaginal ultrasound could be used as a complementary tool in assessment of the anal sphincter in high-risk patients. Its feasibility and easy availability make this technique a promising tool for improving the management of anal sphincter tears.
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Affiliation(s)
- Yannick Hurni
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium. .,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium.
| | - Elise Maes
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium.,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Fiona Avau
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium.,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Lauren Becu
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium.,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Marie Buljubasic
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Alix Danon
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Leila Paquier
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Giulia Garofalo
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium.,Department of Obstetrics and Gynecology, Ultrasound Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Valerie Albert
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium
| | - Ann Pastijn
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium
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Hurni Y, Maes E, Avau F, Becu L, Buljubasic M, Danon A, Paquier L, Garofalo G, Albert V, Pastijn A. Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: a new technical approach. Int Urogynecol J 2021; 33:1689-1692. [PMID: 34453551 DOI: 10.1007/s00192-021-04956-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS In this study we described a new technical approach to adapt endovaginal ultrasound scanning of the anal sphincter complex to the immediate postpartum period. METHODS We analyzed the clinical and ultrasonographic examinations of 18 primiparous women presenting deep perineal tears with potential or clearly identified lesions of the anal sphincter. Potential anal sphincter lesion was defined as a second degree perineal tear extending close to the anal sphincter with exposition of its capsule or muscular fibers. We reported interesting ultrasonographic images explaining our technique in a video. RESULTS We reported clinical and ultrasonographic features in nine cases of grade 2, four cases of grade 3a, four cases of grade 3b and one case of grade 3c perineal tears. The ultrasonographic examination confirmed the intact state of the anal sphincter complex in all patients with clinical grade 2 tears except one in which a grade 3b lesion was detected. We were not able to identify external anal sphincter lesions on ultrasound in any of the patients with clinical grade 3a tears. In patients with clinical grade 3b tears, the ultrasound confirmed the external anal sphincter lesion in all cases, but revealed additional involvement of the internal anal sphincter in 1 case (grade 3c). CONCLUSION Immediate postpartum endovaginal ultrasound could be a promising technique to improve the management of perineal traumas after vaginal delivery.
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Affiliation(s)
- Yannick Hurni
- Department of Obstetrics and Gynecology, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium. .,Department of Obstetrics and Gynecology, perineal clinic, CHU Saint-Pierre, Brussels, Belgium. .,Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium.
| | - Elise Maes
- Department of Obstetrics and Gynecology, perineal clinic, CHU Saint-Pierre, Brussels, Belgium.,Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium
| | - Fiona Avau
- Department of Obstetrics and Gynecology, perineal clinic, CHU Saint-Pierre, Brussels, Belgium.,Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium
| | - Lauren Becu
- Department of Obstetrics and Gynecology, perineal clinic, CHU Saint-Pierre, Brussels, Belgium.,Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium
| | - Marie Buljubasic
- Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium
| | - Alix Danon
- Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium
| | - Leila Paquier
- Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium
| | - Giulia Garofalo
- Department of Obstetrics and Gynecology, obstetric unit, CHU Saint-Pierre, Brussels, Belgium.,Department of Obstetrics and Gynecology, ultrasound unit, CHU Saint-Pierre, Brussels, Belgium
| | - Valerie Albert
- Department of Obstetrics and Gynecology, perineal clinic, CHU Saint-Pierre, Brussels, Belgium
| | - Ann Pastijn
- Department of Obstetrics and Gynecology, perineal clinic, CHU Saint-Pierre, Brussels, Belgium
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Martinez Franco E, Ros C, Santoro GA, Cassadó Garriga J, Amat Tardiu L, Cuadras D, Espuña M. Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique? Eur J Obstet Gynecol Reprod Biol 2020; 257:70-75. [PMID: 33360872 DOI: 10.1016/j.ejogrb.2020.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/22/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES "Significant" obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. METHODS Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck's and the Norderval's systems. Intraobserver and inter-techniques correlations were calculated. RESULTS From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, "button hole" tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck's Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval's classification. CONCLUSIONS OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.
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Affiliation(s)
- Eva Martinez Franco
- Obstetrics and Gynecology. Parc Sanitari Sant Joan de Déu, Sant Boi del Llobregat, Barcelona, Spain.
| | - Cristina Ros
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - Jordi Cassadó Garriga
- Obstetrics and Gynecology. University Hospital Mutua Terrassa, Terrassa, Barcelona, Spain
| | - Lluís Amat Tardiu
- Obstetrics and Gynecology, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Daniel Cuadras
- Statistical Advising Service, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Montserrat Espuña
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Subramaniam N, Dietz HP. What is a significant defect of the anal sphincter on translabial ultrasound? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:411-415. [PMID: 31271480 DOI: 10.1002/uog.20390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two-thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound. METHODS This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed. RESULTS There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single-slice defect angle on TUI was low, and areas under the receiver-operating-characteristics curves were too low to determine a distinct cut-off value for defect angle. CONCLUSIONS Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single-slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut-off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Subramaniam
- Sydney Medical School Nepean, The University of Sydney, Penrith, Australia
| | - H P Dietz
- Sydney Medical School Nepean, The University of Sydney, Penrith, Australia
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8
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Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries. Am J Obstet Gynecol 2019; 221:134.e1-134.e9. [PMID: 30981717 DOI: 10.1016/j.ajog.2019.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/18/2019] [Accepted: 04/08/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The optimal imaging modality of obstetric anal sphincter injuries needs to take into consideration convenience, availability, and ability to assess the sphincter morphologic condition. Endoanal ultrasound imaging currently is regarded as the reference standard, but it is not widely available in obstetric units. Exoanal alternatives exist, such as 3-dimensional introital or transperineal ultrasound imaging, which are already readily available in most obstetrics and gynecology units. OBJECTIVE The primary objective was to evaluate the diagnostic accuracy of 3-dimensional introital and 3-dimensional transperineal ultrasound imaging compared with 3-dimensional endoanal ultrasound imaging as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate a diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort that is experienced for each imaging modality. STUDY DESIGN A cross-sectional study was conducted of 250 women who sustained obstetric anal sphincter injuries, all of whom underwent 3-dimensional introital, transperineal, and endoanal ultrasound imaging. Introital and transperineal ultrasound imaging were assessed with tomographic ultrasound imaging. All of the women completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on receiver operating characteristic curves with endoanal ultrasound imaging as the reference standard. Diagnostic test characteristics of introital and transperineal ultrasound imaging were calculated with the use of these optimal cut-offs. RESULTS Optimal cut-off for a significant external anal sphincter defect was ≥3 of 7 slices; sensitivity and specificity were 0.65 and 0.75 on introital imaging and 0.70 and 0.69 on transperineal ultrasound imaging. Optimal cut-off for a significant internal anal sphincter defect was ≥2 of 5 slices; sensitivity and specificity were 0.59 and 0.84 on introital imaging and 0.43 and 0.97 on transperineal ultrasound imaging. The area under the curve for the diagnosis of external and internal anal sphincter defects ranged from 0.70-0.74 (P<.001) for introital and transperineal imaging. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63, and negative predictive value ranged from 0.85-0.93 for introital and transperineal ultrasound imaging. Endoanal ultrasound imaging was the only modality for a defect to correlate with symptoms; mean modified St. Mark's score for a defect sphincter was 2.4 (standard deviation, 4.1) and for an intact sphincter was 0.9 (standard deviation, 2.7; P<.01). Introital and transperineal ultrasound imaging were associated with less discomfort than endoanal ultrasound imaging. CONCLUSION Endoanal ultrasound imaging remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound imaging are not suitable for the identification of sphincter defects; however, high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardization of a significant defect. In women with a history of obstetric anal sphincter injuries, introital and transperineal ultrasound imagings are suitable to screen for an intact sphincter if endoanal ultrasound imaging is not available. When defects are found, women should then have endoanal ultrasound imaging to verify the diagnosis.
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9
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Ros C, Martínez-Franco E, Wozniak MM, Cassado J, Santoro GA, Elías N, López M, Palacio M, Wieczorek AP, Espuña-Pons M. Postpartum two- and three-dimensional ultrasound evaluation of anal sphincter complex in women with obstetric anal sphincter injury. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:508-514. [PMID: 27087312 DOI: 10.1002/uog.15924] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/22/2016] [Accepted: 03/16/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS). METHODS External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated. RESULTS Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (κ = 0.01), fair for 2D-TPUS (κ = 0.30) and good for 3D-TPUS (κ = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (κ = 0.41) and 2D-TPUS (κ = 0.52) and good for 3D-TPUS (κ = 0.66). Good intraobserver (3D-EAUS, κ = 0.73; 3D-TPUS, κ = 0.78) and interobserver (3D-EAUS, κ = 0.68; 3D-TPUS, κ = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04). CONCLUSIONS 2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Ros
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - E Martínez-Franco
- Department of Obstetrics and Gynecology, Parc Sanitari Sant Joan de Déu, Sant Boi del Llobregat, Barcelona, Spain
| | - M M Wozniak
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - J Cassado
- Department of Obstetrics and Gynecology, Hospital Universitari Mutua de Terrassa, Terrassa, Barcelona, Spain
| | - G A Santoro
- Pelvic Floor Unit, First Department of Surgery, Treviso Regional Hospital, Treviso, Italy
| | - N Elías
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - M López
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - M Palacio
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - A P Wieczorek
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - M Espuña-Pons
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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10
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Kumar L, Emmanuel A. Internal anal sphincter: Clinical perspective. Surgeon 2016; 15:211-226. [PMID: 27881288 DOI: 10.1016/j.surge.2016.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 08/05/2016] [Accepted: 10/23/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To summarise current knowledge of Internal anal sphincter. BACKGROUND The internal anal sphincter (IAS) is the involuntary ring of smooth muscle in the anal canal and is the major contributor to the resting pressure in the anus. Structural injury or functional weakness of the muscle results in passive incontinence of faeces and flatus. With advent of new assessment and treatment modalities IAS has become an important topic for surgeons. This review was undertaken to summarise our current knowledge of internal anal sphincter and highlight the areas that need further research. METHOD The PubMed database was used to identify relevant studies relating to internal anal sphincter. RESULTS The available evidence has been summarised and advantages and limitations highlighted for the different diagnostic and therapeutic techniques. CONCLUSION Our understanding of the physiology and pharmacology of IAS has increased greatly in the last three decades. Additionally, there has been a rise in diagnostic and therapeutic techniques specifically targeting the IAS. Although these are promising, future research is required before these can be incorporated into the management algorithm.
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Affiliation(s)
- Lalit Kumar
- GI Physiology Unit, University College Hospital, London, UK.
| | - Anton Emmanuel
- GI Physiology Unit, University College Hospital, London, UK; University College London, UK.
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11
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Karcaaltincaba D, Erkaya S, Isik H, Haberal A. The immediate effect of vaginal and caesarean delivery on anal sphincter measurements. J Int Med Res 2016; 44:824-31. [PMID: 27353519 PMCID: PMC5536623 DOI: 10.1177/0300060516653066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/11/2016] [Indexed: 11/20/2022] Open
Abstract
Objective This study evaluated the effects of vaginal and caesarean delivery on internal and external anal sphincter muscle thickness using translabial ultrasonography (TL-US). Methods This prospective cohort study enrolled nulliparous women who either had vaginal or caesarean deliveries. The thickness of the hypoechoic internal anal sphincter (IAS) and hyperechoic external anal sphincter (EAS) at the 12, 3, 6, and 9 o’clock positions at the distal level were measured before delivery and within 24–48 h after delivery. Results A total 105 consecutive women were enrolled in the study: 60 in the vaginal delivery group and 45 in the caesarean delivery group. The IAS muscle thickness at the 12 o’clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.31 ± 0.74 mm versus 1.81 ± 0.64 mm, respectively). The EAS muscle thickness at the 12 o’clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.42 ± 0.64 mm versus 1.97 ± 0.85, respectively). Conclusions There was significant muscle thinning of both the IAS and EAS at the 12 o’clock position after vaginal delivery, but not after caesarean delivery.
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Affiliation(s)
| | - Salim Erkaya
- Department of Obstetrics and Gynaecology, Etlik Zübeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Hatice Isik
- Department of Obstetrics and Gynaecology, Zonguldak Karaelmas University, Zonguldak, Turkey
| | - Ali Haberal
- Department of Obstetrics and Gynaecology, Gazi University, Ankara, Turkey
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12
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Keighley MRB, Radley S, Johanson R. Consensus on Prevention and Management of Post-Obstetric Bowel Incontinence and Third Degree Tear. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/135626220000600605] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - S. Radley
- Department of Surgery, University of Brimingham
| | - R. Johanson
- Department of Surgery, University of Brimingham
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13
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Albuquerque A, Pereira E. Current applications of transperineal ultrasound in gastroenterology. World J Radiol 2016; 8:370-377. [PMID: 27158423 PMCID: PMC4840194 DOI: 10.4329/wjr.v8.i4.370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 01/23/2016] [Accepted: 03/04/2016] [Indexed: 02/06/2023] Open
Abstract
Transperineal ultrasound is an inexpensive, safe and painless technique that dynamically and non-invasively evaluates the anorectal area. It has multiple indications, mainly in urology, gynaecology, surgery and gastroenterology, with increased use in the last decade. It is performed with conventional probes, positioned directly above the anus, and may capture images of the anal canal, rectum, puborectalis muscle (posterior compartment), vagina, uterus, (central compartment), urethra and urinary bladder (anterior compartment). Evacuatory disorders and pelvic floor dysfunction, like rectoceles, enteroceles, rectoanal intussusception, pelvic floor dyssynergy can be diagnosed using this technique. It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature, with images obtained at rest, straining and sustained squeezing. This technique is an accurate examination for detecting, classifying and following of perianal inflammatory disease. It can also be used to sonographically guide drainage of deep pelvic abscesses, mainly in patients who cannot undergo conventional drainage. Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence, postpartum and also following surgical repair of obstetric tears. There are also some studies referring to its role in anal stenosis, for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.
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14
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Nevler A, Beer-Gabel M, Lebedyev A, Soffer A, Gutman M, Carter D, Zbar AP. Transperineal ultrasonography in perianal Crohn's disease and recurrent cryptogenic fistula-in-ano. Colorectal Dis 2013; 15:1011-8. [PMID: 23489598 DOI: 10.1111/codi.12204] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/05/2012] [Indexed: 12/25/2022]
Abstract
AIM Successful anal fistula care is aided by specialized imaging accurately defining the site of the internal opening and fistula type. Imaging techniques are complementary, designed to answer specific anatomical questions. There are limited data concerning the clinical value of transperineal ultrasound (TP-US) in both cryptogenic fistula-in-ano and perianal Crohn's disease (PACD). The aim of the study was to assess the accuracy of TP-US compared with operative findings in patients with perirectal sepsis. METHOD Patients with recurrent cryptogenic anal fistula and PACD referred for sonography were examined using TP-US by a single examiner blinded to the operative results. Fistulae were categorized by the Parks classification predicting the site of the internal fistula opening. Ancillary horseshoe collections, abscesses and secondary tracks were defined. RESULTS Fourteen patients with PACD and 27 patients with recurrent cryptogenic fistula-in-ano were analysed with comparative images and operative data. Correlation of fistula type for cryptogenic and PACD patients respectively was 23/27 (85.2%) and 12/14 (85.7%), with a correlative internal opening site (when found at surgery) of 16/22 (72.3%) and 12/14 (85.7%). Misclassification of fistula type in cryptogenic cases occurred in the presence of ancillary abscesses with associated acoustic shadowing. In PACD patients, TP-US was used when anal stenosis precluded endoanal ultrasonography, assisting in the diagnosis of recto-vaginal fistulae. CONCLUSION TP-US is a useful complementary technique to assess fistula-in-ano and has special advantage when there is anal canal distortion, complex fistula type or suspicion of a recto-vaginal fistula.
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Affiliation(s)
- A Nevler
- Department of Surgery and Transplantation, Tel Hashomer Hospital, Ramat Aviv, Israel
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15
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Abdool Z, Sultan AH, Thakar R. Ultrasound imaging of the anal sphincter complex: a review. Br J Radiol 2012; 85:865-75. [PMID: 22374273 PMCID: PMC3474057 DOI: 10.1259/bjr/27314678] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 07/05/2011] [Accepted: 07/06/2011] [Indexed: 12/25/2022] Open
Abstract
Endoanal ultrasound is now regarded as the gold standard for evaluating anal sphincter pathology in the investigation of anal incontinence. The advent of three-dimensional ultrasound has further improved our understanding of the two-dimensional technique. Endoanal ultrasound requires specialised equipment and its relative invasiveness has prompted clinicians to explore alternative imaging techniques. Transvaginal and transperineal ultrasound have been recently evaluated as alternative imaging modalities. However, the need for technique standardisation, validation and reporting is of paramount importance. We conducted a MEDLINE search (1950 to February 2010) and critically reviewed studies using the three imaging techniques in evaluating anal sphincter integrity.
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Affiliation(s)
- Z Abdool
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa.
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16
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Olsen IP, Wilsgaard T, Kiserud T. Development of the maternal anal canal during pregnancy and the postpartum period: a longitudinal and functional ultrasound study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:690-697. [PMID: 22253200 DOI: 10.1002/uog.11104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Normal anatomical and physiological development of the maternal anal canal during and after pregnancy has been documented scarcely. We aimed to study the position and volume of the anal canal, during and after pregnancy, in women without previous delivery. METHODS This was a longitudinal study in which transvaginal three-dimensional ultrasound was used to measure anatomical structures in the anal canal during rest and squeeze in 23 nulliparous women. The total anal canal volume (ACV), anorectal curvature (ARC), anovaginal angle (AVA) and anal canal length were determined at 18, 28 and 36 weeks of pregnancy and at 3 months postpartum. RESULTS Total ACV at rest increased from a mean of 10.17 cm(3) at 18 weeks to 12.37 cm(3) and 12.21 cm(3) at 28 and 36 weeks, respectively (P = 0.001 and P = 0.010 vs. first measurement). For anal canal length, the corresponding mean measurements were 3.91 cm, 4.07 cm (P = 0.13) and 4.21 cm (P = 0.017). Postpartum, the mean total ACV was 10.86 cm(3) and length was 3.90 cm (P = 0.10 and P = 0.70 vs. first measurement). No significant changes were observed in ARC and AVA during or after pregnancy. Compared to at-rest status, the anal length significantly increased on voluntary squeeze (P = 0.007, 0.007, 0.022 and 0.004 at the four time points), while no differences in total ACV were observed. In mid-pregnancy AVA significantly increased during squeeze (P = 0.006 and 0.002 at weeks 18 and 28, respectively). CONCLUSION Anal canal length and total ACV increase during pregnancy in women without previous delivery. Voluntary squeezing elongates the anal canal and increases the angle formed with respect to the direction of the vagina. During postpartum involution, the characteristics of the anal canal revert to those observed at 18 weeks of pregnancy.
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Affiliation(s)
- I P Olsen
- Department of Obstetrics and Gynecology, Hammerfest Hospital, Hammerfest, Norway.
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17
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Bove A, Pucciani F, Bellini M, Battaglia E, Bocchini R, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V, Gambaccini D, Bove V. Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis). World J Gastroenterol 2012; 18:1555-64. [PMID: 22529683 PMCID: PMC3325520 DOI: 10.3748/wjg.v18.i14.1555] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/21/2011] [Accepted: 03/10/2012] [Indexed: 02/06/2023] Open
Abstract
Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.
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18
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Thekkinkattil DK, Dunham RJ, O'Herlihy S, Finan PJ, Sagar PM, Burke DA. Measurement of anal cushions in continent women. Colorectal Dis 2011; 13:1040-3. [PMID: 20478004 DOI: 10.1111/j.1463-1318.2010.02316.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Anal cushions are connective tissue complexes thought to be involved in anal continence. This study aimed to assess them in continent subjects. METHOD Continent women undergoing a transvaginal ultrasound scan for gynaecological reasons were included. The anal cushions were visualized at the mid-canal level. The cross-sectional area within the internal anal sphincter (Area 1) and the area enclosed within the anal cushions (Area 2) were measured and a Cushion:Canal (C:C) ratio was derived for each patient. The measurements were repeated in the semi-erect position. RESULTS One hundred and two patients with a median age of 41 (IQR 32-49) years were included. The median C:C ratio was 0.68 (IQR 0.61-0.73). Inter-observer error was 0.98 and intra-observer error was 0.99. There was no significant correlation between age and C:C ratio. The C:C ratio was significantly higher in parous than in nulliparous women (P = 0.04). A history of obstetric trauma or minimal haemorrhoidal symptoms did not influence C:C ratio. There was a significant increase in C:C ratio in the erect position. (P = 0.04). CONCLUSION There was a wide range of variability in the measurement of anal cushions in normal continent women. These were not influenced by age.
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Affiliation(s)
- D K Thekkinkattil
- John Goligher Colorectal Unit, The General Infirmary at Leeds, Leeds, UK
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19
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The diagnostic accuracy of endovaginal and transperineal ultrasound for detecting anal sphincter defects: The PREDICT study. Clin Radiol 2011; 66:597-604. [PMID: 21440249 DOI: 10.1016/j.crad.2010.11.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/21/2010] [Accepted: 11/24/2010] [Indexed: 12/25/2022]
Abstract
AIM To determine the accuracy and predictive value of transperineal (TPU) and endovaginal ultrasound (EVU) in the detection of anal sphincter defects in women with obstetric anal sphincter injuries and/or postpartum symptoms of faecal incontinence. MATERIALS AND METHODS One hundred and sixty-five women were recruited, four women were excluded as they were seen years after their last delivery. TPU and EVU, followed by endonanal ultrasound (EAU), were performed using the B&K Viking 2400 scanner. Sensitivity and specificity, as well as predictive values with 95% confidence intervals, for detecting anal sphincter defects were calculated for EVU and TPU, using EAU as the reference standard. RESULTS On EAU a defect was found in 42 (26%) women: 39 (93%) had an external (EAS) and 23 (55%) an internal anal sphincter (IAS) defect. Analysable images of one level of the EAS combined with an analysable IAS were available in 140 (87%) women for EVU and in 131 (81%) for TPU. The sensitivity and specificity for the detection of any defect was 48% (30-67%) and 85% (77-91%) for EVU and 64% (44-81%) and 85% (77-91%) for TPU, respectively. CONCLUSION Although EAU using a rotating endoprobe is the validated reference standard in the identification of anal sphincter defects, it is not universally available. However while TPU and/or EVU with conventional ultrasound probes can be useful in identifying normality, for clinical purposes they are not sensitive enough to identify an underlying sphincter defect.
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20
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Zbar AP, Murison R. Transperineal ultrasound in the assessment of haemorrhoids and haemorrhoidectomy: a pilot study. Tech Coloproctol 2010; 14:175-9. [PMID: 20390316 DOI: 10.1007/s10151-010-0572-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Accepted: 03/09/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of the study was the measurement of the anal cushion area using static transperineal ultrasound in a group of patients with symptomatic grade III and IV haemorrhoids about to undergo haemorrhoidectomy and compare them with a group of age-matched normals and the measured area following haemorrhoidectomy. METHODS Transperineal sonography was performed using a linear transducer measuring the anal cushion area by subtracting the measured luminal diameter of the undisturbed anal canal from the inner border of the internal anal sphincter. Measures were made 6 weeks following haemorrhoidectomy. RESULTS Comparisons were made between 22 normals and 36 patients with haemorrhoids (31 evaluable post-operatively). The median area of normals was 0.78 cm², that of pre-operative patients 2.25 cm² and that of post-operative cases 1.20 cm². There was a significant difference between pre- and post-operative cases with cushion areas of normal patients being significantly lower than post-operative cases. Variance of measurement in all 3 groups was negligible. CONCLUSION Static transperineal sonography measuring the anal cushion area is reproducible and shows marked differences between normals and patients with symptomatic haemorrhoids. There is a marked effect on measured area resultant from haemorrhoidectomy.
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Affiliation(s)
- A P Zbar
- Department of Surgery, Tamworth Rural Referral Centre, Universities of New England and Newcastle, PO Box 2064, Tamworth, NSW 2340, Australia.
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21
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Santoro GA, Wieczorek AP, Stankiewicz A, Woźniak MM, Bogusiewicz M, Rechberger T. High-resolution three-dimensional endovaginal ultrasonography in the assessment of pelvic floor anatomy: a preliminary study. Int Urogynecol J 2009; 20:1213-1222. [PMID: 19533007 DOI: 10.1007/s00192-009-0928-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 05/27/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to evaluate the morphological characteristics of the female pelvic floor that may be further elucidated with three-dimensional endovaginal ultrasonography (3D-EVUS). METHODS A consecutive series of 20 nulliparous females underwent 3D-EVUS. Measurements were determined according to pre-established criteria. Descriptive statistics and Spearman's correlation test were performed. RESULTS The levator hiatus (LH) was measured in the oblique plane parallel to the pubovisceral muscle. A positive correlation was found between LH area and age (p = 0.03). The anteroposterior diameter of the urogenital hiatus, measured in the axial plane tilted from the symphysis pubis to the ischiopubic rami, correlated with LH area (p = 0.008). No urethral rotations were observed in the coronal plane. Significant correlations were found among urethral parameters. Mean anal sphincter measurements were comparable to previously reported magnetic resonance imaging and ultrasound measurements. CONCLUSIONS 3D-EVUS allows measurements of key pelvic floor structures in planes that cannot be determined by conventional imaging modalities.
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Thekkinkattil DK, Dunham RJ, O'Herlihy S, Finan PJ, Sagar PM, Burke DA. Measurement of anal cushions in idiopathic faecal incontinence. Br J Surg 2009; 96:680-4. [PMID: 19384910 DOI: 10.1002/bjs.6597] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Faecal incontinence affects a heterogeneous population and aetiology can be multifactorial. In a subset of patients the aetiology remains idiopathic despite standard investigations. Anal cushions are important in normal continence, but have rarely been studied. The aim of this study was to measure the size of the anal cushions and to evaluate their role in patients with idiopathic faecal incontinence. METHODS Women in whom idiopathic faecal incontinence was diagnosed after standard anorectal investigations underwent transvaginal ultrasonography. The area of the anal cushions was measured and a cushion : canal (C : C) ratio derived, which was compared with that in a control group of women without faecal incontinence. RESULTS Some 21 patients with incontinence (median age 60 years) and 102 asymptomatic controls (median age 41 years) underwent scanning. The median (interquartile range) C : C ratio in the symptomatic group was significantly lower than that for controls (0.57 (0.54-0.66) versus 0.68 (0.61-0.73) respectively; P = 0.001). C : C ratio was not influenced by age (r = 0.023, P = 0.821). CONCLUSION The C : C ratio was reduced in patients with idiopathic faecal incontinence.
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Affiliation(s)
- D K Thekkinkattil
- Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK. [corrected]
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Al-Ali S, Blyth P, Beatty S, Duang A, Parry B, Bissett IP. Correlation between gross anatomical topography, sectional sheet plastination, microscopic anatomy and endoanal sonography of the anal sphincter complex in human males. J Anat 2009; 215:212-20. [PMID: 19486204 DOI: 10.1111/j.1469-7580.2009.01091.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This study elucidates the structure of the anal sphincter complex (ASC) and correlates the individual layers, namely the external anal sphincter (EAS), conjoint longitudinal muscle (CLM) and internal anal sphincter (IAS), with their ultrasonographic images. Eighteen male cadavers, with an average age of 72 years (range 62-82 years), were used in this study. Multiple methods were used including gross dissection, coronal and axial sheet plastination, different histological staining techniques and endoanal sonography. The EAS was a continuous layer but with different relations, an upper part (corresponding to the deep and superficial parts in the traditional description) and a lower (subcutaneous) part that was located distal to the IAS, and was the only muscle encircling the anal orifice below the IAS. The CLM was a fibro-fatty-muscular layer occupying the intersphincteric space and was continuous superiorly with the longitudinal muscle layer of the rectum. In its middle and lower parts it consisted of collagen and elastic fibres with fatty tissue filling the spaces between the fibrous septa. The IAS was a markedly thickened extension of the terminal circular smooth muscle layer of the rectum and it terminated proximal to the lower part of the EAS. On endoanal sonography, the EAS appeared as an irregular hyperechoic band; CLM was poorly represented by a thin irregular hyperechoic line and IAS was represented by a hypoechoic band. Data on the measurements of the thickness of the ASC layers are presented and vary between dissection and sonographic imaging. The layers of the ASC were precisely identified in situ, in sections, in isolated dissected specimens and the same structures were correlated with their sonographic appearance. The results of the measurements of ASC components in this study on male cadavers were variable, suggesting that these should be used with caution in diagnostic and management settings.
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Affiliation(s)
- S Al-Ali
- Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Ornö AK, Marsál K, Herbst A. Ultrasonographic anatomy of perineal structures during pregnancy and immediately following obstetric injury. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:527-534. [PMID: 18726927 DOI: 10.1002/uog.6122] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To assess perineal anatomy using ultrasound before and immediately after delivery. METHODS Structures in the perineum were studied by real-time two-dimensional transvaginal and endoanal ultrasound imaging using a combined linear and semicircular (up to 200 degrees sector) probe. We examined 45 nulliparous pregnant women and 44 primiparae immediately after delivery (40 with anal sphincter tears and four without sphincter injury). In each case a single longitudinal image was later assessed by two observers in order to evaluate interobserver agreement. RESULTS In pregnancy, the perineal membrane, puboperineal muscles, conjoined longitudinal muscle and central point were identified on real-time examination in 91%, 98%, 100% and 100% of cases, respectively. At offline evaluation of the longitudinal images obtained for each of the pregnant women, the percentage of cases in which each structure was identified by both observers ranged from 64% to 100%. In the women who were examined postpartum, all structures were identified by both observers in all four of the women without sphincter injury. In the women with sphincter tears, the perineal membrane, puboperineal muscles, conjoined longitudinal muscle and central point were found by ultrasound to be intact in 10%, 10%, 55% and 18%, respectively. The agreement between two observers regarding identification of intact structures in a single longitudinal image was good for perineal membrane (kappa index, 0.66), fair for puboperineal muscles (kappa index, 0.40), and poor for conjoined longitudinal muscle and central point (kappa index, 0.08 and 0.17, respectively). CONCLUSIONS Ultrasonography might be helpful in the evaluation of perineal anatomy and extent of perineal tears. However, the relatively poor agreement between the two observers evaluating single linear transvaginal images implies that both transverse and longitudinal projections are necessary to obtain relevant information. Further studies are needed regarding the importance of specific sonographically identified structures and their role in pelvic floor dysfunction after delivery.
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Affiliation(s)
- A-K Ornö
- Department of Obstetrics and Gynecology, Clinical Sciences, Lund University, Lund, Sweden.
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25
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Gurland B, Hull T. Transrectal ultrasound, manometry, and pudendal nerve terminal latency studies in the evaluation of sphincter injuries. Clin Colon Rectal Surg 2008; 21:157-66. [PMID: 20011414 PMCID: PMC2780206 DOI: 10.1055/s-2008-1080995] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fecal incontinence may be due to postpartum anal sphincter injuries or neurological damage even in the absence of obvious perineal trauma. Anal physiologic testing with transrectal ultrasound, manometry, and pudendal nerve terminal latency studies help to identify those patients with anal sphincter injuries who might benefit from anal sphincter repair. In this article, the authors discuss the specific tests that are available and how to interpret them.
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Affiliation(s)
- Brooke Gurland
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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26
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Huebner M, Margulies RU, Fenner DE, Ashton-Miller JA, Bitar KN, DeLancey JOL. Age effects on internal anal sphincter thickness and diameter in nulliparous females. Dis Colon Rectum 2007; 50:1405-11. [PMID: 17665265 PMCID: PMC2288793 DOI: 10.1007/s10350-006-0877-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
Abstract
PURPOSE Age can affect the delicate physiologic balance of the internal anal sphincter diameters and pressure governed by Laplace's law. This study compares the effect of aging on the internal anal sphincter thickness and diameter in younger and older nulliparous females without symptoms of fecal incontinence undisturbed by an endoanal probe. METHODS Magnetic resonance images were selected from a large database of nulliparous females to form two groups: "younger" females, aged 30 years and younger (n = 32), and "older" females, aged 50 years and older (n = 32). All patients were scanned without endoanal coils to allow undistorted measurement of the internal anal sphincter diameters. Inner and outer diameters were measured from axial magnetic resonance images and used to calculate sphincter thickness and mean radius by two independent investigators blinded to patient age. RESULTS The mean age in the younger group was 26 +/- 2.8 years, whereas that of the older group was 61.8 +/- 7.6 years. Older females had a 33 percent thicker internal anal sphincter (younger vs. older: 4.5 +/- 0.7 vs. 5.9 +/- 1 mm; P < 0.001), a 20 percent larger inner diameter (7.1 +/- 1.3 vs. 8.5 +/- 1.8 mm; P = 0.001), and a 27 percent larger outer diameter (16 +/- 2.1 vs. 20.3 +/- 3.3 mm; P < 0.001) than younger females. Neither sphincter thickness nor inner or outer diameter correlated with body mass index. CONCLUSIONS There is an increase in internal anal sphincter thickness, inner diameter, and outer diameter, which correlates with age in asymptomatic nulliparous females.
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Affiliation(s)
- Markus Huebner
- Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI 48109-0276, USA.
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27
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Brusciano L, Limongelli P, Pescatori M, Napolitano V, Gagliardi G, Maffettone V, Rossetti G, del Genio G, Russo G, Pizza F, del Genio A. Ultrasonographic patterns in patients with obstructed defaecation. Int J Colorectal Dis 2007; 22:969-77. [PMID: 17216218 DOI: 10.1007/s00384-006-0250-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal-vaginal-dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls. MATERIALS AND METHODS Ninety-two consecutive patients (77 women; mean age 51 years; range 21-71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated. RESULTS The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values. CONCLUSION Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.
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Affiliation(s)
- L Brusciano
- First Division of General and Gastrointestinal Surgery, School of Medicine, Second University of Naples, Naples, Italy.
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28
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Valsky DV, Messing B, Petkova R, Savchev S, Rosenak D, Hochner-Celnikier D, Yagel S. Postpartum evaluation of the anal sphincter by transperineal three-dimensional ultrasound in primiparous women after vaginal delivery and following surgical repair of third-degree tears by the overlapping technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 29:195-204. [PMID: 17219371 DOI: 10.1002/uog.3923] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Intrapartum damage to the anal sphincter is an important factor in fecal incontinence. Recognized lacerations occur in 0.36-8.4% of vaginal deliveries, and occult sphincter damage in up to 35% of primiparous women. We examined the role of three-dimensional transperineal ultrasound (3DTUS) in the evaluation of the anal sphincter in primiparous women after vaginal delivery and after surgical repair of third-degree intrapartum tears by the overlapping technique. METHODS During 2004-2005 139 primiparous women without clinically recognized third- to fourth-degree anal sphincter tears were prospectively studied 24-72 h postpartum (Group 1) and 13 primiparous women were examined 48 h to 4 months following surgical repair of third-degree tears with the overlapping technique (Group 2). A 3D 5-9-MHz transvaginal probe was placed in the area of the fourchette and perineal body in transverse and sagittal planes and 2-4 volumes were stored. The parameters studied were: examination duration; continuity of the internal and external sphincters; occult sphincter damage; internal sphincter and external sphincter width-measured 1.5 cm from the distal margin of the anus-at the '12, 3, 6 and 9 o'clock positions'; length of the posterior internal sphincter. RESULTS Scanning was possible in all women and the stored volumes were adequate in 127/139 (91.4%) cases. Mean examination time was 3.5 min. In Group 1, occult sphincter defect was suspected in 10/127 women (7.9%). These patients were excluded from measurement calculations, leaving 117 cases for analysis. The internal sphincter was consistently visualized in all the remaining patients (n = 117), while the external sphincter was fully visualized in 99/117 women (84.6%), and partially visualized in the remainder. Mean internal sphincter thickness was 2.60, 2.55, 2.60 and 2.72 mm at the 12, 3, 6 and 9 o'clock positions, respectively, and mean internal sphincter length was 3.34 cm. Mean external sphincter thickness was 4.15, 4.20, 4.21 and 4.20 mm at the 12, 3, 6 and 9 o'clock measurement points. In Group 2, 3DTUS confirmed anatomic abnormalities in all the women in the area surrounding the 12 o'clock position. Evaluation of sphincter tears and their position and length was possible using the longitudinal view. Thinning of the internal sphincter in the area of damage and thickening on the opposite side, the 'half moon sign', sphincter discontinuity, thickening of the external sphincter in the area of repair and abnormality of mucous folds, seemed to be common signs of third-degree intrapartum sphincter tears, even after repair. CONCLUSIONS 3DTUS is an accessible and promising method for postpartum sphincter evaluation, that is apparently well tolerated by patients. Reference data for sphincter anatomy representative of findings at transperineal ultrasound in primiparous women in the postpartum period have been established.
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Affiliation(s)
- D V Valsky
- Department of Obstetrics and Gynecology, Hadassah University Hospital-Mt Scopus, Jerusalem, Israel
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Abstract
PURPOSE This study was designed to characterize rectal sensations by visualizing the internal and external anal sphincter and intra-anal transport of bolus during elicited rectal sensations. METHODS The anal canal was visualized with real-time transperineal ultrasonography in 13 healthy female volunteers. Rectal sensations were elicited by injecting water into the rectum. The ultrasound images were recorded on a videotape and analyzed offline. RESULTS The median time between an injection of water and the events studied was calculated in 105 rectal sensations. A relaxation in the internal anal sphincter (4 seconds after the injection of water), an antegrade transport of bolus (4 seconds) into the anal canal, and a contraction in the external anal sphincter (5 seconds) were observed before a sensation (6 seconds) was reported. The antegrade flow continued until the distal internal anal sphincter contracted (18 seconds) and the bolus moved in a retrograde transport direction (17 seconds) thereafter the sensation disappeared (18 seconds) and the external anal sphincter relaxed (22 seconds). A significant correlation in time between the end of the sensation, contraction in the internal anal sphincter, reversed flow of anal contents, and relaxation of the external anal sphincter was found (Pearson, P<0.01). CONCLUSIONS The results verified that the internal anal sphincter contributes to the perception of rectal sensations by a relaxation allowing intra-anal bolus to increase the pressure on the anoderm during rectal contraction. A new observation is presented on the time relation between contraction in the distal internal anal sphincter, reversed flow in the anal canal, and the end of rectal sensations.
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Affiliation(s)
- Ann Kristin Ornö
- Department of Obstetrics and Gynecology, Clinical Sciences Lund, Lund University, Lund, Sweden.
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Nicholls MJ, Dunham R, O'Herlihy S, Finan PJ, Sagar PM, Burke D. Measurement of the anal cushions by transvaginal ultrasonography. Dis Colon Rectum 2006; 49:1410-3. [PMID: 16729219 DOI: 10.1007/s10350-006-0550-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The anal cushions are believed to contribute to the anal continence mechanism. Transvaginal ultrasound previously has been used to visualize the anal sphincters. Using this method, visualization of the anal cushions has been described but no quantitation of the cushions has been undertaken. Because impairment of the anal cushion function may lead to anal incontinence, this study was designed to evaluate the use of transvaginal ultrasound to measure the anal cushions. METHODS Patients attending a gynecologic ultrasound list were recruited into the study. By measuring cross-sectional areas, a cushion:canal ratio was calculated. RESULTS Fifty females were studied. Results showed that the area enclosed within the internal anal sphincter had a median of 2.37 cm(2) (interquartile range, 1.76-2.61). The cushion:canal ratio was 0.66 (interquartile range, 0.57-0.7). Interobserver error was 0.98 and intraobserver error 0.99. CONCLUSIONS In this pilot study, we conclude that transvaginal ultrasonography is a reliable method of measuring the anal cushions in healthy control subjects. A narrow normal range can be established. This may be compared later with anal cushion size in patients who have symptoms of incontinence and may be used to assess changes in the size of the cushions in response to recently described anal cushion bulking agents.
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Affiliation(s)
- M J Nicholls
- Department of Colorectal Surgery, The General Infirmary at Leeds, Great George Street, Leeds, United Kingdom
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31
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Yagel S, Valsky DV. Three-dimensional transperineal ultrasonography for evaluation of the anal sphincter complex: another dimension in understanding peripartum sphincter trauma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 27:119-23. [PMID: 16435322 DOI: 10.1002/uog.2714] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
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Ornö AK, Marsál K. Sonographic investigation of the rectoanal inhibitory reflex: a qualitative pilot study in healthy females. Dis Colon Rectum 2006; 49:233-7. [PMID: 16322962 DOI: 10.1007/s10350-005-0259-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The rectoanal inhibitory reflex has been studied using various methods, e.g., anometry and electromyography. The aim of this study was to apply ultrasound for direct visualization of the rectoanal inhibitory reflex. METHOD The rectoanal inhibitory reflex was induced in ten healthy females (age range, 21-55 years) by injection of small amounts of water (7, 12, and 20 ml), into the rectum. The intra-anal pressure was measured with a microtransducer and the rectoanal inhibitory reflex was visualized with real-time transvaginal or transperineal sonography. RESULTS The rectoanal inhibitory reflex consisted of a reduction in the intra-anal pressure and relaxation of the internal anal sphincter, manifested as an increase in the inner diameter of the internal anal sphincter from the mean of 11 to 16 mm (P<0.001). Simultaneously, a wave of rectal contents entered the anal canal. The distance from the most distal border of the rectal contents to the anal verge decreased from a mean of 33 to 20 mm (P<0.001). The rectoanal inhibitory reflex ended with a retrograde transport returning anal contents into the rectum. During the retrograde transport a contraction in the internal anal sphincter was observed. CONCLUSIONS The rectoanal inhibitory reflex can readily be visualized with ultrasound as a wave of rectal contents entering the anal canal. The transport into the anal canal was not of voluntary origin and could be either noticed or not noticed by the subjects. The observed retrograde transportation in the anal canal was not noted by the subjects; it is related to a contraction in the internal anal sphincter and visualized for the first time using ultrasound.
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Affiliation(s)
- A-K Ornö
- Department of Obstetrics and Gynecology, Clinical Sciences Lund, University of Lund, Lund, Sweden.
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Timor-Tritsch IE, Monteagudo A, Smilen SW, Porges RF, Avizova E. Simple ultrasound evaluation of the anal sphincter in female patients using a transvaginal transducer. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 25:177-183. [PMID: 15660445 DOI: 10.1002/uog.1827] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE Fecal incontinence affects 0.2% of women aged 15-64 years and about 1.3% of women over 64 years. Most cases are related to instrumental deliveries affecting the anal sphincter complex. We propose a simple technique using the generally available transvaginal transducer to evaluate the anal sphincter complex. METHODS Ninety-two patients underwent ultrasound examination. Group I consisted of 53 nulliparous patients. In Group II there were six patients with normal spontaneous vaginal deliveries without episiotomies. In Group III there were 14 patients with vaginal deliveries and one to three episiotomies but no lacerations. In Group IV there were nine postpartum patients with recently repaired (48 h to 3 weeks) third- and fourth-degree lacerations. All women in Groups I-IV were asymptomatic. Group V consisted of 10 patients symptomatic for fecal incontinence. We used a vaginal probe (5-9-MHz) with the footprint placed in the fourchette pointing towards the anus in a transverse and then in a median (sagittal) plane. If seen, the combined internal and external anal sphincter thickness at the 12 o'clock location was measured. We visualized normal star-shaped mucosal folds on the transverse section and described the sonographic anatomy in both planes. RESULTS The mean sphincter thickness measured at 12 o'clock in Group I was 2.3 (range, 1.0-4.7) mm, in Group II it was 2.9 (range, 2.4-3.4) mm, and in Group III it was 2.3 (range, 1.0-3.7) mm. The differences between these three groups were not significant. Patients from Group IV showed thinning or discontinuous sphincter anatomy at the 12 o'clock position. All symptomatic patients from Group V showed abnormal sphincter anatomy, and the normal star-like appearance of the anal mucosa on the transverse section was deformed, radiating from the point of the sphincter damage. Four of the 10 patients in this group underwent surgical repair. In these patients the sonographic findings were confirmed. CONCLUSIONS The images obtained using this imaging modality show the sphincter muscle anatomy as well as the possible pathology. Due to its simplicity the technique can be applied in any place where a vaginal transducer is available.
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Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Division of Ob/Gyn Ultrasound, Department of Obstetrics and Gynecology, New York, NY 10016, USA.
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Rieger N, Tjandra J, Solomon M. Endoanal and endorectal ultrasound: applications in colorectal surgery. ANZ J Surg 2005; 74:671-5. [PMID: 15315569 DOI: 10.1111/j.1445-1433.2004.02884.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Endoanal and endorectal ultrasound have an important role in colorectal surgery. They can be applied in the management of faecal incontinence, rectal tumours and inflammatory perianal conditions. In faecal incontinence, anal ultrasound will confirm the presence or absence of sphincter defects. This will direct any operative intervention such as direct sphincter repair. Ultrasound in rectal cancer allows staging of the tumour by assessing the depth of invasion through the bowel wall and involvement of mesenteric nodes. Such staging might influence the choice of operation and determine which patients might benefit from preoperative chemotherapy and radiotherapy. Ultrasound has a particular role in recurrent and complex anal fistula and perianal sepsis. Preoperative and perioperative planning with accurate delineation of fistula tracts, extensions and sphincter involvement might help prevent recurrence and impaired continence from sphincter damage after surgery. Correct interpretation of ultrasound images requires training and experience so that the results can be properly correlated with the clinical situation.
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Affiliation(s)
- Nicholas Rieger
- University of Adelaide Department of Surgery, The Queen Elizabeth Hospital, Woodville Road, Woodville, SA 5011, South Australia.
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35
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Tunn R, Schaer G, Peschers U, Bader W, Gauruder A, Hanzal E, Koelbl H, Koelle D, Perucchini D, Petri E, Riss P, Schuessler B, Viereck V. Updated recommendations on ultrasonography in urogynecology. Int Urogynecol J 2004; 16:236-41. [PMID: 15875241 DOI: 10.1007/s00192-004-1228-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Accepted: 08/06/2004] [Indexed: 10/26/2022]
Abstract
Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.
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Affiliation(s)
- R Tunn
- Association of Urogynecology and Pelvic Floor Repair, Germany
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Thakar R, Sultan AH. Anal endosonography and its role in assessing the incontinent patient. Best Pract Res Clin Obstet Gynaecol 2004; 18:157-73. [PMID: 15123064 DOI: 10.1016/j.bpobgyn.2003.09.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Anal endosonography is now recognized as an important investigation in the assessment of faecal incontinence. The endosonographer needs to be aware that the anatomy of the anal sphincter is complex and therefore there can be pitfalls in the interpretation of images. The findings have clinical implications on subsequent management and can contribute to prognosticating outcome. However, anal endosonography has a complementary role and other investigations, such as anal manometry, should be performed before intervention.
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Affiliation(s)
- Ranee Thakar
- Department of Obstetrics and Gynaecology, Mayday University Hospital, London Road, Croydon, Surrey CR7 7YE, UK
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Abstract
PURPOSE OF REVIEW Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking. RECENT FINDINGS Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor. SUMMARY Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.
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Affiliation(s)
- Mira Lal
- Department of Obstetrics and Gynaecology, Wordsley Hospital, Dudley Group of Hospital NHS Trust, Tourbridge, Wesst Midlands, UK.
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Etienney I, De Parades V, Atienza P. Apports de l’échographie endoanale dans l’exploration de l’incontinence anale. ACTA ACUST UNITED AC 2003. [DOI: 10.1007/bf03023676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Shobeiri SA, Nolan TE, Yordan-Jovet R, Echols KT, Chesson RR. Digital examination compared to trans-perineal ultrasound for the evaluation of anal sphincter repair. Int J Gynaecol Obstet 2002; 78:31-6. [PMID: 12113968 DOI: 10.1016/s0020-7292(02)00068-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the adequacy of a third- or a fourth-degree laceration repair by comparing digital and trans-perineal ultrasound measurements. METHOD During a 4-year period, 34 subjects without prior history of anal sphincter injury or fecal incontinence underwent ultrasound measurements of external anal sphincter muscle diameter and perineal length, which were compared to measurements obtained by digital examination. RESULTS Pearson's correlation coefficients for comparing the digital external sphincter examination to trans-perineal ultrasonography, and the digital perineal examination to trans-perineal ultrasonography were 0.88 and 0.40, respectively. Patients (n=4/34) whose external sphincter was identified as less than 1 cm by digital examination were found to have an external sphincter diameter of less than 1 cm by trans-perineal ultrasound. CONCLUSION The digital perineum examination is a reliable method of measuring the external sphincter thickness and perineal body length immediately after primary repair.
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Affiliation(s)
- S A Shobeiri
- Louisiana State University Health Sciences Center, Department of Obstetrics and Gynecology, Section of Female Pelvic Medicine and Reconstructive Surgery, New Orleans, LA, USA.
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Cornelia L, Stephan B, Michel B, Antoine W, Felix K. Trans-perineal versus endo-anal ultrasound in the detection of anal sphincter tears. Eur J Obstet Gynecol Reprod Biol 2002; 103:79-82. [PMID: 12039471 DOI: 10.1016/s0301-2115(02)00021-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare endo-anal and trans-perineal ultrasonography in the detection of anal sphincter lesions. STUDY DESIGN Sixty-four patients sent for a uro-gynaecological consultation were given tests by two ultrasound methods using the same apparatus (Aloka) with different probes. The endo-anal ultrasound (EAUS) was carried out in a supine position using a rotary circular probe at 7.5 MHz. The trans-perineal ultrasound (TPUS) was carried out using a curved linear probe at 5 MHz, applied to the perineum in the transverse direction, allowing a proximal view of the sphincter. For each image the thicknesses of the two components of the sphincter (internal and external) were noted, as well as the presence of any ultrasonographic tear, its position, and its width on the sphincterian circumference. RESULTS The average of the internal and external thickness of the sphincters was of 2.8 and 5.6 mm, respectively for the TPUS, and 2.1 and 6.2 mm for the EAUS. Among the 64 patients, 15 external lesions of the anal sphincter were found with the TPUS, and 14 with the EAUS. The kappa correlation coefficient was 48%, with a confidence interval of 95%. CONCLUSION The endo-anal technique, which provides a staged analysis of the anal sphincter muscle, remains the benchmark of sphincterian imaging. TPUS is a useful method, in that it gives good visualisation of anatomical structures, but its sensitivity in detecting sphincter lesions remain to be demonstrated.
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Affiliation(s)
- Lohse Cornelia
- Department of Gynaecology, University Hospital of Geneva, Geneva, Switzerland
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Abstract
Anal endosonography became a valuable imaging method for diagnosis of anal diseases because of its accessibility, relative simplicity of performance, and low cost. It is used most often to detect anal sphincter defects, to classify anal fistulas and perianal abscesses, and to stage anal tumors. This review presents a normal anatomy of the anal canal, examination technique, and normal endosonographic anatomy of anal sphincters. The endosonographic findings of anal sepsis, malignancy, trauma, abnormalities in Crohn disease, and ulcerative colitis, as well as the role for anal endosonography among other imaging modalities, are discussed.
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Ochsenbein N, Kurmanavicius J, Huch R, Huch A, Wisser J. Volume sonography of the pelvic floor in nulliparous women and after elective cesarean section. Acta Obstet Gynecol Scand 2001. [DOI: 10.1034/j.1600-0412.2001.800705.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sudoł-Szopińska I, Szczepkowski M, Jakubowski W. Anal sphincters defects--verification of the anal ultrasound diagnosis in 'bimanual' examination. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 2001; 13:25-9. [PMID: 11251253 DOI: 10.1016/s0929-8266(00)00122-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this is to evaluate the diagnostic value of anal endosonography performed during pressing anterior wall of anal canal with a finger introduced into the lumen of vagina for the identification of anal sphincter defects. Anal ultrasound (AUS) with a finger introduced into the lumen of vagina was performed in a group of 55 women with anal sphincter defects recognized initially in standard AUS. This technique prevented false positive diagnoses of sphincter defects in 12 out of a group of 55 women (21.8%).
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Affiliation(s)
- I Sudoł-Szopińska
- Department of Diagnostic Imaging, Second Faculty of Medicine, 03-285, Warsaw, Konratowicza 8 st., Poland.
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Segura Cabral JM, Olveira Martín A, del Valle Hernández E. [Endoanal and endorectal echography]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:135-42. [PMID: 11261225 DOI: 10.1016/s0210-5705(01)70141-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- J M Segura Cabral
- Servicio de Aparato Digestivo, Unidad de Ecografía, Hospital La Paz, Madrid
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45
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Abstract
A greater awareness of the therapies now available for pelvic floor dysfunction has increased demand for specialized imaging of this region. Some of the techniques required are available at relatively few centers, and the purpose of this review is to introduce the emerging subspecialty of pelvic floor imaging to a more general readership. Pelvic floor anatomy is complex and is being unraveled by means of magnetic resonance (MR) imaging. This is discussed in detail by using a global, rather than a compartmentalized, anatomic approach. The physiology of normal urinary and anal function and the routine clinical tests applied to them are outlined. The imaging techniques involved include MR imaging, endosonography, and fluoroscopy. The main investigations include video urodynamic imaging, evacuation proctography, dynamic cystoproctography, dynamic MR imaging of the pelvic floor, and endoluminal imaging of the anal sphincters with MR imaging and ultrasonography. These are described in detail, and their role with regard to the main pathologic conditions of the pelvic floor--urinary and anal incontinence, constipation, and prolapse--are discussed.
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Affiliation(s)
- J Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 Amsterdam, The Netherlands.
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Kleinübing H, Jannini JF, Malafaia O, Brenner S, Pinho TM. Transperineal ultrasonography: new method to image the anorectal region. Dis Colon Rectum 2000; 43:1572-4. [PMID: 11089595 DOI: 10.1007/bf02236741] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The aim of this preliminary study was to present an alternative method to assess the anal sphincters by ultrasonography using a conventional ultrasound surface probe by transperineal approach. METHODS Transperineal ultrasonography was performed in 20 asymptomatic volunteers to assess the anal sphincters. Ultrasonographic findings were compared with conventional anal endosonography pictures available in the literature. RESULTS Images of the anal sphincters obtained by transperineal ultrasound were found to be similar to those produced by conventional anal endosonography. Internal and external anal sphincters were easily demonstrated in addition to mucosal and submucosal layers. CONCLUSIONS Transperineal ultrasonography is a new technique that enables imaging of anal sphincters and anal canal structures with potential application in functional and inflammatory anorectal disorders.
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Affiliation(s)
- H Kleinübing
- Department of Colo-Proctology, Hospital São José, Joinville, Federal University of Paraná, Curitiba, Brazil
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Abstract
BACKGROUND Over the past two decades developments in imaging have changed the assessment of patients with anorectal disease. METHODS The literature on imaging techniques for anorectal diseases was reviewed over the period 1980-1999. RESULTS For the staging of primary rectal tumours, phased array magnetic resonance imaging (MRI) may be regarded as the most appropriate single technique. The combination of endosonography or endoluminal MRI with ultrasonography or spiral computed tomography yields similar results. All techniques have limitations both for local staging and in the assessment of distant metastases. MRI or positron emission tomography is preferable for tumour recurrence. For perianal fistula, high-resolution MRI (phased array or endoluminal) is the technique of choice. For constipation, defaecography is the preferred technique, nowadays with emphasis on functional information. The role of magnetic resonance defaecography is currently being evaluated. For faecal incontinence, endosonography and endoluminal MRI give similar results in detecting sphincter defects; endoluminal MRI has the advantage of detecting external sphincter atrophy. CONCLUSION High-resolution MRI, endosonography and defaecography are currently the optimal imaging techniques for anorectal disease.
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Affiliation(s)
- J Stoker
- Department of Radiology, Academic Medical Centre, University of Amsterdam, The Netherlands
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48
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Abstract
Transvaginal ultrasonography (US) is a noninvasive, readily available imaging technique that has greatly enhanced diagnostic sensitivity and accuracy for both gynecologic and nongynecologic disease. High-frequency US probes placed in the vagina allow high-resolution assessment of all the pelvic viscera, including portions of the gut and urinary tract. In addition, they allow visualization of the peritoneum of the pelvic pouch and the pelvic side walls without interference from bowel gas or adipose tissue. Evaluation of these areas requires a modified US technique that includes the use of the highest-frequency probes with angulation of the transducer to allow assessment of the region of interest. In women of childbearing age, the similarity of symptoms in gynecologic and gastrointestinal tract disease in particular underscores the potential utility of transvaginal US, which may, for example, help differentiate appendicitis in a pelvic appendix from pelvic inflammatory disease. Transvaginal US may also help determine the correct course of therapy, thereby improving patient management. Other indications for transvaginal US include assessment for pelvic appendicitis and diverticulitis, rectal and perianal complications of Crohn disease, and ureteric and bladder calculi and tumors as well as evaluation of the anal sphincters in women with fecal incontinence. Transvaginal US is also superior to routine US in the detection and characterization of ascites and peritoneal disease. Transvaginal US examination should include the entire pelvic cavity and contents, especially in women at risk for pelvic sepsis or peritoneal disease.
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Affiliation(s)
- N Damani
- Department of Medical Imaging, The Toronto Hospital, University of Toronto, Ontario, Canada
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Gold DM, Bartram CI, Halligan S, Humphries KN, Kamm MA, Kmiot WA. Three-dimensional endoanal sonography in assessing anal canal injury. Br J Surg 1999; 86:365-70. [PMID: 10201780 DOI: 10.1046/j.1365-2168.1999.01041.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Instrument design limits endosonography of the anal canal to the axial plane, with no capability for longitudinal imaging or measurement. Using three-dimensional reconstructions, the relationship between the radial and linear extent of an anal sphincter tear has been explored, and sex differences in anal canal and sphincter length have been established. METHODS Three-dimensional reconstructions were performed in 20 controls and 24 patients with faecal incontinence found to have 25 external and five internal sphincter defects. The radial and linear extent of any sphincter tear was measured. In controls the length of the sphincters was compared with the total anal canal length, and the maximum and mean internal sphincter thickness was compared. RESULTS The radial angle of an internal or external sphincter defect was significantly related to its length (R2 = 96.8 per cent and R2 = 84.4 per cent respectively; both P < 0.001). The anal canal was longer in men than in women (mean(s.d.) 32.6(5.3) versus 25.1(3.4) mm; P < 0.001). The internal anal sphincter was also longer in men (25.6(6.3) versus 19.8(4.0) mm; P < 0.02), but the mean internal sphincter length as a percentage of total anal canal length did not differ (78.3 versus 78.7 per cent; P not significant). The anterior external anal sphincter was longer in men than in women (32.6(5.3) versus 15.3(2.8) mm; P < 0.001), and formed a greater percentage of total anal canal length (100 versus 62.9 per cent; P < 0.001). CONCLUSION Multiplanar imaging has revealed a direct relationship between the length of a sphincter tear and its radial extent as shown on axial scanning. Marked sex differences in sphincter configuration have been demonstrated. In women the shorter anterior sphincter length highlights the risk of complete sphincter disruption with extensive tears.
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Affiliation(s)
- D M Gold
- Department of Radiology, St Mark's Hospital, Harrow, UK
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