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Anatomical and physiological aspects of anorectal dysfunction
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objective: To analyse the results of anal-sphincter repair; to examine the feasibility of motor latency measurements of the anal sphincter after magnetic sacral stimulation in healthy subjects, patients with a spinal cord injury and patients with faecal incontinence, using a new recording technique; to study, in the same 3 groups, the effects ofphasic magnetic sacral root stimulation on the anal sphincter and rectum; to describe normal, undisturbed anatomy of the anal canal and perianal structures in both men and nulliparous women using high-resolution phased array magnetic resonance imaging; to study pelvic floor movements in healthy volunteers of both sexes using a new instrument.

Methods: Latencies were recorded with an intraanal, bipolar sponge electrode and an intrarectal ground electrode. Rectal volume changes were measured with a barostat. Highresolution magnetic resonance images were obtained without an endoanal coil. Pelvic floor movements where measured with the subject seated, using a magnet attached to a rectal balloon.

Results: After a median period of 40 months, 31/55 female patients rated the result of analsphincter repair as excellent or good. Age>50 years, and post-operative urgency and loose stools were associated with poor outcome. Eight patients became fully continent for stool. 17% of the latency measurements failed. There were no significant differences between leftand right-sided stimulation. Faecal incontinence patients had prolonged pudendal nerve terminal motor latencies and prolonged latencies after left-sided magnetic stimulation. Phasic magnetic stimulation increased anal pressure in 100% of the 14 healthy subjects, 86% of the 14 spinal cord injury patients and 73% of the 18 faecal incontinence patients. A decrease in rectal volume was provoked in respectively 72 %, 79 % and 50 %. In all 33 volunteers, anal and perianal structures could be well defined by magnetic resonance imaging. The mid-anal canal was significantly longer than its anterior and posterior part. The female anterior sphincter was shorter than the male and occupied 30 % of the anal canal length. The female perineal body was thicker and easier to define than the male. The median pelvic floor lift and descent measured in 28 healthy volunteers, were 2 cm and 1.8 cm respectively. Day-to-day and inter-observer reproducibility were good. 20/28 subjects were able to expel the rectal balloon.

Conclusions: Anal-sphincter repair does not restore complete continence but leads to a satisfactory result in more than half of the patients. Additional bowel symptoms are common at follow-up. Latency measurements after magnetic stimulation are minimally invasive and have a low failure rate. They may be used to test the integrity of the distal motor pathway in patients who may benefit from continuous sacral root stimulation. Magnetic sacral root stimulation produces an increase in anal and rectal pressure and a decrease in rectal volume. Phased array magnetic resonance imaging is non-invasive and allows an accurate description of the normal anatomy of the anal canal and perianal structures. The new developed instrument measures cranial and caudal movement of the pelvic floor with minimal discomfort and good reproducibility.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2002. , 96 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 721
Keyword [en]
Anal canal, Anal-sphincter repair, Audit, Magnetic resonance imaging, Magnetic stimulation, Latency, Pelvic floor, Sacral roots
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25693Local ID: 10069ISBN: 91-7373-163-3 (print)OAI: oai:DiVA.org:liu-25693DiVA: diva2:246241
Public defence
2002-03-22, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-17Bibliographically approved
List of papers
1. Audit of anal-sphincter repair
Open this publication in new window or tab >>Audit of anal-sphincter repair
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2001 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 3, no 1, 17-22 p.Article in journal (Refereed) Published
Abstract [en]

Objective

Structural damage of the anterior part of the anal sphincter is a major cause of faecal incontinence. Sphincter repair is the standard surgical treatment. This study was designed to analyse the results of anal sphincter repair, to identify possible predictors of outcome and to investigate the presence of bowel symptoms other than leakage at follow up.

Patients and methods

Fifty-five women (median age 39 years, range 24–73 years) who underwent anal sphincter repair between 1986 and 1997 at the University Hospital of Linköping answered a postal questionnaire. Current bowel function, degree of continence and the patients’ functional result as worse, unchanged, some improvement, good or excellent were assessed. Good or excellent function was regarded as a successful result, the rest as failure. Age, duration of symptoms, type of surgery, morbidity and length of follow up were analysed in relation to outcome. Results of pre- and post-operative anal manometry, endoanal ultrasound, anal sphincter electromyography and pudendal nerve function were also analysed.

Results

After a median (range) follow-up period of 40 months (5–137) months, 31 (56%) patients rated the result as either excellent (n=10) or good (n=21). Twenty-one (38%) patients rated the result as some improvement (n=14), unchanged (n=6) or worse (n=1). In three (5%) patients a colostomy was fashioned because of failure. Patients >50 years at surgery (n=18) had a worse outcome (P=0.001). Successful outcome was correlated to increased squeeze pressures post-operatively. The presence of post-operative urgency (P=0.01) and loose stools (P=0.02) was more common in patients with poor outcome. Eight patients became continent to formed and liquid stool.

Keyword
Anal sphincter repair, Audit, Faecal incontinence
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25046 (URN)10.1111/j.1463-1318.2001.00205.x (DOI)9474 (Local ID)9474 (Archive number)9474 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
2. Latency of compound muscle action potentials of the anal sphincter after magnetic sacral stimulation
Open this publication in new window or tab >>Latency of compound muscle action potentials of the anal sphincter after magnetic sacral stimulation
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2001 (English)In: Muscle and Nerve, ISSN 0148-639X, E-ISSN 1097-4598, Vol. 24, no 9, 1232-1235 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to present the failure rate and normal values for motor latency of the anal sphincter after magnetic sacral stimulation (LMSS) using a modified recording technique. A bipolar sponge electrode was placed in the anal canal for recording. A ground electrode was placed in the rectum to reduce stimulus artifact. Magnetic stimulation was induced through a twin coil energized by a Maglite-r25 generator. Two groups were examined: 14 healthy volunteers and 14 patients with a spinal cord injury (SCI) above the conus. Nine of 56 studies (16%) failed. There were no significant differences in latency between right- and left-sided stimulation or between the healthy group and the SCI patients. As described, LMSS measurements are minimally invasive and have a low failure rate. They may be used to test the integrity of the distal motor pathway in patients with bladder or bowel dysfunction who may benefit from continuous electrical sacral root stimulation.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25053 (URN)10.1002/mus.1138 (DOI)9481 (Local ID)9481 (Archive number)9481 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
3. Evaluation of the sacroanal motor pathway by magnetic and electric stimulation in patients with fecal incontinence
Open this publication in new window or tab >>Evaluation of the sacroanal motor pathway by magnetic and electric stimulation in patients with fecal incontinence
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2001 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 44, no 2, 167-172 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: The aim of this controlled study was to examine whether it was feasible to use magnetic stimulation as a new diagnostic tool to evaluate the motor function of the sacral roots and the pudendal nerves in patients with fecal incontinence.

PATIENTS AND METHODS: Nineteen consecutive patients (17 females) with a median age of 67 (range, 36-78) years referred for fecal incontinence and 14 healthy volunteers (six females) with a median age of 42 (range, 23-69) years were examined. Latency times of the motor response of the external anal sphincter were measured after electric transrectal stimulation of the pudendal nerve and magnetic stimulation of the sacral roots.

RESULTS: The success rates of pudendal nerve terminal motor latency and sacral root terminal motor latency measurements were 100 and 85 percent, respectively, in the control group and 94 and 81 percent, respectively, in the fecal incontinence group. Median left pudendal nerve terminal motor latency was 1.88 (range, 1.4-2.9) milliseconds in the control group and 2.3 (range, 1.8-4) milliseconds in the fecal incontinence group (P <0.006). Median right pudendal nerve terminal motor latency was 1.7 (range, 1.3-3.4) milliseconds in the control group and 2.5 (range, 1.7-6) milliseconds in the fecal incontinence group (P <0.003). Median left sacral root terminal motor latency was 3.3 (range, 2.1-6) milliseconds in the control group and 3.7 (range, 2.8-4.8) milliseconds in the fecal incontinence group (P <3 0.03). Median right sacral root terminal motor latency was 3 (range, 2.6-5.8) milliseconds in the control group and 3.9 (range, 2.5-7.2) milliseconds in the fecal incontinence group (P =0.15).

CONCLUSIONS: Combined pudendal nerve terminal motor latency and sacral root terminal motor latency measurements may allow us to study both proximal and distal pudendal nerve motor function in patients with fecal incontinence. Values of sacral root terminal motor latency have to be interpreted cautiously because of the uncertainty about the exact site of magnetic stimulation and the limited magnetic field strength.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25050 (URN)10.1007/BF02234288 (DOI)9478 (Local ID)9478 (Archive number)9478 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
4. Effects of magnetic sacral root stimulation on anorectal pressure and volume
Open this publication in new window or tab >>Effects of magnetic sacral root stimulation on anorectal pressure and volume
2001 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 44, no 12, 1827-1833 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Electrical sacral root stimulation induces defecation in spinal cord injury patients and is currently under examination as a new therapy for fecal incontinence. In contrast to electrical stimulation, magnetic stimulation is noninvasive. To gain more insight into the mechanism of action of sacral root stimulation, we studied the effects of magnetic sacral root stimulation on anorectal pressure and volume in both fecal incontinence and spinal cord injury patients.

METHODS: Three groups were examined: 14 healthy volunteers, 18 fecal incontinence patients, and 14 spinal cord injury patients. Repetitive magnetic sacral root stimulation was performed bilaterally using bursts of five seconds at 5 Hz. Anal and rectal pressure changes and rectal volume changes were measured.

RESULTS: An increase in anal pressure was seen in 100 percent of the control subjects, in 86 percent of the spinal cord injury patients, and in 73 percent of the fecal incontinence patients (P=0.03). The overall median pressure rise after right-sided and left-sided stimulation was 12 (interquartile range, 8-18.5) and 13 (interquartile range, 6-18) mmHg at the mid anal level. A decrease in rectal volume was provoked in 72 percent of the control subjects, in 79 percent of the spinal cord injury patients, and in 50 percent of the fecal incontinence patients. Overall median volume changes after right-sided and left-sided stimulation were 10 (range, 5-22) and 9 (range, 5-21) percent from baseline volume. An increase in rectal pressure could be measured in 56 percent of the control subjects, 77 percent of the fecal incontinence patients, and 43 percent of the spinal cord injury patients. Median pressure rises after right-sided and left-sided stimulation were 5 (range, 3-12) and 5 (range, 3-5) mmHg.

CONCLUSIONS: Magnetic sacral root stimulation produces an increase in anal and rectal pressure and a decrease in rectal volume in healthy subjects and patients with fecal incontinence or a spinal cord injury.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26134 (URN)10.1007/BF02234462 (DOI)10593 (Local ID)10593 (Archive number)10593 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
5. Anatomy of the anal canal and perianal structures as defined by phased-array magnetic resonance imaging
Open this publication in new window or tab >>Anatomy of the anal canal and perianal structures as defined by phased-array magnetic resonance imaging
2001 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 88, no 11, 1506-1512 p.Article in journal (Refereed) Published
Abstract [en]

Background:

The anatomy of the anal canal and perianal structures has been imaged using endoluminal magnetic resonance imaging (MRI). Phased-array MRI avoids the use of an endoluminal coil that may distort anatomy. The aim of this study was to describe the anatomy of the anal canal and perianal structures using phased-array MRI.

Methods:

Imaging was performed in 14 men and 19 nulliparous women. The dimensions of the anal canal, puborectalis, external anal sphincter, perineal body, superficial transverse perineal muscle, bulbospongiosus, ischiocavernosus and anococcygeal body were measured in different planes, and sex differences were calculated.

Results:

The lateral canal was significantly longer than its anterior and posterior part (P < 0·001). The anterior external anal sphincter was shorter in women than in men (P = 0·01) and occupied, respectively, 30 and 38 per cent of the anal canal length (P = 0·001). The caudal ends of the external anal sphincter formed a double layer. The perineal body was thicker in women than in men (P < 0·001) and easier to define. The superficial transverse muscles had a lateral and caudal extension to the ischiopubic bones. The bulbospongiosus was thicker in men than in women (P < 0·001). The ischiocavernosus and anococcygeal body had the same dimensions in both sexes.

Conclusion:

Phased-array MRI is a non-invasive technique that allows an accurate description of the normal anatomy of the anal canal and perianal structures.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81477 (URN)10.1046/j.0007-1323.2001.01919.x (DOI)
Available from: 2012-09-17 Created: 2012-09-17 Last updated: 2017-12-07Bibliographically approved
6. Clinical measurement of pelvic floor movement: Evaluation of a new device
Open this publication in new window or tab >>Clinical measurement of pelvic floor movement: Evaluation of a new device
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2004 (English)In: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 47, no 5, 787-792 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE:: A new device that measures pelvic floor movement clinically was evaluated.

METHODS:: The device consists of a rectal balloon with a magnet at its exterior end. The magnet moves in an electromagnetic field synchronous with the pelvic floor movements. This movement is measured and displayed on a computer screen in front of the seated patient. Twenty-eight healthy volunteers (15 females) were examined. On a separate day, 17 of them were tested a second time by the same investigator and a third time by a different investigator.

RESULTS:: One volunteer developed a vasovagal reaction. The median (range) pelvic floor lift and descent was 2 (range, 0.6-4.5) cm and 1.8 (range, 0.5-5.6) cm respectively. Day-to-day and interobserver reproducibility was good. Coughing and blowing a party balloon caused pelvic floor descent in the majority of participants. Twenty of 28 volunteers were able to expel the rectal balloon.

CONCLUSIONS:: The device measures cranial and caudal movements of the pelvic floor with minimal discomfort and good reproducibility. The device may have a large potential as biofeedback device in pelvic floor training.

Keyword
Clinical method, Measurement, Movement, Pelvic floor
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-45747 (URN)10.1007/s10350-003-0109-3 (DOI)15073661 (PubMedID)
Note

On the day of the defence day the status of this article was submitted.

Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved

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