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Introduction and hypothesis: Our aim was to explore the association between anal incontinence (AI) and persistent anal sphincter defects diagnosed with 3D endoanal (EAUS), introital (IUS) and transperineal ultrasound (TPUS) in women after obstetric anal sphincter injury (OASI) and study the association between sphincter defects and anal pressure. Methods: We carried out a cross-sectional study of 250 women with OASI recruited during the period 2013–2015. They were examined 6–12 weeks postpartum or in a subsequent pregnancy with 3D EAUS, IUS and TPUS and measurement of anal pressure. Prevalence of urgency/solid/liquid AI or flatal AI and anal pressure were compared in women with a defect and those with an intact sphincter (diagnosed off-line) using Chi-squared and Mann–Whitney U test. Results: At a mean of 23.6 (SD 30.1) months after OASI, more women with defect than those with intact sphincters on EAUS had AI; urgency/solid/liquid AI vs external defect: 36% vs 13% and flatal AI vs internal defect: 27% vs 13%, p < 0.05. On TPUS, more women with defect sphincters had flatal AI: 32% vs 13%, p = 0.03. No difference was found on IUS. Difference between defect and intact sphincters on EAUS, IUS and TPUS respectively was found for mean [SD] maximum anal resting pressure (48 [13] vs 55 [14] mmHg; 48 [12] vs 56 [13] mmHg; 50 [13] vs 54 [14] mmHg) and squeeze incremental pressure (33 [17] vs 49 [28] mmHg; 37 [23] vs 50 [28] mmHg; 36 [18] vs 50 [30] mmHg; p < 0.01). Conclusions: Endoanal ultrasound had the strongest association with AI symptoms 2 years after OASI. Sphincter defects detected using all ultrasound methods were associated with lower anal pressure. [ABSTRACT FROM AUTHOR]

Background: Our aim is to explain the lack of clarity in the ways in which anxiety and depression, which are common in defecatory disorders (DD), may contribute to the disorder. In this study, we evaluate the effects of mental stress and relaxation on anal pressures and the mechanisms thereof. Methods: In 38 healthy women and 36 DD patients, rectoanal pressures were assessed at rest and during mental stressors (ie, word‐color conflict [Stroop] and mental arithmetic tests) and mental relaxation, before and after randomization to placebo or the adrenergic α1‐antagonist alfuzosin. Key Results: During the baseline Stroop test, the anal pressure increased by 6 ± 13 mm Hg (mean ± SD, P = 0.004) in healthy women and 9 ± 10 mm Hg (P = 0.0001) in constipated women. During mental arithmetic, the anal pressure increased in healthy (4 ± 8 mm Hg, P = 0.002) and constipated women (5 ± 9 mm Hg, P = 0.004). After relaxation, anal pressure declined (P = 0.0004) by 3 ± 4 mm Hg in DD patients but not in controls. Alfuzosin reduced (P = 0.0001) anal resting pressure (by 31 ± 19 mm Hg) vs placebo (16 ± 18 mm Hg). However, during the postdrug Stroop test, anal pressure increased (P = 0.0001) in participants who received alfuzosin but not placebo. Conclusions & Inferences: In healthy controls and DD patients, mental stressors likely increased anal pressure by contracting the internal anal sphincter; relaxation reduced anal pressure in DD patients. Alfuzosin reduced anal resting pressure but did not block the Stroop‐mediated contractile response, which suggests that this response is not entirely mediated by adrenergic α1 receptors. [ABSTRACT FROM AUTHOR]

Abstract: Background: The functional lumen imaging probe (EndoFLIP®) is a new technology that measures the distensibility of the anal canal represented by the anal distensibility index. The aims of this study were (i) to compare the anal distensibility index to anal pressure in a cohort of patients with fecal incontinence (FI) and (ii) to compare the diagnostic value of the EndoFLIP® to that of high‐resolution anorectal manometry (HRAM) in the same cohort of patients. Methods: Eighty‐three consecutive patients with FI who underwent EndoFLIP® and HRAM assessments were enrolled. The diagnostic value of the EndoFLIP® was compared to that of HRAM and agreement between EndoFLIP® and HRAM data was assessed. Key Results: More than 70% of the patients diagnosed with anal deficiency at rest and/or during voluntary contractions by HRAM had the same diagnosis using the EndoFLIP®. Two patients with higher distensibility indexes at rest had normal anal resting pressures. Sixteen patients with a normal EndoFLIP® index (ie, normal distensibility index at rest and during voluntary contractions) had an abnormal HRAM result. Seven of these 16 patients (44%) had no sphincter lesion or neuropathic disorder that could explain an abnormal anal sphincter function. Conclusions & Inferences: We demonstrated that the anal distensibility index and HRAM results are largely in agreement. We did, however, identify several discrepancies between the two techniques, indicating that they may be complementary. [ABSTRACT FROM AUTHOR]

Aims This study aimed to assess the dose and volume effects of suppository preparations and safety of NRL001 (one of four possible stereoisomers of methoxamine hydrochloride) on anal sphincter tone using rectal suppositories in healthy adult volunteers. Methods This was a Phase I, single-centre, randomised, double-blind, three-way crossover study during which subjects received three single doses of 1 g rectal suppositories (containing 5 or 10 mg NRL001 or matching placebo) or 2 g rectal suppositories (containing 10 or 15 mg NRL001 or matching placebo) on three separate dosing days. The outcome measures were mean anal resting pressure ( MARP) variables (monitored continuously for 20-30 min before and up to 6 h after dosing), pharmacokinetics ( PK) and safety assessments. Results Twenty-six subjects were dosed with study medication. Two subjects were withdrawn prematurely and were not included in the main analysis. There was a dose-dependent increase in anal sphincter tone ( MARP) when comparing the 5 and 10 mg doses of NRL001; however, the 15 mg dose did not have a significantly greater effect than the 10 mg dose. Suppository size (1 or 2 g) did not appear to have an effect on sphincter tone. There was no evidence against dose proportionality for the PK variables, but the mean maximum plasma concentration ( Cmax) for the 1 g suppository group was higher than for the 2 g group. Twenty-one adverse events were reported in 8 (30.8%) subjects. A dose dependent decrease in heart rate was noted; however, there were no adverse events reported that were related to this reduction in heart rate. Conclusions The increase in anal sphincter tone supports the potential therapeutic use of NRL001 in treating faecal incontinence, with further studies in patients required. NRL001 was well tolerated in single doses of up to 15 mg. [ABSTRACT FROM AUTHOR]

Anal fissure is one of the most common causes of severe anal pain. Factors which predispose people to develop anal fissure include diarrhea, constipation, childbirth, medication as well as constant saddle vibration (amongst professional mountain-bikers) and using a jet of water from a bidet-toilet. For many years, it has been generally accepted that a sphincterotomy, whether surgical or pharmacological, treats chronic anal fissure as it produces a reduction in anal pressure, reverses sphincter spasms and promotes fissure healing. However, recent studies cast doubt upon this explanation. A new theory explains that anal fissure healing depends on biochemical processes taking place in the anal passage. Eruption of tissues in the fissure region during defecation releases platelet products such as ADP, ATP, 5-HT, platelet activation factor, thrombin and substance P which cause the contraction of smooth muscles (of Internal Anal Sphincter and blood vessels) and results in difficulties in fissure healing. Reducing trauma of defecation by posterior perineal support plays an important role in anal fissure healing. It brings a significant improvement in the symptoms of patients with anal fissure. [ABSTRACT FROM AUTHOR]

Objective A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto-anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given. Method Thirty patients underwent DGHAL combined with recto-anal-repair (RAR). Each had rectal examination, anorectal manometry and Quality of Life assessment before and 3 months after the procedure. Results Twenty-nine patients were included in the final analysis. There were three (10.34%) patients of intra-operative and one (3.45%) of postoperative bleeding. Three months after RAR (17.24%) patients with minor residual mucosal prolapse were detected, three (10.34%) patients reported residual symptoms. There was no case of recurrent bleeding. Anal manometry at 3 months after RAR was significantly lower than before the procedure ( P < 0.05). One (3.45%) patient reported occasional soiling 3 months after RAR. Conclusion Recto-anal-repair is safe in treating third and fourth degree haemorrhoids with no major complications and low rate of residual disease. [ABSTRACT FROM AUTHOR]

Colectomy with ileorectal anastomosis for slow transit constipation (STC) is being challenged by other operations, such as segmental resections. The importance of preoperative anorectal physiology testing may therefore be increased. The aim of this study was to identify anorectal abnormalities in patients with STC, which may influence the surgical approach. Fifty consecutive patients with STC (43 women; median age, 49 years) and 28 controls (23 women; median age, 50 years) were examined with anorectal manovolumetry. Anal pressures and rectal volumes were recorded, at stepwise rectal distension. Anal resting pressure was lower in patients (median, 54 cm H2O; range, 22–130) than in controls (median, 68 cm H2O; range, 35–100) ( p<0.05). Squeeze pressure tended to be lower in patients (median, 147 cm H2O; range, 53–382) than in controls (median, 177 cm H2O; range, 65–423) ( p=0.09). Rectal sensory thresholds did not differ significantly between patients and controls, although 10 patients had a threshold for filling above the 95th percentile of controls. Rectal compliance was increased in patients in the pressure interval 5–35 cm H2O ( p<0.05–0.01). The threshold and amplitude of the recto-anal inhibitory reflex did not differ significantly, but the recovery of resting pressure after eliciting the reflex was lower in patients than in controls in the pressure interval 10–50 cm H2O ( p<0.05–0.001). More than half of the patients with STC deviated in some parameter. An impaired internal sphincter function and increased rectal compliance were seen. One fifth of the patients had impaired rectal sensation. [ABSTRACT FROM AUTHOR]

To correlate anorectal function including rectal evacuation with anorectal physiology and endoanal ultrasound in women with third degree obstetric anal sphincter injury repaired at the time of delivery.Forty-four women with repaired third degree tears underwent anorectal physiology, anal ultrasonography and clinical assessment using the St. Marks incontinence score (0–24). Evacuatory disturbance was assessed by questionnaire.There was a significant correlation between disturbed evacuation and incontinence symptoms (P =0.030). There was also a significant correlation between disturbed evacuation and internal anal sphincter (IAS) injury (P = 0.026), but there was no correlation with external anal sphincter (EAS) injury. There was a correlation between disturbed evacuation and low resting anal pressure (P = 0.013). Although IAS defects were associated with low anal pressure, only the correlation with Maximum Squeeze Pressure reached statistical significance (P = 0.018).Women with evacuatory disturbance after repaired third degree tears have a greater level of incontinence than those whose emptying is normal. This association is related to internal sphincter injury and reduced anal sphincter pressures. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate anorectal physiology in relation to clinically defined subgroups of patients with idiopathic constipation and to analyse relationships between anorectal physiology and rectal evacuation. One hundred consecutive patients with idiopathic constipation were clinically categorized as slow transit ( n = 19), outlet obstruction ( n = 52) and a group with mixed symptoms ( n = 29). They were examined by recording anal pressures and also rectal volumes in response to stepwise increases in rectal pressure (5–60 cm H2O). The manovolumetric results were compared with 28 sex and aged matched controls. Rectal evacuation was measured by computer-based image analysis of rectal emptying rate in defaecography. The rectal pressure thresholds for filling, urge and pain did not differ between the groups but there were proportionally more patients in the slow transit and mixed group with thresholds for filling exceeding 25 cm H2O ( P = 0.04). In total, 18% of patients had impaired sensitivity which was associated with long duration of symptoms ( P < 0.05). Patients with grossly impaired rectal sensitivity (filling threshold > 40 cm H2O) had impaired rectal evacuation ( P < 0.05). The rectal compliance was increased in the slow transit and mixed group ( P < 0.01–0.05) in the pressure interval 5–15 cm H2O. Anal resting and squeeze pressures did not differ between the groups although 7/19 in the slow transit group had values around the lower limit of controls. Slow wave frequency was lower in all patient groups ( P < 0.001 vs. controls). Rectal evacuation was not related to sphincter function or to rectal compliance. Clinical categorization of constipated patients defines groups where altered anorectal physiology is not uncommon. Constipation with symptoms of infrequent defaecation may be associated with impaired rectal sensitivity and increased rectal compliance whereas outlet obstruction symptoms are not clearly related to changes in anorectal physiology. [ABSTRACT FROM AUTHOR]

Objective: To compare a systemic transdermal therapeutic system with local application of glyceryl trinitrate ointment in the treatment of anal fissure. Design: Perspective, multicentre, randomised trial. Setting: Three teaching hospitals, Turkey. Subjects: 89 outpatients with chronic anal fissure were randomly assigned to be treated with either transdermal (n = 52) or 0.2% glyceryl trinitrate ointment (n = 37). Interventions: The patients were assessed at the sixth and the twelfth week after initial evaluation by physical examination, anoscopy, and anal manometry. Main outcome measures: Changes in the maximal anal resting pressure, healing rate. Results: Anal fissure was completely healed in 38 (73%) and 24 (64%) of the patients after 6 weeks, and 48 (81%) and 27 (79%) of the patients in transdermal group and ointment group, respectively. Maximal anal resting pressure was reduced by 24% and 21% in transdermal and ointment groups, respectively. Conclusion: Systemic transdermal application glyceryl trinitrate gave a satisfactory healing rate, which was comparable to that of local application of ointment. [ABSTRACT FROM AUTHOR]

Aim: The effect of transanal haemorrhoidal dearterialization (THD) on continence and anorectal physiology has not yet been demonstrated. Method: Twenty patients suffering from 3rd degree haemorrhoids were enrolled and underwent THD, including both dearterialization and mucopexy. Clinical assessment, anorectal manometry, rectal volumetry and endoanal ultrasound were performed preoperatively and at 6 months postoperatively. Results: Postoperatively two and six patients had transient rectal pain and tenesmus, respectively. No patient reported faecal urgency or minor or major incontinence. All patients remained able to discriminate gas from faeces. No significant variation of the mean values of anal manometric and rectal volumetric parameters was recorded at 6 months of follow-up compared with preoperative values. At 6 months both internal and external sphincters were endosonographically intact. Conclusion: THD does not cause trauma to the anal canal and rectum. [ABSTRACT FROM AUTHOR]