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Aims: To reduce maternal morbidity and improve the quality of life of women with obstetric fistula (OF) in Burundi. Methods: A permanent multidisciplinary OF Center was opened in 2010 offering comprehensive care to women with OF including nursing, surgery/anesthesia, medical care, physiotherapy, psycho-social support and education on family planning and nutrition. Outreach activities were conducted to detect patients together with awareness campaigns. Referral system was strengthened through health workers orientation. Results: There were 1559 first admissions and 479 re-admissions. Closure rates and continence rates at discharge after OF surgery were 77% and 61% respectively at the first intervention, and 58% and 41% at repeated intervention. All women with closed OF but incontinences 3 days after bladder catheter removal received physiotherapy. 260 vulnerable women received personal psycho-social support. 4760 health’s workers were given OF orientation and referral from health facilities increased from 14 to 40% in 5 years. Conclusions: OF Center’s care was efficient, affordable and to a certain degree sustainable. Lessons learned on the management of clinical data, the simultaneous offer of different interventions and the provision of diverse trainings show that providing multidisciplinary OF care is very complex and demands specific expertise and continuous monitoring.

To determine whether there is a postprandial increase of rectal pressure in patients with spinal cord injury (SCI) and to compare their rectal pressures with those of healthy volunteers.A before-after trial comparing SCI and control subjects.Patients were recruited from the register of an SCI unit at a rehabilitation medicine department, and the study took place at the university hospital laboratory in Sweden.Ten patients with high traumatic SCI and 9 healthy volunteers. Eight patients had a lesion above level T5.Continuous anorectal manometry was performed. Rectal activity was calculated before and at regular time intervals after a 1000-cal test meal.Rectal activity measured as area under the pressure curve.There was a significant increase in rectal activity of 46% after 10 minutes in the patients but of 72% after 5 minutes in the volunteers. There was no difference in fasting rectal activity, but patients had a stronger mean rectal postprandial response during 60 minutes compared with volunteers.These results support the theory that the colonic response to food is preserved in patients with high SCI.

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.

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.

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

Measurement of anal sphincter muscles: endoanal US, endoanal MR imaging, or phased-array MR imaging? A study with healthy volunteers.Beets-Tan RG, Morren GL, Beets GL, Kessels AG, el Naggar K, Lemaire E, Baeten CG, van Engelshoven JM.Department of Radiology, University Hospital of Maastricht, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands. rbe@rdia.azm.nlPURPOSE: To compare endoanal ultrasonography (US), endoanal magnetic resonance (MR) imaging, and phased-array MR imaging for anal sphincter muscle measurement. MATERIALS AND METHODS: Sixty healthy volunteers underwent 1.5-T phased-array MR, endoanal MR, and endoanal US examinations. Sphincter muscle thicknesses were measured. Measurement reliability was analyzed, and correlations among the imaging methods were calculated. Multivariate analysis was performed to assess the influence of age, weight, height, sex, parity, and obstetric trauma on sphincter dimensions. RESULTS: Both MR methods had good reliability for measurements of all sphincter components, whereas endoanal US was reliable for internal sphincter measurement only. There was little correlation between the techniques, except between the two MR techniques, with a strong correlation for total sphincter and perineal body thickness. The internal sphincter thickened significantly (P =.002) with age at endoanal US and endoanal MR imaging but not at phased-array MR imaging. There were small sex-based differences in sphincter muscle measurements at phased-array MR imaging only. CONCLUSION: Endoanal US enables reliable measurement of only internal sphincter thickness, whereas both MR imaging methods enable reliable measurement of all sphincter components. Sphincter measurement with phased-array MR imaging is as reliable as that with endoanal MR imaging

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

Since some important forms of brain injury in premature infants are caused in considerable part by disturbances in cerebral blood flow (CBF), it is important to be able to detect whether the cerebrovascular autoregulation, the mechanism by which CBF is maintained constant despite alterations in mean arterial blood pressure (MAP), is working properly. A recent study suggested that concordant changes in MAP and cerebral intravascular oxygenation (HbD), measured non-invasively by near-infrared spectroscopy (NIRS) as the difference between the concentration changes of oxygenated hemoglobin (HbO2) and deoxygenated hemoglobin (Hb), reflect impaired cerebrovascular autoregulation. Consequently, premature infants with impaired cerebrovascular autoregulation could be identified by simultaneous, continuous measurements of HbD and MAP. From several premature babies, MAP, HbD and arterial oxygen saturation (SaO2) were measured simultaneously at the University Hospital Leuven, Belgium. The concordance between MAP and HbD was quantitated using three different measures, among which a newly developed measure that looks for similarity of the dynamics between signals. Some preliminary results obtained from the measured data are given.

No normal values of tissue oxygenation index (TOI) of the brain are known regarding premature born infants. We measured TOI, a measure for the cerebral hemoglobin oxygen saturation, on the head of 15 preterm infants with a median postmenstrual age of 28 weeks (interquartile range (IQR) between 26-29 weeks) with spatially resolved spectroscopy (NIRO 300, Hamamatsu) during the first three days of life. Infants with intra-ventricular hemorrhage or periventricular leucomalacia before the first measurement, as shown by ultrasound, were excluded. The first measurement was done within the first 6 hours of life, the second and third measurement at, respectively, 24 and 48 hours after this first measurement. The mean TOI was calculated if saturation did not change by more than 5% for at least 30 minutes. Other parameters measured were PaO2, PCO2, pH, mean arterial blood pressure, heart rate, hemoglobin, glycemia and peripheral oxygen saturation. There was a significant increase of TOI after 24 (p0.05) and 48 (p0.001) hours. The median TOI on the first day was 57% (95% CI: 54-65.7), 66.1% on the second day (95%CI: 61.9-82.3%) and 76.1% on the third day (95%CI 67.8-80.1%). No correlation was found between TOI and peripheral oxygen saturation, blood pressure, PaO2, PaCO2 and hemoglobin concentration after multiple regression analysis. TOI increases in the first three days in premature born babies. The increase of TOI is not due to an increase of oxygenation or mean arterial blood pressure. In our opinion, it reflects the increase in cerebral blood flow during the first three days.

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.

The aim of this study was to examine the long-term results of electromyographic biofeedback training in fecal incontinence.Thirty-seven patients (1 male) received a customised program of 2 to 11 (median, 3) biofeedback training sessions with an anal plug electromyometer. Nine patients had persistent incontinence after anal sphincter repair, a further 8 patients had postsurgical or partial obstetric damage of the sphincter but no sphincter repair, 9 patients had neurogenic sphincter damage, and 11 patients were classified as having idiopathic fecal incontinence. Duration of voluntary sphincter contraction was measured by anal electromyography (endurance score) before and after treatment. A postal questionnaire was used to investigate the following variables: 1) subjective rating on a four-grade Likert-scale of the overall result of the biofeedback training; 2) incontinence score (maximum score is 18, and 0 indicates no incontinence); and 3) rating of bowel dissatisfaction using a visual analog scale (0 to 10).Twenty-two patients (60 percent) rated the result as very good (n = 8) or good (n = 14) immediately after the treatment period. Median endurance score improved from 1 to 2 minutes (P0.0001). Median incontinence score improved from 11 to 7, and bowel dissatisfaction rating improved from 5 to 2.8 (both P0.0001). After a median follow-up of 44 (range, 12-59) months, 15 patients (41 percent) still rated the overall result as very good (n = 3) or good (n = 12). The incontinence score did not change during follow-up. Median bowel dissatisfaction rating deteriorated from 2.8 to 4.2 but remained better than before treatment. Poor early subjective rating and the need for more than three biofeedback sessions were predictive of worsening during follow-up.We think it is encouraging that in this study biofeedback treatment for fecal incontinence with an intra-anal plug electrode resulted in a long-term success rate in nearly one-half of the patients.