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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 65 | Anal Sphincter Damage After Vaginal Delivery [2002년 8월 DCR] | 2011-11-17 | 3707 |
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Relationship of Anal Endosonography and Manometry to Anorectal Complaints
Jan-Willem de Leeuw, Ph.D., Mark E. Vierhout, Ph.D., Piet C. Struijk, B.Sc.,Hajo J. Auwerda, M.D.,Dirk-Jan Bac, Ph.D., Henk C. S. Wallenburg, Ph.D.
From the Departments of Obstetrics and Gynecology and Internal Medicine and Gastroenterology, Ikazia
Hospital, and Department of Obstetrics and Gynecology, Erasmus University Hospital, Rotterdam, the Netherlands PURPOSE: This study was designed to assess the relationship of anal endosonography and manometry to anorectal complaints in the evaluation of females a long time after vaginal delivery complicated by anal sphincter damage.
METHODS: Thirty-four patients with anal sphincter damage after delivery, 22 with and 12 without anorectal complaints, and 12 controls without anorectal complaints underwent anal endosonography, manometry, and rectal sensitivity testing. Complaints were assessed by questionnaire, with a median follow-up of 19 years. RESULTS: Median maximum anal resting pressures were significantly lower in patients with anal sphincter damage with complaints (31 mmHg) than in controls (52 mmHg; P < 0.001). Median maximum
anal squeeze pressures were significantly lower in patients with (55 mmHg) and without (69 mmHg) complaints than in controls (112 mmHg; P < 0.001 for both). Maximum anal resting pressures were significantly lower in patients with anorectal complaints after anal sphincter damage than in patients without complaints (P = 0.02). Results of anal manometry showed a large overlap between all groups. Rectal sensitivity showed no significant differences between the three groups. Persisting sphincter defects, shown by anal endosonography, were significantly more present in patients with anal sphincter damage after delivery with (86 percent) and without (67 percent) complaints than in controls (8 percent; P < 0.001 and P < 0.01, respectively). No differences in the number of echocardiographically proven sphincter defects were found between patients with or without anorectal complaints after anal sphincter damage CONCLUSIONS: Echographically proven sphincter defects are strongly associated with a history of anal sphincter damage during delivery. Sphincter defects are present in the majority of patients with anorectal complaints. Anal manometry provides little additional therapeutic information when performed after anal endosonography in patients with anorectal complaints after anal sphincter damage during delivery. Fecal incontinence is an embarrassing health problem that may lead to social isolation. It is reported to occur in approximately 2.2 percent of the general population. In a recent American study, 13.1 percent of females aged 50 years and 20.7 percent of females aged >=80 years reported fecal incontinence. During the past decade, increasing awareness has developed that injury to the anal sphincter associated with childbirth is a major cause of the development of fecal incontinence in females.
Anal manometry and anal endosonography are considered the methods of choice to evaluate the
condition of the anal sphincter complex after vaginal delivery. Anal manometry may indicate the presence of anal sphincter malfunction when anal resting and squeeze pressures are reduced, and anal endosonography allows reliable visualization of damage to the anal sphincters. However, results of follow-up studies with anal manometry and endosonography in patients who had anal sphincter injury during delivery are conflicting. In some studies, anal manometry showed lower resting and squeeze pressures in patients with sphincter damage than in controls, whereas other studies showed differences in only one of these parameters or no differences at all. Anal manometry showed no differences between patients with and without complaints after anal sphincter damage. Studies using anal endosonography showed significantly more persisting sphincter defects in patients with anal sphincter damage during delivery than in controls. Some studies using anal endosonography in patients with and without anorectal complaints after anal sphincter damage showed significant differences between these groups, whereas others found only differences in the number of defects in one of the sphincters or no differences. The majority of these studies were done shortly after anal sphincter damage had occurred or lacked control groups. The aim of the present study was to assess the relationship of anal manometry and endosonography to anorectal complaints in patients who had demonstrated anal sphincter injury during vaginal delivery, after primary repair and long-term follow-up. DISCUSSION
The present study describes the relationship of anal endosonography and manometry to anorectal complaints at least ten years after anal sphincter injury that occurred during delivery. For comparison of the results of anal manometry and endosonography in patients who had anal sphincter damage during delivery, we sought to establish a control group of females who had an uncomplicated vaginal delivery at approximately the same time and no anorectal complaints. Enrollment of those healthy subjects into the study proved to be difficult, and we had to be satisfied with only 12 subjects in the control group. General and obstetric characteristics were similar between the study group and the controls.
The results of anal manometry were significantly related to previous anal sphincter injury. Both MARP
and MASP were significantly lower in patients with previous anal sphincter damage with complaints than in controls, although in patients with previous anal sphincter damage without complaints, only MASP differed significantly from that in controls. Haadem et al. and Sultan et al. showed that MARP and MASP were significantly reduced in patients with anal sphincter damage shortly after delivery, regardless of the presence of complaints. Sørensen et al. found significantly lower MARP and MASP in patients with anal sphincter damage than in controls 3 months after delivery, but these differences had disappeared 12 months after delivery. Our results indicate that anal sphincter injury during delivery is associated with decreased anal squeeze pressures even more than ten years after delivery, regardless of the presence of anorectal complaints, whereas decreased anal resting pressures are only associated with previous anal sphincter injury in patients with complaints. In patients with anal sphincter damage, MARP was significantly lower in patients with anorectal complaints than in those without complaints, but MASP was not different between groups. The large overlap between MARP and MASP in both groups, as apparent from Figures 1 and 2, limits the predictive value of anal manometry, in accordance with results of previous studies.
Our results showed no differences in any of the parameters of rectal sensitivity between the three groups. Reports on rectal sensitivity tests after anal sphincter damage in the literature are scarce. Poen et al.reported only an increased volume of first sensation in patients with anal sphincter damage but no
differences in other parameters. On the basis of these results, testing of rectal sensitivity in the evaluation of patients with anal sphincter damage appears to have limited clinical value. In the present study ultrasonographic defects in the anal sphincter complex were strongly associated with anal sphincter damage during delivery, in accordance with results of previous studies. Results of previous studies on the relationship between anorectal complaints and anal endosonography are contradictory. Some studies showed a strong association between findings of anal endosonography and the occurrence of anorectal complaints, whereas others found no relationship between fecal incontinence and sphincter defects. In the present study, sphincter defects tended to be more common in subjects who reported fecal incontinence, but this did not reach statistical significance (Table 3).
 In accordance with findings reported by Poen et al., we could not demonstrate a difference in the radial extent of sphincter damage between patients with anal sphincter damage and controls. Contrary to observations reported by Sultan et al.,we found no significant difference in the craniocaudal length of the defects in patients with anal sphincter damage compared with controls. In the entire group of 46 subjects, the results of anal endosonography were in agreement with those of
anal manometry. Sultan et al. reported only lowered resting pressures in patients with internal sphincter defects, whereas in patients with external sphincter defects, no difference was found with regard to maximum squeeze pressures. After subdivision of our study group according to clinical history, an association of the results of anal endosonography with the results of anal manometry could no longer be demonstrated. Our results of anal endosonography were more in line with clinical history than with the results of anal manometry, as shown in Table 3. Although the results of both anal manometry and anal endosonography are associated with anal
sphincter damage during delivery, our results suggest that in the evaluation of patients with anorectal complaints after anal sphincter damage during delivery, anal manometry provides little additional therapeutic information when performed after anal endosonography. With anal endosonography, a sphincter defect can be demonstrated in the vast majority of these patients, even in the presence of normal anal resting and squeeze pressures. The possibility of locating a sphincter defect is of clinical importance, because secondary repair is one of the therapeutic options in these patients. |
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