w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Correlation
of
anorectal
electromanometry
and
anorectal
three-dimensional
ultrasound
findings
in
patients
with
fecal
incontinence
Tracy
Mary
Betinardi
a,∗,
Doryane
Maria
dos
Reis
Lima
a,b,
Gustavo
Kurachi
c,
Mauro
Willemann
Bonatto
a,d,
Tomaz
Massayuki
Tanaka
a,e,
Univaldo
Etsuo
Sagae
a,faFaculdadeAssisGurgacz,Cascavel,PR,Brazil
bUniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
cColoproctologist,Brazil
dUniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil
eEscolaPaulistadeMedicina(EPM),UniversidadeFederaldeSãoPaulo(Unifesp),SãoPaulo,SP,Brazil
fUniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received8August2013 Accepted8June2015
Availableonline2October2015
Keywords: Incontinence Analmanometry 3Dultrasound Anismus
Hypotoniccontraction Hypotoniaatrest Sphincterinjury
a
b
s
t
r
a
c
t
Objective:Toshowthecorrelationofanorectalelectromanometryandthree-dimensional anorectalultrasonographyinpatientswithfecalincontinence.
Method:Prospectivestudyinvolving34women(meanage:55years)withadiagnosisoffecal incontinence.Thesamplesweresubmittedtothree-dimensionalanorectal ultrasonogra-phy/Echodefecographyandanorectalelectromanometry.
Results:Basedonanorectalelectromanometrydata,70.5%of34patientshadhypotoniaat rest,64.7%hadhypotoniccontraction,52.9%hadbothhypotoniaatrestandhypotonic con-traction,and44.1%hadanismus.Bythree-dimensionalanorectalultrasonography,32.3% hadinternalanalsphincterinjury,79.4%hadexternalanalsphincterinjures,and26.4%had bothinternalandexternalanalsphincterinjuries.In38.2%,anismuswassuggestedand 50%showedrectocele.Overall,only5.8%hadnormalresultsforanorectal electromanom-etrycombinedwiththree-dimensionalanorectalultrasonography.Kappaindexwas0.297 andthepresenceofanismusthroughanorectalelectromanometryandthree-dimensional anorectalultrasonographywascomparedbyStudent’sttestapplication,withp<0.0001. Conclusion:Weconcludethattherewasareasonableagreementinthecomparisonof sphinc-terhypotoniabyanorectalmanometryandsphincterinjurybyanorectalthree-dimensional ultrasonographyinagroupofpatientswithfecalincontinence.Theincidenceofanismus inpatientswithfecalincontinenceisconsiderable,andthetherapeuticapproachinthese patientsshouldbemodified.
©2013SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
∗ Correspondingauthor.
E-mail:[email protected](T.M.Betinardi).
http://dx.doi.org/10.1016/j.jcol.2015.06.007
Correlac¸ão
dos
achados
da
Eletromanometria
anorretal
e
Ultrassonografia
anorretal
tridimensional
nos
pacientes
portadores
de
incontinência
fecal
Palavras-chave: Incontinência Manometriaanal Ultrassom3D Anismus
Contrac¸ãohipotônica Hipotoniaemrepouso Lesãoesfinctérica
r
e
s
u
m
o
Objetivo: Demonstraracorrelac¸ãoentreeletromanometriaanorretal(EMAR)e ultrassono-grafiatridimensionalanorretal(3D-US)empacientescomincontinênciafecal.
Método: Estudoprospectivoenvolvendo34mulheres(mediadeidade:55anos)com diag-nósticodeincontinênciafecal.Asamostrasforamsubmetidasà3D-US/Ecodefecografiae EMAR.
Resultados: CombasenosdadosdeEMAR,70,5%das34pacientesexibiamhipotoniaem
repouso,64,7% exibiamcontrac¸ãohipotônica, 52,9%hipotoniaem repousoe contrac¸ão hipotônica,e44,1%exibiamanismus.Combasenosachadosde3D-US,32,3%exibiamlesão noesfíncteranalinterno,79,4%exibiamlesãonoesfíncteranalexterno,e26,4%emambos osesfíncteresanaisinternoeexterno.Pela3D-US,em38,2%daspacienteshouveindíciode anismus,eem50%,retocele.Nototal,apenas5,8%obtiveramresultadosnormais combina-dosparaEMARe3D-US.FoiconstatadoumíndiceKappa=0,297e,notestetdeStudent,a comparac¸ãodeanismusporEMARepor3D-USobtevesignificânciadep<0,0001.
Conclusão: Concluímosterhavidoconcordânciarazoávelaosercomparadaamanomatria anorretalparahipotoniaesfinctéricaeaultrassonografiatridimensionalanorretalparalesão esfinctéricaemumgrupodepacientescomincontinênciafecal.Aincidênciadeanismus empacientescomincontinênciafecaléconsiderável,eaabordagemterapêuticaparaesses pacientesdevesermodificada.
©2013SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
Introduction
Fecalincontinence(FI)isaconditionthatprecludesthe vol-untarycontroloftheelimination ofgasesand feces,being more prevalent in women than in men.1 Anal continence dependsonmultiplefactors,suchasmentalfunction,volume andconsistencyofstools,colonictransit,rectaldistensibility, sphincterfunction,sensitivityandanorectalreflexes.2Thus, anychangeinoneoftheseelementscanleadtoincontinence. Anorectalelectromanometry(AREM)andultrasonography (US) are useful tests in the evaluation and investigation ofFI. Other tests, notwidely available, and recommended inselected patients, includedefecography, pudendalnerve latencytest,andnuclearmagneticresonance.3–5
AREMisthetestforphysiologicalevaluationmorewidely usedinthestudyoffecalincontinence;itallowsthe measure-mentofpressuresatrestandcontractionpressures,aswell asthesizeofthefunctionalanalcanal,capacity,compliance, andrectoanalinhibitoryreflexsurvey.AREMalsoallowsan understandingofthesynchronizationofsensoryandmotor componentsoftheanalcanal.3,6
Anorectal US is characterized by its usefulness for the anatomicidentificationofsphinctericmuscles:internalanal sphincter(IAS),externalanal sphincter(EAS) and puborec-talismuscle, aswellas perianorectaltissue.7–9 Currently, a newtypeofanorectalUSprovidedwithathree-dimensional transducer(3D) isavailable. Thistechnologycreates a hub withastringofwidelymobileaxialimages.10–12Thus,3D-US producesahigh-qualityanatomicalimageoftheanalcanal andsphinctercomplex.13Studiescomparingtheaccuracyof two-and three-dimensional endo-analUS versus MRI with
anendo-rectalcoilinthemeasurementofmusclethickness foundthesameresults.14,15
Theaimofthisstudyistocorrelatethefindingsofanorectal electromanometryandofthree-dimensionalanorectal ultra-sonographyinpatientswithfecalincontinence.
Method
Thisisaprospectivestudyof34womendiagnosedwithfecal incontinence.ThesepatientsunderwentAREMand3D-USin the periodfrom March20,2011to December15,2011.The study was conductedatGastroclínicaCascavel/PR, and the patientsweresubmittedtoAREMand3D-US&ECDbytwo coloproctologists(GK&DMRL).
AREMwascarriedoutwiththewomeninleftlateral decu-bituswiththeirlegsflexedat90◦,withnobowelpreparation. Thedeviceusedhadan8-channelsystemofwaterfor infu-sion(DynapackMPX816,Dynamed).Eachpatienthada5-min periodforheradaptationtotheprobe,andalsoforobtaining stablebaselinerecordings,beforethemeasurements subse-quentlyobtained.WiththeuseofAREM,onecanevaluatethe pressureatrest(normal40–70mmHg),thecontraction pres-sure(normal100–200mmHg),andthemovementofsphincter musclesbeforestraining(relaxation:normal;non-relaxation: suggestsoccurrenceofanismus).
AsolutionwithPhosphoenema® wasappliedtwohours
before3D-US&ECDprocedures;thepatientswerepositioned in left lateral decubitus with their legs flexed at 90◦. The equipment used was a B & K Medical® machine with a
proximal-distaldirection,witha6.0-cmextension.This scan-ningcapturesasequenceoftrans-axialparallelimageswith 0.25mmthickness,resultinginafinalimageinthecube. Ultra-soundgelwasinstilledandthenanECDwasperformed.The parametersanalyzedwith3D-US&ECDwere:internaland externalanalsphincterintegrityandthepresenceofrectocele, intussusceptionandasuggestionofanismus.
TheresultsofAREM,3D-US& ECDwere analyzedusing statisticalcalculations,andacorrelationwascarriedout.
AnanalysisofagreementwithKappa16,17 betweenthese two testswas conducted, and points were awarded tothe changesfoundinAREM,in3D-US,andinECD.Soonafter,we proceededwiththedatacorrelation.Student’sttestwasused inordertocomparethepresenceofanismusinAREM,3D-US &ECDstudies.
Theinclusioncriteriawere:femalegender,agebetween40 and70years,andfecalincontinencecomplaints.The clini-calevaluationwasbasedontheJorge&Wexnerincontinence score.18Exclusioncriteriawere:malegender,presenceof neo-plasia,previoussurgery,andsubjectsagedbelow18/above70 years.
The study was approved by the Ethics Committee on ResearchinHumanBeings,FaculdadeAssisGurgacz (proto-colNo.191/2011andOpinionNo.011/2012-CEP/FAG)issued onJanuary25,2012.
Results
Themeanageofourpatientswas55years.Basedonanorectal manometrydata,70.5%of34patientshadhypotoniaatrest, 64.7%hadcontractionhypotonia,and52.9%hadan associa-tionofhypotoniaatrestandcontractionhypotonia(Fig.1).Of allwomen,44.1%hadasuggestionofanismus(Fig.2).With 3D-US & ECD, 32.3% of patients had internal anal sphinc-terinjuries,79.4%hadexternalanal sphincterinjuries,and 26.4%hadbothinternalandexternalanalsphincterinjuries.
300
250
200
150
100
50
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
Resting pressure (mmHg)
Voluntary contraction pressure (mmHg)
Fig.1–Distributionofvaluesofrestingandcontraction pressures.
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
Arem US-3D
Fig.2–Distributionofpatientswithahintofanismusby AREM,and3D-US&ECD.
In38.2%ofpatients,asuggestionofanismuswasperceived through3D-US&ECD,and50%hadrectocele.
Ofthosepatientswithsphincterhypotonia(atrestand/or withcontractionhypotonia),70.5%hadsomekindofsphincter (internaland/orexternal)injury.Overall,only5.8%ofthe34 patientshadnormalresultswithAREMcombinedwith3D-US &ECD.
Inthecomparisonofthetwotestsused,aKappa=0.297 (p=0.084)wasobtained,withareasonableagreementinthe evaluationofpatientswithFI.WithStudent’sttestcomparing thepresenceofanismusbyAREMversus3D-US&ECD,avalue forp<0.0001wasobtained;thus,thisfindingwasconsidered statisticallysignificant.
Discussion
Fecalincontinenceisacommonconditionandexertsamajor physicalimpactonthepatientandonhis/herpsychological well-being.Itisestimatedthatbetween0.8and15%ofthe gen-eralpopulationsufferfromfecalincontinenceatleastoncea month.Generally,FIisdefinedasthecontinuousorthe period-icalpassageofnon-controlledfecalmatter(morethan10mL) foratleastonemonthinanindividualagedover3years.1In theUSA,theestimatedincidenceofFIliesbetween2and7%, reachingvaluesofup to13.6%inpeopleover65years and of16.9%inpeopleover85years.19,20Intheanalcanal,there arevariousmechanismsandstructureswhichmaintainthe stateofcontinence.TheIASistonicallycontracted, account-ingfor80–85%ofthepressureoftheanalcanalatrest.This sphinctertemporarilyrelaxesinresponsetorectaldistension, andthisreflexrelaxation,mediatedbyentericnerves,isnot undervoluntarycontrol.1,9,17,21–25
EASconsistsofastriatedmusclewithitssomatic inner-vation derivedfromthe pudendalnerve (S2,S3,and S4);it represents the voluntarycomponent offecal incontinence. Thecontractionofthismusclenearly doublesthe pressure intheanalcanal.1
can be envisaged by physical examination and by digital rectal examination, being suggestedby AREM,detected by electromyography,andevidencedbydefecographyand,more recently,byechodefecography(3D-US&ECD)26asafailureof theanorectalangletostraining.
ManypatientswithFIcomplaintsdonothave anatomi-calabnormalities,but doexhibitfunctional changes12 that, onceidentified,canimprovetheincontinencereportedbythis groupofpatients.Themostimportantamongthesefunctional changeswouldbeanismus,whichattheenddevelops symp-tomssuchassoilingandinvoluntaryemissionofflatus/liquid stool,andthisworsens(orevensimulates)theIFpicture.
3D-US is a painless or only slightly painful test, being usuallywell toleratedby patients; this procedure does not require anesthetic sedation.9,21–25 US-3D still presents the characteristicofbeingareproducibleandminimallyinvasive examination,anddoesnotexposethepatienttoradiation.
OneapplicationofAREMistheobjectivemeasurementof internalandexternalanalsphincterpressures.Thistestalso maybecarriedouttomeasurethelengthoftheanalcanal,its complacency,sensitivity,and rectalcapacityinresponseto balloondistention,besidesanevaluationofrectosphincteric reflex.3,27
TheincidenceofchangesperceivedbyAREMinthisgroup ofpatientswasatleastof70.5%;andtheincidenceofsphincter changesobservedin3D-US&ECDwasatleastof79.4%.These resultsdemonstratehowcriticalisananatomicalevaluation forpatientswithFI.Theauthorsobservedareasonable agree-mentwhencomparingsphincterhypotoniabyAREMversus sphincterinjuryby3DUSinagroupofpatientswithFI.
OnecharacteristicofAREMistoallowtheevaluationof themusclesresponsiblebythe strainingphenomenon,and thistestmaysuggestthepresenceorabsenceofparadoxical contractionofsphinctermuscles.Theincidenceofanismus evaluatedinthisstudywas44.1%,andthefindingscompared totheresultsof3D-US&ECDwereregardedasstatistically significant.Thisfunctionalchangemustbetakenintoaccount earlyinthetreatmentofpatientswithFI,andmustbetreated concomitantly(throughamedicalorsurgicalprocedure).The accomplishmentof3D-US&ECDalsoallowstheevaluation ofotherchangesthatmaybeassociatedwiththesepatients, suchasrectocele,intussusception,enteroceleand/orperineal dehiscence.
Conclusion
Our conclusion is that there was a reasonable agreement whensphincterhypotoniathroughanorectalmanometryand sphincterinjurythroughthree-dimensionalanorectal ultra-sonographywerecomparedinagroupofpatientswithfecal incontinence.Theincidenceofanismusinpatientswithfecal incontinenceisconsiderable,andthetherapeuticapproachin thesepatientsshouldbemodified.
Many women withFI complaintsrefer soiling, and this leads us to believe that the soiling is only related to the sphincterhypotonia.Butwhatisrealizedisthatsoilingmay be present in patients with normal pressures and with FI complaintsasamanifestationofanismus.Thus,itis impor-tanttoidentifythiscondition.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1.LazarescuA,TurnbullGK,VannerS.Investigatingand treatingfecalincontinence:WhenandHow.CanJ Gastroenterol.2008;23:301–8.
2.NoviJM,MulvihillBHK,MorganMA.Combinedanal sphincteroplastyandperinealreconstructionforfecal incontinenceinwomen.JAOA.2009;109:234–6.
3.BharuchaAE,WaldA,EnckeP,RaoS.Functionalanorectal disorders.Gastroenterology.2006;130:1510–8[Review].
4.HilfikerPR,DebatinJF,SchwizerW,SchoenenbergerAW,Fried M,MarincekB.Defecography:depictionofanorectalanatomy andpathology.JComputAssistTomogr.1998;22:749–55.
5.RoosJE,WeishauptD,WildermuthS,WillmannJK,Marincek B,HilfikerPR.Experienceof4yearswithopenMR
defecography:pictorialreviewofanorectalanatomyand disease.Radiographics.2002;22:817–32.
6.BaldezJR.AchadosManométricosnasDoenc¸asAnoReto Cólicas.RevbrasColoproct.2004;24:10–4.
7.DragstedJ,GammelgaardJ.Endoluminalultrasonicscanning intheevaluationofrectalcancer:apreliminaryreportof13 cases.GastrointestRadiol.1983;8:367–9.
8.LawPJ,BartramCI.Analendosonography:techniqueand normalanatomy.GastrointestRadiol.1989;14:349–53 [Review].
9.TjandraJJ,MilsomJW,StolfiVM,LaveryI,OakleyJ,ChurchJ, etal.Endoluminalultrasounddefinesanatomyoftheanal canalandpelvicfloor.DisColonRectum.1992;35:465–70.
10.GoldDM,BartramCI,HalliganS,HumphriesKN,KammMA, KmiotWA.Three-dimensionalendoanalsonographyin assessinganalcanalinjury.BrJSurg.1999;86:365–70.
11.ChristensenAF,NielsenMB,EngelholmSA,RoedH,Svendsen LB,ChristensenH.Three-dimensionalanalendosonography mayimprovestagingofanalcancercomparedwith two-dimensionalendosonography.DisColonRectum. 2004;47:341–5.
12.RegadasSMM,RegadasFSP,RodriguesLV,SilvaFR,LimaDMR, Regadas-FilhoFSP.ImportânciadoUltra-somTridimensional naAvaliac¸ãoAnorretal.ArqGastroenterol.2005;42:226–32.
13.EtienneyI,deParadesV.Three-dimensionalendoanal ultrasonographyindailyproctologicalpractice.ClinRes HepatolGastroenterol.2011;35:260–70.
14.Beeets-TanRG,MorrenGL,BeetsGL,KesselsAC,NaggarELK, LemaireE,etal.Measurementofanalsphinctermuscle: endoanalUSendoanalMRimaging,orphase-arrayMR imaging?Astudyhealthyvolunteers.Radiology. 2001;220:81–9.
15.WestRL,DwarkasingS,BrielJW,HansenBE,HussainSM, SchoutenWR,etal.Canthree-dimensionalendoanal ultrasonographydetectexternalandsphincteratrophy?A comparisonwithendoanalmagneticresonanceimaging.IntJ ColorectalDis.2005;20:328–33.
16.SiegelS,CastellanN.Nonaparametricstatisticsforthe behavioralsciences.2nded.NewYork:McGraw-Hill;1988.p. 284–5.
17.FleisJosephL.Statisticalmethodsforratesandproportions. NewYork:JohnWiley;1981.p.212–36.
18.JorgeJMN,WexnerSD.Etiologyandmanagementoffecal incontinence.DisColonRectum.1993;36:77–97[Review].
20.AspirozF.Guíaprácticasobreincontinenciaanal.RevEsp EnfermDig.2003;95:722–6.
21.ZetterströmJP,MellgrenA,MadoffRD,KimDG,WongWD. PerinealBodymeasurementimprovesevaluationofanterior sphincterlesionsduringendoanalultrasonography.DisColon Rectum.1998;41:705–13.
22.SentovichSM,BlatchfordGJ,RivelaLJ,LinK,ThorsonAG, ChristensenMA.Diagnosinganalsphincterinjurywith transanalultrasoundandmanometry.DisColonRectum. 1997;40:1430–4.
23.KleinübingHJr,JanniniJF,MalafaiaO,BrennerS,PinhoTM. Transperinealultrasonography:newmethodtoimagethe anorectalregion.DisColonRectum.2000;43:
1572–4.
24.WilliamsAB,BartramCI,HalliganS,MarshallMM,NichollsRJ, KmiotWA.Multiplanaranalendosonography–normalanal canalanatomy.ColorectalDis.2001May;3:169–74.
25.WilliamsAB,BartramCI,HalliganS,MarshallMM,NichollsRJ, KmiotWA.Endosonographicanatomyofthenormalanal canalcomparedwithendocoilmagneticresonanceimaging. DisColonRectum.2002;45:176–83.
26.Murad-RegadasSM,RegadasFS,RodriguesLV,SouzaMH, LimaDM,SilvaFR,etal.Anovelproceduretoassessanismus usingthree-dimensionaldynamicanalultrasonography. ColorectalDis.2007;9:159–65.
