Vargas CE, Acevedo D, Melo AI, López S, Pérez PM, Aular M, Souble RO

Language: Spanish
References: 16
Page: 5-11
PDF size: 262.90 Kb.

ABSTRACT

Introduction: the physiology of fecal continence control is complex and depends on the integrated action of various factors; therefore, to understand the etiology, detection and classification of fecal incontinence (FI), not only clinical evaluation is used; but various complementary tests such as endoanal ultrasound (EAU) and anorectal manometry (ARM), but with controversy in their usefulness and results. Objective: establish the relationship of a manometric and ultrasound severity scale with clinical symptoms in patients with fecal incontinence. Material and methods: prospective cross-sectional study in patients with FI from the consultation of 3 coloproctology units in the period between 2015-2023, who underwent a complete clinical evaluation by a specialist with digital rectal examination (DRE) at rest and dynamic plus the grade clinical severity by applying the Wexner incontinence scale or Cleveland Clinic Score (CCS); and performance by another specialist of high-resolution anorectal manometry and 3D endoanal ultrasound; thus developing a scale of physiological severity and its correlation with the clinic. Results: 144 patients were evaluated, 90% female, average age 56 years. Average number of pregnancies 3.47 ± 2.26. 26.4% with previous anorectal surgeries. According to CCS, 50% with moderate FI, 43% mild and 7% severe. At DRE 53% had a hypotonic sphincter at rest and 82% had a low response to voluntary squeeze. In the ARM, 60% had decreased resting pressure (RP), 69% had low squeeze pressure (SP), 97% had decreased squeeze endurance (SE), and 49% had altered sensitivity. 32% with anal sphincter injury in the EAU. When analyzing hypotonia at DRE at rest and in voluntary squeeze, it was correlated respectively with RP and low manometric SP (p < 0.001). Injury to the anal sphincters was related to lower manometric pressures and therefore a higher degree of severity (p < 0.04). The physiological severity scale correlated in 88% of the cases with the CCS clinical scale and demonstrates that the greater the alteration of its parameters, the greater the clinical severity (p < 0.05). Conclusions: the proposed physiological severity scale demonstrates an adequate correlation with the severity of clinical FI, and the greater the alteration of its parameters, the greater the severity score. The presence of anal sphincter injury in EAU is related to a decrease in manometric parameters. Clinical evaluation with DRE can predict a significant number of cases of decreased manometric pressure but not objectively nor of associated sphincter injuries, but a greater number of studies must be carried out applying this scale, determining its therapeutic importance and compare it with other clinical scales.

REFERENCES

1. Nelson R, Norton N, Cautley E, Furner S. Community based prevalence of anal incontinence. JAMA. 1995; 274 (7): 559-561.

2. Toglia MR. Pathophysiology of anal incontinence, constipation and defecatory dysfunction. Obstet Gynecol Clin North Am. 2009; 36 (3): 659-671.

3. Mellgren A, Jensen LL, Zetterstrom JP, Wong WD, Hofmeister JH, Lowry AC. Long-term cost of fecal incontinence secondary to obstetric injuries. Dis Colon Rectum. 1999; 42 (7): 857-865; discussion 865-867.

4. Liberman H, Faria J, Ternent CA, Blatchford GJ, Christensen MA, Thorson AG. A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence. Dis Colon Rectum. 2001; 44 (11): 1567-1574.

5. Felt-Bersma RJF, Meuwissen SGM. Anal manometry. Int J Colorect Dis. 1990; 5 (3): 170-173.

6. Freys SM, Fuchs KH, Fein M, Heimbucher J, Sailer M, Thiede A. Inter- and intraindividual reproducibility of anorectal manometry. Langenbecks Arch Surg. 1998; 383 (5): 325-329.

7. Knowles AM, Knowles CH, Scott SM, Lunniss PJ. Effects of age and gender on three-dimensional endoanal ultrasonography measurements: development of normal ranges. Tech Coloproctol. 2008; 12 (4): 323-329.

8. Salvans S, Parés D, Pera M, Pascual M, Alonso S, Courtier R et al. Descripción de los hallazgos de la ecografía endoanal en pacientes con incontinencia fecal mediante un sistema de puntuación. Cir Esp. 2009; 86 (5): 290-295.

9. Muñoz Yagüe T, Álvarez Sánchez V, Ibáñez Pinto A, Solís-Herruzo JA. Clínica, manometría anorrectal y electromiografía de superficie en el estudio de los pacientes con incontinencia fecal. Rev Esp Enferm Dig. 2003; 95: 629-634.

10. Lumi CM, Miravalle OR, La Rosa L, Gualdrini UA, Arias JH, Lueso M et al. Ecografía anorrectal y manometría en el estudio de pacientes con incontinencia fecal. Acta Gastroenterol Latinoam. 2012; 42 (3): 193-198.

11. Murad-Regadas SM, Regadas FSP, Filho FSPR, Borges LB, da Silva Vilarinho A, Veras LB et al. Pubovisceral muscle and anal sphincter defects in women with fecal or urinary incontinence after vaginal delivery. Tech Coloproctol. 2019; 23 (2): 117-128. doi: 10.1007/s10151-018-1895-x.

12. Giordano P, Wexner SD. The assessment of fecal incontinence in women. J Am Coll Surg. 2001; 193 (4): 397-406.

13. Murad-Regadas SM, Dealcanfreitas ID, Regadas FS, Rodrigues LV, Fernandes GO, Pereira Jde J. Do changes in anal sphincter anatomy correlate with anal function in women with a history of vaginal delivery? Arq Gastroenterol. 2014; 51 (3): 198-204.

14. Ciriza de los Ríos C, Ruiz de León A, García Durán F, Tomás Moro E, Carneros Martín JA, Muñoz Yagüe T et al. Calidad de vida en pacientes con incontinencia fecal y su relación con la gravedad de la misma. Gastroenterol Hepatol. 2010; 33: 621-628.

15. Coura MM, Silva SM, Almeida RM, Forrest MC, Sousa JB. Is digital rectal exam reliable in grading anal sphincter defects? Arq Gastroenterol. 2016; 53 (4): 240-245.

16. Bordeianou L, Lee KY, Rockwood T, Baxter NN, Lowry A, Mellgren A et al. Anal resting pressures at manometry correlate with the Fecal Incontinence Severity Index and with presence of sphincter defects on ultrasound. Dis Colon Rectum. 2008; 51 (7): 1010-1014. doi: 10.1007/s10350-008-9230-7.