DO CHANGES IN ANAL SPHINCTER ANATOMY CORRELATE WITH
					ANAL FUNCTION IN WOMEN WITH A HISTORY OF VAGINAL DELIVERY?

MURAD-REGADAS, Sthela Maria; DEALCANFREITAS, Iris Daiana; REGADAS, Francisco Sergio Pinheiro; RODRIGUES, Lusmar Veras; FERNANDES, Graziela Olivia da Silva; PEREIRA, Jacyara de Jesus Rosa

doi:10.1590/S0004-28032014000300006

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Original Articles • Arq. Gastroenterol. 51 (3) • Jul-Sep 2014 • https://doi.org/10.1590/S0004-28032014000300006 linkcopy

DO CHANGES IN ANAL SPHINCTER ANATOMY CORRELATE WITH ANAL FUNCTION IN WOMEN WITH A HISTORY OF VAGINAL DELIVERY?

Alterações na anatomia do esfíncter anal se correlacionam com a função anal em mulheres com história de parto vaginal?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objectives To evaluate anal sphincter anatomy using three-dimensional ultrasonography (3-DAUS) in incontinent women with vaginal delivery, correlate anatomical findings with symptoms of fecal incontinence and determine the effect of vaginal delivery on anal canal anatomy and function.

Methods Female with fecal incontinence and vaginal delivery were assessed with Wexner’s score, manometry, and 3DAUS. A control group comprising asymptomatic nulliparous was included. Anal pressure, the angle of the defect and length of the external anal sphincter (EAS), the anterior and posterior internal anal sphincter (IAS), the EAS + puborectal and the gap were measured and correlated with score.

Results Of the 62, 49 had fecal incontinence and 13 were asymptomatic. Twenty five had EAS defects, 8 had combined EAS+IAS defects, 16 had intact sphincters and continence scores were similar. Subjects with sphincter defects had a shorter anterior EAS, IAS and longer gap than women without defects. Those with a vaginal delivery and intact sphincters had a shorter anterior EAS and longer gap than nulliparous. We found correlations between resting pressure and anterior EAS and IAS length in patients with defects.

Conclusions Avaliar a anatomia do esfíncter anal usando ultra-sonografia tridimensional (3D-US) em mulheres incontinentes com parto vaginal, correlacionar os achados anatômicos com sintomas de incontinência fecal e, determinar o efeito do parto vaginal sobre a anatomia e função do canal anal.

Fecal incontinence, ultrasonography; Anal canal, physiology; Natural childbirth

Variables	EAS defect	EAS/IAS defect	Intact sphincter	Nulliparous
Variables	(n = 25) mean (±)	(n = 08) mean (±)	(n = 16) mean (±)	(n = 13)
Age	58 (12.96)	59 (4.79)	55 (10.74)	48 (13.85)
Incontinence score	4 (3.68)	6 (5.62)	4 (3.94)	0
Resting pressure (mmHg)	37 (3.51)	25 (4.08)	37 (3.82)	-
Maximum squeeze pressure (mmHg)	95 (10.42)	80 (13.83)	105 (10.72)	-
Squeeze pressure for 30 s* (mmHg)	59 (7.81)	55 (9.83)	82 (7.28)	-

Variables	EAS defect	EAS/IAS defect	Intact sphincter	Nulliparous
Variables	(n = 25) mean (±)	(n = 08) mean (±)	(n = 16) mean (±)	(n = 13)
Anterior EAS* (cm)	1.1 (0.13)	0.9 (0.11)	1.6 (0.12)	1.8 (0.22)
Anterior IAS (cm)	2.4 (0.35)	1.2 (0.09)	2.7 (0.08)	2.5 (0.33)
Gap length* (cm)	2.6 (0.48)	2.5 (0.31)	2.2 (0.51)	1.8 (0.42)
Posterior IAS (cm)	3.1 (0.36)	3.0 (0.14)	3.3 (0.38)	3.2 (0.51)
Posterior EAS+PR (cm)	3.2 (0.38)	3.0 (0.10)	3.3 (0.38)	3.2 (0.51)
Radial angle of the defect	141.9 (15.59)	136 (14.93)	-	-

Anorectal manometry	r (95% confidence interval)	P
EAS defect plus EAS + IAS defect (n = 33) Continence score vs
Resting pressure (mmHg)	- 0.383 (- 0.682 to 0.026)	0.0587
Maximum squeeze pressure (mmHg)	- 0.174 (- 0.541 to 0.248)	0.4038
CSqueeze Pressure for 30 s (mmHg)	- 0.108 (- 0.525 to 0.351)	0.6406
Intact sphincter (n = 16) Continence score vs
Resting pressure (mmHg)	- 0.077 (- 0.595 to 0.486)	0.7929
Maximum squeeze pressure (mmHg)	- 0.512 (- 0.825 to 0.042)	0.0610
Squeeze pressure for 30 s (mmHg)	0.024 (- 0.525 to 0.560)	0.9331

Dimensional anal ultrasonography	r (95% confidence interval)	P
EAS defect plus EAS +IAS defect (n = 33) Continence score vs
Anterior EAS (cm)	- 0.260 (- 0.561 to 0.101)	0.1426
Anterior IAS (cm)	- 0.339 (- 0.630 to 0.034)	0.0665
Gap length (cm)	0.023 (- 0.332 to 0.372)	0.8988
Radial angle of the defect	0.017 (- 0.337 to 0.367)	0.9240
Intact sphincter (n = 16) Continence score vs
Anterior EAS (cm)	- 0.402 (- 0.755 to 0.132)	0.1223
Anterior IAS (cm)	- 0.058 (- 0.550 to 0.462)	0.8287
Gap length (cm)	- 0.205 (- 0.646 to 0.337)	0.4443

Anorectal manometry	r (95% confidence interval)	P
EAS defect plus EAS + IAS defect (n = 33) Anterior EAS (cm) vs
Resting pressure (mmHg)*	0.405 (- 0.000 to 0.696)	0.0445
Maximum squeeze pressure (mmHg)	0.113 (- 0.306 to 0.496)	0.5888
Squeeze pressure for 30 s (mmHg)	0.214 (- 0.252 to 0.600)	0.3498
Intact sphincter (n = 16) Anterior EAS (cm) vs
Resting pressure (mmHg)	- 0.149 (- 0.640 to 0.428)	0.6092
Maximum squeeze pressure (mmHg)	0.002 (- 0.541 to 0.544)	0.9937
Squeeze pressure for 30 s (mmHg)	- 0.169 (- 0.652 to 0.411)	0.5636

Anorectal manometry	r (95% confidence interval)	P
EAS defect plus EAS + IAS defect (n = 33) Anterior IAS (cm) vs
Resting pressure (mmHg) *	0.474 (0.085 to 0.738)	0.0165
Maximum squeeze pressure (mmHg)	0.115 (- 0.304 to 0.497)	0.5832
Squeeze pressure for 30 s (mmHg)	0.316 (- 0.147 to 0.665)	0.1629
Intact sphincter (n=16) Anterior IAS (cm) vs
Resting pressure (mmHg)	- 0.170 (- 0.653 to 0.410)	0.5607
Maximum squeeze pressure (mmHg)	- 0.061 (- 0.584 to 0.498)	0.8354
Squeeze pressure for 30 s (mmHg)	0.029 (- 0.521 to 0.563)	0.9192

3-DAUS measurements	ICC (n = 118)	95% CI
Anterior EAS length	0.918	0.330 - 0.983
Anterior IAS length	0.940	0.753 - 0.985
Posterior IAS length	0.962	0.847 - 0.991
Posterior EAS+PR length	0.958	0.829 - 0.990
Gap length	0.982	0.930 - 0.996
Radial angle of the defect	0.973	0.889 - 0.993

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[TFN01t01] * P<0.05; EAS: external anal sphincter; IAS: internal anal sphincter