Exoanal Imaging of the Anal Sphincters

Dietz, Hans Peter

doi:10.1002/jum.14246

Cited by 70 publications

(126 citation statements)

References 42 publications

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“…Most obstetric units have a convex transducer and the method is non‐intrusive and therefore less bothersome for the patient. Furthermore, assessment of the pelvic floor muscles can be performed during both relaxation and contraction of the pelvic floor, and the anal mucosa as well as signs of pelvic organ prolapse can be visualized . Recently, very good repeatability in detecting OASIS with TPUS, regardless of experience, has been shown…”

Section: Introductionmentioning

confidence: 99%

Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury

Stuart

Ignell

Örnö

2019

Acta Obstet Gynecol Scand

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Introduction Endoanal ultrasound is considered the gold standard when assessing the obstetric anal sphincter complex. Due to its relative intrusiveness and economic cost, other ultrasound modalities are on the rise, such as transperineal ultrasound with a convex probe. The aim of our study was to evaluate the agreement between endoanal ultrasound scores (EAUS score) and transperineal ultrasound scores (TPUS score) in assessing residual obstetric anal sphincter defects. Material and methods Fifty‐nine women were examined 6 months after primary suturing of obstetric anal sphincter injury with two ultrasound modalities. A standardized scoring system analyzing the length, depth and radial extent of both the external (EAS) and internal (IAS) sphincter was used. Wexner fecal incontinence score was used to assess the patients’ symptoms. Results Transperineal ultrasound scores score showed a strong significant correlation with EAUS score during both pelvic floor relaxation and contraction: Spearman's rho [rs] = 0.74, P < 0.001, and rs = 0.77, P < 0.001, respectively. For both EAS and IAS, significant correlations were found for all parameters, that is, length, depth and angle between both EAUS and TPUS. A statistically significant correlation was found between EAUS score and Wexner score (rs = 0.36, P = 0.005). A significant correlation between the EAS‐EAUS score (rs = 0.36, P = 0.005) and Wexner score was found, but no significance was found between IAS‐EAUS score and Wexner score (rs = 0.22, P = 0.097). Significant correlations were found for Wexner score and TPUS score in resting state (rs = 0.36, P = 0.01) and contracting state (rs = 0.28, P < 0.05), and between Wexner score and EAS‐TPUS score in resting state (rs = 0.32, P = 0.02). Conclusions The results indicated a strong agreement between endoanal and transperineal ultrasound in assessing residual obstetric anal sphincter defects 6 months after primary suturing. Furthermore, a weak significant correlation was found between the ultrasound scores and the patients’ Wexner fecal incontinence score.

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Section: Introductionmentioning

confidence: 99%

Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury

Stuart

Ignell

Örnö

2019

Acta Obstet Gynecol Scand

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“…), using proprietary software 4D View v10 (GE Healthcare), while blinded to all clinical data. Multislice, or TUI, was used to evaluate external (EAS) and internal (IAS) anal sphincter trauma in volumes obtained with the woman at rest and on PFMC, as described previously. A set of eight transverse TUI slices was obtained.…”

Section: Methodsmentioning

confidence: 99%

What is a significant defect of the anal sphincter on translabial ultrasound?

Subramaniam

Dietz

2020

Ultrasound in Obstet & Gyne

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Objective The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two‐thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound. Methods This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed. Results There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single‐slice defect angle on TUI was low, and areas under the receiver‐operating‐characteristics curves were too low to determine a distinct cut‐off value for defect angle. Conclusions Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single‐slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut‐off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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“…External anal sphincter trauma was evaluated on PFMC using tomographic imaging, as previously described . A set of eight slices was obtained and the EAS was encompassed by placing one slice cranial to the EAS (at the level of the puborectalis muscle) and another caudal to the internal anal sphincter (IAS) at the level of the anal verge, with variable inter‐slice interval, depending on the length of the EAS . The remaining six slices were used to demonstrate the EAS.…”

Section: Methodsmentioning

confidence: 99%

“…The remaining six slices were used to demonstrate the EAS. A significant EAS defect was diagnosed if at least four out of six slices showed an EAS defect of ≥ 30° of circumference . This paper focuses exclusively on EAS trauma as we have previously shown that IAS defects were less likely to be predictive of AI diagnosed using our methodology on translabial ultrasound .…”

Section: Methodsmentioning

confidence: 99%

“…LUG measurements were undertaken by placing callipers in the centre of the hypoechogenic structure indicating the urethral mucosa and smooth muscle, and on the most medial aspect of the muscle insertion on the inferior pubic ramus [18]. External anal sphincter trauma was evaluated on PFMC using tomographic imaging, as previously described [19,20]. A set of eight slices was obtained and the EAS was encompassed by placing one slice cranial to the EAS (at the level of the puborectalis muscle) and another caudal to the internal anal sphincter (IAS) at the level of the anal verge, with variable inter-slice interval, depending on the length of the EAS [19].…”

Section: Methodsmentioning

confidence: 99%

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Is levator trauma an independent risk factor for anal incontinence?

et al. 2019

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Aim To determine the role of levator ani trauma in anal incontinence (AI), whilst controlling for anal sphincter injury. Methods The records of 1273 patients who had attended a tertiary urogynaecology unit between 1st of January to 31st December 2016 were reviewed. AI was assessed using St Mark's score and visual analogue scale (VAS). Levator muscle and anal sphincter trauma were examined by translabial ultrasound using tomographic imaging, with archived data sets investigated blinded against all clinical data. A complete avulsion was diagnosed if at least three central tomographic slices showed an abnormal muscle insertion, rated separately for each side. A significant anal sphincter defect was diagnosed if at least four out of six slices showed a defect of ≥ 30°. Results Avulsion was associated with St Mark's score (P = 0.005) and VAS bother of AI (P = 0.022) both on univariate analysis and when controlling for external anal sphincter (EAS) trauma on translabial imaging, forceps, body mass index (BMI) and age (P = 0.011 and P = 0.04, respectively). AI expressed as a binary variable was significantly associated with avulsion on univariate analysis (P = 0.011), although the association became nonsignificant after controlling for anal sphincter trauma, age, BMI and forceps delivery (P = 0.084). Conclusion In this retrospective observational study, we found a weak association between levator ani avulsion and measures of AI, which largely remained significant when controlling for anal sphincter trauma. However, given the large data set, any clinical effect of levator trauma on AI is likely to be minor.

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Exoanal Imaging of the Anal Sphincters

Cited by 70 publications

References 42 publications

Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury

Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury

What is a significant defect of the anal sphincter on translabial ultrasound?

Is levator trauma an independent risk factor for anal incontinence?

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