Internal sphincter and the nature of haemorrhoids.

Abstract

SUMMARY Internal anal sphincter activity has been studied in 84 patients with haemorrhoids and 40 asymptomatic subjects. Activity was estimated by measuring maximum resting anal pressure with a water filled anal balloon probe 7 mm in diameter connected to a strain gauge pressure transducer. There was greater activity of the internal sphincter in patients with haemorrhoids than in controls, but there was no significant relationship between sphincter activity and duration of symptoms, predominant symptom (bleeding or prolapse), severity of symptoms, history of pain, history of straining at stool, or size of haemorrhoids. Straining at stool occurred significantly more often in patients whose main complaint was prolapse than in those whose main complaint was bleeding. Anal dilatation reduced sphincter activity and the best clinical results were obtained in those with the most active sphincter. An internal sphincter abnormality may be an aetiological factor in some patients but there must be other factors as well. Straining at stool may determine whether bleeding or prolapse is the predominant symptom.The internal sphincter is overactive in some patients with haemorrhoids (Kerremans, 1969;Hancock and Smith, 1975). This is in evidence by an increased resting anal pressure and the presence of ultra slow pressure waves (0-6-1 9/min). This activity when present is abolished by anal dilatation (Hancock and Smith, 1975) with relief of symptoms, so it seems possible that a sphincter abnormality is related to the development of symptoms in patients with haemorrhoids.The clinical picture produced by haemorrhoids is very variable, and, in order to investigate this possible relationship, an attempt was made to correlate internal sphincter function with symptoms and appearances in series of patients with haemorrhoids. MethodsAnal pressure and motility were measured with an anal probe consisting of a small balloon built into a hollow Perspex rod of 7 mm diameter (Fig. 1). The balloon was filled with water and inflated to produce a slight convexity of its surface and was connected via fine polyethylene tubing to a Statham strain gauge pressure transducer. This in turn was connected to a Devices multichannel recording machine and the tracings were produced on heat sensitive paper.Received for publication 20 December 1976 The recording was taken without bowel preparation and before any examination. The recording was taken with the probe at centimetre steps from the anal verge and lasted about 15 minutes and the average pressure at each position in the anal canal was estimated with reference to a calibration of 100 cm H20 (Fig. 2). The resting pressure was often steady (Fig. 3), but sometimes regular pressure waves of long frequency and high amplitude were seen. If these pressure waves had a frequency of less than 2/min and an amplitude greater than 25 cm H20 they were called ultra slow waves (Fig. 3). It has been shown previously that ultra slow waves persist under anaesthesia with the external sphincter paralysed and are associa...

Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids

“…It has also been reported that people with strain 19,20) , or those who spend a long time sitting on the toilet during bowel movements are likely to develop hemorrhoids 21) . Nevertheless, some hemorrhoid patients report normal bowel movements [22][23][24] ,; hence, there lacks sufficient evidence to make a correlation between chronic constipation and hemorrhoids.…”

Esfincterotomia lateral interna associada à hemorroidectomia no tratamento da doença hemorroidária: vantagem ou desvantagem?

“…Hipertonia do esfíncter anal interno também é descrita como uma possível causa de dor nas cirurgias anorretais, incluindo a hemorroidectomia. Desta forma, a esfincterotomia associada à hemorroidectomia tem sido proposta para reduzir este aumento da pressão anal, podendo, inclusive, diminuir as complicações pós-operatórias (dor, retenção urinária, estenose) 12,34,35 . Alguns autores consideram que hemorroidectomia isolada normaliza as pressões anais, uma vez que estas estariam aumentadas devido à presença dos coxins vasculares, e que a esfincterotomia, além de ser desnecessária, poderia causar incontinência anal 34,36 .…”

“…Curiosamente, a intensidade da dor pós-operató-ria nos três primeiros dias (período da 1ª evacuação) foi maior nos pacientes do grupo com ELI, sugerindo que o espasmo do esfíncter anal não tem contribuição importante na dor pós-hemorroidectomia 34,39 . Neste estudo, assim como em outros 34 , observa-se que a associação de ELI no tratamento da doença hemorroidária não reduziu a dor pós-operatória.…”

“…Geralmente, a completa continência anal retorna em alguns meses 12,41 . Alguns autores receiam que a hemorroidectomia associada à ELI aumente o risco de incontinência fecal 34,36 , porém, inú-meros estudos sobre tratamento cirúrgico, com esfincterotomia, da fissura anal mostraram baixa incidência de incontinência anal, quando analisada à longo prazo, sendo, portanto, considerada como de ocorrên-cia transitória 42 .…”

Comparative study between open (milligan morgan) haemorrhoidectomy and stapled haemorrhoidectomy

“…18 Smith et al has noted that urinary retention is the most common problem after haemorrhoidectomy, its degree related to the amount of surgery and the incisions required. 21 The anal sphincter has the same nerve root as the bladder sphincter.…”