PubMed Health⌕ Search

Biomedical subjects

A H Sultan

Publications and source records attributed to A H Sultan.

At least 19 recordsLinked to original sources
PubMed2006

Methods of repair for obstetric anal sphincter injury.

BACKGROUND: Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - is associated with significant maternal morbidity including perineal pain, dyspareunia and anal incontinence. Anal incontinence affects women psychologically and physically. Many do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS): are end-to-end (approximation) repair and overlap repair. OBJECTIVES: To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 January 2006), MEDLINE (January 1966 to 31 January 2006), EMBASE (January 1974 to 31 January 2006), SciSearch (January 1974 to 31 January 2006) and conference proceedings of obstetrics and gynaecology, surgery and coloproctology. SELECTION CRITERIA: Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS. DATA COLLECTION AND ANALYSIS: Trial quality was assessed independently by all authors. MAIN RESULTS: Three eligible trials, of grade A quality, involving 279 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (relative risk (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (RR 0.62, 95% CI 0.11 to 3.39, one trial, 52 women), flatus incontinence (RR 0.93, 95% CI 0.26 to 3.31, one trial, 52 women) and faecal incontinence (RR 0.07, 95% CI 0.00 to 1.21, one trial, 52 women) between the two repair techniques at 12 months but showed a statistically significantly lower incidence in faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women) and lower anal incontinence score (weighted mean difference -1.70, 95% CI -3.03 to -0.37) in the overlap group. Overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. AUTHORS' CONCLUSIONS: The limited data available show that compared to immediate primary end-to-end repair of OASIS, early primary overlap repair appears to be associated with lower risks for faecal urgency and anal incontinence symptoms. As the experience of the surgeon is not addressed in the three studies reviewed, it woudl be inappropriate to recommend one type of repair in favour of another.

Anal Canal↗
PubMed2001

Anal function: effect of pregnancy and delivery.

OBJECTIVE: To investigate the effect of pregnancy and delivery on anal continence, sensation, manometry, and sphincter integrity. STUDY DESIGN: Two hundred eighty-six nulliparous women in the third trimester completed a symptom questionnaire and underwent anorectal sensation and manometric evaluations. Three months postpartum, 161 women returned and the questionnaires and investigations were repeated together with anal endosonographic examinations. RESULTS: The prevalence of fecal urgency before, during, and after pregnancy was 1%, 9.4%, and 10.5%, respectively; the prevalence of anal incontinence before, during, and after pregnancy was 1.4%, 7.0%, and 8.7%, respectively. Vaginal delivery, particularly instrumental, resulted in a decrease in anal squeeze pressures (P =.015) and resting pressures (P =.002) but had no effect on anal sensation. Postpartum anal endosonographic examination revealed sphincter disruption in 38% of women. There was no relationship between symptoms and anal manometry, sensation, or sphincter integrity. Vaginal delivery (P <.0001) and perineal trauma (P <.001) were significantly associated with sphincter defects. CONCLUSION: Vaginal delivery is associated with a decrease in anal pressures and increased anal sphincter trauma but has no effect on anal sensation. These changes were not related to anal symptoms.

Anal Canal↗
PubMed2000

Pregnancy and delivery: a urodynamic viewpoint.

OBJECTIVE: The aims of this study were to establish prospectively the prevalence of objective bladder dysfunction before and after delivery by means of urodynamic investigations and to assess the effect of obstetric variables on bladder function. DESIGN: Prospective longitudinal study. Twin channel subtracted cystometry was performed in the standing and sitting position, with a cough stress test at the end of filling. The investigations were repeated three months postpartum. PARTICIPANTS: Two hundred and eighty-six nulliparae with singleton pregnancies who were delivered between April 1996 and November 1997 attended for antenatal assessment after 34 weeks of gestation and 161 who returned postpartum. SETTING: Department of Obstetrics and Gynaecology in a London teaching hospital. RESULTS: The mean urodynamic values both in pregnancy and postpartum lower than values defined in a non-pregnant population. The prevalence of genuine stress incontinence and detrusor instability were antenatally 9% and 8%, respectively, and postpartum 5% and 7%, respectively. Obstetric and neonatal factors were not related to urodynamic variables. CONCLUSIONS: Despite the reported high prevalence of urinary incontinence related to pregnancy and childbirth, neither pregnancy nor delivery resulted in any consistent effects on objective bladder function. Postpartum urodynamic measurements were not related to either obstetric or neonatal variables, but were dependent on antenatal values.

Adolescent↗
PubMed1999

Antenatal prediction of postpartum urinary and fecal incontinence.

OBJECTIVE: To investigate the effect of pregnancy and delivery on continence and to assess whether physical markers of collagen weakness can predict postpartum urinary and fecal incontinence (including incontinence of flatus). METHODS: In a prospective, longitudinal study in a London teaching hospital, 549 nulliparas were interviewed after 34 weeks' gestation and again 3 months postpartum regarding urinary and fecal symptoms before and during pregnancy and after delivery. Family histories of incontinence, prolapse, and collagen abnormalities were recorded also. Physical examination was done to assess markers of collagen weakness such as striae, hernia, varicose veins, and joint mobility. RESULTS: The prevalence of urinary incontinence before, during, and after pregnancy was 3.6%, 43.7%, and 14.6%, and rates of fecal incontinence were 0.7%, 6.0%, and 5.5%, respectively. Fecal urgency was more common in women who had spontaneous and instrument-assisted vaginal deliveries (n = 413) compared with cesareans (n = 131) (7.3% versus 3.1%; P = .046). Postnatal urinary or fecal dysfunction was not related to antenatal body mass index, smoking, race, striae, varicose veins, hemorrhoids, or family history of incontinence. Higher joint-mobility scores were associated with incontinence of flatus (P = .021) but not with other urinary or fecal symptoms. CONCLUSION: Although collagen weakness was previously implicated in the pathogenesis of incontinence, physical markers in this study could not predict postpartum urinary and fecal incontinence. Either those markers were not representative of collagen weakness, or a larger study with longer follow-up is necessary.

Adolescent↗
PubMed1999

Self-assessment of morbidity following radical hysterectomy for cervical cancer.

The aim of this study was to assess the magnitude of the morbidity following radical surgery for early stage cervical cancer. We performed a retrospective survey of all women who had undergone a radical hysterectomy and lymphadenectomy between the months of July 1995 and December 1996 inclusive at either the Royal Marsden or St George's Hospital (n =38), using a detailed questionnaire on bladder, ano-rectal and sexual function, both before and after treatment. Sixteen women (44.4%) received adjuvant radiotherapy. The mean interval between surgery and inquiry was 16.4% months (range 8-25 months). The mean age at the time of surgery was 40.5 years. Thirty-six out of 38 women contacted responded (94.7%). Overall 33 women (91.7%) reported new bladder, ano-rectal or sexual symptoms. Complaints of urinary incontinence, particularly of urge incontinence, and of voiding difficulties increased significantly after surgery (P <0.05). However, only 5.3% of women had sought treatment. Tenesmus increased significantly (P <0.05), while increases in diarrhoea and faecal incontinence were not statistically significant (P =0.051). Although 12.9% of women stated an improvement in their sex lives, 54.8% thought that their sex life was worse after treatment, and 12.9% of women had ceased sexual activity altogether. Of women of childbearing age 53.8% felt adversely affected by their loss of fertility. Bladder, ano-rectal and sexual symptoms are very common following radical hysterectomy for cervical cancer, with adverse effect on quality of life, and persist into the second year after treatment.

Journal Article↗
PubMed1999

Primary repair of obstetric anal sphincter rupture using the overlap technique.

OBJECTIVE: To evaluate the feasibility of a new technique of primary overlap anal sphincter repair instead of end-to-end repair. SETTING: A teaching hospital and a district general hospital. METHODS: Between June 1995 and November 1996, two obstetricians repaired 32 anal sphincters ruptured during vaginal delivery. A ruptured internal sphincter was repaired separately and the torn ends of the external sphincter were overlapped and sutured with 3/0 polydioxanone sulphate sutures (Ethicon, Edinburgh, UK). MAIN OUTCOME MEASURES: Bowel function, clinical assessment, anal endosonography and manometry performed at a mean of 140 days after delivery. RESULTS: Eight percent of the women experienced incontinence of flatus. Fifteen percent had persistent sonographic external sphincter defects, and 44% had internal sphincter defects. The maximum mean resting pressure was 58 mmHg (range 37-135) and the mean maximum incremental squeeze pressure 54 mmHg (range 8-104). None had defaecatory difficulty and no complications were encountered with the new technique of repair. CONCLUSIONS: Reservations regarding the feasibility of the overlap technique of primary repair are unfounded, as both subjective and objective outcomes are favourable compared with other studies using end-to-end approximation. A multicentre randomised study of the overlap vs end-to-end repair technique is now planned.

Adolescent↗
PubMed1999

Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse.

OBJECTIVE: To undertake a five year follow up of a cohort of women and children delivered by forceps or vacuum extractor in a randomised controlled study. DESIGN: Follow up of a randomised controlled trial. SETTING: District general hospital in the West Midlands. POPULATION: Follow up questionnaires were sent to 306 of the 313 women originally recruited at the North Staffordshire Hospital to a randomised controlled study comparing forceps and vacuum extractor for assisted delivery. Two hundred and twenty-eight women responded (74.5%) and all were included in the study; forceps (n = 115) and vacuum extractor (n = 113). MAIN OUTCOME MEASURES: Bowel and urinary dysfunction, child vision assessment, and child development. RESULTS: Maternal adverse symptoms at long term follow up were relatively common. Urinary incontinence of various severity was reported by 47%, bowel habit urgency was reported by 44% (98/225), and loss of bowel control 'sometimes' or 'frequently' by 20% of women (46/226). No significant differences between instruments were found in terms of either bowel or urinary dysfunction. Overall, 13% (20/158) of children were noted to have visual problems. There was no significant difference in visual function between the two groups: ventouse 11/86 (12.8%), compared with forceps 9/72 (12.5%); odds ratio 0.97, 95% CI 0.38-2.50. Of the 20 children with visual problems, a family history was known in 18, and 17/18 (94%) had a positive family history for visual problems. No significant differences in child development were found between the two groups. CONCLUSIONS: There is no evidence to suggest that at five years after delivery use of the ventouse or forceps has specific maternal or child benefits or side effects.

Adult↗
PubMed1998

Occult anal sphincter trauma following randomized forceps and vacuum delivery.

OBJECTIVE: To determine the prevalence of occult anal sphincter trauma 5 years after randomization to forceps and vacuum delivery. METHOD: Anal endosonography and manometry was performed in 44 of 313 women who had originally participated in one center of the Keele University Multicenter Assisted Delivery Trial at the North Staffordshire Maternity Hospital between September 1989 and May 1990. RESULTS: 50% admitted to defecatory symptoms and anal sphincter defects were identified in 61%. On the basis of intention to treat, 82% of forceps (n = 17) and 48% of vacuum deliveries (n = 27) had occult sphincter defects (P = 0.03). In four women, both instruments were used. However, the preponderance of defects in the forceps group persisted even when analysis was performed according to the final mode of delivery as well as in the group where only one instrument was used (n = 40). There was a significant fall in maximum squeeze anal pressure in the forceps group compared to the vacuum group (56 vs. 36 mmHg; P = 0.0007). Although twice as many in the forceps group suffered anal incontinence (32% vs. 16%) significance was not reached. CONCLUSIONS: Vacuum delivery appears to be associated with less occult anal sphincter trauma than forceps delivery. A large prospective randomized study is required to address the impact of specific situations, such as failed instrumentation with use of a second instrument and rotational delivery.

Adult↗
PubMed1997

Occult obstetric trauma and anal incontinence.

Obstetric trauma is by far the commonest cause of anal incontinence in women. Denervation and reinnervation of the pelvic floor and anal sphincter following vaginal delivery has been previously demonstrated. The advent of anal endosonography, however, has enabled the identification of occult anal sphincter defects following vaginal delivery. It is now possible to identify risk factors and change obstetric practice accordingly so as to minimize anorectal morbidity.

Anal Canal↗
PubMed1997

Anal incontinence after childbirth.

Advances in new imaging techniques have improved our understanding of the pathogenesis of anal incontinence after childbirth. Recent studies have confirmed the high prevalence of anorectal trauma and symptoms, although women rarely volunteer these symptoms. The way forward is to identify obstetric factors associated with anal incontinence and modify current practice to minimize morbidity.

Cesarean Section↗
PubMed1994

Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair.

OBJECTIVES: To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. DESIGN: (i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements. SETTING: Antenatal clinic in teaching hospital in inner London. SUBJECTS: (i) All women (n = 8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. MAIN OUTCOME MEASURES: Obstetric risk factors, defecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. RESULTS: (i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001), birth weight > 4 kg (P = 0.00002), and occipito-posterior position at delivery (P = 0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P = 0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. CONCLUSIONS: Vacuum extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.

Anal Canal↗
PubMed1994

Anal endosonography for identifying external sphincter defects confirmed histologically.

Defects of the external anal sphincter have traditionally been diagnosed by palpation, anal manometry and electromyography (EMG), but anal endosonography enables clear imaging of both the internal and external sphincter muscles. A study was performed to validate the interpretation of ultrasonographic images of external sphincter defects using histology as a 'gold standard'. In addition the accuracy of clinical examination, manometry, EMG mapping and anal endosonography in the diagnosis of sphincter defects were compared prospectively. Twelve consecutive patients with faecal incontinence (11 women, one man; mean age 46 (range 30-64) years) who required sphincter repair underwent clinical assessment, anal manometry, concentric-needle EMG mapping and anal endosonography before surgery. The endosonographer was unaware of the history or results of physiological tests and the surgeon performing the repair was blind to the ultrasonographic findings. At operation most or all of the suspected defect was excised and examined histologically. The pathologist was unaware of the endosonographic or operative findings at the time of reporting. Combined operative and histological examination identified an external sphincter defect in nine of the 12 patients. Anal endosonography correctly identified all nine defects and the three normal sphincters. The accuracy of clinical examination was 50 per cent and that of both EMG and anal manometry 75 per cent. In addition, anal endosonography identified a defect of the internal anal sphincter in eight patients. External sphincter defects identified by endosonography have not been previously verified histologically. Precise sphincter assessment is mandatory for the correct management of faecal incontinence. Anal endosonography is more accurate than clinical and conventional physiological methods and also provides information on the internal sphincter.

Adult↗