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Biomedical subjects

A H Sultan

Publications and source records attributed to A H Sultan.

33 records · Page 2Linked to original sources
PubMed1994

Anterior anal sphincter repair in patients with obstetric trauma.

Anterior sphincter repair for faecal incontinence related to obstetric trauma was performed in 55 patients: 32 with incontinence after delivery and 23 with late onset. Anal endosonography and physiological tests were performed before and after surgery. After a median of 15 (range 6-36) months, 42 patients had improved, 11 had not improved and two were awaiting colostomy closure. The postoperative squeeze pressure was increased (by 20 versus 5 cmH2O, P = 0.05) and the external sphincter was more frequently intact (32 of 35 versus five of 11, P = 0.003) in those with a good outcome. Patients with an intact external sphincter had higher postoperative squeeze pressures (50 versus 20 cmH2O, P = 0.004). Patients with late-onset incontinence were older than those who developed incontinence soon after delivery (median 59 versus 32 years, P < 0.001) and had longer pudendal nerve terminal motor latencies (2.3 versus 2.1 ms, P = 0.03). Failure of repair is related to persistent external sphincter defects. Late-onset incontinence, even with a prolonged pudendal nerve terminal motor latency, does not preclude a good outcome.

Adult↗
PubMed1994

Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy.

PURPOSE: The aim of lateral internal anal sphincterotomy when treating anal fissure is to divide the distal one-third to one-half of the internal anal sphincter. This study aimed to evaluate prospectively the extent of disruption to the internal anal sphincter following lateral anal internal sphincterotomy and also to establish the prevalence of symptoms of anal incontinence in these patients. METHODS: Fifteen patients with anal fissure (ten females and five males) had bowel symptoms assessed and anal endosonography performed preoperatively and two months after lateral internal anal sphincterotomy. RESULTS: Anal endosonography was normal preoperatively in all but two females who had anterior external sphincter defects (presumedly from previous obstetric trauma). Postoperatively, apart from one male in whom no defect could be identified, all had an internal anal sphincter defect corresponding to the site of lateral internal anal sphincterotomy. In nine of the ten females, the defect involved the full length of the internal anal sphincter, but in the other four males, the defect involved the distal internal anal sphincter only. All were continent preoperatively, but after lateral internal anal sphincterotomy, three females became incontinent to flatus (two of whom had a preoperative external sphincter defect). CONCLUSION: In contrast to lateral internal anal sphincterotomy in males, division of the internal anal sphincter in most females tends to be more extensive than intended. This is probably related to their shorter anal canal. In some females, lateral internal anal sphincterotomy may compromise sphincter function and precipitate anal incontinence, particularly in the presence of other sphincter defects. Care should be exercised especially in the presence of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.

Adult↗
PubMed1994

Magnetic resonance imaging of fistula-in-ano.

PURPOSE: Successful management of anal fistulas depends upon accurate assessment of the primary tract and any secondary extensions. Preoperative imaging has, to date, been disappointing. METHODS: A prospective study of 35 patients with a clinical diagnosis of fistula-in-ano was performed comparing magnetic resonance imaging with the independently documented operative findings. Magnetic resonance imaging was also compared with anal endosonography in 20 patients. RESULTS: Magnetic resonance imaging is accurate and demonstrates pathology missed at surgery by experienced coloproctologists. Magnetic resonance imaging is superior to anal endosonography. CONCLUSIONS: Magnetic resonance imaging is advocated as the method of choice when imaging is required for anal fistulas.

Adult↗
PubMed1994

Vaginal endosonography. New approach to image the undisturbed anal sphincter.

PURPOSE: Although anal endosonography provides clear images of anal sphincters, the probe in the anal canal may distort epithelial structures and sphincter muscles may be compressed, producing inaccurate muscle thickness measurements. The aim of this study is to describe a new approach using vaginal endosonography to image the anal canal undistorted. METHODS: Twenty females (10 healthy volunteers and 10 with fecal incontinence) had both anal and vaginal endosonography performed. RESULTS: The undisturbed anorectum, submucosa, anal cushions, and anal sphincter muscles were clearly visualized by vaginal endosonography, and anatomy was described. Although anal and vaginal endosonographic measurements of internal sphincter muscle thickness correlated (r = 0.83; P = 0.01), anal endosonography consistently underestimated the thickness (2.3 +/- 0.5 vs. 3.2 +/- 1.2 mm; mean +/- standard deviation). Anterior internal and external anal sphincter defects were identified accurately with both techniques. CONCLUSIONS: Vaginal endosonography is a new technique that enables accurate imaging of anal sphincters and epithelial structures at rest. In addition to making the diagnosis of anal sphincter defects, it has potential applications in the imaging of anovaginal sepsis and malignancy and possibly in understanding the pathogenesis of anal fissure and hemorrhoids.

Adult↗
PubMed1994

Endosonography of the anal sphincters: normal anatomy and comparison with manometry.

To determine the normal and anatomy in vivo, and endosonography and manometry were performed in 93 nulliparous females, and endosonography alone in 21 healthy males. Endosonography did not reveal any plane of cleavage between the components of the external and sphincter, though a changing pattern at different levels conforming to a trilaminar arrangement was apparent. The deep (proximal) aspect of the external sphincter was annular in 72% of females and 76% of males. The superficial external sphincter was elliptical in 76% and 86%, the subcutaneous part conical in 56% and 57%, respectively. The external sphincter was shorter anteriorly in females. Aberrant insertions from the external sphincter anteriorly were identified in 14%. The longitudinal muscle layer could be distinguished sonographically in all males, as the external sphincter was relatively hypoechoic, but in 60% of the females the longitudinal muscle and external sphincter were of similar echogenicity and sonographically indistinguishable. The subepithelial tissues and internal sphincter were identified in each subject. The external sphincter was thicker bilaterally (P = 0.001) in males (8.6 +/- 1 mm, mean +/- S.D.) compared to females (7.7 +/- 1.1), which related to the higher weight of the males (73 +/- 7 vs 65 +/- 11 kg, P < 0.0001). The mean maximum lateral thickness of the internal sphincter (1.8 +/- 0.5 vs 1.9 +/- 0.6) and the longitudinal muscle (2.5 +/- 0.6 vs 2.9) in females and males were not significantly different. There was no relationship between the manometric resting or squeeze pressures in the anal canal, and the internal or external sphincter thickness.

Adolescent↗
PubMed1994

Pudendal nerve damage during labour: prospective study before and after childbirth.

OBJECTIVE: To establish the effect of childbirth on pudendal nerve function and identify obstetric factors associated with such damage. DESIGN: A prospective investigational study. SETTING: Antenatal clinic, St Bartholomew's (Homerton) Hospital. SUBJECTS: One hundred and twenty-eight unselected pregnant women beyond 34 weeks' gestation. INTERVENTION: Pudendal nerve terminal motor latencies (PNTML) and perineal plane were measured during pregnancy and six to eight weeks after delivery, and remeasured in a subgroup (n = 22) at six months. MAIN OUTCOME MEASURES: Effect of mode of delivery on PNTML and the plane of the perineum. RESULTS: Vaginal delivery resulted in a significant (P < 0.0001) prolongation of the mean PNTML bilaterally in both primipara (n = 57) 1.91 ms (SD 0.19) vs 2.00 ms (SD 0.22), antenatal vs postnatal, right PNTML; 1.96 ms (SD 0.21) vs 2.06 ms (SD 0.24) left PNTML, and multipara (n = 32) (P < 0.01). Perineal descent during straining was also increased after vaginal delivery (P < 0.001). Greater damage to the pudendal nerve occurred on the left side (P = 0.03). PNTML were not altered after elective caesarean section (n = 7), but were increased on the left side when caesarean section was performed during labour (1.94 ms (SD 0.13) vs 2.08 ms (SD 0.29), P < 0.01). A heavier baby and a longer active second stage of labour were both associated with significant prolongation of PNTML. Eight out of 12 women with a prolonged PNTML at six weeks had normal measurements when restudied six months after delivery. CONCLUSION: Vaginal delivery, particularly the first, results in significant pelvic floor tissue stretching and pudendal nerve damage. Women who have a caesarean section during labour may also be at risk of pudendal nerve damage. The process of labour and vaginal delivery can both cause pudendal nerve damage which may be asymmetrical in extent.

Action Potentials↗
PubMed1993

Anal-sphincter disruption during vaginal delivery.

BACKGROUND: Lacerations of the anal sphincter or injury to sphincter innervation during childbirth are major causes of fecal incontinence, but the incidence and importance of occult sphincter damage during routine vaginal delivery are unknown. We sought to determine the incidence of damage to the anal sphincter and the relation of injury to symptoms, anorectal physiologic function, and the mode of delivery. METHODS: We studied 202 consecutive women six weeks before delivery, 150 of them six weeks after delivery, and 32 with abnormal findings six months after delivery. Symptoms of anal incontinence and fecal urgency were assessed, and anal endosonography, manometry, perineometry, and measurement of the terminal motor latency of the pudendal nerves were performed. RESULTS: Ten of the 79 primiparous women (13 percent) and 11 of the 48 multiparous women (23 percent) who delivered vaginally had anal incontinence or fecal urgency when studied six weeks after delivery. Twenty-eight of the 79 primiparous women (35 percent) had a sphincter defect on endosonography at six weeks; the defect persisted in all 22 women studied at six months. Of the 48 multiparous women, 19 (40 percent) had a sphincter defect before delivery and 21 (44 percent) afterward. None of the 23 women who underwent cesarean section had a new sphincter defect after delivery. Eight of the 10 women who underwent forceps delivery had sphincter defects, but none of the 5 women who underwent vacuum extractions had such defects. Internal-sphincter defects were associated with a significantly lower mean (+/- SD) resting anal pressure (61 +/- 11 vs. 48 +/- 10 mm Hg, P < 0.001) six weeks post partum, and external-sphincter defects were associated with a significantly lower squeeze pressure (increase above resting pressure, 70 +/- 38 vs. 44 +/- 13 mm Hg; P < 0.001). There was a strong association (P < 0.001) between sphincter defects and the development of bowel symptoms. CONCLUSIONS: Occult sphincter defects are common after vaginal delivery, especially forceps delivery, and are often associated with disturbance of bowel function.

Adolescent↗
PubMed1993

Anal endosonography and correlation with in vitro and in vivo anatomy.

The endosonographic anatomy of the anal sphincters was studied by in vivo and in vitro correlation with anatomical dissection. Fourteen fresh anorectal specimens (eight abdominoperineal resection, six post mortem) were scanned in a water-bath with sequential dissection and correlation with the ultrasonographic images. Accurate anatomical identification of the layers during dissection was confirmed histologically. Anal endosonography was performed during operation in 12 patients to validate the in vitro findings. The in vivo study confirmed the in vitro results. Basic endosonographic anatomy has been clarified and inaccuracies in the previous description of the longitudinal muscle and external anal sphincter corrected.

Adult↗
PubMed1993

Effect of pregnancy on anal sphincter morphology and function.

Twenty pregnant women were investigated prospectively to establish if pregnancy had any effect on the function and morphology of the anal sphincters. Anal endosonography and manometry were performed during pregnancy and 6 weeks after Caesarean section. Muscle thickness of the puborectalis, longitudinal muscle, internal and external anal sphincter were measured. There was no significant difference in the muscle thickness of either before and after Caesarean delivery. The maximum resting pressure and the maximum squeeze pressure were not significantly changed. No significant correlation was found between anal pressure and muscle thickness of either sphincter. Pregnancy itself does not have a significant effect on anal sphincter morphology or function. Any changes in sphincter function that occur in relation to pregnancy or delivery are likely to be due to mechanical trauma rather than hormonal changes in pregnancy.

Adult↗
PubMed1993

Anal sphincter trauma during instrumental delivery.

OBJECTIVES: To determine the incidence of defecatory symptoms, pudendal nerve damage and mechanical trauma to the anal sphincters during vacuum and forceps delivery. METHODS: Anal endosonography, manometry, pudendal nerve terminal motor latency (PNTML) measurements and perineometry were performed in 43 primiparae who had an instrumental delivery (17 vacuum and 26 forceps) and in 47 who had a normal vaginal delivery (controls). RESULTS: Defecatory symptoms developed in 10 (38%) women following a forceps delivery compared with 2 (4%) in the control group (P = 0.0003), and 2 (12%) following a vacuum extraction (P = NS). Anal sphincter defects occurred in 21 (81%) forceps deliveries compared with 17 (36%) controls (P = 0.0005) and 4 (21%) vacuum extractions (P = NS). Anal pressures were lower in those who developed a sphincter defect (P < 0.00001). PNTML was not significantly altered by the mode of delivery. CONCLUSIONS: Compared with vacuum extraction, forceps delivery is associated with significantly more damage to the anal sphincters and hence an increased incidence of defecatory symptoms.

Adult↗
PubMedDate not supplied

The pelvic floor sequelae of childbirth.

For centuries the structure and function of the pelvic floor and anal sphincter have remained enigmatic. Great strides made in new imaging techniques over the last decade has enabled a better understanding of this complex and dynamic structure. We can now explore pelvic floor dysfunction.

Anal Canal↗