Rehabilitation methods for patients with severe extragenital pathology after reconstructive plastic surgery for various types of urinary incontinence

In recent years, the frequency of operations for genital prolapse and urinary incontinence has been steadily increasing. Neurogenic disorders of urination can be the first manifestations of the disease of extragenital pathology. Neurogenic bladder is bladder dysfunction (lethargy or spasticity) caused by neurogenic damage. Any disease in which the afferent or efferent innervation of the bladder is damaged can lead to a neurogenic bladder.Purpose. To study the features of urinary disorders in women with severe extragenital diseases and to improve the methods of rehabilitation of patients after reconstructive plastic surgery for various types of urinary incontinence.Materials and methods. 153 patients aged 50-70 years (mean age 55.1 ± 6.3 years) and duration of postmenopause from 2 to 5 years (7.6 ± 4.1 years) were examined at the outpatient department of the of Moscow Regional Research Institute of Obstetrics and Gynecology, Russian Federation, who applied for various manifestations of urination disorders. All patients were offered the method of biofeedback in combination with electrical stimulation of the pelvic floor muscles as a treatment. When overactive detrusor therapy was detected, therapy was combined with medicamentous (solifenacin 5 mg [Vesicar] or myrobegron 50 mg [Betmiga] in the morning) in combination with estriol (cream or suppositories) 0.5 mg intravaginally 2 times a week. In the presence of symptoms of climacteric syndrome in the absence of contraindications, menopausal hormonal therapy was prescribed.Results. Subjectively, 150 (98.1 %) patients noted an improvement in their condition, 3 (1.9 %) patients did not notice the effect of treatment. The results showed a significant improvement in all OABSS and bladder diary scores, including frequency of urination during the day and at night, urgency and number of urge incontinence episodes, and urine volume. Analysis of the -hour pad test showed that the volume of urine lost, which averaged 16.5 g before treatment, was negative after treatment in patients who noted the effect. In 2 patients who did not notice the effect, no changes were found. Investigation of the intraurethral pressure profile in 23 (17.6 %) women before treatment revealed insufficiency of the internal sphincter of the urethra, leading to urinary incontinence during stress. After treatment, in 19 (82.6 %) patients, the insufficiency of the internal sphincter was not determined. In 3 (13.0 %) patients, intraurethral pressure remained in the range of 60 to 80 cm of water column and did not lead to urinary incontinence during stress. In 1 (4.3 %) patient, the insufficiency of the urethral closure persisted, which required repeated surgery.Conclusions. In patients with severe extragenital diseases against the background of vulvovaginal atrophy, an overactive bladder and a mixed form of urinary incontinence prevail. Extragenital pathology of various origins, especially concerning various parts of the central nervous system, obesity and diabetes significantly worsens the course of urination disorders in both conservative and surgical and combined treatment and requires additional treatment methods: pelvic floor muscle training, biofeedback therapy in combination with electrical stimulation of the pelvic floor muscles, local hormonal therapy, the use of M-anticholinergics, B-adrenomimetics.

Use of Botulinum Toxin Injections for the Treatment of Chronic Anal Fissure: Results From an American Society of Colon and Rectal Surgeons Survey

Background Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. Methods A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. Results 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. Discussion Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.

Blood supply of the anal canal in patients with chronic hemorrhoids

The most important factors in the development of chronic haemorrhoids today are considered to be the combination of two factors (vascular and mechanical) that lead to the development of hemorrhoids. The underlying vascular factor is the vascular dysfunction, providing arterial blood flow through the arteries to the cavernous bodies and outflow through the cavernous veins, which leads to dilation of cavernous bodies and the formation of vascular malformations.There were performed clinical examination and treatment of 140 patients with chronic hemorrhoids of stage III-IV according to Goligher. The features of arterial blood supply of the anal canal were evaluated by transrectal ultrasound examination.It was found that there was no clear linear relationship between the number of anal arteries with increased blood flow and the number of hemorrhoidal nodes in the patient. Each node was supplied with blood from one or two arteries: the node placed at 11 o'clock had blood supply from the arteries visualized at 10 and 11 o'clock, the node at 3 o'clock - arteries at 3 and 5 o'clock, the node at 7 o'clock - arteries at 7 and 9 o'clock. The arteries were most frequently visualized at the first (89.4%), the third (93.3%), the seventh (88.8%) and the eleventh (93.4%) hours. With less frequency the hemodynamically significant arteries were visualized at the fifth (65.0%), the ninth (62.8%) and the tenth (66.7%) hours. The arteries that were suppliing blood hemorrhoidal vessels were located in the internal sphincter at a depth of 5 to 10 mm. In the area of 3, 7 and 11 hours, they overlapped with a mosaic pattern that corresponded to the localization of the cavernous body and resembled an arteriovenous fistula according to the СDS.

“Prospective, Randomized, Controlled Trial of Ultra-modified Internal Sphincterotomy vs Closed Lateral Internal Sphincterotomy for Chronic Fissure-in-Ano”

Background Currently, the lateral internal sphincterotomy is the treatment of choice for a chronic anal fissure (CAF). However, the length of the internal sphincter incision varies, due to lack of standardization. Insufficient length increases the risk of recurrence. To compare a new ultra-modified internal sphincterotomy (UMIS) to the closed lateral internal sphincterotomy (CLIS) for treating CAF, based on internal anal sphincter function and postoperative complications. The primary endpoint was continence after UMIS. The secondary outcomes were CAF healing complications, visual analog scale pain scores, and sphincter pressures. Methods This was a prospective, randomized, controlled trial (block randomization method). 200 patients with CAFs were randomly assigned to receive either UMIS (n = 100) or the closed lateral internal sphincterotomy (CLIS) (n = 100). Follow-up was 2 years. RESULTS: All (100%) patients in both groups showed clinical improvement at 1 month post-surgery. Recurrences were accompanied by deteriorations in Cleveland Clinic Florida Fecal Incontinence scores at 12 months and 2 years ( P < .05). The groups showed significant differences in fissure healing rates and pain scores. After 1 and 2 years, incontinence rates were significantly higher, and patient satisfaction scores were significantly lower in the CLIS group than the UMIS group ( P < .05). Conclusion UMIS provided a faster healing rate and fewer side effects than the CLIS for treating CAFs. These results might lead to a standardized treatment among surgeons.

A COMPARATIVE STUDY OF 0.2% NIFEDIPINE VERSUS LATERAL SPHINCTEROTOMY IN THE MANAGEMENT OF ANAL FISSURE

Introduction:Anal ssures are longitudinal tears in the squamous epithelium of the anal canal. Anal ssures are located distal to the dentate line, and in around 90% of cases they are located on the posterior midline. The most common pathologies of the anorectal region and can change the quality of life as it causes patient pain and emotional stress while defecation. With a lifetime risk of 11%, anal ssure is a common problem in routine medical care. Anal ssure is mainly treated by relaxing the spasm of the internal sphincter either by dilating the anal canal or sphincterotomy. Reduction of spasticity of anal sphincters is the special treatment for ssure healing. For this purpose, the treatment of anal ssures is performed by lateral sphincterotomy or by anal dilatation. Methods: Out of 100 randomly selected 50 patients with inclusion and exclusion criteria and informed consent were treated with nifedipine ointment and 50 patients with informed consent were treated with lateral sphincterotomy for management of anal ssure. Observations after treatment were recorded at second week, sixth week and twelfth week interval for bleeding, pain and healing and at the twelfth week follow up was documented to analyse the result of treatment. Result: Out of 50 patients undergoing treatment with Nifedipine ointment 42 patients healed completely. 36 patients in the nifedipine group had complaint of bleeding, after treatment with nifedipine ointment 30 patients were relieved from bleeding while 6 were complaining of bleeding on follow up after 3 months. Patients in lateral sphincterotomy group underwent surgery under spinal anaesthesia. In lateral sphincterotomy group, ssure healing was found in 49 (98%)out of 50 patients. In our study out of 50 patients, 48 (96%)were completely relieved from pain and 2 ( 4% ) had pain on follow up at the end of 3 months. In our study , in the lateral sphincterotomy group 34 patients out of 50 patients were complaining of bleeding and after surgery 32 were relieved from bleeding within 12 weeks and 2 were complaining of bleeding. Conclusion:Topical 2% nifedipine should be given as the rst option of treatment for anal ssure. Lateral sphincterotomy, which gives better result to relieve the symptoms but require hospitalization, should be offered to patient who present with relapse and does not respond to pharmacological treatment.

Current concepts in the pathogenesis of cryptoglandular perianal fistula

Cryptoglandular perianal fistula is a common benign anorectal disorder that is managed mainly with surgery. A fistula is typically defined as a pathological communication between two epithelialized surfaces. More specifically, perianal fistula manifests as an abnormal tract between the anorectal canal and the perianal skin. Perianal fistulas are often characterized by significantly decreased patient quality of life. The cryptoglandular theory of perianal fistulas suggests their development from the proctodeal glands, which originate from the intersphincteric plane and perforate the internal sphincter with their ducts. Involvement of proctodeal glands in the inflammatory process could play a primary role in the formation of cryptoglandular perianal fistula. The objective of this narrative review was to investigate the current knowledge of the pathogenesis of cryptoglandular perianal fistula with the specific aims of characterizing the potential role of proinflammatory factors responsible for the development of chronic inflammation. Further studies are crucial to improve the therapeutic management of cryptoglandular perianal fistulas.

Botulinum toxin type A injections for treatment of chronic anal fissures

An anal fissure is one of the most common diseases of the anal canal with the incident rate of 20–23 cases per 1000 citizens. Most of acute anal fissures are healed spontaneously but a few of them can become chronic process. Chronic anal fissures are characterized by any two of the criteria: pain after defecation lasts longer than 3 months, sentinel pile is present, fibers of internal sphincter at the base of the anoderm.The spasm of the internal sphincter is a guiding pathogenetic mechanism in the development of chronic anal fissures. It leads to circulatory disorder in the anoderm and non-healing wounds. Therefore, the treatment of anal fissures primarily must be focus on eliminating of internal sphincter spasms and then excising of fissures.Recently, botulinum toxin type A injection in treatment of chronic anal fissures has become popular as a noninvasive method of eliminating internal sphincter spasms.Botulinum toxin as a medical agent has been studied since the late 1960s. Botulinum toxin type A has been used to treat of various pathologies including coloproctology diseases for more than 40 years.The botulinum toxin injections make the internal sphincter relax, and as a result create optimal conditions for healing chronic anal fissures.Using of botulinum toxin type A does not cause dangerous complication. Fecal incontinence after using botulinum toxin is transitory.The review describes the use of botulinum toxin type A injections to treat chronic anal fissures.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background. Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods. A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results. Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients’ quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions. The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

Long-term outcome of sphincteroplasty with separate suturing of the internal and the external anal sphincter

Background Sphincteroplasty is one of the treatment options for anal incontinence following obstetric injury. The aim of the study was to evaluate the long-term effect of sphincteroplasty with separate suturing of the internal and the external anal sphincter on anal continence. Methods A retrospective study was conducted on women who had sphincteroplasty for treatment of anal incontinence following obstetric injury. Women operated between January 1, 2011 and December 31, 2014 at Sykehuset Innlandet Hospital Trust Hamar, were invited to answer a questionnaire and participate in a clinical examination, including endoanal sonography. Results 111 (86.7%) women participated. Median postoperative follow-up was 44.5 months, and 63.8% of the participants experienced an improvement of at least three points in the St. Mark’s incontinence score. Fecal urgency and daily fecal leakage persisted in 39.4% and 6.4% of the participants, respectively. The internal anal sphincter improvement persisted in 61.8% of the participants, and there was a median reduction of their St. Mark’s score of 6.0 points between the preoperative value and the value at long-term follow-up. There was no significant change in the St. Mark’s score of patients with persistent dehiscence of the internal anal sphincter. Conclusions Sphincteroplasty, with separate suturing of the internal sphincter resulted in continence for stool maintained for at least 3 years in the majority of the patients, while there was an improvement in continence in nearly two-thirds.