Influence of rectal prolapse on the asymmetry of the anal sphincter in patients with anal incontinence

Abstract

Background: Anal sphincter defects have been shown to increase pressure asymmetry within the anal canal in patients with fecal incontinence. However, this correlation is far from perfect, and other factors may play a role. The goal of this study was to assess the impact of rectal prolapse on anal pressure asymmetry in patients with anal incontinence.

Methods: 44 patients, (42 women, mean age: 64 (11) years), complaining of anal incontinence, underwent anal vector manometry, endo-anal ultrasonography (to assess sphincter defects) and pelvic viscerogram (for the diagnosis of rectal prolapse). Resting and squeeze anal pressures, and anal asymmetry index at rest and during voluntary squeeze were determined by vector manometry.

Results: Ultrasonography identified 19 anal sphincter defects; there were 9 cases of overt rectal prolapse, and 14 other cases revealed by pelvic viscerogram (recto-anal intussuception). Patients with rectal prolapse had a significantly higher anal sphincter asymmetry index at rest, whether patients with anal sphincter defects were included in the analysis or not (30 (3) % versus 20 (2) %, p < 0.005). Among patients without rectal prolapse, a higher anal sphincter asymmetry index during squeezing was found in patients with anal sphincter defects (27 (2) % versus 19 (2) %, p < 0.03).

Conclusions: In anal incontinent patients, anal asymmetry index may be increased in case of anal sphincter defect and/or rectal prolapse. In the absence of anal sphincter defect at ultrasonogaphy, an increased anal asymmetry index at rest may point to the presence of a rectal prolapse.

Figure 1

Endo-vaginal ultrasonography of anal sphincter in a patient with rectal prolapse: irregular and asymmetrical appearance of the internal anal sphincter (IAS arrow), without defect (A: anterior, and P: posterior).

Figure 2

Endo-anal ultrasonographic view of the anal sphincter in a patient with rectal prolapse: black arrows indicate a submucosal thickening in the anterior right and left quadrants of the internal anal sphincter (IAS: internal anal sphincter; EAS: external anal sphincter; A: anterior; P: posterior).

Figure 3

For comparison, an endo-vaginal ultrasonographic view of a normal anal sphincter of a patient without rectal prolapse. (IAS: internal anal sphincter; EAS: external anal sphincter; A: anterior; P: posterior).

Figure 4

Individual results of anal sphincter asymmetry index at rest (ASAIr) in patients without anal sphincter defect, depending on the presence (13 patients) or the absence (12 patients) of rectal prolapse. The black bars represent the mean value in each group (p < 0.03).