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Chapter 8 Fecal Incontinence After Rectal and Perianal Surgery
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Part III
Diagnostic Methods
to Detect Incontinence
III
Chapter 9
Chapter 9 Evaluation of Anorectal and Pelvic Floor Muscle
Evaluation of Anorectal
and Pelvic Floor Muscle Function
Fernando Azpiroz,Aniceto Puigdollers, Carlos Amselem
121
9
Contents
9.1 Anatomical Background . . . . . . . . . . . . . . . . . . . 122
9.2 Functional Parameters and Evaluation Techniques . . . . 122
9.2.1 Rectal Reservoir Function . . . . . . . . . . . . . . . . . . 123
9.2.1.1 Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . 123
9.2.1.2 Perception of Rectal Filling . . . . . . . . . . . . . . . . . 124
9.2.2 Anal Sphincter Function . . . . . . . . . . . . . . . . . . . 124
9.2.3 Neural Reflexes . . . . . . . . . . . . . . . . . . . . . . . . 125
9.2.3.1 Rectoanal Inhibitory Reflex . . . . . . . . . . . . . . . . . 125
9.2.3.2 Cough Reflex . . . . . . . . . . . . . . . . . . . . . . . . . 125
9.2.3.3 Anocutaneous Reflex . . . . . . . . . . . . . . . . . . . . . 126
9.2.4 Defecatory Function . . . . . . . . . . . . . . . . . . . . . 126
9.2.4.1 Expulsion Tests . . . . . . . . . . . . . . . . . . . . . . . . 127
9.2.5 Pelvic Floor Muscle Function . . . . . . . . . . . . . . . . 127
9.2.5.1 Perineometry . . . . . . . . . . . . . . . . . . . . . . . . . 127
9.2.5.2 Levator Ani Contraction . . . . . . . . . . . . . . . . . . . 128
9.3 Outcome Measures and Clinical Relevance . . . . . . . . . 128
9.3.1 Rectal Reservoir . . . . . . . . . . . . . . . . . . . . . . . . 128
9.3.2 Anal Sphincters . . . . . . . . . . . . . . . . . . . . . . . . 129
9.3.2.1 Weak Sphincters . . . . . . . . . . . . . . . . . . . . . . . 129
9.3.2.2 Hyperactive Sphincters . . . . . . . . . . . . . . . . . . . . 130
9.3.3 Reflex Activity . . . . . . . . . . . . . . . . . . . . . . . . . 131
9.3.3.1 Anorectal Inhibitory Reflex . . . . . . . . . . . . . . . . . 131
9.3.3.2 Cough Reflex . . . . . . . . . . . . . . . . . . . . . . . . . 132
9.3.4 Impaired Defecation . . . . . . . . . . . . . . . . . . . . . 132
9.3.5 Weak Levator Ani . . . . . . . . . . . . . . . . . . . . . . . 133
9.4 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.4.1 Patients with Incontinence
and/or Pelvic Floor Dysfunction . . . . . . . . . . . . . . 134
9.4.2 Other Indications Not Primarily Related
to Pelvic Floor Damage . . . . . . . . . . . . . . . . . . . . 134
9.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 135
References . . . . . . . . . . . . . . . . . . . . . . . . . . 135
9
122
Fernando Azpiroz,Aniceto Puigdollers,Carlos Amselem
9.1 Anatomical Background
The lower end of the gastrointestinal tract is fitted to control fecal continence and
evacuation. Fecal continence is maintained by two key mechanisms: the rectal reservoir function and the muscular closure of the anal canal (Rasmussen et al. 1990;
Whitehead and Schuster 1987; Diamant et al. 1999;Azpiroz et al. 2002).
Muscular closure of the anal canal is achieved by three components: the internal
anal sphincter, the external anal sphincter and the pelvic floor muscles. The internal
sphincter is a smooth muscle cylinder that surrounds the anal canal. The internal
sphincter can be considered a thickening of the circular muscle layer of the rectum
and exerts a continuous tonic contraction that keeps anal closure during basal conditions. The external anal sphincter is a striated muscle cylinder that surrounds the
internal sphincter. The external sphincter exerts voluntary phasic contractions that
provide additional closure to the anal canal at demand.The pelvic floor muscles constitute a striated muscular diaphragm, the levator ani, of which the most important
component, both from a functional and surgical point of view, is the puborectalis muscle. The puborectal is a muscular sling with two well-developed parallel fascicles that
insert anteriorly in the pubis and fusion together behind the rectum at the top of the
anal canal. The traction of the puborectalis sling maintains the anorectal angulation.
The other components of the levator ani are two thin sheets of muscle,which complete
the pelvic diaphragm, the iliococcygeus and the pubococcygeus, although different
anatomical arrays have been described (Morgan 1949; Milligan and Morgan 1934;
Strohbehn 1998). The external anal sphincter and the pelvic floor muscles exhibit both
type I fibers, with high resistance to fatigue, as well as rapid contracting type II fibers.
The proportion of both types of fibers depends on several factors, such as sex and age,
but the proportion of type II fibers is higher in pelvic floor muscles than in the external sphincter,and hence the former is more of a tonic-type contraction muscle (Beersiek et al. 1979).
Anoperineal muscle function is controlled by intrinsic and extrinsic neural pathways (Parks et al. 1962; Percy et al. 1981). The internal anal sphincter is innervated by
the myenteric plexus, but also receives modulatory innervation from the sympathetic
and parasympathetic nervous system. Alpha adrenergic receptors produce contraction and beta receptors relaxation.Parasympathetic cholinergic innervation exerts an
inhibitory effect.The external sphincter and pelvic floor muscles receive motor innervation from sacral segments II–IV, but whereas the external sphincter is innervated by
the pudendal nerves, the levator ani receives innervation directly from the sacral
roots. Both the external sphincter and the pelvic floor muscles are under voluntary
control via corticospinal descending motor pathways as well as under spinal reflex
control via sacral reflex pathways, and these reflexes are preserved in patients with
complete spinal transection when the lesion is above the sacral segments.
9.2 Functional Parameters and Evaluation Techniques
It is important to keep is mind that incontinence is multifactorial, and hence incontinent patients require a comprehensive evaluation of all the factors that determine continence, including rectal reservoir function, anal closure and innervation pathways
(Meunier 1991; Diamant et al. 1999; Azpiroz et al. 2002). Furthermore, even though it
may seem paradoxical, in patients with anal incontinence it is important to evaluate
Chapter 9 Evaluation of Anorectal and Pelvic Floor Muscle Function
the defecatory function. Normally, perception of rectal filling is followed, when the
conditions are appropriate,by the defecatory maneuver, which completely empties the
rectum. In some patients, the defecatory maneuver is abnormal, resulting in incomplete rectal evacuation. Fecal residues remaining in the rectum may leak, particularly
if anal contraction is weak. The defecatory maneuver consists in an abdominal compression associated to anal relaxation, which allows evacuation of the fecal bolus.
Some patients fail to completely relax the anus during straining, and this results in a
functional outlet obstruction. These patients usually compensate their impaired anal
relaxation by excessive straining, and this repeat, forceful abdominal compression may
in the long term damage the pelvic floor and deteriorate the mechanisms of continence.
9.2.1 Rectal Reservoir Function
The rectal wall is distensible and allows accommodation of the fecal mass. Furthermore, fecal distension activates afferent neural pathways that induce conscious sensation of rectal filling. Evaluation of these two rectal parameters, compliance and sensitivity, provide important information in patients with anal incontinence.
9.2.1.1 Compliance
123
Rectal compliance reflects both the size and the distensibility of the rectal wall (Rasmussen et al.1990; Sun et al. 1990b).Compliance is related to the size (capacity) of the
rectum, e.g., patients with megarectum have a very high compliance. On the other
hand, compliance is also determined by the tonic muscular contraction of the rectal
wall (rectal tone), and this can be seen by administration of a relaxant such as glucagon, which increases compliance. Compliance also depends on the elastic vs viscous
properties of the rectal wall, and on the mobility of the pelvic organs to allow rectal expansion; for instance,rectal fibrosis or pelvic irradiation may produce a rigidity of the
rectal wall with a stiff rectum compliance curve.
Compliance can be measured as the pressure–volume relationship during distension (Diamant et al. 1999; Distrutti et al. 2004). Compliance measured by means of
elastic balloons requires corrections in relation to the intrinsic elastic properties of the
balloon. Flaccid and oversized bags do not interfere with the measurements and seem
more reliable. Compliance can be evaluated by injecting air into the intrarectal bag
and measuring the pressure,or alternatively, using a barostat that distends the rectum
to given pressure levels, and determines the volume at each distending step.With either technique, each distending level should be maintained for several seconds before
making the measurements, because rapid distension may require some time before
the rectum stabilizes. Both systems should give the same result. The compliance curve
is not linear,and hence it is not possible to compile all the information in a single index; rather a graphical plot seems more advisable (Kellow et al. 2000). The position of
the subject during the test determines the extrinsic pressure to the rectum (intra-abdominal pressure at that site), and hence influences compliance.Compliance measurements should ideally be performed in the lateral or prone position, to minimize the
intra-abdominal pressure at the pelvic level. Otherwise abdominal viscera laying on
top of the rectum will interfere with the measurements.
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Fernando Azpiroz,Aniceto Puigdollers,Carlos Amselem
9.2.1.2 Perception of Rectal Filling
The rectum has a sensory innervation that provides conscious recognition of rectal
content. Rectal sensitivity can be evaluated by measuring perception in response to
rectal distension. For clinical purposes, the methods described above to measure rectal compliance may be appropriate. Indeed,perception has to be evaluated considering
compliance: a patient with megarectum requires very large volumes for perception,
and conversely, in patients with a small, stiff rectum, very small volumes induce discomfort. Several responses can be measured such as the first perception and the urge
to defecate. At this stage, the mechanisms (type of receptors) of these responses are
unclear.However, it has been shown that impaired ability to perceive rectal distension
is a risk factor for fecal incontinence (Wald and Tunuguntla 1984). Some recent data
suggest that perception is directly related to the tension of the rectal wall, which can be
calculated based on the intrarectal pressure and volume, by applying Laplace’s law.
These data would indicate that rectal distension procedures could be best standardized using fixed tension levels,by means of a tensostat (Distrutti et al. 2004).However,
for routine clinical evaluation rectal distension at fixed volumes would suffice.
The distension paradigm may influence perception. Particularly,very rapid distensions such as those used for studying evoked potentials may give different responses
than slower distensions. However, it is not clear whether this type of rapid distension
also stimulates other types of pelvic structures that contribute to perception. At this
stage, there are no data to recommend any specific technique for measuring perception, but for clinical purposes stepwise rectal distension seems acceptable for providing the relevant information.
9.2.2 Anal Sphincter Function
Anal sphincter function is usually evaluated by manometry, measuring the pressure in
the anal canal (Meunier 1991; Diamant et al.1999).Anal canal manometry does not reflect the activity of the levator ani. Anal manometry can be performed using low perfusion systems (3 ml/min or less) and commercially available probes of less than 5 mm
in diameter provide reliable measurements. High perfusion rates may induce motor
responses due to mucosal or skin stimulation.Manometric probes may allow measurement of radial pressures, which may be of clinical utility by detecting asymmetries.
Solid state microtransducers are reliable, but do not allow the use of multiple recording sites at short distances and with flexible probes. Pressures should be measured
along the anal canal from the rectum to the anal verge.A stationary pull-through technique is recommended,allowing a few seconds for accommodation at each station before measuring the basal pressure.At each step,the squeeze pressure produced by voluntary anal contraction should also be measured. The dynamic pull-through technique seems unadvisable, because the stimulation of the anal canal by the probe movement induces a contraction of the external anal sphincter,resulting in artifactually increased basal pressures.Alternatively,a manometric probe with multiple, close,special
(5–10 min) recording sites could be used to measure simultaneously the pressures at
different levels of the anal canal from the rectum to the anal verge. Basal pressure reflects by-and-large the activity of the internal anal sphincter. Manometric studies in
patients during pudendal block and other interventions demonstrated that 30% or
more of the basal anal resting pressure can be attributed to the external sphincter (Du-
Chapter 9 Evaluation of Anorectal and Pelvic Floor Muscle Function
thie and Watts 1965).Voluntary contraction of the external anal sphincter is evaluated
by asking the patient to squeeze while the pressure increment at different levels of the
anal canal is being measured. To evaluate squeeze pressure, it is important to make
sure that the patient does not increase simultaneously intra-abdominal pressure, because this may trigger extrinsic reflexes and confound the results.
9.2.3 Neural Reflexes
9.2.3.1 Rectoanal Inhibitory Reflex
This reflex is used to evaluate the function of the intrinsic innervation of the internal
anal sphincter.Normally,distension of the rectum elicits an intrinsic reflex (i.e., via the
myenteric plexus), which produces a relaxation of the internal anal sphincter (Whitehead and Schuster 1987; Schuster et al. 1965; Burleigh 1992). This reflex can be elicited
by inflating a rectal bag or balloon, and the anal response can be measured using a
manometric probe. This technique has replaced the Schuster double balloon method
initially developed for that purpose (Schuster et al.1965). Before testing this reflex, the
presence of a basal anal tone (basal pressures) should be demonstrated. Several technical aspects should be also taken into account such as the application of an appropriate stimulus that is able to distend the rectum even in case of megarectum. For that
purpose, it is important to monitor the intraballoon (intrarectal) pressure. The rectum
should be free of feces, otherwise the balloon may displace the fecal mass without a
real stimulation of the rectal wall. It is also advisable to use several manometric ports
along the anal canal, because inflation of the balloon may produce an interiorization
of the probe with a pressure drop at the orad port. Other potential technical pitfalls are
related to the contraction of the external anal sphincter induced by the perceived rectal distension, which may obscure the relaxation of the internal anal sphincter.In this
case, a pudendal block would reveal the presence of the normal reflex.
125
9.2.3.2 Cough Reflex
This reflex is used to evaluate sacropudendal reflex pathways. Normally, an intra-abdominal pressure increment induces a reflex contraction of the external anal sphincter.This is a multisynaptic sacral reflex, which prevents anal leakage during abdominal compression (Parks et al. 1962; Sun et al. 1990a). Conceivably, this reflex is voluntarily inhibited during the defecatory maneuver via descending inhibitory pathways.
The term ”cough reflex”implicitly excludes other techniques involving sustained abdominal compression. Indeed,this reflex can be elicited by asking the patient to blow
against a fixed pressure level into a manometer, to blow up a balloon or simply to
cough.Also, with a gradual increase in intra-abdominal compression, one may elicit a
reflex inhibition (and not a reflex contraction) in pelvic floor muscles and anal canal
pressure as seen in response to the defecatory maneuver. Hence, cough or very rapid
increase in intra-abdominal pressure is recommended to elicit the cough reflex in a
clinical setting.
This reflex can be tested using a manometric probe. The intra-abdominal pressure
increment should be monitored either using an intrarectal balloon or a manometric
port. The response in the anal canal should be monitored using multiple ports spaced
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Fernando Azpiroz,Aniceto Puigdollers,Carlos Amselem
along the anal canal,because the abdominal compression may produce a displacement
of the probe. The double balloon technique may register a different type of response.
For the evaluation of this reflex, the pressure increment in the abdomen and in the
anal canal should be compared, and in normal conditions the latter should be higher.
Another parameter in evaluating this reflex is the duration of the reflex anal contraction (increment in anal pressure), which should be longer than the intra-abdominal
pressure peak.This parameter is particularly useful in case of damage of the external
anal sphincter resulting in muscular weakness. Nevertheless, the evaluation of the
cough reflex requires the presence of some manometric activity of the external anal
sphincter,and in some cases the interpretation may be difficult.Alternatively, the anal
response may be monitored by electromyography. The precise timing of the anal response in relation to the intra-abdominal pressure increment has not been clearly established. Some data suggest that the anal increment precedes the actual intra-abdominal pressure rise.However, this anticipatory response may reflect learning (i.e., Pavlovian conditioning) rather than reflex activity.
9.2.3.3 Anocutaneous Reflex
This reflex has been used as an alternative method to evaluate the reflex innervation of
the external anal sphincter: scratching the perianal skin elicits a reflex contraction
(Diamant et al. 1999). The use of this reflex is limited, because it requires a relaxed external anal sphincter for the response to be seen; tense subjects may not display a recordable response. Furthermore, this reflex can be inhibited by voluntary efforts or by
asking the subject to relax. However,this reflex is not a conditioned (i.e., learned) response, because it can be elicited in patients with high spinal cord lesions.At present
the clinical relevance of this reflex has not been established,and it is not used for routine clinical testing.
9.2.4 Defecatory Function
Defecation is normally produced by an abdominal compression associated with anal
and pelvic floor relaxation, which results in perineal descent and evacuation of the fecal bolus through the anal canal. It is not clear whether defecation in humans also involves rectal contractions. There is no agreement on the technique to evaluate the defecatory maneuver. It seems important to measure the abdominal compression,for instance by intrarectal pressure recording, and anal relaxation,without interfering with
the normal conditions to prevent artificially abnormal responses. The defecatory maneuver is usually studied with some degree of rectal distension by means of a balloon,
but both rectal compression and anal relaxation can also be observed without any
kind of rectal distension. Laboratory tests do not tell what happens during real defecation, but may provide useful information for the management of the patient.The effect
of the various degrees of lack of privacy and the position of the patient during the test
(left lateral decubitus vs sitting on a commode) has not been clearly established (Duthie and Bartolo 1992).
The defecatory maneuver can be evaluated using a manometric technique.Abdominal compression can be measured by recording intrarectal pressure, usually using a
balloon. The anal relaxation can be measured by pressure recordings along the anal
canal. Manometric evaluation of anal relaxation requires multiple, closely spaced re-
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