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assessing the sphincters after primary or secondary repair of sphincter
defects.
Awareness of the physiological variation in the thickness of the internal
anal sphincter and the sexual differences is important in radiological assess-
ment of patients with faecal incontinence. The posterolateral aspect of the
external sphincter should be intact at all levels in both sexes, but there is a
natural deficiency anteriorly in females at a deep level [53]. Causes of faecal
incontinence include obstetrics-related trauma, postsurgical (anal dilata-
tion, lateral anal sphincterotomy, posthaemorrhoidectomy, multiple fistula
operations), trauma (accidental and intentional injury, anal rape), and
idiopathic.
Childbirth is the most common cause of damage to the anal sphincters.
Endo–anal ultrasound has shown a significantly higher incidence of sphinc-
ter damage than previously recognised clinically (Figure 11.22, Figure
11.23). Thirty-five percent of women undergoing their first normal vaginal
delivery were shown to have endosonographic evidence of sphincter dis-
ruption at 6 weeks that persisted at 6 months. One-third had symptoms of
11. Investigation of Functional Bowel Disorders 231
Figure 11.21. Three-dimensional imaging of the anal canal.
232 P.J. Arumugam et al.
Figure 11.22. Endo–anal ultrasound demonstration of external sphincter defect.
Figure 11.23. Endo–anal ultrasound demonstration of combined internal and
external sphincter defect.
11. Investigation of Functional Bowel Disorders 233
anal incontinence. Significantly higher incidences of defects were found fol-
lowing forceps delivery (8 out of 10) and those undergoing vacuum extrac-
tion were spared [59]. Gold et al. assessed the 3-dimensional EAUS and
emphasised the role of EAUS in showing longitudinal and radial extent of
the tear, which may have a role in determining the success of surgical repair
of sphincter defects [54].
Overzealous manual dilatation of the anus produces varying degrees of
tear at multiple points compared with the precise defect of an internal
sphincterotomy and both can be delineated by EAUS. Remnants of the
sphincter will appear hyperechoic, suggesting fibrotic replacement after
manual dilatation (Figure 11.24), while lateral sphincterotomy produces a
clean break in the sphincter with well-defined edges (Figure 11.25) [53].Sur-
gical damage to the internal sphincter can also be recognised after fistula
surgery and formation of ileo–anal pouch.
Figure 11.24. Internal sphincter disruption following manual anal dilatation.
Speakman et al. studied 12 patients with faecal incontinence who had
manual dilatation for anal fissure and EAUS showed extensive disruption
of internal anal sphincter in 10 of these patients [55]. Sixty-five percent of
patients undergoing anal dilatation had sphincter defects in a study by
Nielsen et al., with 12.5 % of these patients having some degree of faecal
incontinence [56]. Bartram et al.have emphasised that EAUS has an impor-
tant role in making surgeons aware of procedures associated with sphinc-
ter injuries [57].
Sultan et al. assessed the effect of internal anal sphincterotomy for anal
fissures and showed that women, with their shorter anal canal, are more
susceptible to inadvertent extensive sphincterotomy with 9 out of 10 women
in his study having the entire length of the internal sphincter divided [58].
Ho et al. showed the usefulness of EAUS in picking up sphincter defects
iatrogenically caused by stapling instruments [60]. Other causes of faecal
incontinence include trauma (Figure 11.26) and idiopathic faecal inconti-
nence. Idiopathic faecal incontinence is essentially a result of age-related
neuropathy, atrophy, fibrosis, and possibly ischemia. Endo–anal ultrasound
is required to rule out other cause of faecal incontinence. More recently,
MRI using endo–anal coil has proven to be useful in demonstrating these
degenerate changes in the sphincters.
234 P.J. Arumugam et al.
Figure 11.25. Internal anal sphincterotomy demonstrated on an anal scan.
5.3. Solitary Rectal Ulcer Syndrome
Halligan et al. showed marked thickness of internal and external anal
sphincter in patients with solitary rectal ulcer (SRUS) when compared
to asymptomatic controls (Figure 11.27) [61]. The precise aetiology is
unknown; however, it has been proposed a combination of mucosal rectal
prolapse and increased rectal pressure due to internal anal sphincter thick-
ness could be responsible for SRUS.
Marshall et al., in a further small study, demonstrated the predictive value
of internal anal sphincter thickness for diagnosis of rectal intussusception
in patients with SRUS [62].They concluded EAUS has a 91% positive pre-
dictive value in detecting internal anal sphincter thickness in SRUS patients
having rectal intussusception; however, the negative predictive value was
only 57%. It may have a role in patients who failed to evacuate on evacu-
atory proctography and in pregnant women where radiation exposure is
undesirable.
More recently dynamic transperineal ultrasound has been used to de-
monstrate intussusception, rectocoeles, and enterocoeles, which correlate
well with evacuatory proctography [63].
11. Investigation of Functional Bowel Disorders 235
Figure 11.26. Sphincter disruption following anal trauma.
6. Colonic Transit Studies
A colonic transit study is part of the routine assessment in patients with
constipation but is also beneficial in assessing obstructed defaecation. It
also has a place in assessing patients with evacuatory difficulties following
formation of ileo–anal pouch and in assessing drugs altering colonic
motility.
Hinton et al. used 20 radioopaque pellets of barium-impregnated poly-
thene and validated his study by comparing the findings with 25 normal
subjects [64]. He showed all normal subjects passed the first marker
within 66 hours and all except 1 passed 80% of the markers in 5 days.
Markers used must not be absorbed, but measurable and must travel
at a similar rate to the normal contents and must not alter the activity of
the gut. Martelli et al. showed that retention of more than 20% of
markers on day 5 is regarded as abnormal, and this is generally accepted
236 P.J. Arumugam et al.
Figure 11.27. Increased thickness of internal and external anal sphincter in patient
with solitary rectal ulcer (SRUS).
11. Investigation of Functional Bowel Disorders 237
Figure 11.28. Shapes colonic transit study.
as the current criteria for an abnormal study (Figure 11.28, Figure 11.29)
[65].
Metcalf et al. used 3 different markers and a single film to assess
total and segmental colonic transit time and found age or a modest dietary
fiber intake did not affect the transit time [66]. They further showed transit
varied in different segments of the bowel. Oral scintigraphic segmental
238 P.J. Arumugam et al.
Figure 11.29. Shapes colonis transit study.
transit studies have gained importance with oral In-111–labelled DTPA
being used to assess segmental transit (Figure 11.30). Lundin et al., in their
study of 28 patients, showed patients undergoing segmental colectomy
based on scintigraphy had better results and functional outcome [67].
Recently Technetium 99 m tin–colloid has been used to image liquid
stools and I-131 microcapsules to image solids in a study to assess pouch
function using scintigraphy [68]. The beneficial effects of scintigraphy have
also been shown in a technique using In-111–labelled polystyrene particles
in assessing incontinent and constipated patients after a retrograde colonic
washout [69].
Nam et al. assessed reproducibility in colonic transit and showed a colonic
transit study has better correlation coefficient in patients with idiopathic
11. Investigation of Functional Bowel Disorders 239
constipation than patients with colonic inertia [70]. They suggested repeat-
ing the colonic transit study in patients with colonic inertia.
Colonic transit studies are a part of the investigative algorithm in evalu-
ating functional bowel disorders and play an important role in selecting
patients for surgery and in subsequent follow-up care.
7. Summary
The assessment of the patient with a functional bowel disorder is not easy
and requires patience and understanding particularly because there may
be coexistent problems urologically or gynaecologically. Careful history
taking, clinical examination, and use of appropriate investigations are the
keys to dealing with these problems. Full assessment should be followed by
a careful consideration of the therapeutic options available. Appropriate
management of patients with these difficult problems requires a multidis-
ciplinary approach between clinicians with an interest in pelvic floor prob-
lems including coloproctologists,urologists, gynaecologists, radiologists,and
specialist nurses.
Figure 11.30. Oral scintigraphic segmental transit study.
240 P.J. Arumugam et al.
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