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Anorectal physiological assessment

Anorectal physiological assessment. Perineal trauma study day 13 th November 2007 Mrs. Kirsty Cattle MRCS Research Registrar. Faecal incontinence. Causes of incontinence Stool factors Stool delivery Rectum – storage organ Anal sphincters Anatomical Innervation Miscellaneous.

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Anorectal physiological assessment

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  1. Anorectal physiological assessment Perineal trauma study day 13th November 2007 Mrs. Kirsty Cattle MRCS Research Registrar

  2. Faecal incontinence • Causes of incontinence • Stool factors • Stool delivery • Rectum – storage organ • Anal sphincters • Anatomical • Innervation • Miscellaneous

  3. www.aafp.org/afp/20010615/2391_f1.jpg

  4. Anorectal physiology • Manometry • Including anorectal inhibitory reflex • Rectal sensation • PNTML • Pudendal nerve terminal motor latency • Endoanal ultrasound

  5. Manometry

  6. Resting pressure • Reflects internal anal sphincter function • Normal: > 45 cm H2O, usually ~ 70 cm H2O • Difference between maximum resting anal pressure and rectal pressure

  7. Pressure (cm H2O) Maximum resting pressure Distance from anal verge (cm)

  8. Squeeze pressure • Reflects external anal sphincter function • Normal in women: ~ 70 cm H2O • The “best squeeze” is documented as the maximum squeeze pressure, i.e. the biggest increase generated from resting anal pressure

  9. Pressure (cm H2O) Maximum squeeze pressure Distance from anal verge (cm)

  10. Anorectal inhibitory reflex • Reflex relaxation of the internal anal sphincter when the distal rectum is distended

  11. Inflation of balloon in rectum with 20-30 ml air Rectal balloon deflated Pressure (cm H2O) Time

  12. Rectal sensation • Normal values: • First sensation 40 – 50 ml • Call to stool 80 – 100 ml • Urgency 120 – 150 ml

  13. Pudendal nerve studies • Measurement of conduction speed in terminal pudendal nerve • Transrectal technique: Stimulate nerve near ischial spines, measure time taken to produce twitch of external anal sphincter • Normal range < 2.2 ms • Statistically different between incontinent patients and controls, but may be normal in incontinent patients

  14. http://www.emory.edu/ANATOMY/AnatomyManual/88.jpg

  15. http://med.stanford.edu/interactiveimages/anatomyweb/media/PL/M/0006/035.gif

  16. http://www.alpinebiomed.com/modules/cms/UserFiles/Image/accessories/StMarks9013L4401.jpg

  17. Ultrasound • 10 MHz rotating probe • Clear visualisation of sphincters • Delineation of simple fistulae

  18. http://radiology.rsnajnls.org/cgi/content/figsonly/224/2/417

  19. http://radiology.rsnajnls.org/cgi/content/figsonly/224/2/417

  20. http://www.thieme-connect.com/bilder/roefo/200112/ro1203-4

  21. Other assessments • Barium enema/Colonoscopy • Defaecating proctogram

  22. Summary • Anorectal physiology studies provide us with: • Function and anatomy of sphincters • Assessment of sensation • Estimation of pudendal nerve function • Use: • Treatment options, including planning of surgery

  23. Thank you • Any questions?

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