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Anatomical Disruption and Length-Tension Dysfunction of Anal Sphincter Complex Muscles in Women with Fecal Incontinence

Kim, Young Sun M.D., Ph.D.1,2; Weinstein, Milena M.D.1; Raizada, Varuna M.D.1; Jiang, Yanfen M.D.1; Bhargava, Valmik Ph.D.1; Rajasekaran, M. Raj Ph.D.1; Mittal, Ravinder K. M.D.1

doi: 10.1097/DCR.0b013e3182a18e87
Original Contributions: Pelvic Floor

BACKGROUND: Anal sphincter complex muscles, the internal anal sphincter, external anal sphincter, and puborectalis muscles, play an important role in the anal continence mechanism. Patients with symptoms of fecal incontinence have weak anal sphincter complex muscles; however, their length-tension properties and relationship to anatomical disruption have never been studied.

OBJECTIVE: This study aimed to assess the anatomy of the anal sphincter complex muscles with the use of a 3-dimensional ultrasound imaging system and to determine the relationship between the anatomical defects and the length-tension property of external anal sphincter and puborectalis muscles in women with incontinence symptoms and in control subjects.

DESIGN: Severity of anal sphincter muscle damage was determined by static and dynamic 3-dimensional ultrasound imaging. The length-tension property was determined by anal and vaginal pressure with the use of custom-designed probes.

PATIENTS: Forty-four asymptomatic controls and 24 incontinent patients participated in this study.

MAIN OUTCOME MEASURES: The anatomical defects and length-tension dysfunction of anal sphincter complex muscles in patients with fecal incontinence were evaluated.

RESULTS: The prevalence of injury to sphincter muscles is significantly greater in the incontinent patients than in the controls. Eighty-five percent of patients but only 9% controls reveal damage to ≥2 of the 3 muscles of the anal sphincter complex. Anal and vaginal squeeze pressures increased with the increase in the probe size (length-tension curve) in the majority of controls. In patients, the increase in anal and vaginal squeeze pressures was either significantly smaller than in controls or it decreased with the increasing probe size (abnormal length-tension).

LIMITATIONS: We studied patients with severe symptoms. Whether our findings are applicable to patients with mild to moderate symptoms remains to be determined.

CONCLUSIONS: The length-tension property of the external anal sphincter and puborectalis muscles is significantly impaired in incontinent patients. Our findings have therapeutic implications for the treatment of anal incontinence.

1 Department of Medicine, Division of Gastroenterology, San Diego VA Health Care System & University of California, San Diego, California

2 Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea

Funding/Support: This work was supported by NIH grant 5R01DK091348.

Financial Disclosure: None reported.

Correspondence: Ravinder K. Mittal, M.D., Gastroenterology (111D), San Diego VA Health Care System, 3350 La Jolla Village Drive, San Diego, CA 92161, Email: rmittal@ucsd.edu

© 2013 The American Society of Colon and Rectal Surgeons