Anal sphincter repair improves anorectal function and endosonographic image - A prospective clinical study

PURPOSE: This study investigated the effect of anal sphincter repair on fecal continence in relation to anal endosonography and anal manometry. METHODS: Eighteen patients (7 male, 11 female) with anal sphincter defects and complaints of fecal incontinence (5), soiling (= liquid discharge; 3), or both (10) were studied before and after sphincter repair with endosonography and anal manometry. Complaints were the result of obstetric trauma (7), surgical trauma (7), both (3), and other trauma (1). Five patients had previous surgery. Preoperative endosonography showed a defect of both sphincters in nine patients, a defect of the external anal sphincter in five patients, and a defect of the internal anal sphincter in four patients. An overlapping sphincter repair was performed. RESULTS: Postoperatively and subjectively (S; patient's view), 13 (72 percent) patients became continent or improved; in 5 (28 percent) patients the complaints were unaltered. Objectively (O) (incontinence or soiling frequency), these figures were 12 (67 percent) and 6 (33 percent). Postoperative endosonographic images improved in 14 (78 percent) patients; defects of the sphincters (almost) disappeared (4) or were smaller (10). In the other four patients, images were unchanged. In two patients, overlapping of the muscle was clearly visible with anal endosonography. Clinical result (subjective (S) and objective (O)) of sphincter repair correlated with changes in anal endosonography (S, r = 0.64, P < 0.004; O, r = 0.51, P = 0.03) and anal manometry (S, r = 0.54, P = 0.038; O, r = 0.44, P = 0.09 (not significant)) and not with pudendal nerve latency. CONCLUSION: In 78 percent of our patients, endosonographic sphincter defect had diminished or disappeared after sphincter repair. There was a good correlation between clinical effect of sphincter repair and changes with anal endosonography and anal manometry. Postoperative persistent incontinence is attributable to remaining sphincter defects. Anal endosonography should be performed as a routine procedure in patients with fecal incontinence or soiling, also after failed surgery.