METHODOLOGY: This was a prospective observational study. Convenience sampling method was used to recruit all HD patients who had definitive pullthrough from January 2019 to December2020 in our institution. High-resolution anorectal manometry (HRAM) was used to record anal resting pressure (ARP), length of high-pressure zone (HPZ), and presence/absence of recto-anal inhibitory reflex (RAIR). The Paediatric Incontinence/Constipation Scoring System (PICSS) was scored for all participants. PICSS is a validated questionnaire with scores mapped to an age-specific normogram to denote constipation, incontinence, and their combinations. Non-parametric and chi-square tests at significance p<0.05 were conducted to examine the relationship between PICSS categories and manometry findings. Ethical approval was obtained.
RESULTS: There were 32 participants (30 boys). Median age at participation was 26.5 months (range: 13.8-156). Twenty-four (75%) had transanal pullthrough, 8(25%) underwent Duhamel procedure. PICSS scored 10(31.3%) as normal, 8(25%) as constipation, 10(31.3%) as incontinent, and 4(12.5%) as mixed. RAIR was present in 12 patients (37.5%). HPZ, maximum ARP, mean ARP were comparable across all PICSS groups without statistically significant differences. Presence of RAIR was not significantly associated with any PICSS groups (p = 0.13).
CONCLUSION: Bowel function does not appear to be significantly associated with HRAM findings after definitive pullthrough for HD, but our study is limited by small sample size. RAIR was present in 37.5% patients after pullthrough.
LEVEL OF EVIDENCE: Level II.
AIMS: This study aimed to assess the pelvic floor ultrasound characteristics of Ugandan women suffering with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse, and determine whether obstructed labour resulting in obstetric fistula causes more levator muscle defects compared to parous women without a history of obstructed labour.
MATERIALS AND METHODS: This was a prospective study in western Uganda assessing 82 women with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse with a pelvic floor ultrasound scan.
RESULTS: Demographic characteristics were significantly different, with women suffering pelvic organ prolapse being older and more parous. Hiatal area on Valsalva was significantly smaller in the obstetric fistula group (mean 21.45 cm2 ) compared to non-obstetric fistula group (unrepaired fourth degree obstetric tears and pelvic organ prolapse; mean 30.44 cm2 ); a mean difference of 9.0 cm2 (95% CI: 5.4-12.6 cm2 , P
AIMS: Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.
METHODS: All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ2 test and results are expressed as odds ratios (OR).
RESULTS: Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.
CONCLUSIONS: Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.
DESIGN: Prospective cohort study.
METHODS: MSM and TGW aged at least 18 years, were enrolled from Indonesia, Malaysia, and Thailand, then followed up 6-monthly for 12 months. Anal swabs were collected at every visit for HR-HPV genotypes to define anal HR-HPV incidence, clearance, and persistence. Logistic regression was used to evaluate factors associated with HR-HPV persistence.
RESULTS: Three hundred and twenty-five MSM and TGW were included in this study, of whom 72.3% were HIV-positive. The incidence of anal HR-HPV persistence was higher in HIV-positive than HIV-negative MSM participants (28.4/1000 vs. 13.9/1000 person-months). HIV-positive participants had HR-HPV lower clearance rate than HIV-negative participants (OR 0.3; 95% CI 0.1-0.7). The overall persistence of HR-HPV was 39.9% in HIV-positive and 22.8% HIV-negative participants. HPV-16 was the most persistent HR-HPV in both HIV-positive and HIV-negative participants. HIV infection (aOR 2.87; 95% CI 1.47-5.61), living in Kuala Lumpur (aOR 4.99; 95% CI 2.22-11.19) and Bali (aOR 3.39; 95% CI 1.07-10.75), being employed/freelance (aOR 3.99; 95% CI 1.48-10.77), and not being circumcised (aOR 2.29; 95% CI 1.07-4.88) were independently associated with anal HR-HPV persistence.
CONCLUSION: HIV-positive MSM and TGW had higher risk of persistent anal HR-HPV infection. Prevention program should be made available and prioritized for HIV-positive MSM and TGW where resources are limited.
METHODS: Surgeons from 42 centers of coloproctology in Europe were asked to complete a questionnaire, including seven questions about their past and present operative treatment strategy for patients with OD.
RESULTS: The questionnaire was completed by 32 experts of pelvic floor surgery in 13 European countries. All but one indicated that they consider surgical treatment for OD. Seventy-four percent of these have been using transanal stapled rectal resection (STARR) and 96 % transabdominal rectopexy. While only 65 %, who have begun performing STARR are still using transanal resection, the technique is still being used by all surgeons performing abdominal procedures. Rectopexy only, STARR only, or both approaches are offered by 52, 3, and 45 % of surgeons, respectively.
CONCLUSIONS: The use of STARR in the treatment of OD is decreasing among European opinion leaders in the field of pelvic floor surgery, while the application of transabdominal procedures continues.
METHODS: This was a retrospective ancillary analysis involving 660 nulliparous women carrying an uncomplicated singleton term pregnancy in a prospective perinatal intervention trial at two Australian tertiary obstetric units. They had been seen antenatally and at 3-6 months postpartum for a standardized clinical assessment between 2007 and 2014. Primary outcome measures were sonographically diagnosed LAM and external anal sphincter (EAS) trauma.
RESULTS: The incidence of LAM avulsion (11.5% vs. 21.3%, P = 0.01) and composite trauma, i.e., LAM avulsion ± EAS injury (29.2% vs. 39.7%, P = 0.03) were higher in one of the two hospitals, where the forceps delivery rate was also higher (10.9% vs. 2.6%, P
METHODS: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR).
RESULTS: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively.
CONCLUSIONS: Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.
OBJECTIVE: In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery.
STUDY DESIGN: This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma.
RESULTS: A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035).
CONCLUSION: The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.
AIM: The present study evaluated the effect of methanolic and aqueous extract of Amorphophallus paeoniifolius tuber on croton oil induced hemorrhoids in rats.
MATERIALS AND METHODS: The methanolic extract was standardized with the major phenolic compound, betulinic acid, by HPLC. The hemorrhoids were induced by applying 6% croton oil preparation in the ano-rectal region. Rats were orally administered methanolic and aqueous extract at doses of 250 and 500mg/kg, each for 7 days. Pilex (200mg/kg) was used as reference anti-hemorrhoidal drug. Hemorrhoids were assessed on eighth day by measuring hemorrhoidal and biochemical parameters along with histology of ano-rectal tissue.
RESULTS: Croton oil application caused induction of hemorrhoids as indicated by significant (p<0.001) increase in plasma exudation of Evans blue in ano-rectal tissue, macroscopic severity score and ano-rectal coefficient as compared to normal rats. It significantly (p<0.001) elevated lactate dehydrogenase and cytokines (TNF-α and IL-6) levels in serum and increased myeloperoxidase activity and lipid peroxidation in ano-rectal tissue along with marked histological damage as compared to normal rats. Treatment with tuber extracts and pilex significantly (p<0.05-p<0.001) ameliorated Evans blue exudation, hemorrhoidal parameters and other biochemical parameters with attenuation of tissue damage compared to hemorrhoid control rats. The results indicate that tuber extracts exhibited curative action on hemorrhoids. The aqueous extract showed more pronounced effect than methanolic extract. The effects may be attributed to anti-inflammatory and antioxidant properties.
CONCLUSION: Results indicate that tuber of Amorphophallus paeoniifolius exhibited curative action on hemorrhoids through anti-inflammatory and antioxidant properties. The study validates the ethnomedicinal use of tuber in hemorrhoids and implicates its therapeutic potential as an anti-hemorrhoidal agent.
RESULTS: We compared the anal microbiota composition of adult survivors of childhood ALL (N = 73) with healthy control subjects (N = 61). We identified an altered community with reduced microbial diversity in cancer survivors, who also exhibit signs of immune dysregulation including increased T cell activation and chronic inflammation. The bacterial community among cancer survivors was enriched for Actinobacteria (e.g. genus Corynebacterium) and depleted of Faecalibacterium, correlating with plasma concentrations of IL-6 and CRP and HLA-DR+CD4+ and HLA-DR+CD8+ T cells, which are established markers of inflammation and immune activation.
CONCLUSIONS: We demonstrated a relationship between microbial dysbiosis and immune dysregulation in adult ALL survivors. These observations suggest that interventions that could restore microbial diversity may ameliorate chronic inflammation and, consequently, development of late effects of childhood cancer survivors.
METHODS: A total of 271 patients were analysed in a retrospective study utilising archived ultrasound volume datasets. Symptoms of obstructed defecation (straining at stool, incomplete bowel emptying, perineal, vaginal and anal digitation) were ascertained on interview. Postprocessing of stored 3D/4D translabial ultrasound datasets obtained on maximal Valsalva was used to diagnose descent of the rectal ampulla, rectocoele, enterocoele and rectal intussusception at a later date, blinded to all clinical data.
RESULTS: Digitation was reported by 39 % of our population. The position of the rectal ampulla on Valsalva was associated with perineal (p = 0.02) and vaginal (p = 0.02) digitation. The presence of a true rectocoele was significantly associated with perineal (p = 0.04) and anal (p = 0.03) digitation. Rectocoele depth was associated with all three forms of digitation (P = 0.005-0.02). The bother of symptoms of obstructed defecation was strongly associated with digitation (all P