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PubMedDate not supplied

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. IX. Single loop continence: a new theory of the mechanism of anal continence.

The role of the external and internal anal sphincters in the mechanism of anal continence is presented. The external sphincter induces continence by 1) preventing internal sphincter relaxation, what I have called the "voluntary inhibition action," and 2) mechanical compression of the rectal neck and anal canal proper. The mechanism of both actions is described. The internal sphincter plays a significant role not only in involuntary, but also in voluntary, continence. The importance of this role in the correction of anal incontinence is clarified. "Stress defecation," a condition which follows internal sphincter damage, is discussed. A "single loop continence" theory is presented, based on the fact that each of the three loops of the external sphincter has its own innervation, attachment, and direction of muscle bundles; each loop thus acts as a separate sphincter. The clinical application of this theory is presented.

Anal Canal↗
PubMed1978

[Technique and results of the colon conduit, continent by means of a new magnetic stoma seal. An animal experiment study. Enterocystoplasty as model of continent urinary diversion. Review and comparison of the results of colocystoplasty, coloprostatoplasty and colourethroplasty (authors transl)].

On the basis of satisfactory results with a new magnetic stoma seal in colostomy patients, this seal, consisting of a magnetic ring and cap, was used in an experimental study to convert the colonic conduit into a continent reservoir. The aim of the study, involving 16 dogs, was to find a method of ring implantation that would avoid infection of the ring and yield complete continence in a higher percentage than had been achieved so far in patients. Complete continence was obtained in all animals but there was a 75% incidence of immediate and delayed infection of the magnetic ring when the ring was inserted transcutaneously. In contrast, all rings were well accepted by the tissue when the procedure was staged with the ring being implanted transperitoneally several weeks prior to fashioning of the conduit. The general problems arising from the colonic conduit when used as continent reservoir are known from the results of colocystoplasty, coloprostatoplasty and colourethroplasty, which are reviewed and compared with our observations. Residual urine was low due to an ideal energy-balance pattern. Coloureteric reflux was successfully prevented in all cases operated on by a long-tunnel modification of the Leadbetter-Clarke technique. Hyperchloremic acidosis and renal function deterioration were not observed. All conduits were infected.

Animals↗
PubMed2001

[Enhanced continent mechanism of the tapered ileum in continent urinary reservoir].

OBJECTIVE: To construct a reliable continent tube that is easy to catheterize and is surgically simple. METHODS: From October 1999 through March 2001, 20 patients underwent a procedure in which ileal segment was tapered as an efferent tube and the partial efferent tube was placed between the back surface of the rectus muscle and the wall of the ileal pouch. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice of the tapered ileum was anastomosed to the umbilicus. Urodynamic study of the efferent tubes and pouch was done 1.5 to 3 months and 6 to 17 months after operation. RESULTS: The stoma was easily catheterized with a 16 F catheter in all patients. One patient died of heart disease 55 days after the operation, while 18 of the remaining 19 were completely continent day and night. At 1.5 to 3 months, the urodynamic study of the efferent tubes showed the maximum close pressure with a full pouch of 46-124 cmH2O(91.53 +/- 17.21), and when the pouch was empty it was 34-84 cmH2O(66.68 +/- 11.60). The difference in the mean maximum closure pressure in full and empty pouches was statistically significant (t = 10.59, P < 0.01). At 6 to 17 months, urodynamic study was performed in 12 patients, the maximum closure pressure in the efferent tube was 77 to 154 cmH2O (100.92 +/- 20.88) when the pouch was filled with saline. When the pouch was empty, it was 56 to 115 cmH2O (74.08 +/- 14.59). The difference in the mean maximum closure pressure in full and empty pouches was statistically significant (t = 8.54, P < 0.01). Reservoir capacity was 360 to 750 ml (455 +/- 110.74). When it was filled to the maximum, the reservoir pressure was 16 to 35 cmH2O (23.17 +/- 5.82). There was no contractive wave in filling in any patient. CONCLUSIONS: This study indicates that the continent mechanism of the tapered ileum can be greatly enhanced by fixing it between the abdominal and pouch walls. This maneuver also provides easy catheterization and surgical simplicity.

Adult↗
PubMed2002

Urodynamic study of enhanced continent mechanism using tapered ileum as continent urinary reservoir.

OBJECTIVE: To investigate the effect of extramural support from the pouch and abdominal wall to enhance the continent mechanism of tapered ileum. METHODS: A total of 24 patients underwent a procedure in which an ileal segment was tapered into an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. A urodynamic study of the efferent tubes and pouch was done 1.5 to 3 months and 6 to 24 months postoperatively. RESULTS: One patient died of heart disease 55 days postoperatively, while 22 of the remaining 23 were completely continent day and night. At 1.5 to 3 months, the urodynamic study of the efferent tubes demonstrated that the maximum closure pressure with a full pouch was 46 - 124 cmH(2)O (91.26 +/- 15.71 cmH(2)O) and with an empty pouch was 34 - 84 cmH(2)O (67 +/- 10.60 cmH(2)O). The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -11.78 and P = 0.00001). At 6 to 24 months, a second urodynamic study was performed on 18 cases, demonstrating a reservoir capacity of 420 to 750 ml (481.67 +/- 78.83 ml). Reservoir pressure was 6 to 9 cmH(2)O (7.17 +/- 1.17 cmH(2)O) when the pouch was filled to 50 ml, and 16 to 35 cmH(2)O (24.12 +/- 5.61 cmH(2)O) when it was filled to maximum capacity. There was no contractive wave during the filling in any patient. Maximum closure pressure in the efferent tube was 80 to 194 cm H(2)O (98.89 +/- 26.34 cmH(2)O) when the pouch was filled with saline, and 64 to 128 cmH(2)O (74.78 +/- 14.54 cmH(2)O) when the pouch was empty. The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -7.58 and P = 0.00003). CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by extramural support from the abdominal and pouch walls.

Adult↗
PubMed1992

[Clinical studies on Kock continent urinary reservoir and Indiana continent urinary reservoir].

Recently, the continent urinary reservoir which provides the patient with a better quality of life has become popular. Many types of reservoirs have been reported, but the optimal procedure remains to be established. From July 1987 through November 1988, we performed Kock pouch construction on 11 patients (ages 39 to 76 years). Between July 1989 and March 1991, 9 patients (ages 44 to 66 years) underwent Indiana pouch operation. The first 4 patients underwent ileal patch type, and the subsequent 5 underwent Heineke-Mikulicz type procedure. A one-stage radical cystectomy and continent urinary reservoir construction was performed on 19 patients, and bilateral cutaneous ureterostomy was converted to Kock pouch in one patient. There were no perioperative deaths, but reoperation was required for urinary leakage from the reservoir on one patient in each group. As the late complications in the Kock pouch group, one patient required revisional operation of the continent valve mechanism, 2 patients experienced intermittent prolapse of the nipple valve of the efferent limb, and 2 had malfunction of the afferent nipple valve. In the Indiana pouch group unilateral hydronephrosis was noticed in one patient, and 4 had mild difficulty of catheterization. Although 3 patients in both groups had mild urinary leakage, all patients had good quality of life with capacity of reservoir over 500 ml and with good renal function. We changed the type of operative procedure from Kock pouch to Indiana pouch because of the high complication ratio in the former.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2006

Post-robotic prostatectomy urinary continence: characterization of perfect continence versus occasional dribbling in pad-free men.

OBJECTIVES: To review and characterize two groups of men who report being pad-free after robot-assisted laparoscopic prostatectomy (RLRP): those with occasional incontinence and those with complete control. METHODS: The study included 106 out of a total of 195 men who underwent RLRP. Inclusion requirements were adequate follow-up and no-pad continence status. All patients completed self-administered American Urological Association symptom score (AUAss) and continence questionnaires and underwent measurement of peak urinary flow rates, postvoid residual volumes, and voided volumes (VV) before and 3 months after surgery. All data and standard clinical characteristics were entered prospectively into an electronic database. RESULTS: Two distinct groups reported wearing no pads: the "perfect" group (n = 32) reported never leaking, and the "imperfect" group (n = 74) reported occasional leakage but did not wear pads. Preoperatively, the "imperfect" group was older (62.2 versus 59 years) and had more urinary symptoms (all P < 0.05). Postoperatively, the "imperfect" group took longer to achieve a pad-free status (median 39.8 versus 19.3 days), had larger prostates (mean 50.9 versus 43.2 g), had lower VV (324 versus 405 mL), and more urinary symptoms (AUAss 7.4 versus 4.3; all P < 0.05). CONCLUSIONS: Sixty-nine percent of men who attain "pad-free continence" after RLRP have occasional urinary leakage. Preoperatively, these men are characteristically older and have larger prostates, AUAss, and bother scores. Postoperatively, the "imperfect" group takes longer to achieve pad-free status and has smaller bladder capacities and more urinary symptoms. These results suggest that an overactive detrusor is the likely contributing etiology.

Humans↗
PubMed1994

A new theory of micturition and urinary continence based on histomorphological studies. 3. The two parts of the musculus sphincter urethrae: physiological importance for continence in rest and stress.

The urethral component of continence is the object of a lively discussion. A large number of the examiners interpret the external striated urethral muscle as part of the muscular pelvic diaphragm, formed partially or completely by the so-called musculus transversus perinei profundus. About 30,000 histological sections have been examined by light microscopy in a systematical manner. In contrast to numerous suggestions in the literature the musculus sphincter urethrae has been found to be an independent morphological unit in our investigation. It is separated from the surroundings by a segment of connective tissue. Furthermore, with the help of transversal, sagittal and frontal serial sections it was possible to show that the musculus transversus perinei profundus does not exist. In the female as well as in the male in the direction of the urethra the outer sphincter always borders on a layer of smooth muscle cells. In order to distinguish both parts the terms musculus sphincter urethrae transversostriatus and musculus sphincter urethrae glaber are introduced. In the context of a new continence theory three structures capable of occluding the urinary bladder will be discussed. It should be emphasized that the musculus sphincter urethrae glaber makes long-term continence possible.

Cadaver↗
PubMed1991

Continence mechanisms following continent urinary diversion and orthotopic bladder replacement.

It is obvious that significant advances have been made in reconstruction of the lower urinary tract following radical pelvic surgery. In contrast to the standard ileal loop, patients no have an option to void per urethra, have social continence and avoid self-intermittent catheterization in the presence of an abdominal stoma. Further refinements in construction of the continence mechanism will undoubtedly occur in the future.

Animals↗
PubMed1996

Simplified uretero-intestinal implantation in continent cutaneous urinary diversion using ileovalvular segment as afferent loop and appendix as continent outlet.

PURPOSE: We performed continent cutaneous urinary diversion with implantation of ureters as in ileal loop diversion to reduce the risk of ureterointestinal implantation stricture. MATERIALS AND METHODS: Four patients underwent colonic pouch and 11 underwent ileocecal continent urinary diversion the ileocecal segment used as an afferent loop and the sphincter-like function of the ileocecal valve used as an antireflux mechanism. RESULTS: All preoperatively undilated renal units (26 of 30) remained postoperatively undilated. Of the 4 preoperatively dilated renal units 3 also showed postoperatively improvement (mean followup 8 months). However, after 3 to 14 months transient reflux occurred during contraction waves in the reservoir in 6 renal units. CONCLUSIONS: Our modified technique simplifies ureteral reimplantation and appears to diminish the postoperative complication of anastomotic structure. The solution to the problem of occasional reflux may be reinforcement of the ileocecal valve.

Adult↗
PubMed2006

Role of the rectosigmoidal junction in fecal continence: concept of the primary continent mechanism.

HYPOTHESIS: At mass contraction of the descending colon, the colonic contents stop at the sigmoid colon (SC) and do not pass directly to the rectum. We investigated the hypothesis that a continent mechanism seems to exist at the rectosigmoidal junction (RSJ), preventing the direct passage of stools from the descending colon to the rectum. METHODS: The SC in 16 healthy volunteers (mean +/- SD age, 38.6 +/- 10.2 years; 9 men and 7 women) was distended with an isotonic sodium chloride solution-filled balloon, and the pressure response of the RSJ and the rectum was recorded at rapid and gradual filling of the balloon. The test was repeated after the SC and RSJ were anesthetized separately. RESULTS: Rapid SC balloon distension with a mean +/- SD of 52.1 +/- 3.6 mL of isotonic sodium chloride solution effected an RSJ pressure increase to a mean +/- SD of 67.8 +/- 18.4 cm H(2)O (P<.01) with no rectal pressure response (P>.05). Slow SC filling produced a progressive increase in RSJ pressure but no rectal pressure change. At a mean +/- SD SC distending volume of 86.3 +/- 4.1 mL, the RSJ pressure decreased to 9.6 +/- 2.8 (P<.01), and the balloon was dispelled to the rectum; rectal pressure increased (P<.001), and the balloon was expelled to the exterior. The RSJ pressure did not respond to distension of the anesthetized SC. CONCLUSIONS: Contraction of the RSJ at rapid SC distension with big volumes implies a reflex relationship that we call the RSJ guarding reflex. This reflex seems to prevent the descending colon contents from passing directly to the rectum. It is considered the first continent reflex and may serve as an investigative tool in the study of fecal incontinence.

Adult↗
PubMed2005

The colon flap/extension Malone antegrade continence enema: an alternative to the Monti-Malone antegrade continence enema.

PURPOSE: In situations where the appendix is not available for the Malone antegrade continence enema (MACE) procedure a Yang-Monti channel or a colon flap conduit can be created. We report our experience with colonic flap conduits used for the MACE. MATERIALS AND METHODS: A total of 169 MACE procedures were performed between February 1997 and March 2003. In 11 patients 12 colon flaps or cecal extensions were used to construct the MACE conduit. Diagnoses included myelomeningocele (8 patients), caudal regression (1), sacral agenesis (1) and gunshot wound (1). Mean age at creation of MACE was 11.3 years (range 4.4 to 16.9). Seven cecal flaps, 1 descending colon flap and 4 cecal extension flaps were created. RESULTS: Average followup was 22.8 months (range 2.6 to 34.6). Indications for colon flap MACE were appendicovesicostomy (6 patients), short appendix (2), shortened mesentery (1), retrocecal appendix (1), prior appendectomy (1) and right hemicolectomy (1). Initially all patients easily catheterized and flushed the MACE once daily. All 11 patients achieved fecal continence. Complications occurred in 3 cases. One obese patient could not visualize the umbilical stoma and it stenosed, requiring conversion to a spiral Monti-MACE. One patient with a cecal extension had development of a false passage, resulting in complete channel stenosis. One patient had development of stomal leakage, which was successfully treated with dextranomer/hyaluronic acid copolymer injection. CONCLUSIONS: A colon flap MACE conduit is a simple technique to provide access to the colon for irrigation. When faced with situations were the appendix is not available for the MACE procedure the colon flap can be a good option.

Adolescent↗
PubMed1996

Continent reconstruction of detrusor hyperreflexia by sacral bladder denervation combined with continent vesicostomy.

We describe a two-stage surgical procedure for complex hyperreflexic detrusor dysfunction refractory to conservative therapy. First, ventral and dorsal sacral rhizotomies (S2 to S4/5) are performed to restore vesical storage function and abolish autonomic dysreflexia. Then, after an interval of several weeks to allow for detrusor relaxation, continent vesicostomy is performed for suprapubic clean intermittent catheterization. The procedure is effective both objectively and subjectively, is only moderately invasive, and requires neither sophisticated nor expensive medical equipment.

Adult↗
PubMed1994

A new theory of micturition and urinary continence based on histomorphological studies. 2. The musculus sphincter vesicae: continence or sexual function?

Results of a histomorphological study of serial sections carried out in frontal, transversal and sagittal directions in 65 bladder necks are presented. It is shown that the trigonal system of the urinary bladder consists of two anatomical structures: first, of a muscle originating from the muscle system of both ureters and converging to form within the bladder the interureteric ridge, the musculus interuretericus and of a second structure forming the actual trigonum vesicae. It is the musculus sphincter trigonalis or musculus sphincter vesicae. This muscle elliptically embraces the internal urethral orifice and is only formed by one muscle lamella. It does not as has often been described extend in any form to the urethra or to the surroundings. The so-called Bell muscle does not exist. During the reproductive years the lower part of the sphincter trigonalis is strongly pervaded with prostate tissue. This could enable the muscle to have a double function: a continence function in accordance with a consequent distinction between the urinary bladder and the urethra as urinary and sexual tract, and during ejaculation the muscle could prevent the retrograde ejaculation and on the other hand the contraction of the muscle could lead to the release of the prostate secretion.

Adolescent↗
PubMed1989

Mechanisms of continence and voiding, with international continence society classification of dysfunction.

The two functions of the lower urinary tract are storage of urine within the bladder and timely expulsion of urine from the urethra. Bladder filling occurs with little or no increase in intravesical pressure, despite large increases in urine volume. This process, called accommodation, results from viscoelastic properties of the bladder wall and reflex inhibition of detrusor contractility. Urinary continence is maintained at rest by outflow resistance generated by the urethral sphincteric mechanism. With increases in intra-abdominal pressure, urethral resistance is augmented by passive pressure transmission to the bladder neck and proximal urethra and possibly by reflex muscular activity within the urogenital diaphragm. Normal voiding is a reflex act under voluntary control that involves relaxation of the urethra and sustained contraction of the bladder until emptying is complete. The ICS has classified lower urinary tract dysfunction as disorders of the filling or storage phase and as disorders of the emptying phase. Although urodynamic testing is not always necessary, some evaluation of both bladder and urethral function in each phase is required for accurate diagnosis.

Female↗