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PubMed2004

Rupture of the sphincter ani: the recurrence rate in second delivery.

BACKGROUND: Injury to the genital tract sustained during childbirth can lead to transient or protracted morbidity. Attention should be paid to avoidable risk factors that can cause this complication. AIM: To analyse the recurrence, at a later delivery, of trauma to the genital tract, subsequent to perineal laceration of the sphincter ani (third or fourth degree), sustained at an earlier delivery. DESIGN: A population-based study. SETTING: In Sweden, 1973-1997 inclusive. POPULATION: All women with a vaginal, singleton delivery in Sweden. METHODS: The Medical Birth Registry, the National Board of Health and Welfare, was used to identify cases of ruptured sphincter ani. MAIN OUTCOME MEASURES: OR was calculated with 95% confidence interval. A stratified analysis was performed using the Mantel-Haenszel technique. Major end point Rupture of the sphincter ani (third or fourth degree) at second delivery. RESULTS: The incidence of anal sphincter rupture increased sixfold during the study period, from 0.5% in 1973 to 3.0% in 1997. Women who had sustained a laceration of this type ran a significantly increased risk of a recurrence at a later delivery. This effect persisted even after stratification for birthweight, year of birth, parity and maternal age (OR 4.74, 95% confidence interval 4.34-5.17). When only fourth degree rupture was considered (rupture of both anal sphincter and rectum), the corresponding figures were 6.52 (95% CI 5.29-8.04). This effect also persisted after stratification for birthweight, year of birth, parity and maternal age. The OR for giving birth a second time, subsequent to a third or fourth degree perineal laceration at first delivery, was 0.68 (95% CI 0.67-0.70). CONCLUSION: Our findings suggest that the risk of an anal sphincter rupture at delivery increases five to sevenfold when there has been a similar rupture at a previous delivery. Further study is needed before safe recommendations can be made concerning the subsequent mode of delivery to be adopted, following rupture in the sphincter ani at a previous birth.

Adult↗
PubMed1991

Globular and asymmetric forms of acetylcholinesterase in the rat levator ani muscle.

The endplate (+EP) and non-endplate (-EP) distribution of molecular forms of acetylcholinesterase (AChE) was compared in the dimorphic levator ani and diaphragm muscles from adult male rats. Enzyme activity was measured by the thiocholine method and AChE forms were separated on the basis of solubility in sodium phosphate buffer of different ionic strength. For the dimorphic levator ani muscle, total AChE activity was 324.6 +/- 18.9 nmol ASCh hydrolyzed min-1 muscle-1, 90% of which was globular and predominated in the -EP region (78%). The asymmetric forms were almost exclusively detected in the +EP region (9%). In diaphragm muscle, total AChE activity was 176.7 +/- 11.0 units; 66% was mainly globular and located in the -EP region (56%); the asymmetric forms (34%) were either in -EP (11%) or +EP (23%) regions. Thus, a greater proportion of globular form was present in the dimorphic levator ani muscle than in diaphragm muscle. In view of the control exerted by testosterone on dimorphic muscles, it is suggested that the greater synthesis of the globular form in the levator ani occurs under the trophic influence of testosterone.

Acetylcholinesterase↗
PubMed1990

Histology of the connection between the vagina and levator ani muscles. Implications for urinary tract function.

The proximal urethra is a mobile structure, and voluntary control of its position is an integral part of the initiation of urination and continence. This paper describes the histology of the vagina's attachment to the medial portion of the levator ani muscles, which, because of the intimate attachment of the vagina and urethra, is responsible, in part, for control of the urethral position. A histologic examination of 1,500 serial microscopic slides from eight women, dissection of four bodies and study of whole pelvis cross-sections from two cadavers were performed. Smooth muscle, collagen and elastin fibers of the vaginal wall and paraurethral tissues directly interdigitate with the muscle fibers of the most medial portion of the levator ani, in the region of the proximal urethra. This strong connection lies at a level just below the entry of the urethra into the bladder and extends downward to the level of the perineal membrane (urogenital diaphragm) in an area corresponding to the mobile portion of the urethra. The inseparable nature of the vagina and urethra in this region makes it possible for the connection of the levator ani to the vagina to control the proximal urethral position. These observations suggest a specific role of the medial levator ani muscle in controlling vesical neck position and open the question of the specific part played by this arrangement in voiding and continence relative to other factors known to influence lower urinary tract function.

Adolescent↗
PubMed1987

Physiological study of pruritus ani.

Physiological abnormalities in the anorectum of 34 patients with pruritus ani, and 20 age and sex matched controls were assessed. A saline infusion (1500 ml) test showed that leakage started after infusion of 600 ml in patients with pruritus ani compared with 1300 ml in controls (median values: P less than 0.001). There was an inverse relationship between the severity of the symptoms of pruritus ani and the volume of first leakage on the saline infusion test P less than 0.02. Studies to assess anal sphincter function, rectal sensation to balloon distension, rectal compliance, and perineal descent did not show any significant differences between pruritic patients and controls. However, pruritic patients without co-existing anal pathology had a significantly greater fall of anal pressure when a rectal balloon was inflated (57 per cent) when compared with controls (40 per cent) P less than 0.05.

Adult↗
PubMed1994

Abnormal transient internal sphincter relaxation in idiopathic pruritus ani: physiological evidence from ambulatory monitoring.

Patients with idiopathic pruritus ani have an abnormal rectoanal inhibitory reflex and a lower threshold for internal sphincter relaxation during the saline continence test. This led to the hypothesis that these patients may exhibit abnormalities of the transient internal anal sphincter relaxation reflex. To study this, 23 men of median age 41 (range 27-64) years with idiopathic pruritus ani and 16 male controls of median age 39 (range 26-68) years were assessed using computerized ambulatory anorectal electromyography and manometry. Resting anal pressure, maximum anal squeeze pressure, internal sphincter electromyogram frequency, the number of internal sphincter relaxations and pudendal nerve terminal motor latency were similar for the two groups. The rise in rectal pressure during internal sphincter relaxation was higher in patients with pruritus than in controls (median (range) 29 (18-60) versus 18 (11-37) cmH2O, P < 0.01). Furthermore, the fall in anal pressure was greater in patients with pruritus than in controls (median (range) 39 (15-52) versus 29 (21-43) cmH2O, P < 0.01). The duration of internal sphincter relaxation was prolonged in patients compared with controls (median (range) 29 (18-55) versus 8 (5-12) s, P < 0.001). Fourteen patients reported staining of underclothes and 17 complained of perianal itch within 1 h of these episodes of abnormal internal sphincter relaxation. Pruritus ani may result from occult faecal leakage as a result of abnormal transient internal sphincter relaxation.

Adult↗
PubMed1990

Treatment of intractable pruritus ani.

The majority of patients with idiopathic pruritus ani respond favorably to conservative treatment. Moreover, response to specific medical therapy is almost always favorable in certain dermatologic diseases such as psoriasis, mycotic dermatitis, and contact dermatitis. When surgery is performed for anorectal disorders such as hemorrhoids and fistulas, or potentially malignant entities such as extramammary Paget's disease, the accompanying pruritus ani invariably improves as well. Only patients with chronic intractable pruritus ani are included in the current study. Methylene blue (methylthionine chloride) 0.5 percent is injected intracutaneously on the anodermal and perianal skin. With one treatment, long-term cure has been observed.

Adult↗
PubMed1989

The fecal microflora in pruritus ani.

Pruritus ani is a common condition in which there is a tendency for liquids to leak from the anal canal, resulting in perianal soiling. In order to ascertain if an abnormal fecal flora contributes to the irritant effects of fecal material, qualitative and quantitative measurement of the fecal microflora was performed in 20 patients with pruritus ani and 20 matched controls. No differences were found between the two groups. This study has failed to provide evidence for a microbiologic basis for pruritus ani.

Adult↗
PubMed2003

Squamous cell carcinoma of the anal margin with pruritus ani of long duration.

BACKGROUND: Anal margin is an unusual location for squamous cell carcinoma (SCC). On rare occasions, anal margin carcinoma is the cause of pruritus ani. OBJECTIVE: To describe a case of SCC of the anal margin with pruritus ani of long duration. RESULTS: A 52-year-old man had been aware of perianal itching for over 10 years. Examination of the perianal area revealed a reddish, eroded, hard nodule that was 2.0 x 1.5 x 0.3 cm in size located in the 3 o'clock position. The histopathologic diagnosis was well-differentiated SCC. The nodule was totally excised with a 1-cm margin. No recurrence or metastases were observed for 7 months. CONCLUSION: When pruritus ani does not respond to conservative therapy and when symptoms have existed for a long time, we should suspect the presence of malignancy.

Anus Neoplasms↗
PubMed1988

Pruritus ani.

Although the importance of the anal zone is well known in psychoanalysis, pruritus ani has not been studied recently in the psychoanalytic literature. This paper is presented to show how bisexuality in a male patient has been analysed through pruritus ani as the main presenting symptom. After giving the case history of Fernand, pruritus ani is analysed from three main points of view: phallic, anal and oral. This is done to illustrate the connexions of the psychopathological material at the three stages and their expression through one symptom of the 'instincts and their vicissitudes'. Finally, the importance of the anal stage and its symptomatology as an attempt to diminish the affective charge brought up in the individual by the oral and phallic conflicts is discussed briefly.

Adult↗
PubMed2003

Innervation of the levator ani and coccygeus muscles of the female rat.

In humans, the pelvic floor skeletal muscles support the viscera. Damage to innervation of these muscles during parturition may contribute to pelvic organ prolapse and urinary incontinence. Unfortunately, animal models that are suitable for studying parturition-induced pelvic floor neuropathy and its treatment are rare. The present study describes the intrapelvic skeletal muscles (i.e., the iliocaudalis, pubocaudalis, and coccygeus) and their innervation in the rat to assess its usefulness as a model for studies of pelvic floor nerve damage and repair. Dissection of rat intrapelvic skeletal muscles demonstrated a general similarity with human pelvic floor muscles. Innervation of the iliocaudalis and pubocaudalis muscles (which together constitute the levator ani muscles) was provided by a nerve (the "levator ani nerve") that entered the pelvic cavity alongside the pelvic nerve, and then branched and penetrated the ventromedial (i.e., intrapelvic) surface of these muscles. Innervation of the rat coccygeus muscle (the "coccygeal nerve") was derived from two adjacent branches of the L6-S1 trunk that penetrated the muscle on its rostral edge. Acetylcholinesterase staining revealed a single motor endplate zone in each muscle, closely adjacent to the point of nerve penetration. Transection of the levator ani or coccygeal nerves (with a 2-week survival time) reduced muscle mass and myocyte diameter in the iliocaudalis and pubocaudalis or coccygeus muscles, respectively. The pudendal nerve did not innervate the intrapelvic skeletal muscles. We conclude that the intrapelvic skeletal muscles in the rat are similar to those described in our previous studies of humans and that they have a distinct innervation with no contribution from the pudendal nerve.

Animals↗
PubMed2007

Levator ani trigger point injections: An underutilized treatment for chronic pelvic pain.

AIMS: We conducted this study to examine the role of trigger point injections in females with chronic pelvic pain (CPP) of at least 6 months duration and specific levator ani trigger points. METHODS: This prospective study included 18 consecutive female patients with CPP and specific palpable levator ani trigger points. Pain was evaluated before and after trigger point injection on a Visual Analog Scale (VAS). Patient global satisfaction (PGS) and cure rates (PGC) were also measured by a VAS on a scale of 0-100%. The trigger points were identified manually by intravaginal palpation of the levator ani bilaterally. A mixture of 10 cc of 0.25% bupivacaine, 10 cc of 2% lidocaine and 1 cc (40 mg) of triamcinolone was used for injection of 5 cc per trigger point. A 5.5'' Iowa trumpet pudendal needle guide was used for injection. All but one injection were performed in the office setting without sedation. Pelvic floor muscle exercises were taught for use after injection. Success was defined as a decrease in pain as measured by a VAS of 50% or more, as well as PGS and PGC scores of 60% or greater. There was a mean follow up of 3 months after trigger point injection. RESULTS: Thirteen of 18 women improved with the first trigger point injection resulting in a comprehensive success rate of 72%. Six (33%) of 18 women were completely pain free. CONCLUSION: In the management of CPP, a non-surgical office-based therapy such as trigger point injections can be effective in selected patients.

Adult↗
PubMed2005

Subject specific finite element modelling of the levator ani.

Understanding of the dynamic behaviour of the levator ani is important to the assessment of pelvic floor dysfunction. Whilst shape modelling allows the depiction of 3D morphological variation of the levator ani between different patient groups, it is insufficient to determine the underlying behaviour of how the muscle deforms during contraction and strain. The purpose of this study is to perform a subject specific finite element analysis of the levator ani with open access magnetic resonance imaging. The method is based on a Mooney-Rivlin hyperelastic model and permits dynamic study of subjects under natural physiological loadings. The value of the proposed modelling framework is demonstrated with dynamic 3D data from nulliparous, female subjects.

Computer Simulation↗
PubMed1976

[The importance of the Musculus canalis ani for continence and anorectal diseases (author's transl)].

The functional morphology of the M. canalis ani is described. Hitherto this muscle has not been studied in detail. The M. canalis ani is located inside of the M. sphincter ani internus and reaches through the spatium submucosum et subcutaneum of the analcanal. This muscle is part of a described "organ of continence". Its importance in the course of anorectal disease is shown.

Anal Canal↗
PubMed2002

Ultrastructural localization of Ani s 1, a major allergen from the fish parasite Anisakis simplex.

No data about the nature or function of the first major Anisakis simplex allergen, named Ani s 1, is available. The aim of this study was to investigate the ultrastructural localization of this protein, to obtain further information about it. Ani s 1 was detected in secretory granules of the excretory gland and occasionally lining the main excretory canal. Our results suggest that Ani s 1 could be a secretory product and could have an enzymatic function related to mechanisms of infection.

Allergens↗
PubMed1991

The same myosin isoforms are found in the female and male sexually dimorphic levator ani muscle of the rat, but their postnatal transitions are not synchronous.

The levator ani of the female adult rat is greatly atrophied in comparison to the same muscle in males. In the present study, the female levator ani was, nevertheless, found to contain type IIb myosin isoforms similar to those contained in the male muscle. These adult type isoforms were, however, synthesized later in the female than in the male levator ani: the half-transition times of the myosin transition curve were 20 days postnatal in the male and 35 days postnatal in the female. The transition curves for castrated and uncastrated male rats were the same. Thus, the presence of male gonadal hormones apparently did not affect the myosin transition.

Animals↗
PubMed1990

Effect of almond and anis oils on mouse liver alcohol dehydrogenase, aldehyde dehydrogenase and heart lactate dehydrogenase isoenzymes.

The effects of short-term intraperitoneal injection of diluted almond or anis oil on heart lactate dehydrogenase isoenzymes, liver alcohol dehydrogenase and subcellular aldehyde dehydrogenase were studied in the female mouse. Hepatic alcohol dehydrogenase was induced from control by administration of almond oil 3.2 g/kg/d for 7 days, or anis oil 1.6 g/kg/d for 7 days. Treatment with almond but not anis oil inhibited both cytoplasmic and mitochondrial liver aldehyde dehydrogenase. The mitochondrial isoenzyme with an apparently low Km was also inhibited by the almond oil trial. No significant changes occurred in heart lactate dehydrogenase isoenzymes by the treatments used. The enzymatic inhibition kinetics were found to be non-competitive. The apparent Km for almond-treated mouse aldehyde dehydrogenase was greater than the controls. This indicates lower substrate affinity for almond oil than for acetaldehyde. The results suggest adverse hepatic metabolic interaction between almond oil and alcohol.

Alcohol Dehydrogenase↗
PubMed2005

Insulin-like growth factor-1 gene splice variants as markers of muscle damage in levator ani muscle after the first vaginal delivery.

OBJECTIVE: Studies in animals and human muscle have demonstrated differential splicing of the insulin-like growth factor-1 gene in response to mechanical strain and damage. We conducted a study on the expression of insulin-like growth factor-1 splice variants in the levator ani muscle after the first vaginal delivery. STUDY DESIGN: Ten women were recruited after the first vaginal delivery. Biopsy specimens were taken vaginally of the pubovisceral component of the levator ani muscle. Five nonpregnant women were recruited as control subjects. Samples were processed with real-time quantitative polymerase chain reaction, with specific primers for the insulin-like growth factor-1 splice variants. RESULTS: Insulin-like growth factor splice variants mechano growth factor and insulin-like growth factor-1Ea were significantly up-regulated (100- and 1000-fold) in the delivery population, compared with control subjects (P=.012 and .04, respectively). Statistical analysis indicated a correlation between the expression of the insulin-like growth factor-1 splice variants and the length of the second stage. CONCLUSION: These results show that damaged levator ani muscle results from stretch and overload after the first vaginal delivery.

Adult↗
PubMed2006

Neuropathic injury to the levator ani occurs in 1 in 4 primiparous women.

OBJECTIVE: We measured levator ani neuromuscular function before and after first delivery to identify the location, timing, and mechanism of injury. STUDY DESIGN: Fifty-eight primiparous women underwent electromyographic examination of the levator ani antepartum at 6 weeks and 6 months after the delivery. Antepartum turns/amplitude data were pooled to create a normal range. We calculated each woman's percentage of outliers from this range and assessed relationships between delivery and extent of injury. RESULTS: At 6 weeks, 14 of 58 women (24.1%) had neuropathy, with 9 of those 14 women recovering by 6 months. At 6 months, 17 of 58 women (29.3%) were neuropathic, which included 12 new injuries. Women who had elective cesarean delivery had virtually no injury, but all other modes of delivery had similar injury rates. CONCLUSION: Obstetric delivery is associated frequently with electromyographic evidence of neuropathic injury to the levator ani. The entire levator complex is at risk, and cesarean delivery while in labor is not protective.

Adult↗