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PubMed2003

Topical capsaicin--a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study.

PURPOSE: Pruritus ani is a common and embarrassing proctological condition which can be very difficult to treat. We report the results of a double blind placebo controlled study of treatment with capsaicin. METHODS: Firstly, a pilot open study was carried out on five patients to establish which of two doses was the most acceptable by comparing effectiveness and side effects. Secondly, a double blind, placebo controlled, crossover study of topical capsaicin was performed. This study involved two four week treatment phases separated by a one week washout phase. Forty four patients were randomised to receive locally either active capsaicin (0.006%) or placebo (menthol 1%) ointment over a four week period (22 patients per group). After four weeks of treatment and a one week washout period, the placebo group began to receive capsaicin while the treated group received placebo (menthol 1%) for another four weeks. At the end of the controlled study, responders from both groups continued with capsaicin treatment in an open labelled manner. RESULTS: Thirty one of 44 patients experienced relief during capsaicin treatment periods and did not respond to menthol; all patients not responding to capsaicin also failed on menthol (p<0.0001). In 13 patients, treatment with capsaicin was unsuccessful: eight patients did not respond to capsaicin treatment, one responded equally to capsaicin and placebo, and four others dropped out because of side effects. During the follow up period (mean 10.9 (SD 5.8) months), 29 "responders" needed a mean application of capsaicin every day (1.6 (SD 1.2); range 0.5-7 days) to remain symptom free (or nearly symptom free). CONCLUSION: Capsaicin is a new, safe, and highly effective treatment for severe intractable idiopathic pruritus ani.

Administration, Topical↗
PubMed1988

A randomised trial of simple excision of non-specific hypertrophied anal papillae versus expectant management in patients with chronic pruritus ani.

Forty-one patients with non-specific hypertrophied anal papillae and chronic idiopathic pruritus ani were randomly assigned to simple excision of the anal papillae (n = 21) or expectant management (n = 20). The patients were examined blindly 1 and 4 weeks after treatment and 1 year later. None of the patients were lost to follow-up. Of 21 patients treated with simple excision, 14 (67%) were symptom-free at 1 year after treatment compared to 11 out of 20 patients (55%) maintained on expectant management (P greater than 0.05). It is concluded that simple excision of non-specific hypertrophied anal papillae is without effect on chronic idiopathic pruritus ani.

Adult↗
PubMed2006

Interrater reliability and physical examination of the pubovisceral portion of the levator ani muscle, validity comparisons using MR imaging.

AIMS: Defects in the pubovisceral portion of the levator ani muscle are seen with MR imaging. This study aims to determine interrater reliability of physical examination in detecting these defects, and to validate findings from physical examination using comparisons with MR images. METHODS: Two examiners palpated the pubovisceral muscles of 29 women to assess for defects in this muscle. Each examiner was blinded to the others findings. MR scans were acquired on a further 24 women after structured clinical examination by one examiner. These images were read to determine pubovisceral muscle defects, blinded to patient identifiers. Agreement between raters and between MR imaging and clinical examination were calculated. RESULTS: The two examiners had positive agreement (presence of a defect) of 72.7% and negative agreement (absence of a defect) of 83.3%. The positive agreement between physical examination and MR imaging was 27.3% and the negative agreement 86.5%. CONCLUSION: The structured physical examination to detect defects in the pubovisceral portion of the levator ani muscle can be learned as shown by good interrater agreement. However, examination alone underestimates these defects compared with MR imaging.

Adult↗
PubMed2006

Comparison of the growth-promoting effects of testosterone and 7-alpha-methyl-19-nor-testosterone (MENT) on the prostate and levator ani muscle of LPB-tag transgenic mice.

BACKGROUND: 7-alpha-methyl-19-nortestosterone (MENT) is being considered for androgen replacement in testosterone deficient men and as a male contraceptive. Because androgenic effects on the prostate are a major concern, we have evaluated MENT in a transgenic model of prostate cancer. METHODS: LPB-Tag mice were castrated and infused with testosterone (T; 5 or 30 microg/day) or MENT (5 or 30 microg/day) for 4 weeks. Prostate, seminal vesicle, and levator ani muscle (LAM) weights were compared. RESULTS: At an equivalent dose, MENT maintained or stimulated the mean weights of these organs more than T. However, the dorsolateral prostate/LAM ratio of weights did not favor MENT, but DNA/mg tissue and Ki 67 immunostaining suggested that MENT may increase DNA less than T. CONCLUSIONS: MENT is more potent than T in maintaining or stimulating prostate, seminal vesicle, and LAM. Using doses that resulted in comparable stimulation of the levator ani muscle, MENT had similar effect on prostate weight, but increased DNA/mg prostate less than T in this transgenic mouse model of prostate cancer.

Animals↗
PubMed1994

Testosterone-induced masculinization of the rat levator ani muscle during puberty.

Previous study of the development of the levator ani muscle (LA) revealed that the sex difference in muscle fiber number is under the control of testosterone during the perinatal period. In this study, the development of the LA muscle was examined in both sexes to test the hypothesis that testosterone action determines a further sex difference at the onset of puberty. This period is of key importance because plasma testosterone concentration rises sharply between Postnatal Days 40 and 60 in the male, while in the female testosterone level stays very low. In the male, a transient increase in the satellite cell number occurs between Days 42 and 47, followed by a persistent myonuclei increase. Hence, when the pubertal process has been completed, the myonuclei number is increased by about 50%. Moreover, sexual dimorphism related to the muscle fiber width becomes more marked: before puberty (Day 30), the mean cross-sectional area of muscle fibers is 2-fold higher in males than in females, while between Days 30 and 78, a further hypertrophy is observed which leads to a mean cross-sectional area about 10-fold higher in the male. In the female, during the same period, there is neither satellite cell increase nor myonuclei increase and the fiber cross-sectional area remains constant. Treatment with testosterone before the onset of puberty induces a marked but transient satellite cell increase not only in male but also in female LA muscle as early as 3 days after the time of injection. This cell proliferation is followed by a subsequent increase in the myonuclei number. Results indicate that (1) the levator ani muscle in the male exhibits high sensitivity to testosterone during the pubertal process; during this period, sexual dimorphism related to fiber width and myonuclei number is emphasized; (2) the myonuclei increase is subsequent to the testosterone-induced satellite cell proliferation; and (3) the female LA muscle presents the same sensitivity to testosterone as the male. Hence, the female muscle does not acquire specific male characteristics, owing to the very low concentration of circulating androgens.

Animals↗
PubMed1980

[The anorexia nervosa inventory for self-rating (ANIS) (author's transl)].

The Anorexia Nervosa Inventory for Self-Rating (ANIS) was developed as a reliable and valid instrument for diagnostic purposes and for longitudinal assessments in the course of therapy of anorexic patients. Appropriate items, which were selected from a larger pool of items by expert ratings, were subjected to factor analyses. The analyses were based on self-ratings of a sample of 101 patients suffering from anorexia nervosa and a sample of 118 high school students comparable in sex and age. The factor analytic studies based on maximum likelihood procedures resulted in a 31-item self-rating scale consisting of six interpretable factors. The rotated factor structure was stable for the different patient and student samples. The factors identified were labeled: (1) figure consciousness; (2) feeling of insufficiency; (3) anancasm; (4) adverse effect of meals; (5) sexual anxieties and (6) bulimia. The first two factors are discussed in the context of concepts formulated by Bruch (1973) concerning 'disturbances in body image' and an 'all-pervasive feeling of ineffectiveness' in anorexic patients. The usefulness of the ANIS scale to discriminate between healthy and anorexic subjects and for self-assessment of patients during the process of therapy is demonstrated.

Adolescent↗
PubMed2001

Effects of Eurycoma longifolia jack on laevator ani muscle in both uncastrated and testosterone-stimulated castrated intact male rats.

It has been reported that Eurycoma longifolia Jack commonly known as Tongkat Ali has gained notoreity as a symbol of man's ego and strength by the Malaysian men because it increases male virility and sexual prowess during sexual activities. As such, the effects of 200, 400 and 800 mg/kg of butanol, methanol, water and chloroform fractions of E. longifolia Jack were studied on the laevator ani muscle in both uncastrated and testosterone-stimulated castrated intact male rats after dosing them for 12 consecutive weeks. Results showed that 800 mg/kg of butanol, methanol, water and chloroform fractions of E. longifolia Jack significantly increased (p<0.05) the leavator ani muscle to 58.56+/-1.22, 58.23+/-0.31, 60.21 +/-0.86 and 62.35 +/-0.98 mg/100 g body weight, respectively, when compared with the control (untreated) in the uncastrated intact male rats and 49.23+/-0.82, 52.23+/-0.36, 50.21+/-0.66 and 52.35+/-0.58 mg/100 g body weight, respectively, when compared to control (untreated) in the testosterone-stimulated castrated intact male rats. Hence, the pro-androgenic effect as shown by this study further supported the traditional use of this plant as an aphrodisiac.

Animals↗
PubMed2003

Focal levator ani eventrations: detection and characterization by magnetic resonance in patients with pelvic floor dysfunction.

The aim of this study was to assess the frequency and imaging characteristics of focal levator eventrations in patients with pelvic floor dysfunction on magnetic resonance (MRI). A review of 81 dynamic MR pelvic examinations in patients with pelvic floor dysfunction was carried out to detect and characterize focal eventrations in the levator ani muscle. These were defined as muscle outpouchings which made an angle of >180 degrees with the remainder of the muscle and had a depth of >or=1 cm. Of 81 patients 11(13.5%) had focal eventrations in the levator muscle on MRI: bilateral in 2 cases, right in 5 and left in 4. There was protrusion of pelvic viscera into the eventration in 5 cases, fat in 7 and fluid in 1. Focal levator ani muscle abnormalities are not uncommon on MRI in patients with pelvic floor dysfunction. Characterization of levator muscle morphology can be useful as a research tool in this population.

Adult↗
PubMed2006

Interrater reliability of assessing levator ani muscle defects with magnetic resonance images.

The objective of this study is to determine interrater reliability of assessing pubovisceral levator ani muscle defects with magnetic resonance images. Normal pubovisceral muscle was assigned a grade of 0; PVM defects were graded as mild=1 (less than half missing), moderate=2 (more than half missing), and severe=3 (total or near total loss). Among six pairs of examiners, percent agreement and weighted kappa coefficients were calculated to determine agreement between pairs of examiners and among all examiners (i.e., "overall"). For unilateral scoring, exact agreement was found in 83.7%, and differences of one, two, and three grades were found in 14.7, 1.5, and 0.1%, respectively. For bilateral scoring, exact agreement and differences of one, two and three grades were found in 75.4, 15.9, 6.9, and 1.6%, respectively. Thus, exact agreement or a one-point difference was reached in 91.3% of cases. When defect status was categorized as none/normal, minor, and major, the overall weighted kappa coefficient was 0.86 (95% CI 0.83, 0.89). There was variation among examiner pairs with unilateral (p=0.002) and bilateral (p=0.02) scoring, but not when defect status was categorized as none/normal, minor, and major (p=0.59). There was agreement to within one point in 91% of cases when six examiner pairs scored levator ani defects on a seven-point scale. Examiner pairs discriminated injury similarly when defect status was categorized as normal/none, minor, or major.

Adult↗
PubMed2003

Etiology of the resting myoelectric activity of the levator ani muscle: physioanatomic study with a new theory.

Of all the striated muscles in the bodies of mammals, only the pelvic floor muscles, which include the levator ani (LA), have resting electric activity. The cause and function of this resting myoelectric activity are not exactly known. The current study investigated the effect of intraabdominal pressure (IAP) and visceral weight on the electromyographic (EMG) activity of the LA, seeking to elucidate its cause and function. A series of 18 subjects (12 women, 6 men, mean age 38.6 years) were subjected to laparoscopic cholecystectomy for calcular cholecystitis. Prior to cholecystectomy, the resting LA EMG and IAP were recorded with the patient in the recumbent and erect positions. During laparoscopic cholecystectomy, the IAP was elevated by CO2 insufflation in increments of 5 cm of H(2)O, and the LA EMG activity was recorded for the recumbent and vertical positions during inflation and after deflation at the end of the operation. In 5/18 patients in whom laparoscopic cholecystectomy was extended to open cholecystectomy, the IAP and LA EMG were also registered. The study also included histologic examination of the LA muscle from 15 cadavers (7 adults, 8 neonates). Levator ani EMG increased ( p < 0.05) on standing. At operation, IAP elevation was associated with a significant increase of LA EMG activity. On deflation, the IAP and LA EMG activity level returned to the pre-insufflation state. In open cholecystectomy, the IAP was zero and the LA EMG recorded no activity for the recumbent position, but there was an activity for the vertical position. Histologically, the lateral part of the LA in the adult cadavers consisted solely of skeletal muscle fibers. Proceeding medially, smooth muscle fibers started to appear and gradually increase until, at the midportion, the LA split into two layers, a deep layer consisting of smooth muscle fibers and a superficial layer consisting of skeletal fibers. In neonates, the LA was composed of purely skeletal muscle fibers. The LA EMG activity seems to be related to both the IAP and the visceral weight. It is probably attributable to the presence of smooth muscle bundles in the LA muscle. The LA EMG activity increased with the elevation of the IAP and visceral weight, which resulted in increased muscle tone to oppose the augmented pressure or weight. This effect seems to be mediated through the straining-levator reflex. A chronic increase of IAP or visceral overload is suggested to affect muscle integrity and function.

Abdomen↗
PubMed2006

Ultrasonographic and Doppler velocimetric evaluation of the levator ani muscle in premenopausal women with and without urinary stress incontinence.

OBJECTIVES: The objective was to evaluate the cross-sectional area (CSA) and the Doppler velocimetric parameters of the levator ani muscle vessels in premenopausal women with and without urinary stress incontinence. STUDY DESIGN: Sixty-three premenopausal women constituted three groups: GI (nulliparous), GII (continent multiparous), and GIII (incontinent multiparous). The patients had undergone transperineal ultrasound in which the CSA was measured and Doppler velocimetry was performed. The examination was repeated by a second observer using the same procedure. RESULTS: There was a statistically significant correlation between the measurements of the observers I and II regarding all the parameters studied, except for the A/B ratio in GIII. The CSA was significantly greater in GI and GII than in GIII. As far as Doppler velocimetry is concerned there were no differences in the Doppler velocimetric indices among the three groups. Concerning the absent end diastolic shift, it was observed that there was a significantly greater incidence of such findings in GI+GII (continent women) towards GIII (incontinent women). CONCLUSIONS: The CSA evaluation and the Doppler velocimetry of the levator ani muscle vessels were highly reproducible. The CSA was higher in continent women and the frequency of the absent end diastolic shift was higher in incontinent women.

Adolescent↗
PubMed2005

Testosterone modulates Ca(v2.2) calcium channels' functional expression at rat levator ani neuromuscular junction.

Spinal nucleus of bulbocavernosus and its target musculature, the bulbocavernosus and levator ani muscles, are sexually dimorphic, and their sexual differentiation depends on plasmatic levels of testosterone. Electrophysiological and immunocytochemical studies have demonstrated that at mammalian adult neuromuscular junctions only P/Q-type Ca2+ channels (Ca(v2.1)), mediate evoked transmitter release. Here we report that N-type Ca2+ channel (Ca(v2.2)) blocker omega-Conotoxin GVIA, as well as Ca(v2.1) blocker omega-Agatoxin IVA, significantly reduced quantal content of transmitter release by approximately 80% and approximately 70% respectively at levator ani muscle of the adult rats, indicating that neuromuscular transmission is jointly mediated by both types of channels. In these synapses, we also observed that castration and restitution of plasmatic testosterone in rats resulted in changes in the sensitivity to omega-Conotoxin GVIA. Castration induced, whereas testosterone treatment avoided, functional loss of Ca(v2.2), as mediators of transmitter release in these synapses. Strikingly, the expression and localization of alpha1B subunits, which form the pore of the Ca(v2.2) channel, were similar at control, gonadectomized and gonadectomized testosterone-treated rats, suggesting that testosterone may regulate the coupling mechanisms between Ca(v2.2) and transmitter release at the neuromuscular junctions of these sexually dimorphic motoneurons.

Animals↗
PubMed1987

A case of congenital colonic atresia associated with atresia ani.

The association of atresia ani with congenital colonic atresia is extremely rare, with only one such case having been reported up to date. We have recently treated a female infant with atresia ani (covered anus complete) accompanied by atresia of the sigmoid colon, who was managed by three stage surgery.

Anal Canal↗
PubMed2000

Satellite cell numbers in senile rat levator ani muscle.

Ageing in skeletal muscle results in motor frailty and a reduced capacity for self repair after injury. The contractile characteristics of muscle are determined principally by the myosin heavy chain (MHC) composition of its myofibers. During the restorative process, satellite cells play a central role. The present study compares the levator ani muscle of very old (32 months) and young (4 months) male WI/HicksCar rats in terms of structural integrity, MHC and satellite cell content. Myofiber typing was carried out by indirect immunohistochemistry using a panel of anti-MHC antibodies. Single myofibers for nuclear enumeration were isolated by an enzymatic technique while fiber cross-sectional areas and satellite cell frequencies were determined by computerized planimetry and electron microscopy. In both groups of rats, the myofiber population was homogeneously MHC type IIb-reactive. Cross-sectional data reflected a marked degree of atrophy in the muscle of the senile rats (710.05 +/- 63.6 microm2, compared with 1519.98 +/- 79.0 microm2 in young). The myofiber population was reduced by only about 6.7% with ageing and the representation of satellite cells, as a fraction of total sublaminal nuclei, was relatively stable (1.15 versus 1.91% in young; P > 0.05). The results indicate that ageing had a considerable atrophic effect on the levator ani muscle but induced neither MHC isoform transition nor massive depletion of the satellite cell pool. They suggest that the well-documented impairment of the restorative capacity of senile muscle could be due more to alterations in the nature of microenvironmental cues than to quantitative aspects of its cellular capacity to respond.

Aging↗
PubMed2001

Conduct of labor and rupture of the sphincter ani.

OBJECTIVE: To determine whether the conduct of the second stage of labor and delivery technique influences the incidence of rupture of the anal sphincter. MATERIAL AND METHOD: A total of 1072 primipara delivered vaginally at term at Rigshospitalet in 1998. A questionnaire on prenatal risk factors, conduct of the second stage of labor, and delivery technique was completed by the attending midwife immediately after delivery in 90 cases with rupture of the sphincter and in two subsequent controls (n = 164), matched by use of vacuum extractor and episiotomy. RESULTS: Partial or total sphincter rupture was found in 8.4% of primipara who delivered vaginally, in 20.9% of those delivered by vacuum extraction, and in 6.4% of those with episiotomy only. The prenatal risk factors--maternal age, birth weight, shoulder dystocia, and edema of the perineum were found to have a statistically significant effect on the incidence of rupture of the sphincter ani. In non-instrumental vaginal deliveries easing of the perineum over the caput as it advanced helped prevent a rupture of the anal sphincter. Vacuum extraction performed with the woman in a semi-recumbant position was associated with an increased risk of rupture of the anal sphincter, whereas attention to the perineum during extraction decreased the risk. CONCLUSIONS: The significant effect of prenatal risk factors did not explain a correlation between delivery technique and rupture of the sphincter ani. The present study indicates that a reduction in the incidence of sphincter rupture may be accomplished by improved obstetric care: fewer vacuum extractions and improved delivery technique.

Adolescent↗
PubMed1993

The relative proportions of type I and type II muscle fibers in the external sphincter ani muscle at different ages and stages of development--observations on the development of continence.

The external sphincter ani muscles were partially or completely removed from 11 fetuses, 3 infants, 2 children and 12 adults, none of whom had had anorectal disease and all of whom had died of diseases not affecting the anorectal organ of continence. Muscle fiber-typing was carried out. In the fetuses ages 26-40 weeks, we found a predominance of Type II (rapid) fibers. With increasing gestational age Type II fibers started to diminish along with a simultaneous increase in Type I (slow) fibers. At the same time, stromal restructuring took place. Three infants, ages 1, 2 and 10 months, showed further increases of Type I fibers, until finally, in the two older children studied (5 and 8 years), there was a predominance of Type I fibers. This persisted in adults between ages 56 to 70, but after age 70 Type I fibers diminished, so that the ratio of slow to rapid fibers in the 78 to 81 year-old group was 3:2. This study shows that in contrast to other skeletal muscles the fiber distribution in the external sphincter ani muscle is not established from the beginning, but is the result of a developmental process. The predominance of Type II (twitching) fibers explains the state of reflex continence of the young infant. With increasing maturation of tonic Type I fibers, an additional voluntary component to continence is made possible with the help of the supporting pelvic musculature. This maturation is determined by the increasing strain on the pelvic floor as the child learns to sit and walk.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Use of high voltage pulsed galvanic stimulation for patients with levator ani syndrome.

Levator ani syndrome is characterized by brief, intermittent pain and discomfort in the perirectal or rectal region that can be aggravated by sitting. Physical therapists are beginning to receive referrals for pain reduction in this patient population. The purpose of the study was to examine the use of high voltage pulsed galvanic stimulation (HVPGS) for reducing symptoms in patients with levator ani syndrome. A descriptive research design was used. Treatment consisted of one hour of HVPGS at a frequency of 120 Hz and at an intensity to the patient's maximum tolerance applied through a rectal probe. Results on 28 patients indicate that 50% had pain or symptom relief, or both, after an average of eight treatments. Those patients who were unresponsive to treatment had a primary diagnosis of irritable colon or were postsurgical. We are continuing to examine this treatment and will conduct follow-up examinations on those patients who obtained pain relief. Based on these preliminary results, we believe that HVPGS is an effective treatment for selected patients in this population.

Adult↗
PubMed2006

Obstetric factors associated with levator ani muscle injury after vaginal birth.

OBJECTIVE: To identify obstetric factors associated with development of levator ani injury after vaginal birth. METHODS: Magnetic resonance images were taken of the pelvic floor of 160 women 9 to 12 months after first term vaginal delivery. Half the women had de novo stress incontinence and half were continent controls. Abnormalities of the pubovisceral portion were identified on magnetic resonance as present or absent. Defect severity was further scored in each muscle from 0 (no defect) to 3 (complete muscle loss). A summed score for the 2 sides (0 to 6) was assigned and grouped as minor (0-3) or major (4-6). Obstetric details were collected. The association between obstetric variables and muscle injury were analyzed using Fisher exact test and t tests. RESULTS: The following increased odds ratios for levator defect were found: forceps use 14.7 (95% confidence interval [CI] 4.9-44.3), anal sphincter rupture 8.1 (95% CI 3.3-19.5) and episiotomy 3.1 (95% CI 1.4-7.2) but not vacuum delivery 0.9 (95% CI 0.19-4.3), epidural use 0.9 (95% CI 0.4-2.0), or oxytocin use 0.8 (95% CI 0.3-1.8). Women with levator injury were 3.5 years older and had a 78-minute longer second stage of labor. Differences in gestational age, birth weight, and head circumference were not statistically significant. A major defect in the pubovisceral muscle was seen in 22 women and a minor defect in 7 women. CONCLUSION: Injuries to the levator ani muscles in women after their first vaginal delivery are associated with several obstetric factors indicating difficult vaginal birth and with older age. LEVEL OF EVIDENCE: II-3.

Adult↗