Endoanal ultrasound is now regarded as the gold standard for evaluating anal sphincter pathology in the investigation of anal incontinence.
The advent of three-dimensional ultrasound has further improved our understanding of the two-dimensional technique. Endoanal ultrasound requires specialised equipment and its relative invasiveness has prompted clinicians to explore alternative imaging techniques.
Transvaginal and transperineal ultrasound have been recently evaluated as alternative imaging modalities. However, the need for technique standardisation, validation and reporting is of paramount importance. We conducted a MEDLINE search to February and critically reviewed studies using the three imaging techniques in evaluating anal sphincter integrity.
Over the last three decades the anal sphincter complex has been the subject of increasing interest involving a variety of disciplines including obstetricians, colorectal surgeons, gastroenterologists, physiotherapists, paediatric surgeons, anatomists, Anal sphincter area and midwives. Obstetric trauma is the major cause of faecal incontinence. However, the precise mechanism of maintaining continence is complex, and our understanding of the major mechanism underlying the development of anal incontinence has evolved from that of progressive pudendal neuropathy [ 12 ] to that of unrecognised mechanical anal sphincter trauma at Anal sphincter area time of vaginal delivery [ 3 - 5 ].
Although cadaveric dissections [ 6 ], physiological testing [ 7 ], ultrasound images [ 8 ] and MRI [ 9 ] have enabled progressive improvement in understanding the anatomy, function and pathophysiology of the anal sphincter, much remains to be understood.
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The sonographic anatomy of five layers of the anal canal were described: In Sultan et al [ 6 ] correlated endosonographic findings with anatomical dissection and rectified the previous description. Inthey demonstrated the normal sonographic anal sphincter anatomy and highlighted differences between males and females [ Anal sphincter area ].
Sultan et al [ 12 ] then validated the appearance on internal sphincter defects by prospectively comparing images before and after lateral internal sphincterotomy.
Anal endosonography is currently regarded as the diagnostic tool of choice in the investigation of anal incontinence. Recently, two-dimensional 2D and three-dimensional 3D volumetric endovaginal ultrasound EVUS and transperineal ultrasound TPUS have been proposed as alternative imaging modalities to describe anal sphincter integrity. Anal sphincter area aim of this review was, first, to critically evaluate the different ultrasound imaging modalities of the anal sphincter complex and, second, to analyse comparator studies between the three imaging modalities to determine the reproducibility of anal sphincter morphology and biometry among the three different methods namely Anal sphincter area, endovaginal and transperineal.
The patient is usually scanned in the left lateral position, although the prone position may be preferred by others [ 13 ]. After the probe is inserted into the anal canal up to approximately 6 cm it is gently withdrawn down the anal canal, during which cross-sectional images of the puborectalis muscle, the longitudinal muscle, EAS, IAS and the anal epithelium are obtained Figure 1 [ 14 ]. Schematic representation of the anal canal with the probe in situ.
Level 2, deep proximal external anal sphincter EAS. Level 3, superficial mid EAS. Level 4, subcutaneous distal EAS.
External anal sphincter: anal canal:...
In earlier studies, anal sphincter defects were noted at three areas along the Anal sphincter area canal: InGold et al [ 15 ] noted that the intra-observer and interobserver agreement for anal sphincter injury was influenced by the ease with which the IAS and EAS were visualised endosonographically. In this study of 51 adults referred for investigation of possible sphincter injury, there was no disagreement with respect to IAS tears but some disagreement with assessing the radial and linear extent, as well as the sonographic boundaries of the EAS tears.
This investigator then performed 3D EAUS reconstructions on 24 consecutive patients with sphincter defects on EAUS, with specific attention to the radial and longitudinal extent of the defect. The shorter Anal sphincter area part of the EAS as compared with males and the direct relationship between the radial and longitudinal extent of sphincter trauma was noted using volume imaging [ 16 ].
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The author also found a significant decrease in the length of the anterior EAS in an group of 22 females after an atraumatic vaginal delivery and no endosonographic evidence of sphincter trauma after delivery Table 1 [ 18 ].
Furthermore, the images can be rotated and sliced to enable visualisation from different angles. Offline analysis using proprietary software is also an advantage and has important research implications, as the image can be stored and reviewed for a second opinion, and also shortens the duration of procedure. Note that the external anal sphincter is Anal sphincter area at a more distal level to the puborectalis. Investigators in the field have noted that most endoanal scanners are located in specialised radiological centres and also require specialised training, and thus transvaginal ultrasound TVUS and TPUS have been evaluated as alternative imaging modalities.
Anal sphincter area must be noted that images obtained with both these techniques might be complex, and thus require training as well. Transvaginal probes and the standard convex 5 MHz probe are available in almost all obstetric and gynaecological units.
With this in mind several studies followed using the transvaginal and transperineal route to establish its place in the evaluation of the anal sphincter. The advantages and disadvantages of the two methods are mentioned in the conclusion.
Subjects included 20 females 10 healthy volunteers and 10 with faecal incontinence. With the patient lying in the left lateral position the probe was inserted 3 cm into the vagina. By gradually Anal sphincter area the probe, the puborectalis muscle, EAS, IAS, anal submucosa and anal cushions were clearly imaged.
What is the anal sphincter?
Anal sphincter area The shorter EAS anteriorly in females as seen previously during endoanal endosonography [ 8 ] was also confirmed. When vaginal sonographic findings were correlated with anal endosonography it was found that anal endosonography consistently underestimated the thickness of the internal anal sphincter 2. Sandridge et al [ 20 ] performed vaginal endosonography on Anal sphincter area females as part of an indicated endovaginal scan.
Patients with previous anorectal surgery and complaints of faecal or flatus incontinence were excluded. Using an Aloka CL scanner Aloka, Wallingford, CT fitted with a 5 MHz phased array vaginal probe, an attempt was made to obtain at least three images per subject in a dorsal lithotomy position.
The probe was placed vertically just inside the hymenal ring with the tip directed towards the floor.
The anal length and diameter, the thickness and angle of the puborectalis muscle, and the thickness of the IAS and EAS were measured. These findings were not directly compared with anal endosonography.
Alexander et al [ 21 ] and Poen et al [ 22 ] demonstrated that, apart from detecting sphincter defects, TVUS was also Anal sphincter area in determining other causes of faecal incontinence such as rectal fistulae and abscesses.
Although TVUS is more readily accessible in most units, is cheaper than the endoanal probe and eliminates distortion of anal epithelium, interpretation of images requires more expertise and clear images of the full length of the anal canal are not always obtainable [ 23 ].
This may be due to the utilisation Anal sphincter area the Anal sphincter area probe for transvaginal scanning; the endoanal probe is approximately 55 cm long and obtaining optimum views of the anal canal may not be ergonomically possible, especially when the patient is in the supine position [ 162224 ]. With TVUS, It is important to keep the transducer inserted into the vagina in a neutral position, since excessive pressure of the transducer on the perineum and inappropriate angle of incidence of the ultrasound beam to the anal sphincter may distort images and lead to erroneous results.
In the quest for a less invasive, more user-friendly, more accessible and more patient-acceptable imaging modality, the transperineal approach was evaluated. Similar to the technological advancement of EAUS and TVUS, studies were performed with TPUS to determine the incidence of occult sphincter defects [ 25 ] and normal anal sphincter parameters [ 26 - 29 ], as well as its accuracy in detecting sphincter defects [ 2530 ].
Another advantage of transperineal scanning is the ability to study the dynamic interaction between the pelvic floor and pelvic viscera without using an endocavity probe endovaginal and endoanal [ 31 ]. TPUS is usually performed with the patient placed in the dorsal lithotomy position, with the hips flexed and abducted, and the convex transducer positioned Anal sphincter area the perineum between the mons pubis and the anal sphincter.
In this study In the group that sustained third-degree tears repaired by overlap technique TPUS was possible as early as 48 h post-partum.
Hall et al [ 26 ] placed a 4—8 MHz curvilinear endovaginal probe Phillips ; Philips Medical Systems, Bothell, WA at the introitus of 60 Hispanic and Caucasian females presenting for a gynaecological ultrasound for symptoms other than pelvic organ prolapse and urinary or faecal incontinence.
The aim was to determine normal values of IAS and EAS measurements at the proximal, middle and distal levels of the anal canal using clock-face terminology. Peschers et al [ 27 ] applied a conventional 5 MHz convex transducer Siemens SI ; Siemens Healthcare, Munich, Germany to the perineum exoanal ultrasound of a heterogenous group of 68 females 25 with faecal incontinence, 11 asymptomatic Anal sphincter area and 32 asymptomatic parous females.
In both axial and sagittal planes, all the layers of the anal sphincter complex Anal sphincter area described by EAUS were visualised. The presence of sphincter defects were determined from video records by two independent examiners blinded to Anal sphincter area other's results.
All defects detected by the transperineal method were verified at sphincter reconstructive surgery five patients.
Using a 5—9 MHz endovaginal transducer Voluson ; GE Healthcare placed at the introitus and then Anal sphincter area posteriorly on the perineum, Lee et al [ 28 ] acquired 3D volumes to evaluate dynamic Anal sphincter area in anal sphincter measurements and the levator hiatus during rest and squeeze in 22 asymptomatic nulliparous females in the lithotomy position.
There was no difference in IAS transverse thickness at the proximal level puborectalis level and distal level middle of the EAS at the 3 and 9 o'clock positions during rest and squeeze.
The internal anal sphincter, IAS,...
Huang et al studied the biometry of the anal sphincter in 55 nulliparous Chinese females, and also demonstrated that all the levels of Anal sphincter area EAS can be visualised using an endovaginal probe placed at the perineum, and that the EAS was thinner at 12 o'clock [ 29 ].
As can be seen in Table 4many of the TPUS studies utilised vaginal transducers placed on the perineum with alteration of the axis to obtain optimal views.
Stewart et al [ 23 ] documented Anal sphincter area their TVUS and EAUS sonographic findings were in agreement in a group of 40 out of 44 patients imaged prospectively 24 with intact sphincters and 20 with sphincter defects.
Poen et al [ 22 ] and Ramirez et al [ 24 ] highlighted Anal sphincter area added value of TVUS in identifying perianal pathology e. When compared with EAUS, difficulties encountered with TPUS include poor visualisation of the lateral border of the EAS, and the fact that the anal mucosa and submucosa cannot be viewed as separate entities [ 32 ].
The external anal sphincter (or...
However, the authors did not mention the technique of TPUS or the levels along the length of the sphincter used to detect lesions Table 5. Currently there are limited transvaginal and transperineal ultrasound studies that are directly compared with EAUS. It has Anal sphincter area shown to be useful, safe and well tolerated by patients. Imaging has evolved from static 2D imaging to dynamic 3D volumetric imaging, and recently even four-dimensional 4D imaging.
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This review highlights that normal anal sphincter morphology and anal sphincter measurements can be obtained using both transvaginal and transperineal routes. Advantages of the transvaginal and transperineal route include availability of commonly used transducers, absence of distortion of the anal canal and better patient acceptability.
The transvaginal route Anal sphincter area be more valuable in patients with a short anal canal and wide introitus [ 24 ], and since the need for insertion of an endocavity probe is negated with TPUS, it may be more acceptable and less painful in patients with perianal pathology.
There is a need for further corroboration, technique standardisation especially with TPUS and reporting of defects, as current studies differ in methodology and include heterogeneous samples [ 34 ].
National Center for Biotechnology InformationU. Journal List Br J Radiol v. Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Endoanal ultrasound is Anal sphincter area regarded as the gold standard for evaluating anal sphincter pathology in the investigation of anal incontinence. Open in a separate window. Table 1 Anal endosonography studies.
Table 2 Transvaginal ultrasound studies. Transperineal ultrasound In the quest for a less invasive, more user-friendly, more accessible and more patient-acceptable imaging modality, the transperineal approach was evaluated. Table 4 Transperineal ultrasound studies. Table 3 Comparative Anal sphincter area Inserted into the vagina until the rectum was visualised and gradually withdrawn while images of the PR and anal sphincters were taken.
Table 5 Comparative studies: Hitachi convex and linear probe, 3.
Aloka SSDb 7. Pelvic floor damage and childbirth: Br J Obstet Gynaecol ; Injury to innervation of pelvic floor sphincter musculature in childbirth. Anal-sphincter disruption during vaginal delivery.
N Engl J Med ; Learn about the anal sphincter, a muscle that surrounds the anus and The Diseases and Conditions That Can Occur in Anal sphincter area Perianal Area. The anal canal high pressure zone which is, in turn, generated by the internal and external anal sphincters, the latter being intimately related to the musculature.
In earlier studies, anal sphincter defects were noted at three areas along the anal canal: the upper (proximal), middle and Anal sphincter area anal canal. Using these defined.
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To examine the anatomy of the internal and external anal sphincters in the area of midline obstetric lacerations, to gain insight into sphincter damage and repair. The length, craniocaudal extent, and overlap of the internal and external anal sphincters in the perineal body were measured in 17 cadavers. Further anatomic observations were made in four sets of whole pelvis cross-sections taken in the sagittal, coronal, and transverse planes.
During the repair of 20 acute fourth-degree lacerations, observations were made to determine the internal sphincter visibility following birth. The external and internal and sphincters overlap by The internal sphincter extends an additional In pregnant women who sustained a fourth-degree laceration, we found that the internal sphincter can be identified as a rubbery white layer adjacent to the anal submucosa lying between the external sphincter and the anal canal.
The internal anal sphincter lies between the anal mucosa and the external anal sphincter and extends more than a centimeter above the cranial margin of the external sphincter, a region where it is disrupted when a fourth-degree obstetric laceration has occurred.
Anal Canal - Simplified Anatomy
ENDOANAL ULTRASOUND IS NOW REGARDED AS THE GOLD STANDARD FOR EVALUATING ANAL SPHINCTER PATHOLOGY IN THE INVESTIGATION OF... ANAL STENOSIS | DISEASES OF THE RECTUM | MUSC DDC
The internal anal sphincter, IAS, (or sphincter ani internus) is a muscular ring that surrounds about – cm of the... The anal sphincter is a complex part of the body that maintains a seal that can... External anal sphincter | anatomy | zawm.info Ultrasound imaging of the anal sphincter complex: a review External anal sphincter: anal canal: The external sphincter is a layer of voluntary (... When a tubular organ or blood vessel becomes excessively narrow such that...
What is the anal sphincter?
The apparent anal sphincter before sphincter ani externus is a sluggish jet of husky fibers, oblique wearing embody in words after that intimately supporter near the husk proximate the scope of the anus. Inside a sizeable extent of cases the fibers decussate trendy party of the anus, also are unbroken together with the passing crossways perineal force. Posteriorly, they are not friendly towards the coccyx, other than are loosely continual by means of those of the diverse trait in the wake of the anal inland waterway.
The higher advantage of the sway is indefinable, ever since fibers are certain at leisure since it headed for be adjacent to the levator ani. Pert chart demonstrating the investigation of hemorrhoids.
Commence Wikipedia, the on the loose encyclopedia. Sphincter ani externus weight Coronal split over and do with the anal duct. Hollow of urinary bladder V.
The internal anal sphincter Erudite, IAS Injunction, or sphincter ani internus is a muscular give someone a buzz that surrounds about 2. Its game is from head to toe involuntary, furthermore it is in a state of continuous maximal contraction.
It helps the Sphincter ani externus just before occlude the anal slit and aids in the expulsion of the feces. Sympathetic fibers from the superior rectal and hypogastric plexuses wake up and keep in good condition internal anal sphincter short form. Its reduction is repressed by parasympathetic fiber motivation. This sphincter is tonically contracted a good number of the time on the way to prevent leak of gas or chat, but is relaxed leading distention of the rectal ampulla, requiring voluntary retrenchment of the puborectalis plus external anal sphincter.
It is vastly important as regards bowel continence, especially in behalf of liquid after that gas.
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How do I tell my best friends sister I'm interested? External anal sphincter: anal canal: The external sphincter is a layer of voluntary ( striated) muscle encircling the outside wall of the anal canal and anal opening. External anal sphincter (EAS) is a striated muscle under voluntary control which is .. This results in a smooth, usually wedge-shaped area in the 12 or 6 o'clock.. Youtube Video
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