Patel, D; (2012) Anal sphincters, support structures and atrophy in major obstetric injury. Doctoral thesis , UCL (University College London).

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Abstract

Mechanical anal sphincter trauma and traction pudendal neuropathy secondary to vaginal childbirth represent the most frequent aetiological factors in the development of faecal incontinence in women. More recently it has been speculated that vaginal childbirth may damage pelvic support structures, thereby contributing to faecal incontinence. Anal sphincter and pelvic floor atrophy resulting from degenerative pudendal neuropathy is thought to also play an important aetiopathogenic role. Measurement of puborectalis function is therefore essential in providing a baseline assessment and observing response to treatment of puborectalis muscle strength in pelvic floor dysfunction disorders. Until recently there has been difficulty in understanding the role of puborectalis function due to the absence of a standardised measurement technique. So far, Magnetic Resonance Imaging (MRI) has been proposed for accurate structural assessment however, no consensus has yet been reached on the ‘gold standard’ for the physiological measurement of puborectalis strength. This thesis primarily looked at finding novel structural and physiological measures of puborectalis in a cohort of asymptomatic nulliparous controls, women with clinically reported obstetric anal sphincter injuries and women with idiopathic faecal incontinence. The first technique I used was vaginal manometry to quantify the constrictor function of puborectalis. I was unable to show the previously reported specific high pressure vaginal zone in either study groups and I found poor agreement between vaginal and anorectal manometry in the measurement of pelvic floor squeeze. The second technique I used was the 2 point Dixon fat water decomposition MRI technique to quantify fatty atrophy of the anal sphincter complex and puborectalis. I was able to demonstrate a relationship between external anal sphincter percentage fat content with both patient symptom load and subjective atrophy score demonstrating it as a promising objective measure of fatty atrophy.

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