Anal sphincter tears in patients with rectal prolapse and faecal incontinence.

OBJECTIVE: Faecal incontinence often persists after surgery for rectal prolapse. Multiple mechanisms have been proposed as responsible, however, anal sphincter integrity has only been studied in a handful of cases. This study assesses the incidence of ultrasound detected anal sphincter tears in patients with rectal prolapse and faecal incontinence.
METHODS: Retrospective search of medical records at Flinders Medical Centre over a 7-year period to identify patients with full thickness rectal prolapse and faecal incontinence who had undergone endosonographical imaging of the anal sphincter complex. Anal manometry and pudendal nerve terminal motor latency studies were also included.
RESULTS: Twenty-one patients were identified (1 male, 20 female) of median age 67.5 years. Fifteen (71%) subjects had an abnormality in the anal sphincter complex on endoanal ultrasound. Of these, the defects in 4 (19%) patients were isolated to the internal sphincter, 3 (14%) to the external sphincter and in the remaining 8 (38%) subjects, defects were found in both internal and external sphincters. The degree of sphincteric defect was variable but at least 6 (29%) of the study group had full-length external sphincter tears. In the 19 patients studied, anal manometry revealed reduced basal and squeeze pressures in the majority. Delayed pudendal nerve terminal motor latency was evident in 9 of 18 patients studied.
CONCLUSION: Anal sphincter tears are common in patients presenting with rectal prolapse and faecal incontinence. The faecal incontinence associated with prolapse appears to be multifactorial in aetiology. Anal sphincter defects are likely to contribute to persistent faecal incontinence or recurrence following rectal prolapse. Endoanal ultrasound derived knowledge of anal sphincter injury may guide surgical management in problematic cases.