The acute effect of straining on pelvic floor neurological function

  • A. F. Engel
  • M. A. Kamm
Original Articles

Abstract

Integrity of sensory and motor function is essential in the maintenance of continence. The pudendal nerve assumes a central role being a mixed sensory and motor nerve. Neuropathic changes may therefore lead to incontinence and stretch injury to the pudendal nerve has been implicated as an aetiological factor. However pudendal neuropathy, altered anal sensation and perineal descent do not always correlate in the same patient. To investigate this further we evaluated the effect of a simulated defaecation strain on pelvic floor neurological function in a group of patients with constipation and incontinence. Pudendal nerve terminal motor latency (PNTML) and anal electrosensitivity (AS) were measured at rest and after a simulated defaecation strain of 1 minute. At rest PNTML correlated with AS (r=0.461, P=0.003). Twenty-five patients had perineal descent of more than 1 cm on straining, and 13 had descent below the ischial tuberosities. After 1 minute of straining AS was significantly (P<0.001) blunted and PNTML was significantly (P<0.001) prolonged both changes returning to normal after 3 minutes. AS was significantly (P=0.01) more blunted in patients with perineal descent of more than 1 cm. PNTML was significantly (P=0.01) more prolonged in patients with perineal descent of more than 2 cm. Age was significantly correlated with AS (r=0.45, P=0.004) and PNTML (r=0.49, P=0.002). Anal sensation and PNTML are acutely affected by defaecation straining, and changes may occur in patients without perineal descent. Functional changes occur equally in constipated and incontinent patients.

Résumé

L'intégrité des fonctions sensitives et motrices est essentiel dans le maintien de la continence. Le nerf honteux interne joue un rôle central étant un nerf mixte sensitif et moteur. Les atteintes neuropathiques peuvent entraîner une incontinence de même que l'étirement d'un nerf honteux interne considéré comme un facteur éthiologique de l'incontinence. On observe toutefois, pas toujours chez un patient donné, une corrélation entre neuropathie du nerf honteux interne, altération de la sensibilité rectale et degré de descente du périnée. Nous avons étudié l'effet d'un effort simulé d'exonération sur la fonction neurologique du plancher périnéal chez un groupe de patients souffrant de constipation et d'incontinence. Le temps de latence du nerf honteux interne (TLNHI) et l'électrosensibilité (ES) du canal ont été mesurés au repos et après un effort simulé d'exonération d'une durée d'une minute. Au repos, le TLNHI est corrélé avec l'ES (r=0.401, P=0.003). Vingt-cinq patients présentent une descente du périnée de plus d'un centimètre à l'effort; chez treize le périnée s'abaisse en dessous des tubérosités ischiatiques. Aprè une minute de poussée, l'ES est significativement émoussée (P<0.001) et le TLNHI est prolongé significativement (P<0.001); les deux valeurs retournent à la normale après trois minutes. L'ES était significativement plus émoussée (P=0.01) chez les patients dont la descente périnéale est supérieure à 1 cm. Le TLNHI est significativement (P=0.01) prolongé chez les patients dont la descente périnéale est supérieur à 2 cm. L'âge est corrélé avec l'ES (r=0.45, P=0.004) et avec le TLNHI (r=0.49, P=0.002). La sensibilité anale et le TLNHI sont modifiés de façon aiguë par les efforts de défécation, ces modifications peuvent même se produire chez des patients sans descente périnéale. Des modifications fonctionnelles se produisent également chez les sujets constipés et chez des incontinents.

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Copyright information

© Springer-Verlag 1994

Authors and Affiliations

  • A. F. Engel
    • 1
  • M. A. Kamm
    • 1
  1. 1.The Sir Alan Parks' Physiology UnitSt. Marks' HospitalLondonUK

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