Fecal Continence Revisited: The Anal External Sphincter Continence Reflex
Fecal Continence Revisited: The Anal External Sphincter Continence Reflex
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DOI：
10.1097/dcr.0b013e3182a42d16
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发表时间：
2013-11-01
影响因子：
3.9
通讯作者：
Boix Ochoa, Jose
中科院分区：
文献类型：
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作者：
Broens, Paul M. A.;Penninckx, Freddy M.;Boix Ochoa, Jose
背景：目前关于大便失禁的理论都无法充分解释大便失禁。 目的：本研究旨在评估控制大便失禁的机制。 设计：对 17 名对照者在浅表局部肛门麻醉前后以及 6 名对照者在脊髓麻醉前后进行肛门电敏度、肛门直肠压力和直肠压力容量测试。对 1 名患者注射局部肛门麻醉前后以及 3 名 Th3 至 L3 脊髓病变患者进行了相同的测试。结果：在浅表肛门局部麻醉后，肛门电敏感性下降，但基础肛门压力保持不变。挤压压力降低，直肠充盈感水平保持不变。局部麻醉可降低渐进式直肠充盈过程中远端肛管中记录的肛门压力。在注射局部肛门麻醉剂后，情况也是如此，尽管更明确。椎管内麻醉后，肛管对电刺激变得不敏感，但基础压和挤压压值大幅下降，球囊留置试验时肛压的增加完全消失。在脊髓损伤的患者中，外括约肌不能根据指令被挤压，但在球囊保留测试中，肛门括约肌确实在超过 300 mmHg 的压力下自主挤压。 局限性：这些是部分实验测量。所发现的模型在日常临床实践中的相关性必须在后续研究中进行研究。 结论：我们的结果支持这样的假设：由外括约肌收缩介导的大便失禁的组成部分取决于肛门外括约肌失禁反射，而不涉及大脑。据推测，该反射的传入感受器是位于远端肛管粘膜或粘膜下层表面的接触感受器。因此，肛门外括约肌失禁反射功能失常会导致大便失禁（参见视频，补充数字内容 1，http://links.lww.com/DCR/A116）。
BACKGROUND: None of the current theories on fecal incontinence can explain fecal continence adequately.OBJECTIVE: This study aims to evaluate the mechanism controlling fecal continence.DESIGN: Anal electrosensitivity, anorectal pressures, and rectal pressure volumetry tests were performed in 17 controls before and after superficial local anal anesthesia and in 6 controls before and after spinal anesthesia. The same tests were performed in 1 patient before and after injected local anal anesthesia and in 3 patients with spinal cord lesions at levels Th3 to L3.RESULTS: After superficial local anal anesthesia, anal electrosensitivity decreased, but basal anal pressure remained unaltered. Squeeze pressure decreased and rectal filling sensation levels remained. Local anesthesia reduced anal pressure recorded in the distal anal canal during progressive rectal filling. This was also the case, albeit more explicit, after the local anal anesthetic was injected. After spinal anesthesia, the anal canal became insensitive to electric stimulation, but basal and squeeze pressure values decreased substantially, and the increase in anal pressure during the balloon-retaining test disappeared completely. In the patients with spinal cord lesions, the external sphincter could not be squeezed on command, but during the balloon-retaining test, the anal sphincter did squeeze autonomously at more than 300 mmHg.LIMITATIONS: These were partially experimental measurements. The relevance of the found model in the daily clinical practice will have to be studied in a following study.CONCLUSIONS: Our results support the hypothesis that the component of fecal continence mediated by contraction of the external sphincter depends on a anal external sphincter continence reflex without involving the brain. Presumably, the afferent receptors of this reflex are contact receptors located superficially in the mucosa or submucosa of the distal anal canal. A nonfunctioning anal external sphincter continence reflex would, therefore, result in fecal incontinence (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A116).