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Anal Acoustic Reflectometry (AAR) is a technique that has been studied in our department over the last 6 years. Sound waves pass into a balloon placed in the anal canal and are used to measure the cross-sectional area. By gradually increasing and decreasing the pressure in the balloon the investigators can measure the pressure at which the cross-sectional area starts to increase and decrease, and the anal canal starts to open and close. This assessment mimics the natural opening and closing of the anal canal and the effect of squeezing the muscles.
The gold standard investigation of the anal sphincter muscles has been manometry which measures anal canal pressure at rest and during squeeze. However, it has limitations. Despite the two measurements being within the normal range, some patients can have significant faecal incontinence. This has prompted clinicians to search for a better investigation to guide the management of this condition.
AAR is a reproducible and repeatable technique that has been used as a research technique in the assessment of faecal incontinence. It has been shown to correlate with symptom severity and, unlike manometry, is able to distinguish between different symptomatic subgroups with faceal incontinence. In our studies so far the investigators have increased the bag inflation pressure a step at a time which means that each study takes about 20 minutes to perform. The limitation of this method is that during the measurement of squeeze pressure the sphincter muscle is subject to fatigue. A recent study using the acoustic technique in the urethra has demonstrated a faster method of recording measurements over an 8 minute period. The investigators propose to study the fatiguability effects of this faster technique and validate the method against the existing step-wise technique and standard anal manometry.
Patients will be randomised into two groups:
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Faecal Incontinence: fast-fill measurement first | Observational study where patients with faecal incontinence undergo two AAR measurements; one with the original step-wise technique and the second with the newer fast-fill technique. A further standard manometry measurement will be taken. 18 patients will undergo fast-fill measurement first. | ||
| Faecal Incontinence: step-wise measurement first. | Observational study where patients with faecal incontinence undergo two AAR measurements; one with the original step-wise technique and the second with the newer fast-fill technique. A further standard manometry measurement will be taken. 18 patients will have step-wise measurement first. |
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| Measure | Description | Time Frame |
|---|---|---|
| Opening Pressure | Opening Pressure (Op - cm H2O) - the point at which the anal canal just begins to open | 10 minutes |
| Opening Elastance | Opening Elastance (Oe - cm H2O/mm2) - the resistance of the anal canal to stretch | 10 minutes |
| Closing Pressure | Closing Pressure (Cp - cm H2O) - the pressure at which the anal canal closes after a period of opening | 10 minutes |
| Closing Elastance | Closing Elastance (Ce - cm H2O/mm2) - the ability of the anal canal to close passively after a period of stretch | 10 minutes |
| Hysteresis | Hysteresis (%) - the energy dissipated during opeing and closing of the anal canal | 10 minutes |
| Squeeze Opening Pressure | Squeeze opening pressure (SqOp - cm H20) - the pressure at which the anal canal just starts to open whilst the patient is voluntarily trying to keep the anal canal closed | 10 minutes |
| Squeeze Opening Elastance | Squeeze opening elastance (Sq)e - cm H20/mm2) - the resistance of the anal canal to stretch whilst the patient is voluntarily trying to keep the anal canal closed | 10 minutes |
| Measure | Description | Time Frame |
|---|---|---|
| Manometry - Resting Pressure | anal manometry measured in cmH20 | 10 minutes |
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Inclusion Criteria:
Exclusion Criteria:
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Patients presenting to the pelvic floor clinic and neurogastroenterology with symptoms of faecal incontinence
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| Name | Affiliation | Role |
|---|---|---|
| Karen J Telford, MBChBMDFRCS | University Hospital of South Manchester | Study Chair |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University Hospital of South Manchester | Manchester | Greater Manchester | M23 9LT | United Kingdom |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 23506115 | Background | Klarskov N, Saaby ML, Lose G. A faster urethral pressure reflectometry technique for evaluating the squeezing function. Scand J Urol. 2013 Dec;47(6):529-33. doi: 10.3109/21681805.2013.776629. Epub 2013 Mar 19. | |
| 23132420 | Background | Hornung BR, Mitchell PJ, Carlson GL, Klarskov N, Lose G, Kiff ES. Comparative study of anal acoustic reflectometry and anal manometry in the assessment of faecal incontinence. Br J Surg. 2012 Dec;99(12):1718-24. doi: 10.1002/bjs.8943. |
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individual patient data will not add any further information to the overall data
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Patients attending clinic for routine evaluation of faecal incontinence were approached to particpate in this study
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| ID | Title | Description |
|---|---|---|
| FG000 | Stepwise First, Then Fast-fill | Observational study where patients with faecal incontinence undergo two AAR measurements; one with the original step-wise technique and the second with the newer fast-fill technique. A further standard manometry measurement will be taken. To reduce the bias of one test on the other, the order of the test were randomised so that half of the patients will undergo stepwise measurement first and another half of the patients will have stepwise measurement first. Patients in this arm underwent stepwise, followed by a two minute rest, then fast fill, followed by a two minute rest, and then by manometry |
| FG001 | Fast-fill First, Then Stepwise | Observational study where patients with faecal incontinence undergo two AAR measurements; one with the original step-wise technique and the second with the newer fast-fill technique. A further standard manometry measurement will be taken. To reduce the bias of one test on the other, the order of the test were randomised so that half of the patients will undergo fast-fill measurement first and another half of the patients will have step-wise measurement first. Patient min this arm underwent fast fill, followed by a two minute rest, then step wise, followed by a two minute rest, and then by manometry |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
Analysis of a total of 32 patients was performed. Measurement data from four patients was not able to be accurately interpreted
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| ID | Title | Description |
|---|---|---|
| BG000 | Faecal Incontinence | Observational study where patients with faecal incontinence undergo two AAR measurements; one with the original step-wise technique and the second with the newer fast-fill technique. A further standard manometry measurement will be taken. 16 patients will undergo fast-fill measurement first and another 16 patients will have step-wise measurement first |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Analysis of a total of 32 patients was performed. Measurement data from four patients was not able to be accurately interpreted |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Opening Pressure | Opening Pressure (Op - cm H2O) - the point at which the anal canal just begins to open | Posted | Median | Full Range | cmH2O | 10 minutes |
|
Patients were recruited over a 12 month window. This study treatment and data was collected on one day (a point in time measurement) and any adverse events (if present) would occur at the time of measurement. If no events were noted at this point, then further data was not collected
AEs or SAEs would occur during or directly after the procedure and noted by the attending clinician.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Stepwise First, Then Fast-fill | Stepwise First, Then Fast-fill measurement. Observational study where patients with faecal incontinence undergo two AAR measurements; first with the original step-wise technique and the second with the newer fast-fill technique. A further standard manometry measurement will be taken. To reduce the bias of one test on the other, the order of the test were randomised so that half of the patients will undergo stepwise measurement first and another half of the patients will have stepwise measurement first. Patients in this arm underwent stepwise, followed by a two minute rest, then fast fill, followed by a two minute rest, and then by manometry Previous Work has been carried out looking at the sequence has shown no difference in the order. Therefore to keep consistency this method has been continued and results combined |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Karen Telford | University Hospital of South Manchester | 01612916654 | karen.telford@uhsm.nhs.uk |
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| ID | Term |
|---|---|
| D004688 | Encopresis |
| ID | Term |
|---|---|
| D012817 | Signs and Symptoms, Digestive |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D001526 | Behavioral Symptoms |
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| 22381095 | Background | Klarskov N. Urethral pressure reflectometry. A method for simultaneous measurements of pressure and cross-sectional area in the female urethra. Dan Med J. 2012 Mar;59(3):B4412. |
| 22228166 | Background | Mitchell PJ, Klarskov N, Telford KJ, Hosker GL, Lose G, Kiff ES. Viscoelastic assessment of anal canal function using acoustic reflectometry: a clinically useful technique. Dis Colon Rectum. 2012 Feb;55(2):211-7. doi: 10.1097/DCR.0b013e31823b2499. |
| 21825892 | Background | Mitchell PJ, Klarskov N, Telford KJ, Hosker GL, Lose G, Kiff ES. Anal acoustic reflectometry: a new reproducible technique providing physiological assessment of anal sphincter function. Dis Colon Rectum. 2011 Sep;54(9):1122-8. doi: 10.1097/DCR.0b013e318223fbcb. |
| 22457059 | Background | Saaby ML, Klarskov N, Lose G. Urethral pressure reflectometry before and after tension-free vaginal tape. Neurourol Urodyn. 2012 Nov;31(8):1231-5. doi: 10.1002/nau.22239. Epub 2012 Mar 27. |
| Count of Participants |
| Participants |
|
| Age, Continuous | Median | Full Range | years |
|
| Sex: Female, Male | Measurement data from four patients was not able to be accurately interpreted | Count of Participants | Participants |
|
| Race and Ethnicity Not Collected | Race and Ethnicity were not collected from any participant. | Count of Participants | Participants |
|
| Region of Enrollment | Measurement data from four patients was not able to be accurately interpreted | Number | participants |
|
| Units | Counts |
|---|---|
| Participants |
|
|
| Primary | Opening Elastance | Opening Elastance (Oe - cm H2O/mm2) - the resistance of the anal canal to stretch | Posted | Median | Full Range | cm H2O/mm2 | 10 minutes |
|
|
|
| Primary | Closing Pressure | Closing Pressure (Cp - cm H2O) - the pressure at which the anal canal closes after a period of opening | Posted | Median | Full Range | cmH2O | 10 minutes |
|
|
|
| Primary | Closing Elastance | Closing Elastance (Ce - cm H2O/mm2) - the ability of the anal canal to close passively after a period of stretch | Posted | Median | Full Range | cm H2O/mm2 | 10 minutes |
|
|
|
| Primary | Hysteresis | Hysteresis (%) - the energy dissipated during opeing and closing of the anal canal | Posted | Median | Full Range | percentage | 10 minutes |
|
|
|
| Primary | Squeeze Opening Pressure | Squeeze opening pressure (SqOp - cm H20) - the pressure at which the anal canal just starts to open whilst the patient is voluntarily trying to keep the anal canal closed | Posted | Median | Full Range | cmH2O | 10 minutes |
|
|
|
| Primary | Squeeze Opening Elastance | Squeeze opening elastance (Sq)e - cm H20/mm2) - the resistance of the anal canal to stretch whilst the patient is voluntarily trying to keep the anal canal closed | Posted | Median | Full Range | cmH20/mm2 | 10 minutes |
|
|
|
| Secondary | Manometry - Resting Pressure | anal manometry measured in cmH20 | 29 patient analysed due to equipment issues performing for other 3 patients. It was pre-specified to combine data collected from the manometry regardless of the sequence of administration of techniques for AAR measurements as previous study had previously shown that the order of data collection did not impact on the measurements obtained | Posted | Median | Full Range | cmH20 | 10 minutes |
|
|
|
| 0 |
| 18 |
| 0 |
| 18 |
| 0 |
| 18 |
| EG001 | Fast-fill First, Then Stepwise | Fast-fill measurement then Stepwise measurement. Observational study where patients with faecal incontinence undergo two AAR measurements; with the newer fast-fill technique and the second with the original step-wise technique. A further standard manometry measurement will be taken. To reduce the bias of one test on the other, the order of the test were randomised so that half of the patients will undergo fast-fill measurement first and another half of the patients will have step-wise measurement first. Patient min this arm underwent fast fill, followed by a two minute rest, then step wise, followed by a two minute rest, and then by manometry. Previous Work has been carried out looking at the sequence has shown no difference in the order. Therefore to keep consistency this method has been continued and results combined | 0 | 18 | 0 | 18 | 0 | 18 |
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| D001519 | Behavior |
| D019960 | Elimination Disorders |
| D001523 | Mental Disorders |