science

Perianal injectable bulking agent

Perianal injectable bulking agent is a science topic covered in the lgStudy science library. This page brings together a partial reference excerpt, illustrations, worked examples, real-world applications and a short study plan, so you can understand Perianal injectable bulking agent rather than just read about it. In short: These procedures aim to inject bio-compatible material (perianal injectable bulking agents, also termed sphincter bulking agents or biomaterial injectables) into the walls of the anal canal, in order to bulk out these tissues. This may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and thereby reducing fecal incontinence.

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Reference excerpt

These procedures aim to inject bio-compatible material (perianal injectable bulking agents, also termed sphincter bulking agents or biomaterial injectables) into the walls of the anal canal, in order to bulk out these tissues. This may bring the walls of the anal canal into tighter contact, raising the resting pressure, creating more of a barrier to the loss of stool, and thereby reducing fecal incontinence. This procedure has many advantages over more invasive surgery, since there are rarely any serious complications.

History Originally, injectable bulking agents were used to treat stress urinary incontinence in females. The procedure aimed to bulk out the tissues of the neck of the bladder, and it was successful. The technique was first used for FI in 1993 by an Egyptian surgeon. He used polytetrafluroethylene (PTFE/polytef/Teflon) paste injected into the submucosal layer of anal canal. Later publications described autologous transplantation of fat from the abdominal wall or the buttock. After about the year 2000, many different materials started to be used as well as variations of the technique. Some of these materials were concurrently being used to treat urinary incontinence. The latest development of this technique is the implantable bulking agents "Gatekeeper" and "Sphinkeeper". These are not injectable materials but rather implants which expand after placement. As such, they are termed "self-expandable prostheses", and the term "non-self-expandable prostheses" is used to refer to older injectable materials.

Procedure The exact methods of this procedure are not standardized and vary considerably, for example the exact number and locations of the injections and the volume of the injected material. Before the operation, antibiotic prophylaxis may be given. The rectum is prepared with a phosphate enema at least 2 hours before the procedure. The procedure can be carried out under local anesthetic on an out patient basis, or with caudal epidural anesthesia, or with intravenous sedation, or under general anesthesia. Ultrasound guidance may be used during the injections, which is sometimes reported as being more effective than the surgeon simply palpating (feeling) and looking where to inject. The site of the bulking material can be inter-sphincteric (in the space between the IAS and the EAS), submucosal injections (under the mucosal layer, usually just above the dentate line), or within the IAS itself. Injection of the material can be by the different routes: transanal route, trans-sphincteric, intersphincteric, perianal route (going through the muscle complex) or transcutaneous route. As such, there are several different variations of injection location and route:

Trans-sphincteric route into the IAS, Inter-sphincteric route into the IAS, Inter-sphincteric route into the submucosa, Trans-anal injection into the submucosa (similar to injection sclerotherapy for haemorrhoids), Trans-sphincteric route into the inter-sphincteric space, Inter-sphincteric route into the inter-sphincteric space, Trans-sphincteric route injecting submucosally. The perianal injection route (intersphincteric or transsphincteric) gives better results than the transanal route according to one review. Submucosal implant location may have a higher risk of erosion and sepsis.

Injectable materials Many different materials have been used as perianal injectable bulking agents. The ideal injectable or implantable material would be biocompatible, non-migratory, non-allergenic, non-carcinogenic and non-immunogenic (and therefore induce a minimal inflammatory and fibrotic reaction). The material should also be easy to inject. The particles should be greater than 80 μm in diameter in order to prevent migration away from the injection site. On the other hand, materials with particles small enough to be used in small caliber needles may be desirable, in order to leave a smaller needle track, which may reduce the chance of leakage of the material via the needle track. Alternatively, some materials are shape-retaining porous hydrogels with no particles. The ideal material should produce an improvement in continence not only in the short term, but in the long term, and repeated procedures should not be necessary. Technically, most materials are particles suspended in a carrier (excipient) solution, which is usually a biodegradable gel. It is not known which of the available materials is the best.

Autologous fat (fat tissue transferred from elsewhere in the body). Teflon. Bovine glutaraldehyde cross-linked collagen (collagen from cows). Carbon-coated zirconium/graphite beads ("Durasphere"). Polydimethylsiloxane elastomer (silicone) biomaterial implants ("PTQ implant"). Dextranomer in non-animal stabilised hyaluronic acid ("Solesta", "NASHA Dx"). Hydrogel cross-linked with polyacrylamide ("Bulkamid"). Porcine dermal collagen (collagen from pig skin, "Permacol"). Synthetic calcium hydroxylapatite ceramic microspheres. Polyacrylonitrile in cylinder form. aluminum potassium sulfate and tannic acid (ALTA).

Teflon (polytef) This was the original material used as a bulking agent, first used to treat urinary incontinence in 1964, and then about 20 years later it was the first material used as a bulking agent to treat FI. Polytef paste is polytetrafluoroethylene, glycerin and polysorbide. The particles are mostly very small in size (4–40-μm). Research in animals has shown that these particles migrate and may be found in lymph nodes, lungs, kidneys, spleen and brain. If the material mostly migrates away, any benefit will be temporary, and there are safety concerns that it could lead to the formation of foreign body granulomas and the development of sarcoma.

Autologous fat transplant This variation of the procedure uses the patient's own fat cells, and therefore is non-allergenic and non-immunogenic. The fat cells are taken from the abdominal wall by suction. Then they are purified and put into a saline solution before injection. When used in other fields such as urology or facial surgery, autologous fat transplants have very rarely been reported to cause fat embolism and stroke. This material is also subject to rapid digestion and migration.

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Worked examples

Example 1 — a first encounter with Perianal injectable bulking agent

Start with the simplest possible case. Write down what Perianal injectable bulking agent claims or describes in one sentence, then invent the smallest concrete situation in which that sentence is true. In science, the smallest case is usually a single object, a single equation or a single measurement. Check that every symbol or term in your sentence has a meaning in that case.

Example 2 — changing one variable

Take the situation from Example 1 and change exactly one quantity: double it, halve it, or set it to zero. Predict what should happen to Perianal injectable bulking agent before you calculate. Comparing your prediction with the result is the fastest way to find out whether you understand the idea or only the words.

Example 3 — an exam-style question

Typical questions about Perianal injectable bulking agent ask you to (a) state it precisely, (b) apply it to given data, and (c) explain a limitation. Practise writing all three answers in under five minutes; the third part is what separates a full-mark answer from an average one.

Applications of Perianal injectable bulking agent

In research: Perianal injectable bulking agent appears in science research whenever the underlying quantities have to be modelled precisely. Papers usually cite it as a starting assumption and then explore where it breaks down.
In technology and industry: Engineering practice reuses Perianal injectable bulking agent in design rules, simulations and safety margins. Knowing the idea lets you read a specification sheet and understand why the numbers look the way they do.
In the classroom: Perianal injectable bulking agent is common in secondary-school and first-year university syllabi. It links to neighbouring topics Colorectal surgery, Incontinence, so understanding it makes those chapters shorter.
In everyday life: Look for Perianal injectable bulking agent outside the textbook — in sport, cooking, traffic, electronics or the sky above you. An example you found yourself is remembered far longer than one you were given.

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Frequently asked questions

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