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Applied anatomy
The anal canal measures about 3.5 cm in length. The external anal sphincter (EAS) is striated muscle and is subdivided into subcutaneous, superficial and deep regions and is responsible for voluntary squeeze and reflex contraction pressure
Applied anatomy
The internal anal sphincter (IAS) is a thickened continuation of the circular smooth muscle of the bowel.
It contributes about 70% of the resting pressure and is under autonomic control.
Introduction
Obstetric
Introduction
The
overall risk of
women without obvious anal sphincter tears during labour and delivery (occult injury).
Importance
Anal
involuntary loss of faeces, flatus or urge incontinence that is adversely affecting a womans quality of life.
Up
fourth degree perineal tears during childbirth suffer from anal incontinence.
Grade B
sonographic abnormalities of the anal sphincter anatomy has been identified in up to 36% of women after vaginal delivery, in prospective studies.
A
with evidence of genital tract trauma should be examined systematically to assess the severity of damage prior to suturing.
Grade B
Surgical techniques
For repair of the external anal sphincter, either an overlapping or end-to-end (approximation) method can be used, with equivalent outcome. Where the IAS can be identified, it is advisable to repair separately with interrupted sutures. Repair of third- and fourth-degree tears should be conducted in an operating theatre, under regional or general anaesthesia.
(Grade A)
Overlap technique
Surgical techniques
A systematic review on the method of repair showed that no significant difference in: perineal pain ,dyspareunia ,flatus incontinence and faecal incontinence & quality of life between the two repair techniques at 12 months But showed a significantly lower incidence in faecal urgency in the overlap group.
(Grade A)
Surgical techniques
Repair in an operating theatre will allow the repair to be performed under aseptic conditions with appropriate instruments, adequate light and an assistant.
Regional or general anaesthesia will allow the anal sphincter to relax, which is essential to retrieve the retracted torn ends of the sphincter without any tension (Grade C)
The use of absorbable synthetic material polyglactin 910 (vicryl) when compared with catgut, is associated with less :
(Grade A)
The use of a more rapidly absorbed form of polyglactin 910 (Vicryl) is associated with a significant reduction in pain and a reduction in suture removal when compared with standard absorbable synthetic material.
In the light of current evidence, rapid-absorption polyglactin 910 (Vicryl) is the most appropriate suture material for perineal repair. (Grade A)
When repair of the IAS muscle is being performed, fine suture size such as 3-0 PDS and 2-0 Vicryl may cause less irritation and discomfort. (Grade C)
Burying of surgical knots beneath the superficial perineal muscles is recommended to prevent knot migration to the skin. (Good practice point)
Method of repair
A loose, continuous non-locking suturing for (vaginal tissue, perineal muscle and skin) & the use of a continuous subcuticular technique for perineal skin closure is associated with less short term pain than techniques employing interrupted sutures. (Grade A)
Surgical competence
Obstetric
Postoperative management
The
Postoperative management
All
women who have had obstetric anal sphincter repair should be : pelvic-floor exercises for 612 weeks after repair.
Prognosis
Women should be advised that the prognosis following EAS repair is good, with 6080% asymptomatic at 12 months. Most women who remain symptomatic describe incontinence of flatus or faecal urgency.
(Grade A)
Future deliveries
All women with an obstetric anal sphincter injury in a previous pregnancy should be :
Counselled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery.
Advised that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies. (good practice point)
Future deliveries
All
sphincter injury in a previous pregnancy and who are symptomatic or have abnormal endoanal ultrasonography should have the option of elective caesarean birth.
(good practice point)
Risk management
There
the injury after delivery, leading to subsequent anal incontinence and rectovaginal fistulae.
Poor
Practice recommendations
Avoiding
been noted to increase the risk of obstetric anal sphincter injury and altered fecal continence , by between 2-7 fold .
Practice recommendations
Routine episiotomy is not recommended. Episiotomy use should be restricted to situations where it directly facilitates an urgent delivery .
A mediolateral incision, instead of a midline, should be considered for persons at high risk of obstetric anal sphincter injury ,with careful attention to the angle cut away from the midline.
Practice recommendations
The
anal sphincter or rectal mucosa have a worse prognosis for future continence problems .
Practice recommendations
All
women, especially those with surveyed for symptoms of anal incontinence at postpartum follow-up .