Delayed surgical management of the disrupted anal sphincter
- Liliana Bordeianou, MD, MPH
Liliana Bordeianou, MD, MPH
- Associate Professor of Surgery
- Harvard Medical School
Fecal incontinence is the involuntary loss of flatus or feces. Data are conflicting as to whether the rate is higher in women than in men [1,2]. Fecal incontinence affects 9 percent of women aged 40 to 59 years old and as many as 21 percent of women aged over 80 years old . Unfortunately, it is often unrecognized by clinicians because patients do not report their symptoms. The emotional, psychological, and social problems created by fecal incontinence can be devastating, debilitating, and costly . (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Epidemiology'.)
The most common cause of fecal incontinence in healthy women is obstetric trauma, which can result in mechanical disruption of the anal sphincter muscles or damage to the nerves that innervate these muscles. The injury may be occult and symptoms may not occur until many years after delivery [5,6]. A rectovaginal fistula is another cause of fecal incontinence; it may occur after breakdown of a repair of third or fourth degree lacerations. (See "Effect of pregnancy and childbirth on anal sphincter function and fecal incontinence" and "Approach to episiotomy" and "Rectovaginal and anovaginal fistulas".)
Delayed repair of anal sphincter disruption will be reviewed here. The anatomy and physiology of the anal sphincter, pathogenesis of anal sphincter dysfunction, and evaluation of patients with fecal incontinence are discussed separately. (See "Fecal incontinence in adults: Etiology and evaluation".) Primary surgical repair of anal sphincter injury related to childbirth is also discussed separately. (See "Repair of episiotomy and perineal lacerations associated with childbirth".)
Chronic third and fourth degree lacerations occur from unrecognized obstetric trauma or breakdown of a primary perineal repair after childbirth. Women who suffer from chronic third or fourth degree lacerations typically complain of fecal urgency, and can have incontinence to gas, mucus, liquid, and even solid feces. The severity of symptoms is, at least in part, dependent on the size of the tear, but also on the amount and functionality of the residual muscle .
Physical examination — Women with chronic fourth degree lacerations frequently have complete disruption of the perineal body, as well as the external and internal anal sphincter. Disruption of the sphincter complex occurs anteriorly, and in many patients, the tear is easily identifiable on examination. Occasionally, the tear is less obvious: physical examination alone can miss a tear in as many as 25 percent of women who present with fecal incontinence . Therefore, endoanal ultrasound should always be obtained as part of the evaluation of fecal incontinence and prior to any surgical repair. (See 'Preoperative diagnostic studies' below.) In addition, the rectovaginal septum is often attenuated. The anal mucosa usually is in direct proximity to the distal vaginal epithelium; however, in some women, a thin bridge of perineal skin is present between the vaginal and anal epithelium.
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- CLINICAL MANIFESTATIONS
- Physical examination
- PREOPERATIVE DIAGNOSTIC STUDIES
- Endoanal ultrasound
- Anorectal physiology tests
- PREOPERATIVE MANAGEMENT
- Bowel preparation
- Foley catheter
- Surgical goals
- Alternative techniques
- - Sacral nerve stimulator
- - Artificial sphincter
- POSTOPERATIVE CARE
- ADJUVANT NONSURGICAL MANAGEMENT
- FUTURE OBSTETRICAL DELIVERIES
- SUMMARY AND RECOMMENDATIONS