E-mail:[e-mail]

1
?????????? ?????? ?? ?????? ????????????

• ???? ???? ?????
• ???? ?????????? ??????? ???? ?????
• ??????? ????? ??????? ???? ????? ?????
• ????? ???? ????? ??? ?????
• E-mailrazizimd_at_hotmail.com

2
Anatomy physiology of continenceintroduction

• The ability
• to retain a bodily discharge voluntarily. The
• word has its origins from the Latin continere or
• tenere, which means to hold. The anorectum is
  the
• caudal end of the gastrointestinal tract, and is
• responsible for fecal continence and defecation.
  In
• humans, defecation is a viscero somatic reflex
  that is
• often preceded by several attempts to preserve
  continence

3
(No Transcript)
4
Mechanisms of Continence and Defecation
5
Risk Factors in Fecal IncontinenceObstetric
Events

• Sphincteric Injury
• Pudental Nerve Injury
• Secondary Rectal Sensorimotor Dysfunction

6
Kamm MA (1994) Obstetric damage and fecal
incontinence.Lancet 344730Bharucha AE (2003)
Fecal incontinence. Gastroenterology1241672-1685

• There is now clear recognition, supported
• by a considerable body of evidence, that
• Obstetric trauma is, by far, the major risk
  factor for the development
• of acquired fecal incontinence in women

7
In a frequentlyreferenced study by Sultan and
colleagues in 1993,ultasound at 6 weeks
postpartum revealed sphincter injuries in 35 of
primiparous women and 44 of multiparous women.

• Sultan AH, Kamm MA, Hudson CN et al (1993) Anal
  sphincter
• disruption during vaginal delivery. N Eng J
• Med 32919051911

8
(No Transcript)
9
the prevalence ofsymptoms of fecal incontinence
postpartum instudies involving gt130 subjects and
shows thatgreater than 10 of women will
complain of bowelsymptoms in the first few
months following childbirth

• 1-Chaliha C, Kalia V, Stanton SL et al (1999)
  Antenata
• prediction of postpartum urinary and fecal
  incontinence
• Obstet Gynecol 94689-694
• MacArthur C, Glazener CM, Wilson PD, et al(2001)
  Obstetric practice and faecal incontinence three
  months after delivery. BJOG 108678-683
• MacArthur C, Bick DE, Keighley MR (1997) Faecal
• incontinence after childbirth. Br J Obstet
  Gynaeco10446-50

10
Oberwalder and colleagues performed a
meta-analysis of 717 vaginal deliveries has
threenotable results First, the incidence of
anal sphincterdefects in primiparous women was
26.9. Second,multiparous women had an 8.5
incidence of newsphincter defects. Third, the
calculated probabilitythat postpartum fecal
incontinence was due to asphincter defect was
76.882.8.

• Oberwalder M, Connor J, Wexner SD (2003)
  Metaanalysis
• to determine the incidence of obstetric anal
• sphincter damage. Br J Surg 9013331337

11
Episiotomy was at one time believed to be
protectiveto the perineum during childbirth and
was usedto prevent the occurrence of third- and
fourth-degreetears . There is now evidence that
episiotomy notonly fails to protect the perineum
but has beenassociated with increased tearing
and anal sphincterinjury

• 1-Thacker SB, Banta HD (1983) Benefits and risks
  of episiotomy
• an interpretive review of the English language
  literature. Obstet Gynecol Surv 38322338
• 2-Klein MC, Gauthier RJ, Robbins JM et al (1994)
  Relationship of episiotomy to perineal trauma and
  morbidity, sexual dysfunction, and pelvic floor
  relaxation.
• Am J Obstet Gynecol 171591598

12
Many papers have been published
regardingobstetric lesions as they relate to
incontinence. However,it is difficult to
accurately quantify the prevalenceof obstetric
injury and its effect on the incidenceof
incontinence.
13
In addition to direct trauma to the sphincter
muscle,pudendal neuropathy is another
consequence ofvaginal delivery, which
contributes to fecal incontinence.The pudendal
nerve is believed to be damagedby the fetal
head, which compresses the nerve,
causingischemia or stretching its branches

• repeated pregnancies and deliveries add
• to the damage, the neuropathy progresses as the
• woman ages, and the worsening over time causes
  significant
• fecal incontinence that presents between 50
• and 60 years of age

14
Cesarean section has been advocated as an
optionto protect the pelvic floor and reduce the
incidence ofpostpartum fecal incontinence
however, this issue iscontroversial. Cesarean
section performed aftercervical dilation,
especially if performed late in thesecond stage
of labor, is not entirely protectiveagainst
direct sphincter trauma or pudendal neuropathy

• At this time, the best practice seems to be
  evaluation of a
• womans risk factors, informed consent regarding
• her risk of pelvic floor trauma from vaginal
  delivery,
• proper recognition of injury at the time of
  delivery
• , and effective postpartum evaluation

15
Nelson et al. covering 15 studies
encompassing3,010 Caesarean section and 11,440
vaginal deliveries showed no difference between
the rate of either fecal or flatus incontinence
between the two different modes of delivery. The
implication of both of these studies is that it
is pregnancy itself, perhaps in relation to
connective tissue properties or perhaps an
inherited susceptibility, that can lead to pelvic
floor disorders.

• Nelson RL, Westercamp M, Furner SE (2006)A
  systematic review of the efficacy of Cesarean
  section in the preservation of anal continence.
  Dis Colon Rectum491587-1595

16
Risk Factors

• Anorectal Anomalies
• Spina Bifida
• Isolated Sacral Agenesis
• Hirschprungs Disease
• Cerebrovascular Accidents
• Parkinson's Disease
• Multiple Sclerosis
• Spinal Cord Injury

• Diabetes Mellitus
• Ageing
• Inflammatory Bowel Disease
• Irritable Bowel Syndrome
• Anal Surgery
• Rectal Resection
• Rectal Evacuatory Disorder
• Rectal prolapse

17
(No Transcript)