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Faecal Incontinence Anterior Sphincter Repair. Normal Continence. Internal sphincter: - Visceral innervation - 85% continence. External sphincter: - Somatic innervation - 15% continence. Secondary Muscles of continence. Primary Muscles of continence.
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Normal Continence Internal sphincter: - Visceral innervation - 85% continence External sphincter: - Somatic innervation - 15% continence Secondary Muscles of continence Primary Muscles of continence
Faecal IncontinenceThe Issues 1. Structure vs Function 2. Surgery vs Conservative
No Defect ‘No Repair’
Incidence of Perineal Trauma • 90% of incontinent women with an obstetric history have a sphincter defect (Burnett, S.J. BJS 1991) • Women with 30/40 tear • 74% Symptomatic • 59% Incontinent of Gas • 90% Sphincter Defect (Goffeng, A.R. Act.OGS 1998) • 35% of Primiparous women will have a sphincter defect after delivery (13% symptomatic) (Sultan, A.H. NEJM 1993)
Obstetric Injuryde Parades et al. DCR 2004 • 93 females : Single forceps delivery • Results • 11% partial external defects • 1% partial external and complete internal defects • Symptoms • 18% flatus incontinence • 4% liquid stool incontinence • Correlates • Perineal tear predicts sphincter defect
Obstetric InjuryMechanisms Rectovaginal septum - rectocoele Ischaemic injury - fistula Sphincter complex - incontinence
Faecal Incontinence Which Treatment • Tailored for individual patient • Tailored to degree of perceived symptoms • Tailored to anatomy of sphincter • Tailored to other injury • Start simple • Avoid complex
Faecal IncontinenceAlgorithm Defect No defect Conservative Symptoms + Symptoms - Conservative Surgical Graciloplasty Artificial sphincter Sacral nerve stimulation Surgical Anterior sphincter repair Stoma
Acute Sphincter Repair ‘End to End’ Vs ‘Overlapping’
Obstetric InjuryFitzpatrick et al. Am J Ob Gyn 2000 • RCT Overlapping vs approximation • 112 females with third degree tears • Results • Incontinence scores • 0/20 (Ov) vs 2/20 (Ap) • Urgency • 11 (Ov) vs 17 (Ap) • Manometry and US • No differences • 66% had persistent US defects
Obstetric InjuryPinta et al. DCR 2004 • 52 females : Third and fourth degree tears • Primary repair • Results • 61% symptoms of anal incontinence • 20% symptoms of faecal incontinence • Significantly worse than a control group • Persistent external defects • 75% in repair group • 20% in control group
Predicting OutcomeResidual endosonographic defect after repair • Residual endosonographic defect in • 30% of Successful Group • 80% of Failed Group • Positive predictive value of intact repair 70% • Negative predictive value of persistent defect 80%
Success Fail Fail Predicting OutcomeLength of repaired sphincter 6 Failed repair Successful Repair 4 Number of women 2 0 6 - 10 11 - 15 16 - 20 0 - 5 Length of anterior external anal sphincter (mm)
Anterior Sphincter RepairLong Term Outcome • 55 pts undergoing overlap repair • Early- 42 continent solid and liquid 15 months • Late • 46 at least 5 year follow up • 27 symptoms improved • 23 improved by at least 50% • 38 pts (7 further surgery, 1 stoma) • 0 continent solid and flatus • 4 continent to solid and liquid • 6 no urgency, 8 no soiling • 20 needed pads, 25 lifestyle restriction • 14 evacuation disorder Malouf et al Lancet 2000
Summary • Carefully assess patient • Arrange appropriate investigations • Try simple measures • Fix prolapse • If there is a defect repair it • Be aware of long term results • If there is no defect DO NOT repair it • Tailor your treatment to the patient