Uroginekologi (OASIS)
Uroginekologi (OASIS)
Uroginekologi (OASIS)
Sphincter Injury
Ratih Krisna
Anatomy
Made up of circular smooth
Internal muscle
Anal Function:
to close the lumen of the
Sphincter anal canal and control
INVOLUNTARY passage of
(IAS) faeces and flatus
Made up of striated
muscle.
External Function:
to close the lumen of
Anal the anal canal and
control VOLUNTARY
passage of faeces and
Sphincter flatus
(EAS)
Obstetric
anal
sphincter
injuries
(OASI) https://www.sydneypelvicfloorhealth.com/anal-sphincter-muscle
during
childbirth
Upcoming problems of OASIS
https://commons.wikimedia.org/wiki/File:Fecal_incontinence.jpg
1. Norton C, Christiansen J, Butler U, et al. Anal incontinence. In Abrams P, Khoury CL & Wein A (eds) Incontinence, 2nd edn. Plymouth: Health Publication Ltd, 2002, pp 985–1044.
OCCULT OASIS
Tears of the sphincters not apparent or identified
on clinical examination:
• Truly Occult only 1.2%.
• Missed, unrecognised1 or wrongly classified as
second degree tear2 20-41%.
• Residual Defect after repair.
1. Groom KM, Paterson-Brown S. Can we improve the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol
2002;101:19 –21.
2. Sultan AH, Kamm MA, Hudson CN. Obstetric perineal trauma: an audit of training. J Obstet Gynaecol 1995;15:19–23.
TRULY OCCULT
1
OASIS
Sultan AH & Christine K (2007)
ONLY 1.2%2
1. Sultan AH, Christine K. Diagnosis of Perineal Trauma. In: Sultan AH,Thakar R, Fenner ED, eds. Perineal and Anal Sphincter
Trauma London: Springer, 2007, pp 13-9.
2. Andrews V, Sultan AH, Thakar R, Jones P. Occult anal sphincter injuries – myth or reality? Br J Obstet Gynaecol 2006;113:195–
200.
Unrecognised or Underdiagnosed
• Sultan et al (1993)1:
• 35% of women undergoing their first vaginal delivery
develop occult sphincter injury.
• Approximately one-third develop defecatory symptoms
(urgency and/or AI) within 2 months of delivery. Others
are at increased risk of developing incontinence later in life
when the cumulative effects of the menopause,
neuropathy, and muscle loss playing roles.
• Prospective studies have
. identified “occult” injuries
ranging between 20%2 and 41%.3
1. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med
1993;329:1905–11.
2. Zetterstrom J, Mellgren A, Jensen LJ, Wong WD, Kim DG, Lowry AC, Madoff RD, Congilosi SM. Effect of delivery on anal
sphincter morphology and function. Dis Colon Rectum 1999;42:1253–60.
3. Rieger N, Schloithe A, Saccone G, Wattchow D. A prospective study of anal sphincter injury due to childbirth. Scand J
Gastroenterol 1998;33: 950–5.
BJOG 2006; 113:195–200.
Timor-Tritsch IE, Monteagudo A, Smilen SW et al. Simple ultrasound evaluation of the anal sphincter in
female patients using a transvaginal transducer. Ultrasound Obtet Gynecol 2005;25:177–183.
Fourchette
Anus
Transverse Scanning Plane
Sagittal Scanning Plane
IAS Mucosal Star
EAS
Timor-Tritsch IE, Monteagudo A, Smilen SW et al. Simple ultrasound evaluation of the anal sphincter in
female patients using a transvaginal transducer. Ultrasound Obtet Gynecol 2005;25:177–183.
Normal anal
sphincter
(coronal view)
Normal anal
sphincter
with
contraction
Normal anal
sphincter
(sagittal view)
Anal Sphincter
with internal &
external defect
(coronal)
Anal Sphincter
with internal
and external
defects
(sagittal)
3D Transvaginal Sonography
3D Transvaginal
Sonography
3D Transvaginal
Sonography(3)
Transperineal/labial Sonography
Transperineal/labial Sonography
Normal view of
sphincter ani
Steensma AB. The central and posterior compartment. In: Dietz HP, Hoyte LPJ, Steensma AB. Atlas of Pelvic Floor Ultrasound.
1st ed. London: Springer-Verlag;2004.p.63-75.
Defect of external & internal
sphincter ani
Steensma AB. The central and posterior compartment. In: Dietz HP, Hoyte LPJ, Steensma AB. Atlas of Pelvic Floor Ultrasound.
1st ed. London: Springer-Verlag;2004.p.63-75.
Variation of 3rd grade
trauma repair
Steensma AB. The central and posterior compartment. In: Dietz HP, Hoyte LPJ, Steensma AB. Atlas of Pelvic Floor Ultrasound.
1st ed. London: Springer-Verlag;2004.p.63-75.
•What next?
Delivery Procedure for 3rd and 4th Degree
Perineal Tear
• EAUS is gold standard tool to evaluate anal sphincter structure but not
easily available