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    Uroginekologi (OASIS)

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    Eka Handayani Oktharina
    This document discusses obstetric anal sphincter injuries that can occur during childbirth. It begins by describing the anatomy of the internal and external anal sphincters. It then notes that obstetric anal sphincter injuries can lead to anal incontinence. It discusses that some injuries may be occult or missed during examination and can be diagnosed later through endoanal ultrasound. Ultrasound evaluation post-delivery or repair can identify any residual defects. Transperineal, transvaginal, and 3D ultrasound are introduced as methods to evaluate the anal sphincters. The document concludes by discussing next steps in delivery planning based on prior sphincter injury status and ultrasound findings.

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    Uroginekologi (OASIS)

    Uploaded by

    Eka Handayani Oktharina
    13 views41 pages
    This document discusses obstetric anal sphincter injuries that can occur during childbirth. It begins by describing the anatomy of the internal and external anal sphincters. It then notes that obstetric anal sphincter injuries can lead to anal incontinence. It discusses that some injuries may be occult or missed during examination and can be diagnosed later through endoanal ultrasound. Ultrasound evaluation post-delivery or repair can identify any residual defects. Transperineal, transvaginal, and 3D ultrasound are introduced as methods to evaluate the anal sphincters. The document concludes by discussing next steps in delivery planning based on prior sphincter injury status and ultrasound findings.

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    6. Uroginekologi (OASIS)

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    This document discusses obstetric anal sphincter injuries that can occur during childbirth. It begins by describing the anatomy of the internal and external anal sphincters. It then notes that obstetric anal sphincter injuries can lead to anal incontinence. It discusses that some injuries may be occult or missed during examination and can be diagnosed later through endoanal ultrasound. Ultrasound evaluation post-delivery or repair can identify any residual defects. Transperineal, transvaginal, and 3D ultrasound are introduced as methods to evaluate the anal sphincters. The document concludes by discussing next steps in delivery planning based on prior sphincter injury status and ultrasound findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views41 pages

    Uroginekologi (OASIS)

    Uploaded by

    Eka Handayani Oktharina
    This document discusses obstetric anal sphincter injuries that can occur during childbirth. It begins by describing the anatomy of the internal and external anal sphincters. It then notes that obstetric anal sphincter injuries can lead to anal incontinence. It discusses that some injuries may be occult or missed during examination and can be diagnosed later through endoanal ultrasound. Ultrasound evaluation post-delivery or repair can identify any residual defects. Transperineal, transvaginal, and 3D ultrasound are introduced as methods to evaluate the anal sphincters. The document concludes by discussing next steps in delivery planning based on prior sphincter injury status and ultrasound findings.

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    of 41

    Obstetric Anal

    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

    • Anal incontinence (AI) is the involuntary loss of flatus or faeces that is


    a social or hygienic problem.1

    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)

    a. Intact perineum b. “bucket handle” tear c. Torn external sphincter

    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.

    Results Fifty-nine (24.5%) women sustained OASIS. The prevalence of OASIS


    increased significantly from 11% to 24.5% when women were re-examined. Of
    these, 30 occurred in deliveries by midwives who missed 26 (87%) and 29
    following deliveries by doctors who missed 8 (28%) injuries. All clinically
    apparent OASIS were also identified on endoanal ultrasound. In addition, three
    (1.2%) women had an occult anal sphincter injury. Two of these occult sphincter
    injuries were isolated to the internal anal sphincter (IAS) and would not usually
    be clinically detectable.

    Conclusions OASIS occur more frequently than previously reported. Many


    remain undiagnosed and are subsequently classified as occult when identified
    on anal endosonography. Genuine occult injuries are rare. Training in perineal
    anatomy and recognition of OASIS needs to be enhanced in order to increase
    detection of OASIS and minimise the risk of consequent anal incontinence.
    HOW CAN WE SEE “OCCULT” OASIS?
    Any Residual • Evaluation post repair
    Defect from our • 6 weeks post repair
    surgery repair? • 3 – 6 months post repair
    Transintroital Sonography of anal sphincter

    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

    The normal anal sphincter unit. Lower transverse section


    Transverse sections higher vs lower plane

    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

    History of 3rd and 4th degree perineal tear


    • Refer to perineum clinic for follow up and treatment for the next
    delivery
    • USG should be done

    If continensia fecal If incontinensia fecal


    If continensia and no
    with anal sphincter with sphincter ani
    anal sphincter defect defect
    defect
    • Vaginal delivery with • SC • Normal delivery
    senior midwife or with secondary anal
    doctor. sphincter suture
    Take Home Messages

    • EAUS is gold standard tool to evaluate anal sphincter structure but not
    easily available

    • TPUS can be considered as alternative to evaluate anal sphincter structure


    • The evaluation result would be used to determined the next
    delivery plan.
    • Practice makes perfect!
    THANK YOU

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