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Incontinenza anale dopo il parto
- 1. Pelvic Floor Center Montecchio Emilia Reggio Emilia- Italy INCONTINENZA ANALE DOPO IL PARTO P. Talento, M.D.P. Talento, M.D. Colorectal Surgeon
- 3. Fecal Incontinence “Impaired ability to control gas and stool” Disabling and distressing condition Potentially under-estimated condition
- 4. Pasquale Talento, www.coloprocto.it Damage to Internal Anal Sphincter (IAS) Rectum Anal canal Dentate line Mechanical ContributorsMechanical Contributors
- 5. Pasquale Talento, www.coloprocto.it Damage to External Anal Sphincter (EAS) Mechanical ContributorsMechanical Contributors
- 7. ObstetricalObstetrical perineal damageperineal damage Medio-lateral Episiotomy Posterior Episiotomy (AVOID!!!!!)
- 10. Complete section of IAS and EAS with rectal mucosal involvement Partial or complete EAS section with or without IAS damage Obstetrical perineal damageObstetrical perineal damage
- 11. Damage to Pelvic Floor Nerve Complex Mechanical ContributorsMechanical Contributors
- 12. MaiMai RaramentRarament ee QualcheQualche voltavolta SpessoSpesso SempreSempre Feci solideFeci solide 00 11 22 33 44 Feci liquideFeci liquide 00 11 22 33 44 GasGas 00 11 22 33 44 Uso di pannoloniUso di pannoloni 00 11 22 33 44 Alterazioni attivitàAlterazioni attività quotidianequotidiane 00 11 22 33 44 FECAL INCONTINENCE : CCF – Wexner Continence Score Raramente = meno di un episodio al mese Qualche volta = meno di un episodio alla settimana e più di un episodio al mese Spesso = meno di un episodio al giorno e più di un episodio alla settimana Sempre = più episodi al giorno Score = 0-20
- 13. Women: Childbirth InjuryWomen: Childbirth Injury Common cause of incontinence forCommon cause of incontinence for women resulting from injury to:women resulting from injury to: – Internal anal sphincterInternal anal sphincter – External anal sphincterExternal anal sphincter – Motor and sensory pathwaysMotor and sensory pathways Typically seen as anterior sphincterTypically seen as anterior sphincter defect (or scar) from stretching, tearingdefect (or scar) from stretching, tearing or episiotomyor episiotomy
- 14. Fecal Incontinence: ClinicalFecal Incontinence: Clinical AssessmentAssessment • Anal ManometryAnal Manometry • Endoanal Ultrasonography (EAU)Endoanal Ultrasonography (EAU) • DefecographyDefecography • ProctosigmoidoscopyProctosigmoidoscopy • Pudendal Nerve Terminal LatencyPudendal Nerve Terminal Latency ((PNTML)PNTML)
- 15. A: tessuto subepiteliale B : sfintere anale interno C: muscolo longitudinale D : sfintere esterno
- 16. Pasquale Talento, www.coloprocto.itPasquale Talento, www.coloprocto.it Scansione profonda F
- 17. Pasquale Talento, www.coloprocto.itPasquale Talento, www.coloprocto.it Scansione media F
- 18. Pasquale Talento, www.coloprocto.itPasquale Talento, www.coloprocto.it Scansione superficiale F
- 21. Defect Score Degree of Defect 1 - 4 Small 5 - 7 Moderate ≥ 8 Large EAUS – Sphincter Lesions Starck Scoring System Diagnosis
- 22. Score Defect characteristic 0 1 2 3 External sphincter Length of defect None Half or less More than half Whole Depth of defect None Partial Total --- Size of defect None ≤ 90° 91 – 180° > 180° Internal sphincter Length of defect None Half or less More than half Whole Depth of defect None Partial Total --- Size of defect None ≤ 90° 91 – 180° > 180° EAUS – Sphincter Lesions Starck Scoring System No defect = score 0; Maximal defect = score 16 Diagnosis
- 23. Fecal Incontinence PATIENT’S EVALUATION Definition of symptoms Past Medical and Surgical History Physical examination Anorectal physiology studies Manometr y Anal Ultrasoun d Investigatio n EMG Histor y Physical Therapeutic Options Symptom s PNTML
- 25. SPHINCTER REPAIRSPHINCTER REPAIR TECHNIQUE:TECHNIQUE: – Direct AppositionDirect Apposition – OverlappingOverlapping INDICATIONS:INDICATIONS: – Isolated sphincter defect (better inIsolated sphincter defect (better in absence of pudendal neuropathy)absence of pudendal neuropathy)
- 26. Surgical TreatmentSurgical Treatment Sphincteroplasty - Overlapping Muscle RepairSphincteroplasty - Overlapping Muscle Repair
- 27. SurgicalSurgical TreatmentTreatment Graciloplasty & Dynamic GraciloplastyGraciloplasty & Dynamic Graciloplasty Muscle Harvesting SNS
- 28. SurgicalSurgical TreatmentTreatment Unstimulated Bilateral GluteoplastyUnstimulated Bilateral Gluteoplasty .
- 29. Sacral neuromodulation Good patient Selection Criteria
- 30. Patologie funzionali pavimento pelvico trattate
- 31. Patologie funzionali pavimento pelvico trattate – anno 2013
- 32. Stima fabbisogno annuo per trattamento pazienti afferenti al centro pavimento pelvico N° 20 primo tempo N° 23 stimolatori per nuovi impianti e sostituzioni
- 33. PELVIC FLOOR TEAMPELVIC FLOOR TEAM
- 34. ER: Montecchio Emilia Sassuolo 8 Imola 12 Ferrara 3 toscana: Firenze 45 Pisa 15 Poggibonsi (SI) 4 Marche: Ancona 12 Pergola 5 Veneto: Verona 10 Negrar (VR) 10 Padova 7 Lombardia: Milano 45 mantova 5 Brescia 8
- 35. Confronto dati primo semestre 2013 versus primo semestre 2014 Centro Pavimento Pelvico Montecchio Emilia
- 36. Analisi dati proctologia 0 50 100 150 200 250 300 350 400 450 500 1° SEM 2013 1° SEM 2014 visite controlli sintesi nms eco mano
- 37. Analisi dati uroginecologia 0 50 100 150 200 250 300 350 400 450 1° SEM 2013 1° SEM 2014 visite controlli urodinamica
- 38. Analisi dati riabilitazione 0 100 200 300 400 500 600 1° SEM 2013 1° SEM 2014 procto urogine
- 39. Postpartum Fecal IncontinencePostpartum Fecal Incontinence Prepartum obstetrical evaluationPrepartum obstetrical evaluation Avoid episiotomy if it’s possibleAvoid episiotomy if it’s possible Be careful on previous episiotomyBe careful on previous episiotomy Previous tears (3°°°-4) can suggest differentPrevious tears (3°°°-4) can suggest different strategystrategy Incontince score pre and after deliveryIncontince score pre and after delivery Proctological evaluationProctological evaluation Repair sphincter defect soon (better result)Repair sphincter defect soon (better result) Anal Endosonography helpful for blind analAnal Endosonography helpful for blind anal sphincter defectsphincter defect
- 40. PELVIC FLOOR TEAMPELVIC FLOOR TEAM Montecchio EmiliaMontecchio Emilia
Editor's Notes
- The anal canal is surrounded by two rings of sphincteric muscles, the internal anal sphincter (IAS) and the external anal sphincter (EAS). The IAS is indicated on the above slide. This muscle encircles the anal canal, and is “internal” to the other sphincter muscle. Control of this muscle is involuntary (subconscious) – it provides constant pressure to the the anal canal. This pressure is generally referred to as “resting pressure” or “basal pressure.” Normally, his small amount of pressure prevents accidental leakage of small amounts of stool, but won’t stop a “locomotive.” Depending on capacity comfort, this muscle can be overridden, i.e., diarrhea. The dentate line is the line of demarcation between intestinal mucosa and external derma (skin). This line is visible by the naked eye. The internal anal sphincter straddles this dentate line. Half of the muscle is above the dentate line and half is below. The dentate line is the primary “reference point” for the Secca procedure.
- The external anal sphincter (EAS) is the second of the two sphincter muscles. The EAS is a voluntary muscle. This muscle is longer than the internal anal sphincter, coming from above and encircling the anal canal like a cone. When we sense that stool is in the rectum, we are able to squeeze our external anal sphincter and create a high level of “squeeze pressure” to prevent defecation until the selected time. The EAS is able to exert a much higher level of pressure than the IAS. Comparatively, the IAS exerts about 15%, the EAS about 85%.
- Foto 6
- This area is highly innervated. Not only does this tissue determine the type of rectal contents, but it is also very sensitive to pain. A surgical hemorrhoidectomy is perceived the most painful surgery. This tissue is VERY sensitive. Because this mucosal tissue is so sensitive, it is critical that during the Secca procedure, this tissue is preserved and not damaged. Creating lesions on this tissue could cause the patient much pain.
- Childbirth causes physical traumatic injury to the muscle or pudendal nerve injury. In many cases, the sphincter muscle will have an identifiable (or “discrete”) scar on the anterior side of the sphincter muscle. This is the side of the sphincter which is toward the vaginal canal and is injured by stretching or tearing. Additionally, episiotomies may play a role.. If the patient is young, has fecal incontinence, and has this injury, the surgeon should repair this “defect” using “sphincter repair” surgery, where the surgeon dissects the scar, overlaps the tissue, and sews it together again, overlapping the scar tissue. The end goal is a full ring of healthy sphincter muscle, which improves continence. The success of this procedure is 80% to 90% initially, but long term results which have recently come to light show that 50% of patients are incontinent again 5 years after surgery.
- The work-up of the incontinent patient includes he following tests: Manometry is similar to that used to confirm GERD. The anal canal is tested to determine how tight the anal sphincter is during rest and during a tight voluntary squeeze. Additionally, the length of the sphincter is measured. Lastly, sensation to rectal distention is tested to determine if a patient can detect (and defer passage of) stool stretching the rectum. PNTML is a nerve test for each of the pudendal nerves. Delay in nerve transmission may cause fecal incontinence. Proctography is an X-ray video of a bowel movement to study rectal sigmoid and sphinteric function. Proctosigmoidoscopy is similar to colonoscopy, only performed on the sigmoid colon. Ultrasound images the integrity of each sphincter muscle, evaluating for fibrosis of not previous repaired or unhealed injuries. Importantly, in studies evaluating various treatments for fecal incontinence, these tests do not necessarily correlate with outcomes. In fecal incontinence, the best measurements of success of a therapy are symptom severity, incontinence frequency and patient satisfaction.
- Procedural Review: Overlapping Muscle Repair Patient in lithotomy position - Infiltration of local anesthesia. Placement of circular incision. Mobilization of anoderm. Dissection of sphincter muscles. Mobilization of severed ends of sphincter muscles. Muscle ends ore overlapped Scars are left are left at each end to hold the mattress sutures. At completion of suturing, anal canal should accommodate one finger snugly. Perianeal reconstruction. Wound is packed open. Can also be performed with the Gluteous Maximus Muscle
- Graciloplasty with the support of Sacral Nerve Stimulation is also called Dynamic Graciloplasty. It is marketed by Medtronic as the last alternative prior to colostomy. Post surgery it is a two step process; first, the papient learns how to program the initial “pacemaker/programmer,” for about 4-6 weeks, thereafter the pacemaker is permanently programmed and implanted inside the patient. Currently, this procedure is performed only at investigational sites. The Sacral leads with long needle electrodes are connected to S2, S3 or S4 foramens in the sacral juncture. Once stimulated the muscles tighten to constrict the neorectum and is released to relax the sphincter. Medtronic has marketed this for urinary incontinence and now hopes to market this as the last option for patients with severe fecal incontinence is a stoma, or diversion of stool into a bag from the abdomen (colostomy).
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