Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management

204 Pages·2007·22.15 MB·English

by  Ranee Thakar

Perineal and Anal Sphincter Trauma
Abdul H. Sultan, Ranee Thakar and Dee E. Fenner (Eds)
Perineal and
Anal Sphincter Trauma
Diagnosis and Clinical Management
Abdul H. Sultan, MB ChB, MD, FRCOG Ranee Thakar, MB BS, MD, MRCOG
Consultant Obstetrician and Gynaecologist Consultant Obstetrician and Urogynaecologist
Mayday University Hospital Mayday University Hospital
Croydon, UK Croydon, UK
and and
Honorary Senior Lecturer Honorary Senior Lecturer
St George’s Medical School St George’s Medical School
University of London University of London
London, UK London, UK
Dee E. Fenner, MD
Furlong Professor of Women’s Health
Director of Gynecology
Department of Obstetrics and Gynecology
University of Michigan
Ann Arbor, MI, USA
British Library Cataloguing in Publication Data
A Catalogue record for this book is available from the British Library
Perineal and anal sphincter trauma
1 . Perineum – Wounds and injuries 2. Perineum – Surgery
3. Anus – Wounds and injuries 4. Anus – Surgery
I. Sultan, Abdul H. II. Thakar, Ranee III. Fenner, Dee E.
617.5'55
ISBN 978-1-85233-926-5 e-ISBN 978-1-84628-503-5
DOI 10.1007/978-1-84628-503-5
Printed on acid-free paper.
© Springer-Verlag London Limited 2009
First Published 2007 in hardcover as ISBN 978-1-85233-926-5
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Foreword
One of the rewards of medical teaching is to see the next generation advance the art and
science of medicine beyond their forebears. We can be justifi ably proud of this anthology
on Perineal and Anal Sphincter Trauma, which owes so much to the endeavours of the
editorial team. In addition to their own contributions, they have recruited a body of
topic authors of international standing. The result is a book of wide breadth and depth,
covering many aspects of disorders of the posterior pelvic compartment, which have
hitherto not been found in one volume. The choice of topics is wide, and the description
and illustrations are clear and concise. They cover both innovative and current practice,
all founded on an evidence basis.
The intended readership is multidisciplinary, going beyond all those involved in
“front line” obstetric care, to reach physicians, surgeons, radiologists and others, who
deal with long term adverse effects of childbirth. This mirrors the professional back-
ground of the authorship. We are confi dent of its broad appeal and wish the book every
success.
Christopher N. Hudson
Emeritus Professor of Obstetrics and Gynaecology
University of London
London, UK
Stuart L. Stanton
Emeritus Professor of Urogynaecology
University of London
London, UK
Bob L. Shull
Professor of Obstetrics and Gynecology
Vice-Chairman, Department of Obstetrics/Gynecology
Chief, Section of Female Pelvic Medicine and Reconstructive Pelvic Surgery
Scott and White Clinic
Texas A&M College of Medicine
Temple, USA
v
Preface
In the last two decades, there has been an increasing interest in obstetric perineal and
anal sphincter trauma. This can be largely attributed to innovations in imaging, as it
was the development of anal endosonography that led to the diagnosis of unrecognised
anal sphincter trauma during childbirth. These sonographic injuries were initially con-
sidered to be occult, but it has now been established that the vast majority are in fact
visible at the time of childbirth but remain undiagnosed. Consequently, attention is now
focused on structured training programmes and hands-on workshops to improve under-
standing of anatomy and repair of perineal and anal sphincter trauma.
However, despite primary repair of anal sphincter injuries, the outcome is not uni-
versally optimal, and research on the ideal management continues. This highlights the
need to identify risk factors in order to minimise the development of perineal and anal
sphincter trauma.
This textbook aims not only to address these issues but also to provide in-depth
information about anatomy and pathophysiology. In addition, other issues such as
female genital mutilation, the management of faecal incontinence and medicolegal
implications are also covered.
In producing this book, we would like to acknowledge our mentors for their teaching
and inspiration, the patients who made us question our practice and the research fellows
who contributed to the research. We would like to thank the multidisclipinary authors
for their timely submission of chapters; last but not least we would like to extend our
appreciation to our families for their perseverance and understanding.
Abdul H. Sultan
Ranee Thakar
Dee E. Fenner
vii
Contents
Foreword by Christopher N. Hudson, Stuart L. Stanton, and Bob L. Shull. . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
1 Anatomy of the Perineum and the Anal Sphincter . . . . . . . . . . . . . . . . . . . . 1
Ranee Thakar and Dee E. Fenner
2 Diagnosis of Perineal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Abdul H. Sultan and Christine Kettle
3 Repair of Episiotomy, First and Second Degree Tears . . . . . . . . . . . . . . . . . . 20
Christine Kettle and Dee E. Fenner
4 Third and Fourth Degree Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Abdul H. Sultan and Ranee Thakar
5 Prevention of Perineal Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Ranee Thakar and Erica Eason
6 Postpartum Problems and the Role of a Perineal Clinic . . . . . . . . . . . . . . . . 65
Ranee Thakar and Abdul H. Sultan
7 Female Genital Mutilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Harry Gordon
8 Pathophysiology of Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Peter J. Lunniss and S. Mark Scott
9 Investigations of Anorectal Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
S. Mark Scott and Peter J. Lunniss
10 Imaging of the Anal Sphincter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Clive Bartram and Abdul H. Sultan
11 Conservative Management of Anal Incontinence . . . . . . . . . . . . . . . . . . . . . . 133
Christine Norton
12A Surgical Management of Anal Incontinence. Part A. Secondary Anal
Sphincter Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Robin K. S. Phillips and Timothy J. Brown
ix
x Contents
12B Surgical Management of Anal Incontinence. Part B. Advanced
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Steven D. Wexner and Susan M. Cera
13 Rectovaginal Fistulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Rebecca G. Rogers and Dee E. Fenner
14 Medicolegal Considerations: The British and U.S. Perspective . . . . . . . . . . 178
Nicholas A. Peacock, Kara Jennings, and Kjell Erik Roxstrom
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Contributors
Clive Bartram, FRCS, FRCP, FRCR Christine Kettle, PhD
Department of Radiology Obstetric Department of Obstetrics and
St Mark’s Hospital Gynaecology
Harrow, UK University Hospital of North Staffordshire and
Staffordshire University
Timothy J. Brown, BSc, MB, BS, MRCS Stoke-on-Trent, UK
Physiology Unit
St Mark’s Hospital Peter J. Lunniss, MS, FRCS
Harrow, UK Centre for Academic Surgery and GI Physiology
Unit
Susan M. Cera, MD
Barts and The London, Queen Mary’s School of
Department of Colorectal Surgery
Medicine and Dentistry
Cleveland Clinic Florida
The Royal London Hospital
Weston, FL, USA
London, UK, and
Academic Department of Medical and Surgical
Erica Eason, MD
Gastroenterology
Division of General Obstetrics and Gynecology
Homerton Hospital
Department of Obstetrics and Gynecology
London, UK
University of Ottawa
The Ottawa Hospital
Christine Norton, PhD, MA, RN
Ottawa, ON, Canada
Burdett Institute of Gastrointestinal Nursing
St Mark’s Hospital
Dee E. Fenner, MD
London, UK, and
Division of Gynecology
Florence Nightingale School of Nursing
Department of Obstetrics and Gynecology
King’s College London
University of Michigan
London, UK
Ann Arbor, MI, USA
Harry Gordon, MBBS, FRCS (Edin), FRCOG Nicholas A. Peacock, MA
Consultant to the African Clinic Hailsham Chambers
Central Middlesex Hospital London London, UK
London, UK
Robin K. S. Phillips, MBBS, FRCS
Kara Jennings, JD Department of Surgery
Legal Services of South Central Michigan St Mark’s Hospital
Ann Arbor, MI, USA Harrow, UK
xi
xii Contributors
Rebecca G. Rogers, MD Abdul H. Sultan, MB ChB, MD, FRCOG
University of New Mexico Health Sciences Department of Obstetrics and Gynaecology
Center Mayday University Hospital
Department of Obstetrics and Gynecology Croydon, UK
Albuquerque, NM, USA
Ranee Thakar, MB BS, MD, MRCOG
Kjell Erik Roxstrom, JD Department of Obstetrics and Gynaecology
AnnArbor, MI, USA Mayday University Hospital
Croydon, UK
S. Mark Scott, PhD
Centre for Academic Surgery and GI Physiology Steven D. Wexner, MD, FACS, FRCS, FRCS (Ed)
Unit Department of Colorectal Surgery
Barts and The London, Queen Mary’s School of Cleveland Clinic Florida
Medicine and Dentistry Weston, FL, USA
The Royal London Hospital
London, UK