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Pelvic Floor CenterMontecchio Emilia Reggio Emilia- Italy
INCONTINENZA ANALE DOPO IL PARTO
P. Talento, M.D.P. Talento, M.D.Colorectal Surgeon
Fecal Incontinence
“Impaired ability to control
gas and stool”
Disabling and distressing condition
Potentially under-estimated condition
Pasquale Talento, www.coloprocto.it
Damage to Internal Anal Sphincter (IAS)
Rectum
Anal canal
Dentate line
Mechanical ContributorsMechanical Contributors
Pasquale Talento, www.coloprocto.it
Damage to External Anal Sphincter (EAS)
Mechanical ContributorsMechanical Contributors
Obstetrical Obstetrical perineal damageperineal damage
Medio-lateral Episiotomy
Posterior Episiotomy (AVOID!!!!!)
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
Damage to Pelvic Floor Nerve Complex
Mechanical ContributorsMechanical Contributors
MaiMai RaramentRaramentee
Qualche Qualche 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 attività Alterazioni attività quotidianequotidiane
00 11 22 33 44
FECAL INCONTINENCE : CCF – Wexner Continence Score
Raramente = meno di un episodio al meseQualche volta = meno di un episodio alla settimana e più
di un episodio al meseSpesso = meno di un episodio al giorno e più di un
episodio alla settimanaSempre = più episodi al giorno
Score = 0-20
Women: Childbirth InjuryWomen: Childbirth Injury Common cause of incontinence for Common 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 sphincter Typically seen as anterior sphincter defect (or scar) from stretching, tearing or defect (or scar) from stretching, tearing or episiotomyepisiotomy
Fecal Incontinence: ClinicalFecal Incontinence: Clinical AssessmentAssessment
• Anal Manometry Anal Manometry • Endoanal Ultrasonography (EAU)Endoanal Ultrasonography (EAU)• DefecographyDefecography• ProctosigmoidoscopyProctosigmoidoscopy • Pudendal Nerve Terminal LatencyPudendal Nerve Terminal Latency
((PNTML)PNTML)
A: tessuto subepitelialeB : sfintere anale internoC: muscolo longitudinale
D : sfintere esterno
Pasquale Talento, www.coloprocto.it Pasquale Talento, www.coloprocto.it
Scansione profonda F
Pasquale Talento, www.coloprocto.it Pasquale Talento, www.coloprocto.it
Scansione media F
Pasquale Talento, www.coloprocto.it Pasquale Talento, www.coloprocto.it
Scansione superficiale F
Defect Score Degree of Defect
1 - 4 Small
5 - 7 Moderate
≥ 8 Large
EAUS – Sphincter LesionsStarck Scoring System
Diagnosis
ScoreDefect 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 sphincterLength of defect None Half or less More than half WholeDepth of defect None Partial Total ---Size of defect None ≤ 90° 91 – 180° > 180°
EAUS – Sphincter LesionsStarck Scoring System
No defect = score 0; Maximal defect = score 16
Diagnosis
Fecal Incontinence PATIENT’S EVALUATION
Definition of symptoms Past Medical and Surgical History Physical examination Anorectal physiology studies
Manometry
AnalUltrasoun
d
Investigation
EMG
History
Physical
Therapeutic Options
Symptoms
PNTML
Pelvic Floor Exercise
SPHINCTER REPAIRSPHINCTER REPAIR
TECHNIQUE: TECHNIQUE: – Direct AppositionDirect Apposition– OverlappingOverlapping
INDICATIONS:INDICATIONS:– Isolated sphincter defect (better in Isolated sphincter defect (better in
absence of pudendal neuropathy)absence of pudendal neuropathy)
Surgical TreatmentSurgical TreatmentSphincteroplasty - Overlapping Muscle RepairSphincteroplasty - Overlapping Muscle Repair
SurgicalSurgical TreatmentTreatmentGraciloplasty & Dynamic GraciloplastyGraciloplasty & Dynamic Graciloplasty
Muscle Harvesting
SNS
SurgicalSurgical TreatmentTreatmentUnstimulated Bilateral GluteoplastyUnstimulated Bilateral Gluteoplasty
.
Sacral neuromodulation
Good patient Selection Criteria
Patologie funzionali pavimento pelvico trattate
Patologie funzionali pavimento pelvico trattate – anno 2013
Stima fabbisogno annuo per trattamento pazienti afferenti al centro pavimento pelvicoN° 20 primo tempoN° 23 stimolatori per nuovi impianti e sostituzioni
PELVIC FLOOR TEAMPELVIC FLOOR TEAM
ER: Montecchio EmiliaSassuolo 8Imola 12Ferrara 3
toscana: Firenze 45Pisa 15Poggibonsi (SI) 4Marche:Ancona 12Pergola 5Veneto:Verona 10Negrar (VR) 10Padova 7Lombardia:Milano 45mantova 5Brescia 8
Confronto dati primo semestre 2013 versus primo semestre 2014
Centro Pavimento PelvicoMontecchio Emilia
Analisi dati proctologia
050
100150200250300350400450500
1° SEM 2013 1° SEM 2014
visitecontrollisintesinmsecomano
Analisi dati uroginecologia
050
100150200250300350400450
1° SEM 2013 1° SEM 2014
visitecontrolliurodinamica
Analisi dati riabilitazione
0
100
200
300
400
500
600
1° SEM 2013 1° SEM 2014
proctourogine
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 different Previous tears (3°°°-4) can suggest different
strategy strategy Incontince score pre and after deliveryIncontince score pre and after delivery Proctological evaluation Proctological evaluation Repair sphincter defect soon (better result)Repair sphincter defect soon (better result) Anal Endosonography helpful for blind anal Anal Endosonography helpful for blind anal
sphincter defect sphincter defect
PELVIC FLOOR TEAMPELVIC FLOOR TEAMMontecchio EmiliaMontecchio Emilia