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Schmidt PC, Fenner DE. Repair of episiotomy and obstetrical perineal lacerations (first-fourth). Am J Obstet Gynecol 2024; 230:S1005-S1013. [PMID: 37427859 DOI: 10.1016/j.ajog.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 07/11/2023]
Abstract
Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal trauma is associated with both short- and long-term morbidity, including persistent pain, dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new mother's ability to care for her newborn. The morbidity experienced after perineal injury is dependent on the type of laceration incurred, the technique and materials used for repair, and the skill and knowledge of the birth attendant. After all vaginal deliveries, a systematic evaluation including visual inspection and vaginal, perineal, and rectal exams is recommended to accurately diagnose perineal lacerations. Optimal management of perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique and materials used for repair, providers experienced in perineal laceration repair, and close follow-up. In this article, we review the prevalence, classification, diagnosis, and evidence supporting different closure methods for first- through fourth-degree perineal lacerations and episiotomies. Recommended surgical techniques and materials for different perineal laceration repairs are provided. Finally, best practices for perioperative and postoperative care after advanced perineal trauma are reviewed.
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Affiliation(s)
- Payton C Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Dee E Fenner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Jiménez-Arbeláez AL, Giraldo-Giron P, Arias-Zapata C, Campo-Campo MN, Echavarria-Restrepo LG, Cuesta-Castro DP. Incidencia, complicaciones inmediatas y tempranas de desgarros perineales graves durante el parto en una institución de referencia de atención obstétrica en Medellín, Colombia. IATREIA 2023. [DOI: 10.17533/udea.iatreia.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Introducción: los desgarros perineales severos (DPS) son complicaciones obstétricas que se presentan durante la atención del parto. Pueden desencadenar fístulas rectales e incontinencia fecal y urinaria, morbilidad a mediano y largo plazo que requiere un diagnóstico, manejo y seguimiento adecuado. Objetivo: determinar la incidencia de los DPS y las complicaciones relacionadas inmediatas −primeras 48 horas− y tempranas −primeros tres meses− posteriores a la atención del parto.Metodología: se hizo un estudio de cohorte descriptiva de pacientes con DPS durante la atención del parto en un centro de referencia de atención obstétrica en Medellín, Colombia, entre enero del 2015 y diciembre del 2017. Se revisaron las historias clínicas y se registraron los datos clínicos y las complicaciones inmediatas y tempranas en las que asistieron a cita de control de piso pélvico. Se presentan medidas descriptivas de resumen.Resultados: se atendieron 14.247 partos vaginales. La incidencia de DPS fue del 1,6 % (233/14.247), 1,3 % (184/14.267) de grado III y 0,3 % (49/14.247) de grado IV. El 66,5 % (155/233) tuvo parto vértice instrumentado, 81,9 % (191/233) episiotomía; la mediana del periodo expulsivo fue de 19 minutos (RIQ 12-35), y el 3 % (7/233) presentó distocia de hombros. Las complicaciones inmediatas en las pacientes con DPS fueron: 0,85 % (2/233) dehiscencia de sutura e infección de la herida, 0,85 % (2/233) solo dehiscencia y 0,42 % (1/233) solo infección de la herida. El 18,4 % (43/233) asistieron al control uroginecológico al tercer mes. Entre ellas, el 38,2 % (13/43) tuvo al menos una complicación, principalmente incontinencia fecal y de flatos, 16,3 % (7/43) y 13,9 % (6/43) respectivamente. Conclusiones: la incidencia de DPS y de complicaciones del posparto inmediato en la institución fueron poco frecuentes. Se deben mejorar las estrategias de seguimiento posparto mediante protocolos institucionales, con el fin de identificar y brindar un manejo oportuno de las complicaciones a mediano plazo.
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Hubka P, Dvorak J, Lincova M, Masata J, Martan A, Svabik K. When to assess residual anal sphincter defect after OASI by ultrasound. Eur J Obstet Gynecol Reprod Biol 2022; 277:8-11. [PMID: 35964398 DOI: 10.1016/j.ejogrb.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months. STUDY DESIGN This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation. RESULTS Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination. CONCLUSIONS In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.
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Affiliation(s)
- Petr Hubka
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and Na Bulovce Faculty Hospital, Charles University, Prague, Czech Republic.
| | - Jan Dvorak
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Marcela Lincova
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and Na Bulovce Faculty Hospital, Charles University, Prague, Czech Republic.
| | - Jaromir Masata
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Alois Martan
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Kamil Svabik
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
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Bilateral Inferiorly Based Labia Majora Flaps: A Simple Technique for Post Episiotomy Dehiscence Coverage. World J Plast Surg 2022; 11:78-83. [PMID: 36694685 PMCID: PMC9840771 DOI: 10.52547/wjps.11.3.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/06/2022] [Indexed: 12/23/2022] Open
Abstract
Episiotomy dehiscence because of infection is a cause of major physical, psychological and social problems. Management depends on the degree of injury. The loco-regional flap can be considered in recurrent dehiscence with loss of tissue. We report a case of a 26-year-old female who presented with a post episiotomy wound in the perineal region extending from the posterior fourchette to the anal opening. She gave the history of resuturing of dehiscence twice but the result was the same. On examination, there was a loss of skin and subcutaneous tissue between vaginal and anal opening with pouting of the anal and vaginal mucosa. Per rectal examination, the anal tone was normal. Her wound was covered with bilateral inferiorly based labia majora flaps with a good outcome. So, an inferiorly based labia majora flap can be a useful option in coverage of recurrent perineal dehiscence.
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New Findings at the Internal Anal Sphincter on Cadaveric Dissection and Review of Sphincter-Related Surgery in a Newer Prospective. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03537-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Wang X, Liu YN, Sun D, Chen S, Huang BL, Tai JD. Modified Perineal Reconstruction Combined with Anal Sphincter Repair for Obstetric Anal Sphincter Injuries. Ther Clin Risk Manag 2022; 18:739-744. [PMID: 35923602 PMCID: PMC9342695 DOI: 10.2147/tcrm.s346899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to investigate the clinical effectiveness of modified perineal reconstruction combined with anal sphincter repair in the treatment of obstetric anal sphincter injuries (OASIS). Methods Twenty consecutive patients with an OASI who underwent modified perineal reconstruction combined with anal sphincter repair in the Department of Colorectal and Anal Surgery of the First Hospital of Jilin University from October 2015 to September 2017 were retrospectively enrolled in this study. Anal function was evaluated using the Williams grade, the Wexner score, anorectal manometry, and transrectal ultrasound. Results Differences in both the Williams grade and the Wexner score prior to operation and following surgery indicated that anal function had improved, and these differences were statistically significant (P < 0.05). These indices also showed further improvement six months after surgery as compared with values at one month, and again, these differences were statistically significant (P < 0.05). In addition, anorectal manometry at six months following surgery showed statistically significant differences in the maximum anal resting pressure, maximum anal systolic pressure, and anal defecation pressure as compared with values prior to operation (P < 0.05). Postoperative endorectal ultrasound revealed that the anal sphincter presented with close imbricated overlapping. Conclusion Modified perineal reconstruction combined with anal sphincter repair in the treatment of female perineal defect is associated with a good clinical outcome, strengthening anal function, and reconstructing the perineum, and is a possible method for clinical treatment.
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Affiliation(s)
- Xu Wang
- Department of Colorectal Surgery, The First Hospital of Jilin University, Changchun, 130000, People’s Republic of China
| | - Yi-Nan Liu
- Department of Colorectal Surgery, The First Hospital of Jilin University, Changchun, 130000, People’s Republic of China
| | - Di Sun
- Department of Colorectal Surgery, The First Hospital of Jilin University, Changchun, 130000, People’s Republic of China
| | - Si Chen
- Department of Colorectal Surgery, The First Hospital of Jilin University, Changchun, 130000, People’s Republic of China
| | - Bao-Lei Huang
- Department of Colorectal Surgery, The First Hospital of Jilin University, Changchun, 130000, People’s Republic of China
| | - Jian-Dong Tai
- Department of Colorectal Surgery, The First Hospital of Jilin University, Changchun, 130000, People’s Republic of China
- Correspondence: Jian-Dong Tai, Department of Colorectal Surgery, the First Hospital of Jilin University, No. 1 of Xinmin Street, Chaoyang District, Changchun, 130000, People’s Republic of China, Tel +86 431-88782291, Fax +86 431-85612352, Email
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Balaphas A, Meyer J, Meier RPH, Liot E, Buchs NC, Roche B, Toso C, Bühler LH, Gonelle-Gispert C, Ris F. Cell Therapy for Anal Sphincter Incontinence: Where Do We Stand? Cells 2021; 10:2086. [PMID: 34440855 PMCID: PMC8394955 DOI: 10.3390/cells10082086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/12/2022] Open
Abstract
Anal sphincter incontinence is a chronic disease, which dramatically impairs quality of life and induces high costs for the society. Surgery, considered as the best curative option, shows a disappointing success rate. Stem/progenitor cell therapy is pledging, for anal sphincter incontinence, a substitute to surgery with higher efficacy. However, the published literature is disparate. Our aim was to perform a review on the development of cell therapy for anal sphincter incontinence with critical analyses of its pitfalls. Animal models for anal sphincter incontinence were varied and tried to reproduce distinct clinical situations (acute injury or healed injury with or without surgical reconstruction) but were limited by anatomical considerations. Cell preparations used for treatment, originated, in order of frequency, from skeletal muscle, bone marrow or fat tissue. The characterization of these preparations was often incomplete and stemness not always addressed. Despite a lack of understanding of sphincter healing processes and the exact mechanism of action of cell preparations, this treatment was evaluated in 83 incontinent patients, reporting encouraging results. However, further development is necessary to establish the correct indications, to determine the most-suited cell type, to standardize the cell preparation method and to validate the route and number of cell delivery.
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Affiliation(s)
- Alexandre Balaphas
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
- Department of Surgery, Geneva Medical School, University of Geneva, 1205 Geneva, Switzerland
| | - Jeremy Meyer
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Raphael P. H. Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Emilie Liot
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Nicolas C. Buchs
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Bruno Roche
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Christian Toso
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
| | - Leo H. Bühler
- Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland; (L.H.B.); (C.G.-G.)
| | - Carmen Gonelle-Gispert
- Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland; (L.H.B.); (C.G.-G.)
| | - Frédéric Ris
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland; (J.M.); (E.L.); (N.C.B.); (B.R.); (C.T.); (F.R.)
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Martínez-Vazquez S, Rodríguez-Almagro J, Hernández-Martínez A, Delgado-Rodríguez M, Martínez-Galiano JM. Long-Term High Risk of Postpartum Post-Traumatic Stress Disorder (PTSD) and Associated Factors. J Clin Med 2021; 10:488. [PMID: 33573115 PMCID: PMC7866544 DOI: 10.3390/jcm10030488] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/20/2022] Open
Abstract
Postpartum post-traumatic stress disorder (PTSD) is not a specific process but can last for months and may manifest itself during any subsequent pregnancies or even become chronic. This study aimed to determine the factors associated with long-term PTSD symptoms one year after delivery. A cross-sectional study was conducted on 1301 Spanish puerperal women. Data were collected on sociodemographic, obstetric, and neonatal variables. The Perinatal Post-Traumatic Stress Disorder Questionnaire (PPQ) was administered online through midwives' associations across Spain. Crude odds ratio (OR) and adjusted odds ratio (aOR) and their 95% confidence intervals were calculated. A PPQ score ≥ 19 (high-risk) was recorded for 13.1% (171) of the participants. Identified risk factors were not respecting a birth plan (aOR = 1.89 (95% CI 1.21-2.94)), formula-feeding of the baby at discharge (aOR = 2.50 (95% CI 1.20-5.17)), postpartum surgical intervention (aOR = 2.23 (95% CI 1.02-4.85)), hospital readmission (aOR = 3.45 (95% CI 1.21-9.84)), as well as verbal obstetric violence (aOR = 3.73 (95% CI 2.52-5.53)) and psycho-affective obstetric violence (aOR = 3.98 (95% CI 2.48-6.39)). During childbirth, some clinical practices, such as formula-feeding of the newborn at discharge or types of obstetric violence towards the mother, were associated with a higher risk of PTSD symptoms one year after delivery.
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Affiliation(s)
- Sergio Martínez-Vazquez
- Department of Nursing, Faculty of Health Sciences, University of Jaen, 23071 Jaen, Spain; (S.M.-V.); (J.M.M.-G.)
| | - Julián Rodríguez-Almagro
- Department of Nursing, Physiotherapy and Occupational Therapy, Ciudad Real Faculty of Nursing, University of Castilla-La Mancha, 13071 Ciudad Real, Spain;
| | - Antonio Hernández-Martínez
- Department of Nursing, Physiotherapy and Occupational Therapy, Ciudad Real Faculty of Nursing, University of Castilla-La Mancha, 13071 Ciudad Real, Spain;
| | - Miguel Delgado-Rodríguez
- Department of Health Science, University of Jaen, 23071 Jaen, Spain;
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
| | - Juan Miguel Martínez-Galiano
- Department of Nursing, Faculty of Health Sciences, University of Jaen, 23071 Jaen, Spain; (S.M.-V.); (J.M.M.-G.)
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
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Abstract
Rectovaginal fistula (RVF), defined as any abnormal connection between the rectum and the vagina, is a complex and debilitating condition. RVF can occur for a variety of reasons, but frequently develops following obstetric injury. Patients with suspected RVF require thorough evaluation, including history and physical examination, imaging, and objective evaluation of the anal sphincter complex. Prior to attempting repair, sepsis must be controlled and the tract allowed to mature over a period of 3 to 6 months. All repair techniques involve reestablishing a healthy, well-vascularized rectovaginal septum, either through reconstruction with local tissue or tissue transfer via a pedicled flap. The selection of a specific repair technique is determined by the level of the fistula tract and the status of the anal sphincter. Despite best efforts, recurrence is common and should be discussed with patients prior to repair. As the ultimate goal of RVF repair is to minimize symptoms and maximize quality of life, patients should help to direct their own care based on the risks and benefits of available treatment options.
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Affiliation(s)
- Aaron J. Dawes
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Hickman LC, Propst K. Accurate diagnosis and repair of obstetric anal sphincter injuries: why and how. Am J Obstet Gynecol 2020; 222:580.e1-580.e5. [PMID: 32142829 DOI: 10.1016/j.ajog.2020.02.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/11/2020] [Accepted: 02/22/2020] [Indexed: 11/30/2022]
Abstract
Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.
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Affiliation(s)
- Lisa C Hickman
- Urogynecology and Reconstructive Pelvic Surgery, OB/Gyn & Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Katie Propst
- Urogynecology and Reconstructive Pelvic Surgery, OB/Gyn & Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Kim M, Reibetanz J. [Surgical reconstruction of traumatic sphincter muscle defects]. Chirurg 2020; 91:870-877. [PMID: 32474615 DOI: 10.1007/s00104-020-01206-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Traumatic anal sphincter muscle defects often occur after childbirth and surgery and can lead to fecal incontinence that requires further treatment. OBJECTIVE The aim of this article is to illustrate the etiology of traumatic sphincter muscle defects, the treatment options of subsequent fecal incontinence and their evaluation on the basis of current studies. MATERIAL AND METHODS Selected studies are presented. RESULTS Fecal incontinence presenting with a traumatic sphincter muscle defect is often due to multiple factors especially in the aged and makes the use of extended diagnostic tools necessary; however, the subjective complaints do not always correlate with morphological or functional diagnostic findings. Besides reconstructive procedures, such as sphincteroplasty and graciloplasty, sphincter augmentation techniques and sacral nerve stimulation can also be applied in traumatic sphincter muscle defects that are often associated with a loss of efficacy in the long term or a high rate of adverse events. CONCLUSION The fecal incontinence associated with traumatic sphincter insufficiency represents a diagnostic and therapeutic challenge due to the multifactorial origin. It is not uncommon that patients have to undergo several surgical and conservative interventions.
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Affiliation(s)
- M Kim
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
| | - J Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
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