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