Perineal and Anal Sphincter Trauma

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 Consultant Obstetrician and Gynaecologist Mayday University Hospital Croydon, UK and Honorary Senior Lecturer St George s Medical School University of London Ranee Thakar, MB BS, MD, MRCOG Consultant Obstetrician and Urogynaecologist Mayday University Hospital Croydon, UK and Honorary Senior Lecturer St George s Medical School University of London 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 978-1-84800-996-7 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 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Springer Science+Business Media springer.com

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 justifiably 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 background of the authorship. We are confident of its broad appeal and wish the book every success. Christopher N. Hudson Emeritus Professor of Obstetrics and Gynaecology University of London Stuart L. Stanton Emeritus Professor of Urogynaecology University of London 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 considered 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 understanding of anatomy and repair of perineal and anal sphincter trauma. However, despite primary repair of anal sphincter injuries, the outcome is not universally 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........ Preface................................................................ v 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 Department of Radiology St Mark s Hospital Harrow, UK Timothy J. Brown, BSc, MB, BS, MRCS Physiology Unit St Mark s Hospital Harrow, UK Susan M. Cera, MD Department of Colorectal Surgery Cleveland Clinic Florida Weston, FL, USA Erica Eason, MD Division of General Obstetrics and Gynecology Department of Obstetrics and Gynecology University of Ottawa The Ottawa Hospital Ottawa, ON, Canada Dee E. Fenner, MD Division of Gynecology Department of Obstetrics and Gynecology University of Michigan Ann Arbor, MI, USA Harry Gordon, MBBS, FRCS (Edin), FRCOG Consultant to the African Clinic Central Middlesex Hospital London Kara Jennings, JD Legal Services of South Central Michigan Ann Arbor, MI, USA Christine Kettle, PhD Obstetric Department of Obstetrics and Gynaecology University Hospital of North Staffordshire and Staffordshire University Stoke-on-Trent, UK Peter J. Lunniss, MS, FRCS Centre for Academic Surgery and GI Physiology Unit Barts and The London, Queen Mary s School of Medicine and Dentistry The Royal London Hospital, and Academic Department of Medical and Surgical Gastroenterology Homerton Hospital Christine Norton, PhD, MA, RN Burdett Institute of Gastrointestinal Nursing St Mark s Hospital, and Florence Nightingale School of Nursing King s College London Nicholas A. Peacock, MA Hailsham Chambers Robin K. S. Phillips, MBBS, FRCS Department of Surgery St Mark s Hospital Harrow, UK xi

xii Rebecca G. Rogers, MD University of New Mexico Health Sciences Center Department of Obstetrics and Gynecology Albuquerque, NM, USA Kjell Erik Roxstrom, JD AnnArbor, MI, USA S. Mark Scott, PhD Centre for Academic Surgery and GI Physiology Unit Barts and The London, Queen Mary s School of Medicine and Dentistry The Royal London Hospital Contributors Abdul H. Sultan, MB ChB, MD, FRCOG Department of Obstetrics and Gynaecology Mayday University Hospital Croydon, UK Ranee Thakar, MB BS, MD, MRCOG Department of Obstetrics and Gynaecology Mayday University Hospital Croydon, UK Steven D. Wexner, MD, FACS, FRCS, FRCS (Ed) Department of Colorectal Surgery Cleveland Clinic Florida Weston, FL, USA