Anatomy of anal sphincter and perineal body

Hi...this presentation was created for better understanding of anatomy of perineal muscles and perineal body...to aid better understanding of episiotomies.

1. ANATOMY OF ANAL SPHINCTER AND PERINEAL BODY & DEGREES OF PERINEAL REPAIR DR.JUHI LOYA(RATHI)

2. ANATOMY OF PERINEUM

3. PERINEUM:

4. ANTERIOR COMPARTMENT- 1) SUPERFICIAL COMPARTMENT

5. 1) SUPERFICIAL COMPARTMENT ♦C losed compartment  infection or bleeding within it remains contained

6. ATERIOR TRIANGLE:DEEP COMPARTMENT

7. INTERIOR OF ANAL CANAL Divided by pectineal line & Hilton’s line into 3 areas Upper (15 mm) Intermediate (15 mm) Lower (8 mm) (Anal verge) Pectinate / dentate line Hilton’s line

8. STRUCTURE OF ANAL CANAL- UPPER HALF(2/3) Mucous membrane of upper half of anal canal is derived from hindgut entoderm . It is lined by columnar epithelium It is thrown into vertical folds called anal columns, which are joined together at their lower end by semilunar folds called anal valves (remains of proctodeal membrane). Nerve supply is derived from autonomic hypogastric plexus. It is sensitive to stretch only. LOWER HALF(1/3) Mucous membrane of lower half is derived from ectoderm of anal pit. It is lined by stratified squamous epithelium. There are no anal columns The nerve supply is from somatic inferior rectal nerve .; it is thus sensitive to pain, temperature, touch and pressure.

9. ANAL SPHINCTERS: 1) External anal sphincter:(8-10cm) Striated muscle in a state of tonic contraction. Innervation by pudendal nerve. Upto 30% resting pressure. Most of the squeeze pressure Contraction mintained for <2 mins Reflex contraction with sudden increase in intra-abdominal pressure. Relaxes during straining Damage results in fecal incontinence.

10. External anal sphincter 1) Subcutaneous part 2) Superficial part 3) Deep part

11. 2) Internal anal sphincter:(2.5-4cm) Smooth muscle Autonomic control Contributes upto 70% of resting pressure. Sympathetic -superior rectal and hypogastric plexus Parasympathetic fibres Damage results in passive soiling and flatus incontinence.

12. PERINEAL BODY The median raphe of levator ani between the anus and vagina, is reinforced by the central tendon of the perineum. IMPORTANCE:Support perineal organs

13. PERINEAL TEARS

14. Perineal tears: Lacerations of perineum are the result of overstreching or too rapid streching of the tissues, especially if they are poorly extensile and rigid. Perineal injuries are more common in primigravida than multigravida.

15. CAUSES: 1)Obstetrical causes 2)Non Obstetrical causes

16. Obstetric Causes : Malpresentations such as breech Contracted pelvic outlet Prolonged labour operative vaginal deliveries( forceps or vaccum) Macrosomic babies Occipitoposterior delivery Precipitate labour Epidural analgesia Induction of labour

17. RIGID PERINEUM: Elderly primigravida Vulval oedema Previous perineal tear Scarred perineum due to previous surgeries. Non-obstetric cause s: R ape, M olestation F all A ccidental injuries like RTA, bull horn injuries etc.

18. RCOG CLASSIFICATION OF PERINEAL TEARS:2007 First degree : Injury to perineal skin only. Second degree : Injury to perineum involving perineal muscles but not involving the anal sphincter. Third degree : Injury to perineum involving the anal sphincter complex: 3a: Less than 50% of EAS thickness torn. 3b: More than 50% of EAS thickness torn. 3c: Both EAS and IAS torn. Fourth degree Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium.

19. FIRST DEGREE PERINEAL TEAR: Involve the fourchette , perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle . These included periurethral lacerations

20. SECOND DEGREE PERINEAL TEAR: Involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter . These tears usually extend upward on one or both sides of the vagina, forming an irregular triangular injury .

21. THIRD DEGREE PERINEAL TEAR: Extend farther to involve the anal sphincter

22. FOURTH DEGREE PERINEAL TEAR: Extends through the rectum's mucosa to expose its lumen .

23. PERINEAL TEARS: Severe perineal trauma incidence was 3% (338/10408), primiparas : 5.4% (239/4405) multiparas 1.7% (99/5990) O ccipito posterior (OP) delivery (OR 3.35, 95% CI 1.75-6.41) and prolonged second stage (OR 1.98, 95% CI 1.46-2.68), gestational diabetes (OR 1.78, 95% CI 1.04-3.03) birth weight >4000g (OR 1.86, 95% CI 1.10-3.15). -Goldbar and associates (1993) found that 21 of 390 or 5.4% with fourth degree laceration experienced significant morbidity. -Stock and coworkers (2013) 7% of 909 high order lacerations had complications Risk factors for severe perineal trauma during vaginal childbirth: a Western Australian retrospective cohort study.Hauck YL1, Lewis L2, Nathan EA3, White C4, Doherty DA5. 2015

24. EPISIOTOMY: A surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues.

25. PURPOSE : ♦Straight surgical incision ♦Postoperative pain is less and healing improved ♦It prevented pelvic floor complications that is, vaginal wall support defects and incontinence

26. TIMING OF EPISIOTOMY: AT the time of crowning. Performed too early, bleeding from the episiotomy may be considerable . Performed too late, lacerations will not be prevented .

27. JUST AT THE TIME OF CROWNING....

28. TYPES OF EPISIOTOMY: Median episiotomy J shaped Mediolateral episiotomy Right (RML) Left (LML )

29. As stated in Williams, “The long held belief's that postoperative pain is less and healing improved with an episiotomy compared with a tear,however,appeared to be incorrect”, Larsson 1991

30. “ Another commonly cited but unproven belief was that it prevented pelvic floor disorders. Number of observational studies showed that routine episiotomies is assosiated with increase chances of anal sphincter sand rectal tears.” Angioli2000,Nager 2001,Rodriguez 2008

31. “ Carroli and Migini 2009 reviewed the Cochrane Pregnancy and child birth Group trial Registry. There were lower rates of posterior perineal trauma,surgical repair and healing complication in women managed with restrictive use of episiotomy.”

32. Alperin and associates reported that “episiotomies performed for the first delivery conferred a five fold risk of second degree or higher order laceration with the second delivery”.

33. Americal College of Obstetrics & gynaecology 2013 has concluded “Restricted use of episiotomy is preferred to routine use.”

34. STUDY COMPARING EPISIOTOMY VS PERINEAL TEAR: ♦ Episiotomy is equivalent to second degree tear and studies indicate that episiotomy may decrease the incidence of anterior tears, but not posterior tears, rather may be associated with increased risk of 3rd & 4thdegree perineal tears (7, 8). ♦ In a study conducted by F.C.R. Williams et al, it was found that the rate of 3rd degree tear was 5 times higher in women with episiotomy as compared to tear . Episiotomy Vs Perineal Tear –A Comparative Study Of Maternal and Fetal OutcomeDr Rumi Bhattacharjee, M.D. Obst& Gynae, Assistant Prof.,Dept. of Obst.&Gynae,Pramukh Swami Med 2013

35. Episiotomy only protects against anterior perineal tears, but does not provide protection against anal sphincter muscle tears, pelvic muscle damage or incontinence in the mother, nor does it prevent neonatal complications. Women who undergo episiotomy have more blood loss, delayed wound healing and more pain after childbirth. CONCLUSION:

36. EPISIOTOMY:(RCOG) LOE 1a : Systemic Review of 6 RCTs ♦Restrictive use results in: -Less posterior trauma -Less suturing -Fewer healing complications -But more anterior trauma ♦No differences in severity of trauma or pain GOR A: Use episiotomy sparingly.

37. REPAIR...

38. PERINEAL TEARS (1ST & 2nd DEGREE)& EPISIOTOMY (INDUCED SECOND DEGREE PERINEAL )REPAIR: Usually done after delivery of the placenta H emostasis and anatomical restoration without excessive suturing

39. FIRST AND SECOND DEGREE PERINEAL TEARS PREREQUISITS: Proper lighting Good analgesia Good assistance Good exposureand proper examination Identifying missing apex on lacerations

40. Adequate analgesia Prefer blunt needle Chromic catgut 2-0 Rapidly absorbed synthetic sutures Slowly absorbed sutures may require removal due to pain or dyspareunia Continuous or interrupted suture

41. TEQNIQUE: All tears that are bleeding should be identified and ligated separately. The stitching starts from the apex of vaginal mucosa using polyglactin stitch with continuous or interrupted sutures. The muscles are stitched using the same stitch taking full thickness of the muscle and achieving hemostasis. The skin is stitched with interrupted sutures.

42. Study comparing continuous VS interrupted skin suture: Results: The study revealed the pain at 48 hours postpartum and day 10 was more in interrupted group ( 83% versus 37% and 57% versus 28% respectively) which was found to be statisitically significant.(p = 0.0005) Conclusion: The continuous suturing techniques for perineal closure, compared to interrupted methods, are associated with less pain at 48 hours and 10th day postpartum. Outcome of Continuous Versus Interrupted Method of Episiotomy Stitching RUBINA IQBAL, AYESHA INTSAR, SAMINA KHURSHEED, SHEHNEELA ZAFAR

43. THIRD AND FOURTH DEGREE REPAIR: OBSTETRICAL ANAL SPHINCTER INJURIES(OASIS) .Prevalence -Primigravida 2.8% Multigravida 0.4%

44. Symptomatology: Immediate: Perineal Pain Perineal hematoma Urinary retention due to painful perineum Urinary incontinence Anorectal dysfunctions like fecal incontinence Bleeding Traumatic PPH - hemorrhagic shock. Delayed: Infected perineum- perineal abscess Uterovaginal prolapse Urinary incontinence (stress and urinary fistula) Fecal incontinence ( rectovaginal fistula) Dyspareunia Feeling of slack vagina during coitus

45. PREVENTION Timely episiotom y primigravida operative delivery ( vacuum and forceps ) B reech delivery B reech extraction done after IPV rigid perineum Proper support of perineum at the time of crowning and expulsion of head.

46. 2. PREREQUISITS: ¥ W ritten consent ¥ General anesthesia/spinal anesthesia/epidural analgesia ¥ Operation theatre ¥ Trained obstetrician ¥ Good light,Good assisstance ¥ Proper instrument and sutures

47. Repair the tear in the operating room. A naesthesia a)General b)Local Examine A ssistant to massage the uterus.

48. REPAIR:(RCOG) I mmediately ( within 24 hours ) If >24 hours then repair at 6 weeks. As accurate an approximation as possible of all the tissues should be secured and no dead spaces are left.

49. ON EXAMINATION Good light Operation theatre Anesthesia Stepwise manner Quantify

50. Equipment for Repair: Sterile drapes & gloves Irrigation solution Needle holder Metzenbaum scissors Suture scissors Forceps with teeth Allis forceps

51. 9. 10ml syringe with 22 guage needle 10. 1% lidocaine 11.3-0 polyglactin 901 (Vicryl) suture on CT-1 needle Vaginal mucosa for perineal muscle skin sutures 14. 2-0 polydiaxone sulfate (PDS) suture on CT-1 needle. (external sphincter sutures)

52. EXTERNAL ANAL SPHINCTER ♦ Appears band of skeletal muscle with fibrinous capsule. ♦Traditionally - end to end technique ♦Allis clamps placed on each end of external anal sphincter. ♦Use 2 polydiaxanone (PDS),a delayed absorbable monofilament sutures. ♦End to end repairs have poorer anatomic and functional outcomes than overlapping technique.

53. INTERNAL ANAL SPHINCTERS: Identified as a glistening,white,fibrous Between the rectal mucosa & the external anal spincter. Retracted laterally, & placement of Allis clamps on the muscle ends Closed with continous 2-0 polyglactin 910 sutures.

54. Change to sterile gloves antiseptic solution R epair T he rectum - interrupted 3-0 or 4-0 sutures 0.5 cm apart to bring together the mucosa. Place the suture through the muscularis ( not all the way through the mucosa).

55. Cover the muscularis lay er- the fascial layer with interrupted sutures. antiseptic solution Repair the skin - interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening .

56. ♦If the sphincter is torn grasp Repair the sphincter with interrupted stitches of 2-0 suture . ♦ antiseptic solution ♦Examine the anus with a gloved finger to ensure the correct repair of the rectum and sphincter.

57. 1) END TO END teqnique

58. 2) Overlapping technique

59. As per RCOG green top guidelines “Repair of external anal sphincter,either an overlapping or end to end method can be used with equivalent outcome however the IAS can be identified,it is advisable to repair separately by interrupted sutures.”

60. To Summarize: 3.Torn anal epithelium repaired with interrupted vicryl withknot tied towards the anal mucosa. 4. Internal anal sphincter interrupted polydiaxone sutures(PDS) by end to end approximation. 5.External anal sphincter <50% End to end repair 3-0,2-0 vicryl >50% Muscle should be pulled across to overlap before suturing it. with 3-o PDS in double breast fashion with enabling overlapping of sutures if not then end to end anastomosis.

61. CHOICE OF SUTURE MATERIAL: When repair of EAS muscle is being performed either monofilament sutures such as polydiaxonone or modern braided sutures such as vicryl used. When repair of IASmuscle is being performed,PDS 3-0 and 2-0 vicryl causes less irritation and discomfort. When obstetrical anal sphincters repair are being performed,burying of surgical knots beneath the superficial perineal muscles is recommended to prevent knot migration to skin. A C

62. POSTOPERATIVE MANAGEMENT: The use of broad spectrum antibiotics is recommended following repair of OASIS to reduce the risk of postoperative infection and wound dehiscence. postoperative laxatives Bulking agents should not be give with laxatives Physiotherapy and pelvic floor exercises 6-12 weeks after repair. Follow up If patient is experiencing incontinence or pain on follow up refer to a special gynaecologists or colorectal surgeon and anorectal manometryshould be considered.

63. PROGNOSIS: Women should be advised that 60-80% of women are asymptomatic 12 months following delivery and EAS repair.

64. Sequelae of obstetric perineal laceration: Chronic perineal pain Dyspareunia Urinary & fecal incontinence

65. MANAGEMENT OF NEGLECTED CASES: A perineal tear is always contaminated with faecal material. If closure is delayed more than 12 hours, infection is inevitable. Delayed primary closure is indicated in such cases. 1) For first and second degree tears, leave the wound open 2) For third and fourth degree tears, close the rectal mucosa with some supporting tissue and approximate the fascia of the anal sphincter with 2 or 3 sutures; close the muscle and vaginal mucosa and the perineal skin 6 days later.

66. Complications if left untreated: Infection Hemorrhagic Shock Cosmetic disadvantage 3 rd and 4 th degree tears if left untreated may lead to fecal incontinence. Pain out of proportion can be sign of vulvar, paravaginal, ischiorectal hematoma or ce llulitis.

67. Infra levator hematoma Needs urgent surgical intervention.

68. CLASSIFICATION OF EVIDENCE LEVELS:RCOG Ia obtained from meta-analysis of RCT Ib obtained from atleast 1 RCT IIa obtained from atleast one well designed controlled study without randomization IIb obtained from atleast one or other type well defined quasi experimental study . III well designed non experimental descriptive study (correlation,comparative,case studies) IV obtained from expert committee report or clinical experinence.

69. GRADES OF RECOMMENDATION:RCOG A Evidence level Ia and Ib B Evidence level IIa IIb and III C Evidence level IV GOOD PRACTICE POINT: RECOMMENDED BEST PRACTICE BASED ON THE CLINICAL EXPERIENCE OF THE GUIDELINE.

70. STUDIES

71. Second Stage Method of Pushing: LOE 4 :Prospective cohort Compared women who were coached to push versus women who were given no instructions. Sutured trauma-63% vs 39% in coached compared to not coached groups. GOR D:Insufficient evidence to recommend style of pushing for prevention of perineal trauma.

72. Operative Vaginal Delivery LOE1:Systematic Review & RCTs Use of Vacum Extraction compared to forceps results in: -Less maternal trauma -Less pain at 24 hours -More cephalohematomas & retinal hemorrhage GOR A : Use of VE over forceps,whenever possible,but be aware of possible neonatal harms.

73. EPIDURAL ANESTHESIA LOE 2a:Use of epidural anesthesia also increases perineal trauma,likely increasing fetal malposition and operative vaginal deliveries,based on systemic review of cohort studies (Lieberman,2002,6 studies) Epidural analgesia was found to be protective (Jango 2014)

74. NON-SUTURING OF PERINEAL TRAUMA: LOE 2b : 2 small RCT (Lundquist 2000,Flemming 2013) -Women who did not have standard suturing of trauma were likely to report at 2-3 days postpartum. -”Burning sensation” -”Soreness” -Better wound healing at 6 weeks in sutured group,reported by Fleming GOR b:There some evidence that non suturing perineal trauma can be harmful.Patients should have the benifitof suturing until there are large enough trials to definitively exclude such harm.

75. NSAIDs suppositories for Perineal pain after trauma: LOE Ib Women in the NSAID group (diclofenac and indomethacin used in RCT) -Experienced less pain 24 hours after birth -Required less supplemental analgesia in first 24 hours. GOR A :there is fair evidence to adopt the use of NSAID suppositories to reduce postpartum. Indomethacin 50mg availablein US A single dose of 200mg PR used in the RCT.

76. DELIVERY POSITION: K neeling versus sitting position has no effect on increase in chances of OASIS while standing might increase the risk of OASIS . A retrospective analysis of 814 women (650 standing, 264 sitting, any parity) in which women standing for their delivery had a nearly 7-fold increase in OASIS (2.5% vs 38%). A 2012 RCT comparing traditional method of delivery versus “alternate” method of delivery “Gasquet” position – with upper hip flexed, foot on stirrup higher than knee) showed no difference in rate of OAS . Gareberg B, Magnusson B, Sultan B, Wennerholm U-B, Wennergren M, Hagberg H. Birth in standing position: a high frequency of third degree tears. Acta Obstet Gynecol Scand 1994;Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair ,SOGC clinical practical guideline Dec 2015

77. PERINEAL MASSAGE IN LABOUR: LOE Ib ● Lower risk oF third degree tear in massage group ● No difference in 1st and 2nd degree tear ● 2nd stage 10 mins less in massage group. GOR A:Perineal massage during labour,may be helpful,especially for primiparous women.

78. FUTURE DELIVERIES:RCOG All women should be counselled for risk of developing anal incontinence or worsening of symptoms with subsequent vaginal delivery. Theres is no evidence to support prophylactic episiotomy in subsequent pregnancies. All women who sustained an obstetrical anal injuries and who are symptomatic and have abnormal endoanal manometry should have option of elective cesarean birth.

79. CHRONIC PERINEAL INJURY WHEN TO REPAIR: after 6 weeks of delivery

80. REPAIR OF CHRONIC COMPLETE PERINEAL TEAR Layered method of repair. Warren flap procedure Noble-Mangert-Fish operation If anorectal mucosa is intact & injury is largely limited to sphincters and perineal body complex,repair consists of anal sphincteroplasty and perrineorrhaphy.

81. 1.LAYERED METHOD OF REPAIR:

82. anorectal mucosa closed using a continuous or interrupted suture of 3-0 delayed absorbable material. A submucosally placed suture is ideal. internal anal sphincter it also serves to imbricate and isolate the mucosal layer and take tension off it helping it heal and seal against infection.

83. External anal sphincteroplasty is done O verlapping approach The ends are widely mobilized with the scar tissue left on, taking care not to dissect beyond the 3 and 9-o’clock position bacause pudendal innervation enters laterally.

84. Restoration of narrower gental hiatus by bringing the puborectalis muscles closer together. delayed- absorbable sutures It is extended till midportion of vagina to produce excellent anatomical support to rectum and anal canal. the superficial transverse perineal muscles and bulbocavernosus. redundant vaginal mucosa is excised and remaining mucosa is approximated in midline with a continuous 2-0 or 3-0 delayed absorbable suture. It followed by subcuticular closure of perineal skin.

85. (II). Warren Flap Operation for complete third degree tear The length of the flap should measure a minimum of 3 cm to provide sufficiet vaginal mucosa. Taking care not to injure the bowel the bowel wall, the flap of mucosa is dissected free from above downwards, stopping short of the margin between the vaginal and anal mucosa. The flap is turned down to hang over the anus.

86. External anal sphincter ends are then dissected free and approximation or overlapping type external anal sphincteroplasty is then performed. The fascia overlying the medial aspect of puborectalis muscles is identified and is brought together with a series of interrupted sutures using 0 or 2-0 delayed absorbable sutures. Margins of vaginal mucosa and graft are approximated in the midline by a continuous locking stich of 3-0 delayed absorbable suture.

87. ‘butterfly appearence’ across the perineum. The initial incision is outlined around the margins of this area following the margin of anal mucosa along tha anatomical defect in rectovaginal septum. Sharp dissection is done to separate tha anal wall from vaginal mucosa. External anal sphincter remnants are sharply mobilized and separated from underlying anal wall. Noble procedure:

88. Ends of external anal sphinter are approximated end to end or overlapping. Genital hiatus is narrowed by bringing puborectalis muscles closer .

89. Transverse perineal muscles and inferior margins of bulbocavernosus are reapproximated. vaginal mucosa is trimmed continuous locking stich of 3-0 delayed absorbable suture. This suture is carried over the perineal body as a subcuticular stich and perianal skin is approximated in midline.

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