دیدگاه از سزارین اندیکاسیونپروکتولوژیست

عزیزی رسول دکترجراحی گروه دانشیار کولورکتال، جراح

ایران پزشکی علوم دانشگاه پزشکی دانشکدهجراحی بخش اکرم، رسول مجتمع

E-mail:razizimd@hotmail.com

Anatomy & physiology of continenceintroduction

The abilityto retain a bodily discharge voluntarily”. The

word has its origins from the Latin continere ortenere, which means “to hold”. The anorectum is the

caudal end of the gastrointestinal tract, and isresponsible for fecal continence and defecation. In

humans, defecation is a viscero somatic reflex that isoften preceded by several attempts to preserve

continence

Mechanisms of Continence and Defecation

Risk Factors in Fecal IncontinenceObstetric Events

*Sphincteric Injury

*Pudental Nerve Injury

*Secondary Rectal Sensorimotor Dysfunction

KAMM MA (1994) OBSTETRIC DAMAGE AND FECAL INCONTINENCE.LANCET 344:730

BHARUCHA AE (2003) FECAL INCONTINENCE. GASTROENTEROLOGY124:1672-1685

There is now clear recognition, supportedby a considerable body of evidence, that

Obstetric trauma is, by far, the major risk factor for the development

of acquired fecal incontinence in women

In a frequentlyreferenced study by Sultan and

colleagues in 1993,ultasound at 6 weeks postpartum revealed sphincter injuries in 35% of primiparous women and 44%

of multiparous women.

Sultan AH, Kamm MA, Hudson CN et al (1993) Anal sphincter

disruption during vaginal delivery. N Eng JMed 329:1905–1911

THE PREVALENCE OFSYMPTOMS OF FECAL INCONTINENCE POSTPARTUM INSTUDIES INVOLVING >130 SUBJECTS AND SHOWS THATGREATER THAN 10% OF WOMEN WILL COMPLAIN OF BOWELSYMPTOMS IN THE FIRST FEW MONTHS FOLLOWING CHILDBIRTH

1-Chaliha C, Kalia V, Stanton SL et al (1999) Antenataprediction of postpartum urinary and fecal incontinenceObstet Gynecol 94:689-694

MacArthur C, Glazener CM, Wilson PD, et al(2001) Obstetric practice and faecal incontinence three months after delivery. BJOG 108:678-683

MacArthur C, Bick DE, Keighley MR (1997) Faecalincontinence after childbirth. Br J Obstet Gynaeco104:46-50–

Oberwalder and colleagues performed a meta-analysis of 717 vaginal deliveries has three

notable results: First, the incidence of anal sphincterdefects in primiparous women was 26.9%. Second,multiparous women had an 8.5% incidence of newsphincter defects. Third, the calculated probabilitythat postpartum fecal incontinence was due to a

sphincter defect was 76.8–82.8%.

Oberwalder M, Connor J, Wexner SD (2003) Metaanalysis

to determine the incidence of obstetric analsphincter damage. Br J Surg 90:1333–1337

Episiotomy was at one time believed to be protectiveto the perineum during childbirth and was used

to prevent the occurrence of third- and fourth-degreetears . There is now evidence that episiotomy not

only fails to protect the perineum but has beenassociated with increased tearing and anal sphincter

injury

1-Thacker SB, Banta HD (1983) Benefits and risks of episiotomy:

an interpretive review of the English language literature. Obstet Gynecol Surv 38:322–338

2-Klein MC, Gauthier RJ, Robbins JM et al (1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.

Am J Obstet Gynecol 171:591–598

Many papers have been published regarding

obstetric lesions as they relate to incontinence. However,

it is difficult to accurately quantify the prevalence

of obstetric injury and its effect on the incidence

of incontinence.

In addition to direct trauma to the sphincter muscle,pudendal neuropathy is another consequence of

vaginal delivery, which contributes to fecal incontinence.

The pudendal nerve is believed to be damagedby the fetal head, which compresses the nerve,

causingischemia or stretching its branches

repeated pregnancies and deliveries addto the damage, the neuropathy progresses as the

woman ages, and the worsening over time causes significantfecal incontinence that presents between 50

and 60 years of age

Cesarean section has been advocated as an optionto protect the pelvic floor and reduce the incidence ofpostpartum fecal incontinence; however, this issue is

controversial. Cesarean section performed aftercervical dilation, especially if performed late in the

second stage of labor, is not entirely protectiveagainst direct sphincter trauma or pudendal

neuropathy

At this time, the best practice seems to be evaluation of awoman’s risk factors, informed consent regardingher risk of pelvic floor trauma from vaginal delivery,

proper recognition of injury at the time of delivery ,and effective postpartum evaluation

Nelson et al. covering 15 studies encompassing3,010 Caesarean section and 11,440 vaginal deliveries

showed no difference between the rate of either fecal or flatus incontinence between the two different modes of

delivery. The implication of both of these studies is that it is pregnancy itself, perhaps in relation to connective tissue properties or perhaps an inherited susceptibility, that can

lead to pelvic floor disorders.

Nelson RL, Westercamp M, Furner SE (2006)A systematic review of the efficacy of Cesarean

section in the preservation of anal continence. Dis Colon Rectum49:1587-1595

Risk Factors

•Anorectal Anomalies•Spina Bifida

•Isolated Sacral Agenesis•Hirschprung’s Disease

•Cerebrovascular Accidents•Parkinson's Disease

•Multiple Sclerosis•Spinal Cord Injury

•Diabetes Mellitus•Ageing

•Inflammatory Bowel Disease

•Irritable Bowel Syndrome•Anal Surgery

•Rectal Resection•Rectal Evacuatory

Disorder•Rectal prolapse