applied anatomy and physiology - suyajna perineumaninsight.pdf · applied anatomy and physiology...
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Applied Anatomy and Physiology
The pelvic floor and anal sphincter
STP- BALLARI
www.suyajna.com
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Perineal membrane Lien KC et al 2004
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Pelvic floor
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Pubococcygeus
Iliococcygeus
Coccygeus
Puborectalis
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Computer model of levator ani muscle bands DeLancey JOL 2005
Early and late second stage of labour
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Translabial ultrasound
Levator avulsion injury Dietz HP et al 2007
Acute intrapartum injury
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Muscles cut during episiotomy
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Anal Sphincter Anatomy The riddle of the sphincters
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Anatomy of the anal sphincter
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Anal Endosonography
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Inside transducer; Walls of transducer; Subepithelium; Internal Sphincter; LM; External Sphincter
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EAS
I
External anal sphincter defect
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3 D anal endosonography
external sphincter defect
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The Pudendal Nerve
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The Pudendal Nerve
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Anorectal Physiology
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Anal Continence
Neurological Function Rectal Compliance
Sphincter Mechanism Stool Consistency
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Mechanism of anal incontinence
IAS relaxation
Contact & Sampling
Inconvenien
t
Convenient
Rectal distension
EAS & Puborectalis
relaxation EAS & Puborectalis
contraction
Colonic accommodation Bowel evacuation
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External anal sphincter
• Striated muscle in a state of tonic contraction • Innervated by pudendal nerve • Contributes up to 30% of resting pressure • Responsible for squeeze pressure
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Mechanism of anal incontinence
IAS relaxation
Contact & Sampling
Inconvenien
t
Rectal distension
EAS & Puborectalis
contraction
Colonic accommodation
Recto-anal inhibitory reflex Damage to EAS
Ineffective EAS
contraction
Anal incontinence associated with
urge
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Internal anal sphincter
• Smooth muscle • Autonomic - myenteric and gut wall plexuses • Contributes up to 70% of resting pressure • Passive soiling and flatus incontinence
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IAS injury
Reduced anal tone
Passive soiling and flatus incontinence
IAS defect
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Anal Incontinence - history
Wide spectrum of symptoms • Urgency • Urge incontinence • Flatus incontinence • Soiling or staining • Incontinence to liquid stool • Incontinence to solid stool
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Anorectal Physiology
Factors necessary to maintain continence • Anal sphincter integrity • Muscle function • Neural connections
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The Pudendal Nerve
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Pudendal Nerve Terminal Motor Latency
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EMG - Reinnervation
normal abnormal
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Summary
• Good understanding of perineal anatomy • Physiology → pathophysiology • No single tests gives a definitive diagnosis • Investigations are complementary • Anal endosonography is now the gold
standard investigation of faecal incontinence