TOG: pelvic floor & sphincter injuries

Question 1

what is the innervation of the pelvic floor?

Answer 1

S2-S4 and some from pudendal nerve

Question 2

what type of muscle is internal anal sphincter and where does it end?

Answer 2

continuation of the circular smooth muscle of bowel. Ends above the anal margin at the junction of the superficial and submit part od EAS

Question 3

what is the innervation to the IAS

Answer 3

sympathetic (L5) and parasympathetic nerves (S2-S4). accounts for 50-85% of resting pressure

Question 4

what is the innervation of EAS?

Answer 4

inferior rectal branch of pudendal nerved contributed to 15-30% resting pressure

Question 5

what percentage of women sustain some kind of perineal injury during vaginal delivery?

Answer 5

85%

Question 6

what is the episiotomy rate in the UK?

Answer 6

8-16%

Question 7

what is the rate of OASI (obs anal sphincter injuries) in centres where mediolateral episiotomies are done compared to where midline episiotomies are done?

Answer 7

OASI rate with mediolateral epis= 1.7% (2.9% in primips)

OASI rate with midline epic= 12% (19% in primips)

Question 8

what is the UK OASI rate? What is the UK OASI rate in primips?

Answer 8

3%. Range of 0-8%

OASI rate in primips= 2.1%

Question 9

what are the symptoms of obstetric-related pelvic floor dysfunction?

Answer 9

anal incontinence
urinary incontinence
pelvic organ prolapse
sexual dysfunction

Question 10

which specific point of the pudendal nerve is particularly prone to injury during childbirth?

Answer 10

the point where it curves around the ischial spine and enters the pudendal canal enclosed in its tight fibrous sheath (Alcock’s canal)

Question 11

what percentage of women suffer with anal incontinence despite primary repair?

Answer 11

39%

Question 12

in women who had transient anal incontinence after a complete tear, what percentage have relapse symptoms after the next delivery?
What is the major long term problem in these women?

Answer 12

39%

Major problem is incontinence of flatus

Question 13

what is the most significant risk factor in developing faecal incontinence after delivery?

Answer 13

full thickness anal sphincter disruption

Question 14

the prevalence of OASI is predominantly associated with which 5 factors

Answer 14

1. forceps delivery
2. unassisted delivery at home
3. large metal head circumference
4. obesity
5. increasing maternal age

Question 15

what are the main risk factors for development of OASI?

Answer 15

1. midline episiotomy
2. first vag del
3. shoulder dystocia
4. persistent OP position

Question 16

what is the only independent factor predicting a major tear, hence higher risk of faecal incontinence?

Answer 16

epidural analgesia

Question 17

in comparing post partum women with and without stress urinary incontinence, what difference is there between the bladder neck of the 2 groups?

Answer 17

women with postpartum SUI have been found to have greater bladder neck mobility during straining before delivery, compared to postpartum women without SUI

Question 18

if woman delivers exclusively by c/s, is she more or less likely to have urinary incontinence, in the long term, compared to women who have had all vaginal deliveries?
What if she has had combination of c/s and vaginal deliveries?

Answer 18

women delivered exclusively by c/s are less likely to have urinary incontinence in the long term, compared to those who only had SVD, BUT not if they had combo of c/s and SVD

Question 19

what percentage of porous women have some degree of POP (pelvic organ prolapse).
What percentage of these women have symptoms?

Answer 19

50%

15% of these women are symptomatic

Question 20

what percentage of symptomatic prolapse is found in nulliparous population?

Answer 20

2%

Question 21

what is the most common morphologic abnormality of the elevator ani seen in 1/3 women after child birth?

Answer 21

avulsion injury of the pubovisceral muscle from the pubic rami

Question 22

what is the most common postpartum sexual disorder.

what are the other common postpartum sexual disorders?

Answer 22

sexual pain.

this is followed by disorders of sexual desire, arousal, orgasm

Question 23

perineal pain occurs more frequently and persists for longer after what type of delivery?

Answer 23

instrumental or breech vaginal delivery

Question 24

when is the ideal time postnatally to see patients suffering with perineal problems? what should the setting be like?

Answer 24

6-8 weeks after delivery.
dedicated perineal clinic
breastfeeding and childcare facilities