In the name of GOD the beneficent, the merciful

In the name of GOD

the beneficent, the merciful

Early and late proctologic complications of delivery prevention and treatment

The earliest evidence of severe perineal injury mummy of Henhenit,

22 yrs old Egyptian woman with rupture of the vagina into the bladder and the lower bowel was found protruding from

the anus.

Childbirth

Predisposing factors

Tissue Damage Nerve Injury

Pelvic Floor Disorder

Ageing Promoting FactorsObstetrical injury

ObesityMenopause

SmokingCaucasian race

PF Muscle Stretch during Labour

• During 2nd stage the PF muscles stretch x 2-3 of their length

• Maximal stretch tolerated by nonpregnant animal muscle tissue = 1.5

Perineal problemsPerineal pain, perineal haematoma, perineal wound Infection

Bowel problemsAnal Fissure, haemorrhoids, constipation

Pelvic Organ ProlapseCystocele, uterine prolapse. Enetrocele , rectocele, rectal mucosal or complete prolapse, descent of PF

IncontinenceUrinary, fecal (gas, liquid or solid stools)

Recto-vaginal Fistula

Sequelae of Childbirth

Pelvic Organ Prolapse

Injury to the pelvic floor during childbirthnumber of vaginal deliveriesmacrosomic infant

O’Boyle et al: the POPQ stage signifcantly higher in the third than in the first trimester

Associated co-Risk factors

defective collagenraceadvancing ageHysterectomychronic raised intra-abdominal pressure

Childbirth and Pelvic Organ Prolapse

Women’s Health Initiative:• single childbirth associated

with raised odds of:– Uterine prolapse (odds ratio

2.1; 95% CI 1.7–2.7) – Cystocoele (2.2; 1.8–2.7) – Rectocele (1.9; 1.7–2.2)

• Every additional delivery increased the risk of worsening prolapse by 10–20% (Hendrix, Am J Obstet Gynecol 2002).

Obstructed DefecationAlterations of anatomic morphology

Obstructed Defecation Syndrome

Obstructed Defecation Syndrome (ODS) is

defined as the normal desire to defecate, but an

impaired ability to satisfactory evacuate the

rectum

Causes of ODS

1. Descent (pelvic floor)2. Rectocele3. Internal mucosal prolapse4. Intususception (recto-rectal/recto-

anal)5. Complete prolapse6. Paradox puborectalis7. SRU8. Puborectalis insufficiency9. Enterocele10.Sigmoidocele11.Genital Prolapse

Mechanical Outlet Obstruction- Dissipation of Force Vectore

•rectocele, descent- Causes Lying inside the Rectum

• Intussusception, mucosal or complete prolapse

Functional Outlet ObstructionDyssynergia

Impaired Rectal Filling Sensationmegarectum, Hirshprung

Principal pathological Mechanisms Obstructed Defecation

Dissipation of Force Vector

Rectocele Descent

Causes Lying Inside the Rectum

Rectal intussusceptionMucosal prolapse

Complete rectal Prolapse

Mechanical

AnatomicalRectal redundancy

RectoceleRectal prolapseRectal mucosal prolapseIntussusception

Complex SituationsRectocele ± intussusception ± descent ±rectal prolapse ± enterocele ± sigmoidocele ± urogenital prolapses

SymptomsStraining too much and repeatedly

Long standing in toiletFrequent calls to defecate

Assisted defecationIncomplete evacuationFragmeted defecation

Pelvic pressure Rectal discomfort

Perineal painLaxative or enema user

Lack of continenceMucorrea

Worsen Quality of Life

Treatment OptionsNon surgical

BiofeedbackDietExerciseBehavioural therapy

SurgicalAbdominal approach

(rectopexy ± sigmoidectomy, colpopexy, LAR)Vaginal approach

(posterior coloporrhaphy)Perineal/Transanal approach

(Altemeir, Delorme, Sleeve mucosal resection, Starr, Transtarr)

SNS

Anal sphincter rupture is highlyassociated with fecal incontinence

85% perineal trauma69% stitches

McCandlish R et al, Br J Obstet Gynaecol 1998

Anal sphincter defects occur at first delivery

• Primips: Before 0% After 35%• Multips: Before 40%

After 44%

Incontinence associated with defect: p=0.0003

• 23% with defects had postpartum incontinence

Sultan et al. NEJM 325:1905;1993

Fecal Incontinence and Parturition

Childbirth & Fecal Incontinence

259 consecutive women delivered single unit31 elective CS no FIPrimaparous delivered vaginally 13% FIAbromowitz Dis Colon Rectum 2000

549 prospective fecal urgency vag 7.3% vs CS 3.1% Chaliha 99 Obstet Gyn

Anal Endosonography before and after Delivery in a Primiparous Woman with a Postpartum Defect of the External Anal Sphincter

Abdul H. Sultan et al, NEJM, 1993

MRI defects in parous womnenUnilateral

1. First degree, superficial– skin and subcutaneous tissue– vaginal mucosa– combination of the (multiple superficial lacerations)

2. Second degree, deeper– superficial perineal muscles (B. spongiosus, T.

perineal)– perineal body.

less trauma next deliverless pain and infectionthe wound heals faster

vaginal birth

Suture or not sutureunacceptable aesthetics Impaired sexual function Impaired PF muscle strength Incontinence and prolapse

Inadequateanatomy training Identifying 3rd degree tears

Doctors 91% 60%Midwives 84% 61%

.

Sultan et al. NEJM, 1993

Intact anal sphincter

Partial tear in EAS

Buttonhole tear of rectal mucosa with an intact EAS

Traditional 3 Layer SuturingContinuous suturing technique

Endo to end Overlap

Repair of third and fourth degree tears

End– to – end or overlap repair?

Internal sphincter repair

Postoperative management

Antibiotics Bladder catheterisation Analgesia Stool softener Patient information

Sphincter rupture rate• No episiotomy: 0 - 6.4%• Episiotomy: 0 - 23.9%

Thacker. Ob Gyn Survey 38:332;1983

Zetterstrom. Obstet Gynecol 94:21;1999

Hartmann K et al. JAMA 293(17):2141-8;2005

Fitzgerald for PFDN, Obstet Gynecol 109:29;2007

Midline episiotomy is highlyassociated with anal sphincter rupture

Sphincteric Rupture

Odds Ratio (p value)Forceps delivery

6.7 (p<0.001)Episiotomy

3.3 (p<0.001)OP position

2.4 (p=0.002)Vacuum delivery

2.3 (p=0.001)

Fitzgerald MP for PFDN, Obstet Gynecol 109:29;2007

Operative delivery isassociated with sphincter rupture

What Is Recommended Practice?

Planned Caesarean vs. Planned Vaginal Birth

Exercise in Pregnancy

Antenatal Pelvic Massage

Position during Labor and Birth

Epidural vs. Narcotics Pain Relief

Early vs. Delayed Pushing

Second stage pushing advice

Spontaneous vs. Forceps birth

Water Birth

Interventions to Prevent Obstetrical Perineal Trauma

Asymptomatic Women

Asymptomatic women who have minimal compromiseof their anal sphincter function (satisfactorypressure measurements and ultrasoundimages) should be allowed to have a vaginal delivery.

These women should be counselled that they have a 95% chance of not sustaining recurrent OASIS9 or developing de novo anal incontinencefollowing delivery.68 However, the delivery should be conducted by an experienced doctor or midwife.If an episiotomy is considered necessary, e.g.because of a thick inelastic or scarred perineum,a mediolateral episiotomy should be performed.There is no evidence that routine episiotomiesprevent recurrence of OASIS.

The threshold at which these women may be considered for a CSmay be lowered if a traumatic delivery is anticipated, e.g. in the presence of one or more additional relative risk factors such as a big baby, shoulder dystocia, prolonged labour, diffi cult instrumental delivery. However,

All symptomatic women are first treated conservatively

symptomatic women

Conservative management of anal incontinenceis described in detail in Chapter 11 and is summarisedas follows:• All women are included in the biofeedback programme(Chapter 11).• If muscle contractility is weak or absent, electricalmuscle stimulation is commenced.• Women with flatus incontinence are givendietary advice, especially the avoidance of gasproducingfoods such as legumes.• Women with faecal incontinence are commencedon a low residue diet and constipatingagents such as loperamide can be used.

Women whose symptoms are adequately controlledby conservative measures are offered CS inany subsequent delivery so as to minimise the riskof further compromise to anal sphincter function.

Women with faecal incontinence in whom conservative measures have failed should be offered anal sphincter surgery (Chapter 12A), whileothers may need advanced surgical techniques asdescribed in Chapter 12B. All women who haveundergone successful incontinence surgery shouldbe delivered by CS.

A management dilemma arises in women who suffer from faecal incontinence but who wish further pregnancies. These women could avoid aCS and undergo a vaginal delivery followed by a secondary sphincter repair at a later date. The only rationale behind this is that most of thedamage that occurs during childbirth occurs with the first vaginal delivery68,70

and therefore the risk of further damage during a subsequent vaginaldelivery is relatively small. However, there is a potentially unquantifi ed risk of deteriorating pudendal neuropathy.

The Effect of Pregnancy Hormones on Connective TissueConnective tissue in the area of the urogenital organs is sensitive to hormones. Duringpregnancy, collagen is depolymerized by placental hormones, and the ratios of theglycosaminoglycans change. (The term ‘proteoglycans’ is used here interchangeablywith ‘glycosaminoglycans’.) The vaginal membrane becomes more distensile, allowingdilatation of the birth canal during delivery. There is a concomitant loss of structuralstrength in the suspensory ligaments. This explains the uterovaginal prolapse so oftenseen during pregnancy. Laxity in the hammock may remove the elastic closure force,causing urine loss on effort. This condition is described as stress incontinence. Lossof membranous support may cause gravity to stimulate the nerve endings (N) at thebladder base, so causing premature activation of the micturition reflex, expressed assymptoms of ‘bladder instability’. This condition is perceived by the pregnant patientas frequency, urgency and nocturia. Laxity may also cause pelvic pain, due to lossof structural support for the unmyelinated nerve fibres contained in the posteriorligaments. The action of gravity on these nerves causes a ‘dragging’ pain. Removal ofthe placenta restores connective tissue

Following the advent of endoanal ultrasound (seeChapter 10), Sultan et al.14 demonstrated that 33%of women sustained “occult” OASIS that were notidentifi ed at delivery (see Chapter 8 for pathophysiology).Prospective studies11 have identifi ed“occult” injuries ranging between 2015 and 41%.

occult or in fact unrecognised at delivery.

It was alarming to find that 87% and 27% ofOASIS were not identified by midwives anddoctors respectively.

Lal et al.20 showed thatsignifi cantly more women develop anal incontinencefollowing a second degree tear than with anintact perineum (23% vs 3%, P = 0.01).

Benifl a etal.21 identifi ed a 16-fold increase in anal incontinencefollowing a second degree tear (P < 0.05).

Both these studies support the fi ndings of Andrewset al. that a large number of OASIS were undiagnosedand wrongly classifi ed as second degreetears.

Faltin et al.22 randomised 752 primiparous womenwith second degree lacerations to conventional

examination (control group) and additionalpostpartum endoanal ultrasound (experimentalgroup) and demonstrated that a considerable

number of women have full-thickness OASIS thatare not recognised at delivery. However, they

excluded partial-thickness sphincter tears fromtheir study. On identifying new injuries in the

experimental group, a formal sphincter repair wasperformed. Overall, severe faecal incontinence

was signifi cantly reduced from 8.7% in the controlgroup to 3.3% in the experimental group.

The morbidity associated with perineal injuryrelated to childbirth constitutes a major health

problem, affecting millions of women worldwide.

In the UK, up to 44% of women will continueto have pain and discomfort for 10 days followingbirth3 and 10% of women will continue to havelong-term pain at 18 months postpartum.4 Furthermore,23% of women will experience superfi -cial dyspareunia at 3 months postpartum;5 up to10% will report faecal incontinence6 and approximately19% will have urinary problems.7 The ratesof complications reported by women depend onthe severity of perineal trauma

A treatment during pregnancyis usually limited to emergency care, consisting of

palliation for symptomatic prolapsing internal hemorrhoids,

temporizing sclerosing injections for bleedinghemorrhoids, incision and expression of painful

external anal thromboses and drainage for the relativelyuncommon perianal abscess.

The first description of rectal prolapse is said to be in theEbers papyrus 1500 BC. The first treatment as outlined byHippocrates involved hanging patients by their heels andshaking them.10 Obviously, this was rarely successful in thelong term.The true incidence of rectal prolapse (mucosal orcomplete) is unknown mostly because of underreporting.It is associated with long-standing constipation, chronicstraining, pregnancy, prior surgery, female gender, aging,neurologic disease, mental illness (up to 53% in a study byVongsangnak et al.), and other pelvic floor disorders.11,12

Obstetric trauma is the most important etiologic factor in the pathogenesis of fecal incontinence in women. Thereis evidence that hormonal changes during pregnancy lead to smooth muscle relaxation attributed to progesterone.Relaxin is an ovarian hormone that peaks late during pregnancyand leads to connective tissue remodeling in the pelvic floor.23 With parturition, there is stretching of the levators, stretching and tearing of the rectovaginal septum,stretching of the vaginal wall, and compression of the pudendal nerves against the pelvic side wall. All these factors may contribute to fecal incontinence.A published study by Sultan et al.24 revealed anal sphincter defects in 30% to 40% of asymptomatic postpartum females. Fortunately, the minority of these patients were symptomatic (32%). However, these patients may becomesymptomatic later in life or with subsequent vaginal deliveries.In addition, pudendal nerve injury documented by electromyography has been demonstrated in 42% of postpartum females by Snooks et al.25,26 Sixty percent of these patients recovered nerve function 2 months after delivery, but 40% did not. Four percent of 906 postpartum women in a study by MacArthur et al.27 reported new symptoms of incontinence after childbirth. Sultan et al.28 showed a 1%incidence of frank fecal incontinence and a 25% incidenceof decreased flatal control at 9 months’ follow-up after vaginal delivery.

The incidence of sphincter injury is higher in patientswith perineal tears. Up to 25% of patients developed fecalincontinence symptoms after a third degree tear in a studyby Wood et al.29 Third degree tears, involving the sphinctermuscle, occur in approximately 0.6% of all vaginal deliveries. Episiotomies, similar to tears, are associated with incontinence.Sultan et al.31 found episiotomy to be associatedwith an increased risk of sphincter injury. Signorello et al.33

showed a threefold increase in fecal incontinence aftermidline episiotomy as compared with spontaneous laceration;therefore, a mediolateral episiotomy is recommended3

Perineal pain is a common symptom followingvaginal delivery, regardless of the presence ofperineal trauma. However, the severity ofperineal pain is directly proportional to the severityof perineal trauma.5,15 Perineal pain occurs in42% of women immediately after delivery but significantly reduces to 22% and 10% at 8 and 12weeks respectively. Compared to a normal delivery,perineal pain occurs more frequently andpersists for a longer period after assisted delivery(forceps, vacuum delivery, vaginal breech delivery).

Perineal Pain

• Soft tissue trauma (regardeless of suturing)

Asceptic techniquePoor surgical techniquesInflammation

Perineal Pain

Often associated with dyspareunia

Systemic Treatment

Local Treatment

Ice packsSit bathsLocal anesteticsHydrocortisone 1%Antenatale perineal massage

ParacetamoleNSAIDSRectal supp

Perineal PainLocal Treatment

Perineal Haematoma1 : 500 and 1 : 900 vaginal deliveries.

• infralevator (vulval, perineal,vaginal) • supralevator (in the broad ligament or paravaginal area)

frequently after an episiotomy But about 20% of cases in apparently intact perineum

A supralevator haematoma forms in the broadligament and could be due to an extension ofa tear of the cervix, vaginal fornix or uterus.

swellingpain, restlessness, inability to pass urine rectal tenesmus within a few hours after deliveryShock in sopraelevator hematomas

Perineal Haematoma

If < 5 cm• Ice packing• Pressure• AnalgesicsIf > 5 cm expanding• Incision & drainage

Infraelevator

sopraelevator

• Conservative with transfusions• Evacuation of clots and packing for 24 hrs• Embolising the bleeding vessel

Anal Fissure

Anal fissure is an ulcer in the squamous epithelium of the anus located just distal to the mucocutaneous junction;

In a prospective study before and after deliveryof 163 consecutive women (84 primiparous),Abramowitz et al.37 reported anal fi ssures in 15%during the fi rst 2 months postpartum.

Anal FissureRisk factors• dyschezia (painful defaecation),• heavier babies, • long second stage of labour, • Anal incontinence after delivery,• primiparity,• forceps deliveries • perineal damage

Caesarean section did not appear to be protective againstanal fissure

Anal FissurePain sorness during defecations

Visual examination of anal margineSmall ulcer at the level of mucocutaneous junction

Treatment

Relief of constipationdiet fibersit bathsstool softeners

Medicaltherapylocal analgesicsGTNBotulinium toxin

Management of Anal Fissurepregnancy and postpartum

Anal fissures in postpartum are associated with low pressure resting tone

HaemorrhoidsRisk factors• straining at defaecation• constipation,• vascular enlargement due to increased intra-abdominal pressure• erect posture• heredity

HaemorrhoidsEffect of Pregnancy

Smooth muscle inhibition

high levels of circulating progesterone

mechanical obstruction by the gravid uterus

Constipation

Increased blood volume by 25–40%

Venous engorgement and dilatation

HaemorrhoidsEffect of Pregnancy

Haemorrhoids

Risk factors include • heavier baby• long second stage of labour• vaginal delivery • instrumental delivery

In an observational study of 11,701 women,MacArthur et al.2 found that 8% reported haemorrhoidsof more than 6 weeks’ duration for the fi rsttime within 3 months of birth and an additional10% reported these as ongoing or recurrent symptoms.Two thirds reported the presence of haemorrhoids1–9 years after delivery. Glazener et al.1found that 17% of postnatal women reportedhaemorrhoids (new and recurrent) when questionedin hospital, 22% between delivery and 8weeks postpartum and 15% after 2 months.

intermittent bleeding (most common symptom) burning sensation itchingIntermittent bleeding of the anusvarying degrees of leakage of mucus, faeces or flatus sensation of fullness or a lumpperianal hygienic problemsdiscomfort and/or painCompromission of the quality of life

affecting the activities of everyday life walkingsitting downemptying bowelssleeping caring for the family or a new baby

Assessment include anoscopydigital examination

Treatment Haemorrhoidsduring pregnancy

relief of symptoms, especially pain control

Often symptoms will resolve spontaneously after birth, and so any corrective treatment is usually deferred to some time after birth.

Complications of haemorrhoids acute thrombosisincarceration of prolapsed internal haemorrhoid Aggressive treatment such as closed excisional haemorrhoidectomy under local anaesthetic.

Treatment Haemorrhoidsduring pregnancy

Conservative Management• dietary modifications

high fibre intake, high liquid intake, stool softeners • stimulants or depressants of the bowel transit • local treatments

sitz baths, creams, ointments or suppositories containing anaesthetics, antiinflammatory drugs, steroids, etc., alone or incombination

• drugs of the flavonoid family such as rutosides that cause decreased capillary fragility

Treatment Haemorrhoidsduring pregnancy

Alternative Management in severe and non-responsive casesambulatory interventions that usually do not need anaesthetics, such as:• injection sclerotherapy,• rubber-band ligation • cryotherapy,• infrared photocoagulation,• laser therapy

Injection sclerotherapy has been used effectively during pregnancy.86% of antenatal patients (24 of 28) became asymptomatic by means of injection of 5% phenol in almond oil.

Treatment Haemorrhoidsduring pregnancy

• excision surgery• stapled anopexyno known trials that have specifically evaluated

treatments for severe haemorrhoids during pregnancy and the postpartumperiod.

Planned Caesarean vs. Planned Vaginal Birth

Exercise in Pregnancy

Antenatal Pelvic Massage

Position during Labor and Birth

Epidural vs. Narcotics Pain Relief

Early vs. Delayed Pushing

Second stage pushing advice

Spontaneous vs. Forceps birth

Water Birth

Interventions to Prevent Obstetrical Perineal Trauma

Routine Episiotomy to Prevent a TearWhat Type of Episiotomy is SafestVacuum vs. ForcepsPerinealSupport: Hand on vs. Hand poised

85% of women who have a vaginal birth will sustain some form of perineal trauma and up to 69% of these will require stitches.Spontaneous or surgical

McCandlish R et al, Br J Obstet Gynaecol 1998;

1. First degree, superficial– skin and subcutaneous tissue of the anterior or posterior perineum– vaginal mucosa– combination of the above resulting in multiple superficial lacerations

2. Second degree, deeper– superficial perineal muscles (bulbospongiosus, transverse perineal)– perineal body.

Suture or not sutureNot suture: less trauma next delivery, less pain and infection, the wound heals faster

unacceptable aesthetics, sexual function, pelvic floor muscle strength incontinence and prolapse

four European and one UK RCTs (n = 1,864 primiparous and multiparous women) continuous subcuticular technique of perineal skin closure, when compared to interrupted transcutaneous stitches, was associated with less perineal painKettle C et al, The Cochrane Library, Issue 3. Oxford: Update Software, 2003.

Suture materiawound closure, control bleeding, minimise the risk of infection and

expedite healing, minimal tissue reaction and be absorbed once the woundhas healed

The first mention of the surgical management ofsevere perineal injury appears in Avicenna’sfamous Arabic book, Al Kanoun. He recommendeda form of a crossed or bootlace suture for therepairs of perineal injuries.

However, success rates with primary wound unionof perineal wounds reported in the late 1800s werein the region of 50–60%.

However, in 1999, Sultan et al, described the overlap technique of primary repair of the EAS (described by Parks previously for secondary sphincter repair).

In addition, Sultan et al, highlighted the importance of separate repair of the freshly torn internal anal sphincter (IAS), responsible for maintaining the resting tone of the anal sphincter. Damage to the IAS is associated with incontinence to gas and passive soiling

The prevalence of third and fourth degree tears, collectively referred to as obstetric anal sphincter injuries (OASIS), appears to be dependent upon the type of episiotomy practised. In centres where mediolateral episiotomies are practised, the rate of OASIS is 1.7% (2.9% in primiparae)9 compared to 12%10 (19% in primiparae)11 in centres practising midline episiotomy.

Thirty-five studies over a 20 yr with follow-up ranging from 1 to 30 mons:Gas incontinence ranges between 15–61% (n = 35; mean = 39%) Faecal incontinence ranges between 2–29% (n = 25; mean = 14%)

End-to-end repair

Thirty-five studies over a 20 yr with follow-up ranging from 1 to 30 mons:following end-to-end repairGas incontinence ranges between 15–61% (n = 35; mean = 39%) Faecal incontinence ranges between 2–29% (n = 25; mean = 14%)

Risk factorsthird/fourth degree tear

• Forceps delivery• first vaginal delivery• large baby• shoulder dystocia • persistent occipito-posterior position

Metanalysis of 21 studies , with good results ranging from 74% to 100%

Jorge and Wexner et al, Dis Colon Rectum, 1993

55 patients with faecal incontinence good clinical outcome in 80% at 15 months.

Engel et al. Br J Surg 1994

overlap technique

Malouf AJ et al. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000;355(9200):260–5.

Sultan et al, compared to matched historical controls who had an end-to-end repair, anal incontinence could be reduced from 41% to 8% using the overlap technique and separate repair of the internal sphincter

Br J Obstet Gynaecol 1999;106:318–23.

Kairaluoma et al. Dis Colon Rectum 2004, 31 consecutive women who sustained OASIS (3b and fourth degree). All had an EAS overlap repair immediately after delivery performed by two colorectal surgeons. In addition to end-to-end repair of the IAS, they also performed a levatorplasty to approximate the levators in the midline with two sutures. At a median follow-up of 2 years, 23% complained of anal incontinence, 23% developed wound infection, 27% complained of dyspareunia and one developed a rectovaginal fi stula. Levatorplastytherefore should be avoided during primary anal sphincter repair.

Poen et al.29 identifi ed 43 women (out of originalcohort of 117) who had subsequent vaginal deliveriesfollowing previous OASIS. The rate of analincontinence was 56% compared to 34% in thosewho did not subsequently deliver (relative risk1.6; 95% confi dence interval 1.1–

Sangalli et al.14 studied 177 women some 13years after OASIS (48 fourth degree tears). Analincontinence was signifi cantly more common inwomen who had sustained fourth degree tearscompared with those with third degree tears (25vs 11.5%; P = 0.049). Unlike women with previousfourth degree tears, those who had sustained aprevious third degree tear did not demonstrate anincrease in anal incontinence symptoms after asubsequent vaginal delivery.

This is in keepingwith the fi ndings of Fenner et al.,25 who found thatthe symptom of worse bowel control was 10 timeshigher in women who sustained fourth as opposedto third degree tears. This could be attributed topersistent injury of the IAS.

Incontinence when stoma1. When there is a cloacal injury. Some injuries are so

extensive that the anterior half of the anus and the lower third of the vagina are one common cavity.

2. When there is an associated rectovaginal fistula. Fistulas to the vagina can be extremely hard to treat;

• 3. In the presence of Crohn’s disease or prior radiation therapy.