Publication: Tratamiento rehabilitador en pacientes con desgarro de esfínter anal obstétrico asintomático y conincontinencia anal
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2017-09-18
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Universidad Complutense de Madrid
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Abstract
La clasificación de los desgarros perineales propuesta por Sultan y aceptada por el Royal College of Obstetricians and Gynaecologists (RCOG) los divide en cuatro grados, correspondiendo el 3º y 4º al desgarro del esfínter anal (DEA). El 3º grado representa la lesión del complejo esfinteriano, y es subdividido en tres subgrupos: el 3ºa corresponde a una lesión de menos del 50% del espesor del esfínter anal externo (EAE), el 3ºb a una lesión de más del 50% del EAE y el 3ºc es una lesión completa del EAE y esfínter anal interno (EAI); y el 4º grado, corresponde a la lesión del esfínter anal (EA) y de la mucosa rectal o epitelio anal. Cuando se analiza la prevalencia del DEA obstétrico se obtienen datos muy variables, entre el 0,5% y 9% de los partos vaginales, dependiendo de los estudios. Entre los factores de riesgo del DEA destacan el parto instrumental, sobre todo el fórceps, la episiotomía de rutina y ser primípara. También se ha descrito como factor de riesgo, un entrenamiento inadecuado del personal sanitario en el diagnóstico y tratamiento correcto de esta complicación en el parto. El DEA obstétrico de 3º y 4º grado puede dar lugar a una serie de complicaciones, inmediatas y a largo plazo, de las cuales la incontinencia anal (IA) es la más frecuente y probablemente la que tiene mayor impacto en la calidad de vida de estas mujeres. También se ha asociado el desgarro esfinteriano con la presencia de incontinencia urinaria (IU); en la fisiopatología de ésta, podría estar implicada una lesión de los mecanismos de soporte uretral y una neuropatía del pudendo. Es importante diagnosticar el DEA en el momento del parto para realizar una adecuada reparación quirúrgica primaria, que podría ayudar a prevenir posibles complicaciones futuras. Ante un DEA obstétrico el RCOG recomienda que las mujeres sean revisadas entre la 6ª y la 12ª semana después del parto por un ginecólogo especializado, en una unidad multidisciplinar de patología de suelo pélvico, además de tener la posibilidad de realizar un programa de rehabilitación de la musculatura del suelo pélvico (MSP) durante 6 a 12 semanas después de la reparación del esfínter anal...
The classification of perineal tears proposed by Sultan and accepted by the Royal College of Obstetricians and Gynaecologists (RCOG) divides them into four degrees; the 3rd and the 4th degree correspond to anal sphincter tears (AST). The 3rd degree stands for tears of the anal sphincter complex, and is divided into three subgroups: 3a corresponds to injuries of less than 50% of the thickness of the external anal sphincter (EAS), 3b to an injury of more than 50% of the EAS, and 3c is a total injury of the EAS and the internal anal sphincter (IAS); the 4th degree means an injury of the anal sphincter and the rectal mucosa or anal epithelium. When we analyse the prevalence of obstetric AST we obtain very variable results: depending on the study, it occurs in 0.5% to 9% of vaginal deliveries. Among the main factors involving the risk of a sphincter injury are instrumental deliveries, notably by forceps, routine episiotomy and being a primiparous mother. Lack of an adequate training of the professionals in regard to the diagnosis and correct treatment of this complication has also been described as a risk factor. 3rd and 4th degree AST can lead to a series of immediate as well as long term complications, of which faecal incontinence (FI) is the most frequent and probably that with the greatest impact on the life quality of these women. Sphincter tear has also been associated with urinary incontinence (UI); injuries of the urethral support mechanisms and pudendal neuropathy might be involved in this physiopathology. It is important to diagnose an AST at the moment of delivery to undertake an adequate primary surgical repair that might help prevent possible future complications. In case of an AST, the RCOG recommends that these women be revised, between the 6th and the 12th week after giving birth, by a specialized gynaecologist in a multidisciplinary pelvic floor pathology unit, and be given the possibility of taking part in a programme for the rehabilitation of the pelvic floor muscles (PFM) 6 to 12 weeks after the repair of the anal sphincter...
The classification of perineal tears proposed by Sultan and accepted by the Royal College of Obstetricians and Gynaecologists (RCOG) divides them into four degrees; the 3rd and the 4th degree correspond to anal sphincter tears (AST). The 3rd degree stands for tears of the anal sphincter complex, and is divided into three subgroups: 3a corresponds to injuries of less than 50% of the thickness of the external anal sphincter (EAS), 3b to an injury of more than 50% of the EAS, and 3c is a total injury of the EAS and the internal anal sphincter (IAS); the 4th degree means an injury of the anal sphincter and the rectal mucosa or anal epithelium. When we analyse the prevalence of obstetric AST we obtain very variable results: depending on the study, it occurs in 0.5% to 9% of vaginal deliveries. Among the main factors involving the risk of a sphincter injury are instrumental deliveries, notably by forceps, routine episiotomy and being a primiparous mother. Lack of an adequate training of the professionals in regard to the diagnosis and correct treatment of this complication has also been described as a risk factor. 3rd and 4th degree AST can lead to a series of immediate as well as long term complications, of which faecal incontinence (FI) is the most frequent and probably that with the greatest impact on the life quality of these women. Sphincter tear has also been associated with urinary incontinence (UI); injuries of the urethral support mechanisms and pudendal neuropathy might be involved in this physiopathology. It is important to diagnose an AST at the moment of delivery to undertake an adequate primary surgical repair that might help prevent possible future complications. In case of an AST, the RCOG recommends that these women be revised, between the 6th and the 12th week after giving birth, by a specialized gynaecologist in a multidisciplinary pelvic floor pathology unit, and be given the possibility of taking part in a programme for the rehabilitation of the pelvic floor muscles (PFM) 6 to 12 weeks after the repair of the anal sphincter...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina Física y Rehabilitación. Hidrología Médica, leída el 04/02/2016