Common causes of damage to the sphincter muscles are the following: > Vaginal Birth. (I-A) 8. Partial disruption and sphincter is repaired by 'end to end' approximation using 3-OPDS. This review is relevant to all who provide care during childbirth and to doctors and healthcare profes-sionals to whom women may subsequently present. 2021 Sep;32(9):2337-2347. doi: 10.1007/s00192-020-04620-x. The presence of a defect in the internal sphincter should be carefully sought out in all cases of Obstetric Anal Sphincter Injury (OASI). Objectif : Analyser les données probantes traitant des lésions obstétricales du sphincter anal (LOSA) en ce qui concerne leur diagnostic, les techniques visant leur réparation et les résultats de l’intervention. This study aimed to determine the short and long term outcomes from anterior sphincter repair and identify factors predictive of long term success. However, in about 1% to 4% of births, there is tearing and damage which extends to the back passage and the anal sphincter. Des laxatifs (p. ex. Should women having their first delivery receive different recommendations for delivery than women who have already had one delivery (either vaginal or cesarean)? Depending on how severe your symptoms are and whether they seem to be getting better or worse with time, your clinician might ask you to come to the office for an evaluation. These tears can involve the perineal skin, the pelvic floor muscles, the external and internal anal sphincter muscles as well as the rectal mucosa (lining of the bowel). Thirty-eight women with rupture of the anal sphincter occurring during childbirth were followed for 3-12 months. Hemorrhoids and Rectal Prolapse. Especially since surgical repair cannot restore normal anorectal anatomy and function, it is critically important to prevent the initial damage at vaginal delivery. Patients who underwent anterior sphincter repair between 1989 and 2001 in one institution were identified. Obstetric-related FI may occur early after childbirth. Careful primary repair of the torn sphincter should be done following the childbirth by an experienced caregiver, using absorbable long-lasting sutures. Would you like email updates of new search results? This can cause considerable problems for some of these women in terms of pain, painful intercourse and faecal incontinence. Found insideBook description to come. Il est nécessaire de procéder à la documentation détaillée de la lésion et de sa réparation. Previous obstetric injury is also a major cause of FI in older women, and risk of FI increases with time and further childbirths. This video is associated with a text under sub. common cause of ABL. The book is well illustrated, up to date and authoritative. (III) d. La présence persistante d’une anomalie du sphincter anal externe longtemps après l’accouchement pourrait accroître le risque de voir apparaître une aggravation des symptômes à la suite des accouchements vaginaux subséquents. However, even when anal sphincter damage is recognized at delivery, current methods of surgical repair are inadequate. Exercises to strengthen and tighten your anal sphincter may help treat bowel incontinence (fecal incontinence) or reduce your chance of leaking stool or gas in the future. Your anal sphincter is composed of thick bands of muscle. After the anorectal mucosa and internal anal sphincter defects are reapproximated, attention is turned to the external anal sphincter. Urethral sphincter function after nerve or muscle damage The risk factors for obstetric anal sphincter injuries include a midline cut of the perineum (episiotomy) to facilitate the birth, forceps delivery and the baby’s back presenting posteriorly (occipito-posterior position). There is no one “right” answer. This procedure repairs a damaged or weakened anal sphincter that occurred during childbirth. Found inside – Page 76When the anal sphincter has been torn, the nerve supply to this muscle is likely to have been damaged, so repair of the sphincter may not be enough and you have pelvic-floor surgery — deeper inside — as well. We use cookies to improve your experience on our site. Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group. after a vaginal birth to determine the presence of any lacerations. (II-2B) 5. Colon and rectal surgeons have completed advanced training in the treatment of colon and rectal problems in addition to full training in general surgery. Before childbirth, the child must first fit past the pelvic muscles and connective tissue. Am J Obstet . MeSH Vaginal childbirth is associated with a high risk of perineal trauma with at least 85 % of women sustaining some form of perineal injury during vaginal delivery in the United Kingdom [].Obstetric trauma is the commonest cause of anal sphincter damage [] and this is reported in 0.6-36 % of women as a consequence of vaginal delivery [].The range depends on the population studied and the method . Doctors identify an injured area of muscle and free its edges from the surrounding tissue. Résultats : La littérature publiée a été récupérée par l’intermédiaire de recherches menées dans Medline, EMBASE et The Cochrane Library en mai 2011 au moyen d’un vocabulaire contrôlé (p. ex. Failure to repair tear Aucune restriction n’a été imposée en matière de date ou de langue. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. Outcomes: Objective: To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. Bowel urgency means that there is very little time (five minutes or less) between the first urge to have a bowel movement and the need to pass stool. The anal sphincter is more likely to be traumatised during a This book reviews the latest advances in the epidemiologic, socio-economic, psychological, diagnostic, and therapeutic aspects of fecal incontinence, helping to establish effective treatment guidelines. The incision, which can be done from the posterior midline of the vulva straight toward the anus or at an angle to the . 2015 Oct 29;2015(10):CD010826. Many women do not seek medical attention because of embarrassment. Ce système permet l’établissement d’une distinction entre le degré de déchirure du sphincter externe (3a < 50 % ou 3b ≥ 50 %) et la présence d’anomalies du sphincter interne (3c). I have been diagnosed with attenuated anal sphincter. Objective To compare two surgical techniques and two types of suture material for anal sphincter repair after childbirth-related injury.. Design Factorial randomised controlled trial.. This volume presents a reasoned, scientific approach to the use of pelvic floor re-education. These tears are classified into four categories by the depth of tissue involved: In the past, episiotomies were performed at almost all vaginal births, especially for women having their first delivery. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Society of Obstetricians and Gynaecologists of Canada. Cochrane Database of Systematic Reviews 2013, Issue 12. This can, in effect, cause long-term faecal incontinence. Our mission is to inform, assist, and support people affected by gastrointestinal disorders. (II-2) Recommandations 1. Fernando R, Sultan AH, Kettle C, Thakar R, Fernando R, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Bowel incontinence includes involuntary leakage or loss of control of gas, liquid stool, mucous, or solid stool. Women should be advised that physiotherapy following repair of OASIS could be beneficial. Epub 2018 Oct 29. However, for other women the symptoms persist and worsen with time. These patients typically complain of fecal urgency and can have incontinence of gas, mucus, liquid, and even solid feces. There was considerable heterogeneity in the outcome measures, time points and reported results. Women and their doctors may have incomplete information about the risks and benefits of different approaches. Definitions Perineal trauma: Injury to the vagina, labia, urethra, clitoris, perineal muscles or anal sphincter. However, scientific evidence accumulated over the past few decades has proven that the exact opposite is true. (II-2) 5. L’utilisation d’agents constipants et d’agents de gonflement n’est pas recommandée. If the first answer you get is “I don’t know,” then politely ask your clinician to find out for you and ask again at the next visit. La littérature grise (non publiée) a été identifiée par l’intermédiaire de recherches menées dans les sites Web d’organismes s’intéressant à l’évaluation des technologies dans le domaine de la santé et d’organismes connexes, dans des collections de directives cliniques, dans des registres d’essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Found inside – Page 2741993 [25], ultrasound at 6 weeks postpartum revealed sphincter injuries in 35% of primiparous women and 44% of multiparous women. However, there are several difficulties in the use of ultrasound to evaluate fecal incontinence in women ... Les anti-inflammatoires non stéroïdiens et l’acétaminophène sont les analgésiques de première intention. doi: 10.1002/ccr3.4309. Malouf AJ, Norton CS, Engel AF, et al. Causes of urethral sphincter nerve and muscle damage. It is the primary sphincter for the control of continence after the prostate is removed. Weakness may occur as part of the aging process. This examination should include a digital rectal examination to evaluate the tone of the anal sphincter [5]. : CD002866. Réparation des lésions obstétricales du sphincter anal : a. L’utilisation de polyglactin 2-0 ou de polydioxanone 3-0 donne lieu, après six semaines, à des taux semblables de morbidité liée aux sutures. Found insidePatients with temporary incontinence after a primary sphincter repair should be informed about the risk for recurrence ... M.M., and Swash, M., Faecal incontinence due to external anal sphincter division in childbirth is associated with ... Epub 2017 Jan 4. Summary of Clinical Research Activities – Incontinence By: Adil E. Bharucha, MD, Professor of Medicine, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, MN Dr. Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives. More complex surgery to construct new sphincter muscles or to create an artificial anal sphincter is sometimes effective; these procedures should only be performed by specialists at centers with experience in these types of surgery. While giving birth, some women sustain perineal trauma that can have short- and long-term physical and psychological consequences. Repair Anal Sphincter, Open CaliforniaHIA.org - Approach = Open (0) - Device = No Device (Z) - Qualifier = No Qualifier (Z) p p p Approach 0DQP0ZZ Repair Rectum, Open Approach 0DQQ0ZZ Repair Anus, Open Approach CHIA Convention & Exhibit June 7-10, 2015 in Palm Springs (Urinary urgency and incontinence are also very common during this time.). Our original content is authored specifically for IFFGD readers, in response to your questions and concerns. The stated goal is avoiding injury to the pelvic floor and thus protecting against the development of pelvic floor disorders. J Obstet Gynaecol Can. Keywords: 2018 Dec;46(12):913-921. doi: 10.1016/j.gofs.2018.10.028. 2006 Jul 19;(3):CD002866. Urethral sphincter function after nerve or muscle damage Failure to recognize the extent of the trauma, an incorrect repair and inadequate pain management during and after the repair may contribute to major physical, psychological and social issues1,2,3. Packed with the most up-to-date recommendations, this invaluable preparatory handbook is a trusted resource for all levels of providers that care for laboring patients. A vaginal tear (perineal laceration) is an injury to the tissue around your vagina and rectum that can happen during childbirth. This book clarifies and explains perineal anatomy and the pathophysiology of anal incontinence as well as applied pharmacology. When a 3rd or 4th degree laceration occurs at childbirth the sphincter muscles are repaired with stitches after delivery. An episiotomy is a procedure that may be used to widen the vaginal opening in a controlled way. When a 3rd or 4th degree laceration occurs at childbirth the sphincter muscles are repaired with stitches after delivery. DOI: 10.1002/14651858.CD002866.pub3, Copyright © 2021 The Cochrane Collaboration. All cases were flatulence, and most happened less than once a week. This narrated, edited video shows the authors' technique for sphincter repair after obstetric perineal trauma. Found insideThis book provides a brief review of the pathophysiology of fecal incontinence with specific focus on women and children. Authorship is drawn internationally, with a strong surgical input. Women who have undergone obstetric anal sphincter repair should be reviewed at a convenient time (usually 6-12 weeks postpartum). (III-B) 3. FI is involuntary loss of solid or liquid stool. Lésions obstétricales du sphincter anal (LOSA) : Prévention, identification et réparation. Use a surgical checklist. If incontinence persists, let your clinician know. However, if the average number is high (for example, higher than 30%), you should discuss with your clinician your concern about the risk of anal sphincter laceration and ask to discuss the situations and reasons why episiotomy is used at such a high rate. The general advice is to complete your family prior to surgery. Cloacal type defect of the anal canal following an obstetric anal sphincter trauma. This repair must be conducted shortly after the birth if it is to be effective. Options: This book will be essential reading for all colorectal surgeons and trainees, general surgeons and trainees, gynecologists as well as specialist nurses in the OR room. 2020 Nov;31(11):2247-2259. doi: 10.1007/s00192-020-04464-5. Nineteen had complete rupture of the external anal sphincter, 14 had a lesion involving more than half of the sphincter muscle and five had a superficial rupture. Like the internal anal sphincter, the ends of the external anal sphincter are often retracted laterally and must be definitively identified and mobilized in order to ensure an adequate tension-free repair. Counselling women about future delivery plans: a. Chez les femmes qui connaissent un accouchement vaginal spontané, le taux de lésions obstétricales du sphincter anal est amoindri lorsque le fournisseur de soins obstétricaux ralentit la tête fœtale au moment du dégagement. Issues : Le critère d’évaluation était la continence anale à la suite d’une réparation primaire de LOSA et à la suite d’un accouchement subséquent. Method Women were randomised into four groups: overlap repair with polyglactin (Vicryl . The majority of sphincter repair operations are successful with 80% of people claiming to have a satisfactory outcome longer than 2 years following surgery. For vaginal childbirth to occur, the baby must be able to fit past the pelvic muscles and connective tissue. (II-2B) L’angle d’incision optimal semble être d’au moins 45 degrés (idéalement, aux alentours de 60 degrés). Childbirth Childbirth is the most common cause in women of damage to one or both anal sphincter muscles. Only three trials with 156 women had 12-month follow-up data, when the overlap technique carried out as soon after childbirth as possible appeared to be better in terms of having faecal urgency and incontinence. 29 It is heartbreaking to see an OASIS repair breakdown in the week following a vaginal delivery. Childbirth Childbirth is the most common cause in women of damage to one or both anal sphincter muscles. There were no date or language restrictions. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Cochrane Database Syst Rev. The trials were of moderate quality and differed in the participants, the outcome measures used and the points in time when they were measured. The attending midwife performed the initial perineal repair. If following an endoanal ultrasound scan, damage to the external anal sphincter has been diagnosed, surgical repair may be an option. Unfortunately, once the sphincter muscles have been damaged, surgery may be able to repair the separation but may not restore normal function to the muscles. Ils pourraient également être appelés à conseiller des femmes ayant déjà connu des LOSA en ce qui a trait à la voie d’accouchement à privilégier pour les grossesses subséquentes. The perineal repair should be completed within 120 minutes after completed third stage at the latest; however, where there is significant blood loss repair should be prompt. Therefore the repair must be completed shortly after the birth. Bethesda, MD 20894, Copyright During vaginal birth, the sphincter muscles can become stretched and damaged as a result of a forceps delivery. External hemorrhoids, which develop under the skin around the anus, can prevent the anal sphincter muscles from closing completely. La présence d’une lésion en boutonnière (button-hole injury) constitue un incident distinct et devrait être classée en conséquence. À la suite de la constatation d’une lésion obstétricale du sphincter anal, les fournisseurs de soins devraient divulguer à leurs patientes le degré de la lésion subie et prendre les dispositions nécessaires à la mise en œuvre d’un suivi. 11.483 deliveries between . Randomised clinical trial of bowel confinement vs. laxative use after primary repair of a third degree obstetric anal sphincter tear. Obstetric anal sphincter injuries may be seen at the time of birth ('overt') or may be detected only after additional ultrasound investigation, after birth ('occult'). Appointments 216.444.6601. The sphincter is the circular group of muscles surrounding the anus that are responsible for . However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings. Found inside – Page 538Sphincteroplasty For patients with a disrupted anal sphincter, sphincter repair may be recommended. A young female with a disrupted internal anal sphincter after childbirth would be a candidate for sphincteroplasty; the patient will ... This can happen due to childbirth, surgery, radiation therapy, spinal cord injuries, etc. During pregnancy each woman should have an open discussion with her clinician about how often episiotomy is used. Epub 2018 Nov 2. This is even more likely if (III) 6. This book is written for nurses and allied health professionals working with patients with disordered bowel function. (II-2) 3. 2018 Dec;46(12):948-967. doi: 10.1016/j.gofs.2018.10.024. Privacy, Help [Perineal tears and episiotomy: Surgical procedure - CNGOF perineal prevention and protection in obstetrics guidelines]. (I-A) 7. Provides students or interns with guidance on how to conduct an episiotomy. Les lésions obstétricales du sphincter anal sont plus souvent associées aux accouchements par forceps qu’aux accouchements par ventouse obstétricale. “Only when necessary” might mean 90% of the time to one clinician, and 10% of the time to another. Values: Injury to the anal sphincter during childbirth is the major cause of faecal incontinence in women and is estimated to affect 5% of women who have a vaginal delivery each year in the UK (Fernando et al, 2002). Found inside – Page 161The RCOG national guidelines [30] and the Cochrane systematic review [31] provide recommendations on every aspect of sphincter repair. The salient points are highlighted in this chapter. All women with perineal trauma after childbirth ... After the operation, sitz baths are recommended to maintain hygiene during healing, and laxatives prescribed to avoid hard stool. Thubert T, Cardaillac C, Fritel X, Winer N, Dochez V. Gynecol Obstet Fertil Senol. If following an endoanal ultrasound scan, damage to the external anal sphincter has been diagnosed, surgical repair may be an option. Childbirth is the most common cause of damage in women. Found inside – Page 327Anal sphincter repair: a report of 60 cases and review of the literature. ... Patterns of fecal incontinence after anal surgery. ... Endosonographic assessment of postpartum anal sphincter injury using a 120 degree sector scanner. Objective: INTRODUCTION. Les opioïdes ne devraient être utilisés qu’avec précaution. Urethral sphincter damage is caused by trauma to the pelvic floor, bladder, and urethra. 1 in 3 women sustain some anal sphincter damage during the birth of their first baby, if it is born naturally through the vagina, but not all of these women will experience symptoms. Vaginal delivery is known to be one of the risk factors for anal incontinence among adults, and women with obstetric anal sphincter injury (OASIS) have higher risk of severe anal incontinence than women without such injury [1, 2].The prevalence of anal incontinence among women who sustained OASIS 1-5 years previously has been found to be 18-53% for flatus and 3-23% for stools [3,4,5,6,7]. anal incontinence; anal sphincter injury; end-to-end repair; obstetrical complications; overlap repair; perineal laceration; pregnancy; sphincteroplasty. Hi there, I am hoping someone out there can help me. Déclarations sommaires 1. There are a number of non-surgical approaches to help you manage. Important questions to think about include whether your symptoms are affected by anything that you eat or drink; whether you had any symptoms like this before pregnancy and delivery; and whether anyone in your family has a bowel disorder, such as Crohn’s disease or ulcerative colitis (inflammatory bowel disease). In particular, occult injury to the anal sphincter complex may occur at the time of an otherwise uncomplicated delivery and, if neglected, can contribute to anal and fecal incontinence [].Even when recognized and repaired, persistent sphincter dysfunction is . ric anal sphincter injury require acute management at the time of delivery, together with follow-up or referral when newly presenting with symptoms months or years after childbirth. Formuler des recommandations permettant d’éclairer les conseils offerts aux patientes ayant connu des LOSA en ce qui a trait à la voie d’accouchement à privilégier dans le cadre des grossesses subséquentes. Questionnaire evaluating symptoms of urinary and anal incontinence in nulliparous women before and after delivery and correlating these symptoms . obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence) appropriés. Childbirth may be accompanied by mechanical or neurologic injury to the anal sphincter. Midline and Mediolateral Episiotomy: Risk Assessment Based on Clinical Anatomy. Persistent anal sphincter defects are present in up to 85% of women who sustain anal sphincter damage and repair at the time of vaginal delivery. (II-2) 4. (II-2B) 2. Surgery to repair muscle damage is sometimes suggested to treat incontinence and different techniques apply depending on the type or extent of damage.When considering surgical treatment, be sure to discuss the risks as well as potential benefits, including chances and degree of expected improvement. Most women, especially women having their first vaginal delivery, have some tears (also called lacerations) of the vagina or perineum. Found inside – Page 290Primary anal sphincter repair is inadequate in most women who sustain third or fourth degree tears, ... urinary symptoms should be identified, documented, and all women educated about possible postnatal symptoms and how to seek help. If the anal sphincter muscles are healing but weak, physical therapy for muscle strengthening might be recommended. Found inside – Page 1055Following oAsIs, a repair of the anal sphincter in the immediate postpartum period is usually performed by an ... months or years after childbirth), it is regarded as a secondary sphincter repair even though a direct primary repair may ... Tears can be around the urethra or in the vagina or perineum. Art. The main functions of the colon and anorectum (collectively known as the large intestine) are to mix and absorb water from ingested material, to store, Presented as “Biofeedback, Incontinence, and the Patient’s Perspective” at a symposium on Treatment of Bowel, Bladder, and Pelvic Floor Disorders, held June 23–26, 2005, at. 2. Doctors identify an injured area of muscle and free its edges from . If your clinician says “Only when necessary,” you should press for an answer that includes an average number. No. Spinelli A, Laurenti V, Carrano FM, Gonzalez-Díaz E, Borycka-Kiciak K. J Clin Med. Background During childbirth, many women sustain trauma to the perineum, which is the area between the vaginal opening and the anus. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d’étude canadien sur les soins de santé préventifs (Tableau). 1 in 3 women sustain some anal sphincter damage during the birth of their first baby, if it is born naturally through the vagina, but not all of these women will experience symptoms. Stavros S, Papapanagiotou IK, Zacharakis D, Migklis K, Mantzioros R, Domali E, Chatzipapas I, Drakakis P, Rodolakis A. Clin Case Rep. 2021 May 24;9(5):e04309. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women). Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. As noted above, about half of women who had anal sphincter laceration and repair at delivery will experience some changes related to their bowel control. At the very least, all expectant mothers should expect the best available information from their doctors, with the understanding that not all questions can be definitively answered at this point. Should recommendations for management at a second delivery be influenced by what occurred at the first delivery. (1-A) 9. La constipation devrait être évitée au moyen d’un laxatif ou d’un émollient fécal. Le système de classification de l’Organisation mondiale de la santé devrait être utilisé pour classer les lésions obstétricales du sphincter anal. This operation consists of a cut in front of the anus. Found inside – Page 450Elective sphincter repair Elective repair of an external sphincter defect is most often undertaken months or years after major sphincter damage sustained in childbirth or during anal surgery . Good operative conditions are essential ... There were 588 women in the six trials analysed. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies. They then bring the muscle edges back together and sew them in an overlapping fashion, strengthening the muscle and tightening the sphincter. eCollection 2021 May. When OASIS occurs, it is often useful to use a surgical checklist to ensure the execution of all steps in the management of the repair and recovery process. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. Plair A, Bennington J, Williams JK, Parker-Autry C, Matthews CA, Badlani G. Int Urogynecol J. Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. If anal sphincter laceration and repair occurred at delivery, it may be possible to tell by physical examination whether the muscles are healing well or whether the muscles have separated. After a successful repair of obstetrical anal sphincter injuries, most women can safely deliver vaginally in a future pregnancy. Disclaimer, National Library of Medicine This valuable text also provides information on the management and treatment of a full range of disorders, from childbirth damage and post-prostatectomy incontinence, to neuropathic voiding dysfunction. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Roper JC, Amber N, Wan OYK, Sultan AH, Thakar R. Int Urogynecol J. In approximately 5% of these women, the trauma involves the anal sphincter, resulting in third- or fourth-degree tears, which are also referred to as obstetric anal sphincter injuries (OASIs). Found insideThis book focuses on the management of children with fecal incontinence and constipation. Despite accurate anatomic reconstruction, many children still suffer from a variety of functional bowel problems. fashion or apposed with 3/0 PDS (Ethicon) sutures. There are four grades of tear that can happen, with a fourth-degree tear being the most severe. Le recours à la technique de suture « en paletot » (chevauchement) nécessite souvent une mobilisation et une dissection de plus grande envergure des extrémités du sphincter; l’utilisation de cette technique n’est possible qu’en présence de déchirures sphinctériennes de degré 3b ou plus. Direct repair of anal sphincter muscle tears is commonly performed immediately after childbirth (see Third and Fourth Degree Perineal Tears leaflet), but sometimes this is also done later in life in women with anal incontinence.