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The etiologic risk factors and associations contributing to pelvic floor disorders include vaginal parity, ageing, hormonal status, pelvic surgery, collagen diseases, and depression. Many of these relationships, including hormonal status, are poorly understood. In addition, not all pelvic floor disorders are explained by the same risk factors or mechanisms. For example, vaginal parity appears to be the greatest risk factor for developing pelvic organ prolapse, while urinary incontinence has many other risks factors with equal or greater influence, including obesity and ageing. The basic mechanisms of disease and structural failure, both gross and microscopic, which lead to pelvic floor disorders need further investigation. A better understanding of the muscular, collagen, and neuronal components of the pelvic organs and their supports would provide targeted areas for prevention and treatment. [ABSTRACT FROM AUTHOR]

Perineal trauma can be associated with considerable short- and long-term morbidity. Perineal laceration and episiotomy are painful, incur blood loss, and may become infected; fistulae occasionally follow. Long-term, other complications of obstetrical trauma to the pelvic floor may affect women's lives even more than the immediately apparent laceration. Dyspareunia related to the tear and its repair may last for months or even years. Pelvic floor muscles and nerves may be stretched, torn or sheared from their attachments, as shown in magnetic resonance imaging studies,1 resulting in urine leakage, urgency or incontinence of faeces or flatus, or pelvic organ prolapse. Apart from the physical and hormonal aspects of pregnancy, the specific effects of childbirth have not yet been clearly distinguished, although some light has been shed by prospective studies, especially by the Term Breech Trial, in which planned vaginal or caesarean birth was randomly assigned.2 [ABSTRACT FROM AUTHOR]

Radiologic imaging of the perineum and sphincteric complex has been a process of evolution in which technical developments from the perineal and endoanal ultrasound, to the newer modalities of three-dimensional (3D) imaging1,2 and endocoil magnetic resonance imaging (MRI),3 have allowed finer details of the perineal anatomy to be unravelled. Endoanal ultrasound was developed in the early 1990s4 as a simple method for imaging the sphincter complex as a complement to manometric studies, so that both the structural and functional aspects of the anal sphincter could be investigated. While the technique may seem relatively simple, the sonographic anatomy of the perineal region has proven to be surprisingly complex.5,6 [ABSTRACT FROM AUTHOR]

When investigation of the anorectum is appropriate (i.e. those patients in whom empirical conservative measures have failed, concurrent disease has been excluded, and there is a significant impact of symptoms on quality of life), assessment should be carried out in the context of global pelvic floor evaluation, aimed at both morphology/ anatomy and function. The former can be evaluated by physical examination, but in more detail by imaging (static or dynamic), and the latter by clinical history and examination, but in more detail by tests of physiology. It is important that assessment is combined with an understanding of the sufferer's expectations of treatment. [ABSTRACT FROM AUTHOR]

The anatomy of the pelvic floor, rectum and anal canal is a complex and surprisingly dynamic field with new insights, discoveries and controversies. The controversies arise as new and different tools are used to study anatomy for varying purposes. Anatomists, sprung through cadaveric dissections, propose a structure that may differ from a surgeon's depiction or understanding of the structure/ function relationships of the pelvis as seen in the operating room. This controversy is best seen in describing the external anal sphincter (EAS) and the puborectalis muscle. Is the puborectalis a part of the EAS? Is the EAS a one, two, or three loop striated muscle? Perhaps all descriptions are correct, depending on the point of view and purpose of evaluation. The goal of this chapter is not to solve these controversies, but to describe the functional and structural anatomy as it is known from cadaveric dissections, radiological imaging and surgical repairs in order to improve the management of our patients. [ABSTRACT FROM AUTHOR]

It would be beyond the aim of this chapter, and probably also the reader's interest, to proffer a highly detailed description of our current knowledge of the mechanisms underlying anal continence and defaecation. Nevertheless, to understand disturbance of these functions, it is important to appreciate that although continence is dependent to a large degree upon the functional integrity of the lowest sphincter of the gastrointestinal tract,1,2 and that this is the structure most threatened by obstetric trauma,1-5 the ability of an individual to retain rectal contents and only allow their passage when desired, results from a multitude of factors in addition to the anal sphincter complex.1,4-7 Such factors include the physical nature of the hindgut contents, the speed at which they are delivered there, and the ability of the hindgut to accommodate that which is delivered to it.1,2,4,6,7 [ABSTRACT FROM AUTHOR]

This chapter is an introduction to the relevant law (both substantive and procedural) of England and Wales (the Scottish system is different) and the United States. It seeks to explain how a lawyer considers and then litigates (or defends) the scenario when a patient wishes to pursue a claim against her doctor for clinical negligence. It considers the elements that a patient must prove in order to establish a right to an award of compensation. It explains the procedure for bringing a claim and gives examples of claims and cases. In both legal systems the laws applied to malpractice claims are predominantly contract and tort law. [ABSTRACT FROM AUTHOR]

Rectovaginal fistula is defined as a communication between the rectum and the vagina. Although relatively rare, the impact on quality of life of patients may be profound. Causes include traumatic, congenital, inflammatory, neoplastic and iatrogenic processes (see Table 13.1). While estimates vary, the most common cause of rectovaginal fistulas is thought to be secondary obstetrical complications, followed by inflammatory and neoplastic disorders.2-4 Fistulas that occur as a result of congenital malformations are beyond the scope of discussion in this chapter. Only the presentation and repair of acquired fistulas with particular emphasis on fistulas that occur as a result of obstetrical trauma will be presented. [ABSTRACT FROM AUTHOR]

Patients with severe faecal incontinence from anal trauma who are unresponsive to conservative measures can be divided into two broad categories of surgical approach. The first group includes those patients with an identifiable and isolated anatomic sphincter defect who can expect 70-80% short-term surgical success with overlapping sphincteroplasty.1 However, the effects of overlapping sphincteroplasty appear to deteriorate with time. Five-year follow-up in 47 patients undergoing sphincteroplasty for obstetric-related trauma revealed a success rate of 57% with no need for further therapy, while 14% required further intervention.2 In a second study involving 6 years of follow-up for sphincteroplasty patients, only 46% were continent of solid, liquid or gas, with only 14% admitting to complete continence.3 Ten-year follow-up of 191 patients revealed 40% with some continence and only 6% with complete continence.4 [ABSTRACT FROM AUTHOR]

As the prevalence of anal ultrasound examinations increases, so will the number of patients seen with a reported abnormality whose significance remains in doubt. Uncertainty regarding the meaning of abnormal studies in relation to long-term sequelae raises a few issues that could prove difficult: for example, the complexity of advising a woman how much improvement she can expect and how long that improvement will last. Furthermore, the actual operation of anal sphincter repair needs to be tailored to the severity of injury, whether it is simple with straightforward faecal incontinence, or a more complex case, either with an associated ano/rectovaginal fistula or with an accompanying evacuation disorder. [ABSTRACT FROM AUTHOR]

Anal incontinence (AI) may be defi ned as any involuntary loss of stool or gas via the anus.1 Specifically, faecal incontinence (FI) is loss of stool, whether liquid or solid. [ABSTRACT FROM AUTHOR]

The morbidity associated with perineal injury related to childbirth constitutes a major health problem, affecting millions of women worldwide. The majority of women following vaginal delivery will suffer some degree of perineal pain or discomfort during the early postpartum period.1 In the UK alone, approximately 1,000 women per day will require perineal repair following vaginal birth. Pain associated with perineal trauma can be very distressing for the new mother and may interfere with her ability to breast feed and cope with the daily tasks of motherhood.2 It also appears to have a clear causal association with sexual dysfunction and ultimately may affect the woman's relationship with her partner. [ABSTRACT FROM AUTHOR]

The earliest evidence of severe perineal injury sustained during childbirth is from the mummy of Henhenit, an Egyptian woman approximately 22 years of age from the harem of King Mentuhotep II of Egypt in 2050 BC.1 Henhenit's pelvis was an abnormal shape, there was a rupture of the vagina into the bladder and the lower bowel was found protruding from the anus. These severe perineal injuries may have been due to cephalo-pelvic disproportion that probably resulted in her early death.1 [ABSTRACT FROM AUTHOR]

More than 85% of women sustain some form of perineal trauma during vaginal delivery in the UK.1 However, the prevalence is dependent on variations in obstetric practice, including rates of episiotomy, which vary not only between countries but also between individual practitioners within hospitals. In the Netherlands, the rate of episiotomy is 8% compared to 14% in England, 50% in the USA and 99% in East European countries.2-4 Episiotomy rates also vary between hospitals in the same country: for example, in the USA the rates varied between 20% and 70% in individual units.5 [ABSTRACT FROM AUTHOR]

The World Health Organisation (WHO) defines female genital mutilation (FGM) as any procedure that involves partial or total removal of the external female genitalia, or any other injury to the female genital organs for cultural or non-therapeutic reasons.1 [ABSTRACT FROM AUTHOR]

Over the past century there has been a dramatic fall in maternal morbidity and mortality, especially in the developed countries. Women therefore have high expectations of pregnancy and childbirth and consequently feel disillusioned when complications occur in the postpartum period. Up to 87% of mothers experience at least one health problem in the first 8 weeks postpartum, reducing to 76% 8 weeks to 18 months after delivery.1 MacArthur et al.2 found that the majority of symptoms that lasted more than a year after birth were still present 1-8 years later, suggesting that problems arising after childbirth can have long-term consequences on women's health. Common postnatal health problems include tiredness, 1,3,4 headache,1,3 haemorrhoids,1,3,4 perineal pain,1,5 breast conditions,1 constipation,1 dyspareunia, 4,6 backache,7 and urinary8-10 and anal incontinence.11-14 However, the majority of women do not consult a health professional even if they feel that they need help.3 [ABSTRACT FROM AUTHOR]