Tratamiento rehabilitador en pacientes con desgarro de esfinter anal obstétrico asintomático y con incontinencia anal

Abstract

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...