Treatments

Infiltration

Sphincter reconstructions

What does this involve?

The function of the sphincter muscle is the control of the closure of the digestive tract. Sphincter reconstruction consists of the repair of this double muscular cylinder aimed at restoring the initial continence.

So why perform sphincter reconstruction?

The most common indication is incontinence related to rupture of the sphincter ring, most often following traumatic childbirth. The lesion is usually located anteriorly (in the direction of the vagina) and requires repair by superimposing the two free muscular edges (sphincteroplasty).

The excision of a fistula, whose path crosses the sphincter muscle will require either an incision or a "coring" of it. Preserving the integrity of the anal canal will require the surgeon to perform a sphincter reconstruction, sometimes protected by mucosal lowering (fistulectomy with mucosal advancement flap) or with the addition of mucosal reconstruction (Musset Cotterel operation).

How do we do it?

Sphincteroplasty is performed through a distal perineal or vaginal incision and requires careful dissection that will highlight the lateralized sphincter stumps and avoid denervation and devascularization. A median suture by overlapping the stumps will reconstitute the sphincter ring and ensure its tightening during muscle contraction. The suture is made of absorbable threads, knotted in separate points. The perineal fat and then the skin are sutured on the midline, recreating the distance lost between the anus and vagina. This procedure can be performed under perineal or general anesthesia and requires a short hospitalization.
Fistula surgery is discussed separately.

What result can we expect?

In the absence of neurological damage to the perineum (involvement of the pudendal nerves), sphincteroplasty for postpartum incontinence gives excellent results. Initial continence to solid and liquid stools exceeds 85%. It must be maintained in the long term by physiotherapy of the perineum and can be practiced at any age. Gas control is more difficult and may require therapeutic adjustments. Some degradation may occur over the years.

Are there alternatives?

In case of injury of the pudendal nerves, or during failure or degradation of the sphincteroplasty, the alternative of choice is sacral neuromodulation, which consists of direct electrical stimulation of the nerves. Other alternatives are discussed in the chapter on incontinence.