Female perineum is the tissue complex between the peritoneum and the skin that closes the pelvis inferiorly and its functionality depends on the interplay between organs, tissues, septae and spaces in it. It is a diamond-shaped region below the pelvic floor and extends between the pelvic diaphragm and the perineal skin. It is a surprisingly dynamic field with new insights, discoveries, and controversies and carries differences in viewpoint among anatomists and surgeons. This book chapter will provide an overview regarding perineal anatomy in the female and will focus on embryology, anatomy of the perineal region with modern proponents. It includes detailed anatomy of Urogenital and Anal triangles, their muscles with blood supply and innervation, anatomy and functions of the perineum, its role in Pelvic Organ Prolapse and clinical significance in urinary and fecal incontinence and contribution towards common obstetric and gynecological pathologies.
Objectives: There is conflicting evidence regarding the indications of urodynamic studies (UDS) and various guidelines. American urogynecologic Society (AUGS), National Instititute of Health and Care Excellence (NICE), and WHO provide variant indications for UDS testing. For developing countries, there are no data to support the usefulness of UDS. Considering the cost, invasiveness, and expertise required for UDS, we planned to review UDS performed at Aga Khan University and Hospital (AKUH) from 2007 to 2014. Our purpose of study was to derive important conclusive messages as a guideline for future practices. Study design: This is a cross-sectional retrospective review of 500 patients undergoing UDS from 2007 to 2014. Results: Comparison between clinical diagnoses and urodynamic diagnoses was done and frequencies were computed. The mean age of the patients was 61.1 years, the mean body mass index was 25 and mean parity was 4.1. There was a matching between clinical and urodynamic findings of stress urinary incontinence (SUI) and overactive bladder (OAB), but disparity was observed in cases of mixed urinary incontinence (MUI) and lower urinary tract symptoms (LUTS). Occult SUI was found in 33% of patients with POP. Conclusion: Key messages were derived for future practice stating that for cases of SUI and OAB, UDS are not required, but patients with complex MUI, chronic LUTS, and neurogenic bladder warrant UDS.
Objective: To perform a clinical audit of the practices of third and fourth degree preineal tears management in our institution. Methods: A review of medical records was performed, of women having singleton term vaginal delivery sustaining obstetric anal sphincter injuries (OASIS) at Aga Khan University Hospital (AKUH), Karachi from January 2008 to December 2018. We compared the change in practices regarding management of OASIS with the results of our previous study done at AKUH in 2008. Results: The frequency of OASIS in our department is 0.56% (142/25370). The documentation of OASIS improved compared to previous study ( 20.7% to 87%). There was also a significant increase in documentation of the method of repair, use of delayed absorbable suture material for the repair of external anal sphincter and follow-up at 06 weeks to see the success of repair and plan next delivery. The use of vaccum vaginal delivery increased to 27(19%) from 5(4%) but there was decrease in the OASIS complicated by instrumental vaginal deliveries, which may be due to the decrease in the use of forceps from 64% to 26%. Conclusions: Despite of increase in the number of deliveries , frequency of OASIS remained similar to the previous study. There was a significant increase in the vaccum vaginal delivery, documentation of degree of tears, use of delayed absorbable suture material and long-term follow-up and decrease in the use of forceps. The compliance to international guideline increased as compared to our previous paper. Continuous...
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