FEKALNA INKONTINENCIJA Nova koncepcija: Uloga unutarnjeg analnog sfinktera pri defekaciji i fekalnoj inkontinenciji

Introduction. Fecal incontinence is involuntary escape of stool, mucus and/or flatus.Its causes are: anal sphincter damage (childbirth trauma, surgical trauma.); constipation; diarrhea; rectocele; rectal prolapse and rarely congenital causes. Fecal material entering the rectum is evacuated by defecation during which: 1. The smooth muscles of the distal colon and rectum contract, propelling the feces into the anal canal; 2.The anal sphincter relaxes allowing defecation to occur. We put forward a recent concept on the patho-physiology of defecation.The mechanism of defecation has two stages: first stage: (in early childhood) before training; second stage is after training. The mother starts to teach her child how to control himself. This is gained by maintaining high alpha sympathetic tone at the internal anal sphincter (IAS) keeping it closed all the time till appropriate place and time are available. Wherever appropriate place is available and there is a desire, six neuromuscular actions will occur: 1) the person will lower the acquired high alpha sympathetic tone at the IAS relaxing it opening the anal canal; 2) through the voluntary nervous system (NS) he will widen the ano-rectal angle to bring the anal canal and the rectum on one axis. This is done through the pelvic floor muscles; 3) through, voluntary NS he will also relax the external anal sphincter (EAS); then synergistic actions between the voluntary and autonomic nervous system occur; 4) the abdominal and diaphragmatic muscles contract, increasing the intra- abdominal pressure and forcing the feces through the anal canal (via the voluntary NS); 5) the smooth muscles of the distal colon and rectum contract, propelling the feces into the anal canal (through the autonomic NS); 6) followed by sequential contractions of the three parts of the EAS (deep then superficial and then the subcutaneous parts) that will squeeze the anal canal propelling any residual contents. Objectives. Imaging of the anal canal by 3-dimension ultrasound (3DUS) in normal women and women suffering from fecal incontinence and from rectocele, to compare the state of the IAS and EAS. Methods. 40 patients with FI were assessed clinically and by imaging using 3DUS, and also 10 normal women not suffering from fecal incontinence (FI) as a control. Results. The anal canal is closed in normal women, with intact IAS. In women suffering from FI the anal canal is wide and open with torn IAS. Conclusion. The internal anal sphincter (IAS) is a collageno-muscular tissue cylinder that surrounds the anal canal innervated by alpha-sympathetic nerve supply from the hypogastric nerves. It is surrounded in its lower part by the EAS which is a striated muscle innervated by the pudendal nerve. Its damage during childbirth causes fecal incontinence, and mending its torn wall restores fecal continence.Uvod. Fekalna inkontinencija (insuficijencija stolice) znači nevoljno bježanje stolice, sluzi i/ili vjetrova. Uzroci su: oštećenje sfinktera (pri rađanju djeteta, kirurška trauma), zatvor stolice, proljev; rektokela, ispadanje rektuma, rijetko prirođeno ispadanje. Stolica ulazi u završno crijevo te iz njega izlazi na sljedeći način: 1. Glatki mišići donjeg i završnog dijela debelog crijeva se stežu, potiskujući feces u analni kanal; 2. Analni sfinkter olabavi i omogući da uslijedi defekacija. Predstavljamo svježe shvaćanje o patofiziologiji defekacije. Mehanizam ima dva razdobkja: prvo razdoblje je rano djetinstvo, bez poduke; drugo razdoblje je nakon poduke. Majka podučava svoje dijete kako se kontrolirati. To se postiže visokim alfa simpatičkim tonusom unutarnjeg analnog sfinktera, držeći ga zatvorenim sve dok se ne ukaže odgovarajuće mjesto i vrijeme. Kad se nađe odgovarajuće mjesto, i ako postoji želja, počinje šest sinergističkih neuromuskularnih aktivnosti: 1) osoba će sniziti postojeći visoki alfa simpatički tonus unutarnjeg analnoga sfinktera i time otvoriti analni kanal; 2) pomoću voljnog živčanog sustava smanjit će ano-rektalni kut i dovesti ih u istu osovinu; to postiže pomoću mišića dna zdjelice: 3) voljnim živčanim sustavom također će omlohaviti vanjski analni sfinkter; tada nastupa sinergistična djelatnost voljnog i autonomnog živčevlja; 4) trbušni i dijafragmalni mišići se stežu, povećavaju intraabdominalni tlak te potiskuju feces kroz analni kanal; 5) stežu se glatki mišići debelog crijeva i rektuma te potiskuju feces u analni kanal (autonomnim živčevljem); 6) slijede segmentalna stezanja sva tri dijela vanjskog sfinktera (dubokog, površnog pa potkožnog), koja će iz analnog kanala istisnuti sve zaostatke. Svrha rada. Trodimenzionalnim ultrazvukom prikazati analni kanal u zdravih žena te u onih koje pate od fekalne inkontinencije i rektokele, usporediti njihov unutrašnji i vanjski analni sfinkter. Metode. Analizirano je klinički i 3DUZ-om 40 pacijentica s fekalnom inkompetencijom i uspoređeno s 10 zdravih žena. Rezultat. Analni kanal je u zdravih žena zatvoren, njihov unutrapnji sfinkter je neoštećen. U žena s fekalnom inkompetencijom analni kanal je širok i otvoren te s razderanim sfinkterom. Zaključak. Unutarnji analni sfinkter je kolageno-mišićno tkivo oblika cilindra koje okružuje analni kanal, inerviran je alfa-simpatičkim živcima iz hipogastričkog pleksusa. Unutarnji sfinkter je okružen donjim dijelom vanjskog analnog sfinktera, koji je građen od prugastog mišićja inerviranog pudendalnim živcem. Njegovo oštećenje tijekom rađanja uzrokuje fekalnu inkontinenciju. Prepravak njegove razderane stijenke uspostavlja fekalnu kontinenciju

KIRURŠKO LIJEČENJE STRES URINARNE INKONTINENCIJE, FEKALNE INKONTINENCIJE I VAGINALNOG PROLAPSA NOVOM OPERACIJOM »URETRO-ANO-VAGINOPLASTIKA«

We put forward a novel concept explaining the mechanism of micturition and the factors that control urinary continence. Also, we describe the mechanism of defecation and the factors that control stool continence and prevent fecal incontinence. A weak internal urethral sphincter (IUS) will not withstand sudden rise of intra-abdominal pressure and urine will leak. The weakness of the IUS is mostly due to traumatic rupture of its wall as a result of the huge vaginal distension that happens during prolonged, difficult and multiple frequent labors. So, surgical correction is by exposing that rupture and mending its walls. Also the marked vaginal distension which occurs in labor will cause lacerations in the internal anal sphincter (IAS) which is intimately related to the posterior vaginal wall. The torn weak IAS will cause fecal incontinence (FI). Exposing the torn IAS and mending the torn walls will restore the sphincter strength and fecal continence. Vaginal prolapse occurs as a result of vaginal wall weakness, redundancy and flabbiness subsequent to its marked stretching of its walls during vaginal deliveries. Overlapping the vaginal flaps both in the anterior and posterior vaginal wall, such repair will strengthen the vaginal walls, as if we put a collagenous mesh but instead this is an autologus collagenous mesh. We innovated an operation called »urethro-ano-vagino-plasty« to surgically treat urinary incontinence, fecal incontinence and and vaginal prolapse. Objectives. To describe this novel operation, and assess its results for a follow up period of 24 months. Methods. 134 patients with SUI and FI were assessed. Urethro-ano-vaginoplasty was done, and the results were assessed immediately and for 24 months follow up. Results. 121 (90.3%) gained urinary and fecal continence and remained continent in the follow up period. Conclusion. The internal anal sphincter (IAS) is a collageno-muscular tissue cylinder that surrounds the anal canal innervated by alpha-sympathetic nerve supply from the hypogastric nerves. It is surrounded in its lower part by the EAS which is a striated muscle innervated by the pudendal nerve. Its damage during childbirth causes fecal incontinence and mending the torn walls restores fecal continence.Predstavljena je nova koncepcija o mehanizmu mokrenja i čimbenicima koji reguliraju mokraćnu kontinenciju. Također, opisan je mehanizam defekacije te čimbenici koji kontroliraju kontinenciju stolice i sprječavaju fekalnu inkontinenciju. Slab unutarnji uretralni sfinkter (IUS) se ne može suprostaviti naglom porastu intraabdominalnog tlaka te će mokraća bježati. Slabost IUS-a je većinom posljedica ozljede njegove stijenke zbog silnog vaginalna širenja koje se zbiva tijekom produljenih, tešlih i učestalih rađanja. Kirurška korekcija se sastoji u nalaženju prsnuća i opskrbi njegove stijenke. Vaginalno širenje tijekom poroda uzrokuje prsnuće unutarnjeg analnog sfinktera (IAS), koji je intimno povezan sa stražnjom vaginalnom stijenkom. Oslabljeni i prsnuti IAS uzrokuje fekalnu inkontinenciju (FI). Prikaz prsnutog IAS-a i šivanje njegovih razderanih stijenki uspostavit će snagu sfinktera i fekalnu kontinenciju. Vaginalni prolaps nastaje kao posljedica slabosti i mlohavosti vaginalne stijenke te njene proširenosti, zbog istezanja tijekom vaginalnog rađanja. Preklapanjem vaginalnih režanja prednje i stražnje stijenke ojačava se stijenka, umjesto umjetne mrežice postavljamo vlastitu autolognu kolagenu mrežicu. Izumjeli smo za korekciju urinarne i fekalne inkontinencije te vaginalna prolapsa novu operaciju i nazcvali je »uretro-ano-vagino-plastika«. Cilj rada je opisati novu operaciju i prosuditi njen uspjeh nakon 24 mjeseca. Metoda. Operirane su 134 bolesnice sa stres urinarnom inkontinencijom i fekalnom inkontinencijom. Rezultati. 121 bolesnica (90,3%) je opet postigla mokraćnu i fekalnu kontinenciju i zadržala ih tijekom praćenja. Zaključak. Unutarnji analni sfinkter je kolegano-mišićni tkivni cilindar, inerviran alfa-simpatičnim živcima iz hipogastričkog pleksusa koji okružuje analni kanal. U donjem dijelu je okružen vanjskim sfinkterom koji je poprečno-prugaste mišićne građe i inerviran ograncima pudendalnog živca. Njegovo oštećenje tijekom rađanja uzrokuje fekalnu inkontinenciju, a šivanje prsnute stijenke uspostavlja fekalnu kontinenciju

Managing adult patients with infectious diseases in emergency departments: international ID-IRI study

We aimed to explore factors for optimizing antimicrobial treatment in emergency departments. A single-day point prevalence survey was conducted on January 18, 2020, in 53 referral/tertiary hospitals in 22 countries. 1957 (17%) of 11557 patients presenting to EDs had infections. The mean qSOFA score was 0.37 +/- 0.74. Sepsis (qSOFA >= 2) was recorded in 218 (11.1%) patients. The mean qSOFA score was significantly higher in low-middle (1.48 +/- 0.963) compared to upper-middle (0.17 +/- 0.482) and high-income (0.36 +/- 0.714) countries ( P < 0.001). Eight (3.7%) patients with sepsis were treated as outpatients. The most common diagnoses were upper-respiratory (n = 877, 43.3%), lower-respiratory (n = 316, 16.1%), and lower-urinary (n = 201, 10.3%) infections. 1085 (55.4%) patients received antibiotics. The most-commonly used antibiotics were beta-lactam (BL) and BL inhibitors (n = 307, 15.7%), third-generation cephalosporins (n = 251, 12.8%), and quinolones (n = 204, 10.5%). Irrational antibiotic use and inappropriate hospitalization decisions seemed possible. Patients were more septic in countries with limited resources. Hence, a better organizational scheme is required