PubMed · 13416144
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J LAURENS. 1957. Proctology.. https://pubmed.ncbi.nlm.nih.gov/13416144/
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OBJECTIVE: We prospectively evaluated the risk of recurrence of anal sphincter disruption ("third degree tear") at next vaginal delivery and whether this complication was predictable by antepartum anal functional assessment. STUDY DESIGN: Among 20,111 consecutive vaginal deliveries, where midline episiotomy was not performed, 342 (1.7%) third degree tears occurred, significantly more often in primiparae (2.9%) than multiparae (0.8%; P<0.001), all of whom underwent postpartum anal manometry and endosonography. Similar testing was performed antepartum and postpartum in 56 of 342 women who delivered again during the study period. RESULTS: Eleven of 56 women were delivered by caesarean in next pregnancy. Third degree tears recurred in 2 (4.4%) of 45 women at next vaginal delivery. Both recurrent injuries occurred in asymptomatic women with normal antepartum manometry and following spontaneous deliveries and were satisfactorily repaired. CONCLUSION: Although anal sphincter injury was increased five-fold at next delivery, compared with all multiparae, 95% of women delivering vaginally after previous third degree tear did not sustain further overt sphincter damage. Recurrence was not predictable using pre-delivery anal physiology testing.
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The urethrogenital (UG) reflex is a spinal sexual reflex that consists of autonomic and somatic nerve activity and vaginal, uterine, and anal sphincter contractions. The UG reflex is under tonic descending inhibition by neurons in the region of the nucleus paragigantocellularis (nPGi). The location of spinal neurons activated by the UG reflex was examined in the female rat using the immediate early gene, c-fos. In addition, the descending inputs from the nPGi onto fos-activated neurons was examined using the anterograde tracer biotin dextran amine injected into the nPGi. The UG reflex resulted in a significant increase in fos-positive nuclei in segments T12-S1, compared with experimental controls in which the UG reflex was not activated. Spinal circuits involved in the UG reflex include neurons relaying afferent information from the pudendal sensory nerve, in the dorsal horn and medial cord of L5-S1. Efferent output includes preganglionic neurons located in the lateral gray of L5-S1 and lateral and medial gray of T13-L2. Spinal interneurons involved in the UG reflex were found close to the preganglionic neurons and in the dorsal horn and intermediate and medial gray of T12-S1. NPGi inputs were found primarily on the autonomic efferents and interneurons in the medial and intermediate gray. These studies demonstrate multisegmental spinal circuits activated with the UG reflex and demonstrate that the descending inhibition from the nPGi is by means of preganglionic and somatic efferents and spinal interneurons closely associated with the efferent output.