Sphincter

Sphincter . Annular muscle with which the opening of a body cavity is opened and closed to release or retain any stool or discharge; like the urine bladder or the anus .

Summary

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  • 1 Potty training
    • 1 Requirements
    • 2 Stages
  • 2 Prosthesis
    • 1 Identification and description of the procedure
    • 2 Benefits
    • 3 Alternatives
  • 3 Consequences of its non-performance
    • 1 Risks
  • 4 Oddi Sphincter Dysfunction
    • 1 Classification
    • 2 Functional disturbances
  • 5 Sources

Potty training

Potty training is not learned. It is acquired when the child is mature for it. Walking , talking , eating are functions that are acquired when children are mature enough. They are slow, gradual acquisitions that take a long time. Well into the second half of the second year of life (that is, after a year and a half), some babies may begin to notice when their diapers are dirty, and even to know when they are “doing it to them.” This is a slow process that can take around 2 more years, leading to potty training.

The neuromuscular function that leads to control of the bladder and anal sphincter takes place over a period of approximately 3 years, between the second and fifth years. Few children reach full control before age 2, and most have no problem other than an occasional accident after age 5. Within these limits there are degrees of variations in the order and in the exact time in which each child reaches that control.

Requirements

To achieve this control requires:

  • Achieve a determined neurological development, be able to wander, understand and express oneself verbally.
  • Be at a level of affective maturation with development of anal and ureteral tendencies.
  • The family is prepared and willing to accompany and guide the child’s process.

Usually at this stage the child has a strong predilection for playing with his body and with plastic substances. These materials in the child’s hands create pleasant play situations that should be facilitated and allowed by parents.

Water , sand , mud , paints, putty , etc. are recommended . And parents need to be tolerant of the dirt implicit in these games. Sphincter control represents a step in socialization, the child learns to eliminate their excreta at a socially appropriate time and place. Normally the anal sphincter is checked first and then the bladder is checked.

Stages

Three stages are classically described:

  1. The child is able to perceive that he has peed or pooped on his diapers and is able to transmit it to his parents.
  2. He perceives and transmits in the moments before or during the act, but is unable to retain.
  3. You can retain or decide the expulsion, both pleasurable sensations.

You can also interrupt or restart.

In the first and second stage the parents will be able to arrange a romper in the bathroom and when he indicates that he has peed or pooped, he can be shown the dirty diaper and the romper simultaneously, clearly expressing to him what he will do there in the future and what it is for the gadget. It is highly inadvisable to practice installing the child in the jumpsuit at times that are close to those usually evacuated.

In the third stage the parents must respond to the child’s request by removing the diaper, to sit him in the baby’s suit. This response needs to be constant and not erratic. It is common for the child to be able to hold onto the seat and successfully evacuate. Satisfaction with the achievement should be expressed, but without making it the event of the century, as it is not uncommon that if the boy detects extreme joy or disappointment as he meets parental expectations or not, he uses the control to express his love or hate and lose as a main reference his own bodily sensations. Many situations of enuresis or encopresis develop at this stage and for pathological link reasons.

In the second and third stages the child can be left without diapers from time to time to have a more immediate contact with his excreta and to become familiar with them, but the final removal will be made when the diapers are no longer necessary or when control is relatively trustworthy. It is usually first day and then night.

Behaviors that imply for the little one a challenge greater than his possibilities will be avoided. As a chronological reference, it is only after a year and a half of age that children begin to pass the first stage and it is only around two to two and a half that for the majority, stages two and three are established.

There are some pictures in which children who controlled sphincters stop doing it and this has to do with urinary tract infections and with psychological regressions. The best way to help the child is not to show anxiety. Restricting the use of drinks does not usually have a significant effect on this pathology. With older children, certain games can be implemented that reward the child when he wakes up without urinating.

Prosthesis

[[File: | 200px | thumb | right | Sphincter Prosthesis]] It consists of an intervention to place the prosthesis at the level of the urethral sphincter and solve problems of difficulty or inability to urinate. This type of intervention is indicated in certain patients with neurogenic bladder and urinary obstruction due to involuntary closure of the external sphincter.

Identification and description of the procedure

The prosthesis is a cylindrical mesh of biocompatible material, usually well tolerated, which can be placed under regional or local anesthesia. Once located in the sphincter urethra, it expands, leaving the duct open to facilitate urination. Or it is a temporary internal prosthesis, which is attached to the neck of the bladder (like a short tube). The postoperative period is short. Sometimes, during the first days it is necessary to carry a bladder catheter, or perform intermittent catheterizations depending on the type of neurogenic delivery.

Benefits

Restore normal urination.

Alternatives

Endoscopic urethrotomy.

Consequences of its non-performance

It is considered as the best option among the possible ones. If not accepted, there is a high probability of persistence and / or progression of the symptomatology of the disease. The possible complications that may occur in the future are unpredictable, including life-threatening.

Risks

From this intervention it is possible but not frequent to expect the following side effects or complications:

  • Failing to regain normal urination.
  • More or less abundant bleeding that may require a blood transfusion.
  • Urinary infection or prosthesis, which may require its removal and with the risk of generalized infection.
  • Intolerance to the prosthesis or mobilization of the same that can force its removal.
  • Obstruction of the lumen of the prosthesis due to the formation of stones or the growth of the urethral tissue.
  • Perineal pain with erection.
  • Urinary Incontinence.

Oddi Sphincter Dysfunction

Oddi sphincter dysfunction presents clinical, diagnostic and therapeutic difficulties, since medical treatment has not been proven in the long term. Functional disturbances of the Oddi sphincter (EO) can lead to intermittent upper abdominal pain and transient increase in liver enzymes, bile duct dilation, temporary increase in pancreatic enzymes, or episodes of pancreatitis. It is not always possible to fully differentiate functional disorders from structural changes, such as histological abnormalities, the presence of microlithiasis, or damage caused by previous passage of stones.

EO dysfunction encompasses associated motility disorders without denoting etiology and comprises two conditions: stenosis and dyskinesia. The first involves a structural alteration characterized by elevated baseline EO pressure on manometry, and the second involves possible smooth muscle dysfunction. Although the etiology of EO dysfunction is uncertain, the proposed causes include damage to the sphincter due to the passage of stones, the division of the nerves that communicate the gallbladder and EO, or intrinsic neuromuscular defects.

Both stenosis and dyskinesia can cause obstruction to flow through the EO and induce biliary retention and pancreatic secretion. In cholecystectomized or impaired EO and gallbladder regulation, increased bile duct or pancreatic duct pressure may be clinically manifested by typical biliopancreatic pain, which apparently results from stimulation of sensory fibers that follow ductal distention caused by increased pressure in the bile duct.

The episodes of pain suggest the diagnosis, particularly when no structural alterations are found that explain the symptoms. Most affected people have a history of cholecystectomy.

Classification

EO dysfunction can be classified according to clinical presentation, laboratory results, and findings of endoscopic retrograde cholangiopancreatography (ERCP): Type I. Patients presenting pain , liver biochemical abnormalities observed on two or more occasions, drainage of slow contrast and dilated common bile duct with a corrected diameter equal to or greater than 12 mm in ERCP. Type II. Pain patients and only one or two of the above criteria. Type III. Patients who have only recurrent biliary pain and none of the above criteria.

EO dysfunction can be confused with pancreatitis due to the significant increase in amylase or lipase. In these cases, the traditional causes of pancreatitis are not identified, so they are frequently classified as idiopathic recurrent pancreatitis. Prevalence of 1% to 1.5% of biliary pain has been reported in unselected cholecystectomized patients and 14% in selected groups. The frequency of dysfunction varies in the different clinical subgroups: 65% to 95% in type I, especially due to OE stenosis; 50% to 63% in type II, and 12% to 28% in type III. EO dysfunction can compromise both the biliary and pancreatic sphincter or both (in 30% of cases).

Functional disturbances

Functional alteration may exist even with an intact biliary tree and gallbladder, and since the symptoms are difficult to differentiate, the diagnosis is commonly made following a cholecystectomy or, less frequently, of appropriate investigations to exclude gallbladder abnormalities.

Symptoms should be differentiated from organic disease and other common functional disorders: dyspepsia due to other causes and symptoms of irritable colon. The diagnostic algorithm of cholecystectomized patients begins with the biochemical analysis of the liver and pancreas, plus the careful elimination of possible structural causes using transabdominal ultrasound and ERCP. Based on available resources, endoscopic ultrasound and magnetic resonance cholangiography may precede ERCP in certain cases.

To predict the outcome of the sphincterotomy, the quantitative evaluation of the bile transit from the hepatic hilum to the duodenum on the common bile duct scintigraphy has been shown to be of value before deciding on manometry. Patients with EO dysfunction types I and II with slow transit may undergo endoscopic sphincterotomy without manometry, while slow biliary transit in type III is an indication of manometry. In patients with characteristics of pancreatic dysfunction, manometry of both sphincters is indicated.

Therapeutics are aimed at reducing resistance to bile or pancreatic flow. Calcium channel blockers and nitrates can lower the pressure on the EO. Injection of botulinum toxin into the sphincter produces symptomatic improvement, although more specific studies are required to assess whether it is a suitable alternative to predict a successful outcome of subsequent sphincter ablation.

The side effects of calcium blockers and nitrates are observed in up to a third of patients. Finally, the long-term outcome is unknown. Hydrostatic balloon dilation has been used with unacceptably high complication rates, mainly pancreatitis, which limits its use.

Endoscopic sphincterotomy is the most widely used procedure. It is less expensive and has less morbidity than open surgery, although it presents a pancreatitis risk of 5% to 16%. For pancreatic EO dysfunction, sphincteroplasty and septectomy have been the preferred treatment. Recently, favorable results of pancreatic duct sphincterotomy were reported after an initial endoscopic sphincterotomy of biliary EO with poor evolution.

Stenting to relieve pain and predict the response of definitive treatment (sphincter ablation) has received only limited application. They are strongly discouraged in the pancreatic duct as severe ductal and parenchymal injury can ensue if the stent is left in place for more than a few days.

 

by Abdullah Sam
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