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=== '''Structural problems''' === ** Anal sphincter disruption *** Obstetric (most common) - ''trial non-operative options, then surgically repair or SNS'' **** Prolonged second stage (pudendal nerve injury) **** Actual passage of baby **** Instruments **** Often doesn't become symptomatic until post-menopause *** Iatrogenic ''- fix underlying cause, then optimise medical management, consider SNS'' **** LIS **** Fistulotomy **** Haemorrhoidectomy **** Radiation *** Anorectal disease ''- fix underlying cause - surgically'' **** Rectal prolapse ***** Lead-point of prolapse acts like an intussusception, causing stretch of anal canal, and subsequent damage **** Prolapsing internal haemorrhoids ** Disruption of pelvic floor - ''surgically repair or SNS'' *** Associated with ageing - diminished muscle bulk and strength *** Excessive perineal descent - associated with denervation of the pelvic floor *** Traumatic **** Perineal impalement **** Voluntary anoreceptive intercourse **** Foreign bodies **** Sexual abuse
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