Donald School Journal of Ultrasound in Obstetrics and Gynecology

Register      Login

VOLUME 12 , ISSUE 1 ( January-March, 2018 ) > List of Articles


Outlet Control, Pathogenesis, and Treatment: The Role of Ultrasound in Its Management

Abdel Karim M El Hemaly, Ibrahim M Kandil, Laila AES Mousa, Abdel AA Aldarwish, Muhammad R Morad, Mervat M Ibrhaim, Mahmoud Eledaisy, Khaled Shehata, Mona M Ragab

Keywords : 3DUS, Collagen chassis, Micturition and urinary continence, Outlet control, Urinary incontinence.

Citation Information : Hemaly AK, Kandil IM, Mousa LA, Aldarwish AA, Morad MR, Ibrhaim MM, Eledaisy M, Shehata K, Ragab MM. Outlet Control, Pathogenesis, and Treatment: The Role of Ultrasound in Its Management. Donald School J Ultrasound Obstet Gynecol 2018; 12 (1):4-12.

DOI: 10.5005/jp-journals-10009-1546

License: CC BY-NC 4.0

Published Online: 01-06-2018

Copyright Statement:  Copyright © 2018; The Author(s).


Introduction: Outlet control means continence, which is how to control body excreta (urine, flatus, and feces), control of temperance, body reaction, and control of sexual behavior and premature ejaculation. It is a nerve–muscle action, controlled by the central nervous system (CNS). Outlet control is an acquired behavior gained by learning and training to control the sympathetic nervous system. Although the sympathetic nervous system is part of the involuntary autonomic nervous system control, its function may be controlled. Evidence of this is seen in the control of body excreta control after toilet training and in how domestic animals can be trained to control body excreta as well. Micturition and urinary continence: Urinary continence depends on a closed and empty urethra created by two factors: one is the presence of a strong intact internal urethral sphincter (IUS), which is a collagen–muscle tissue cylinder that extends from the bladder neck down to the perineal membrane. The other factor is an acquired behavior which is keeping high sympathetic tone at the IUS gained in early childhood from toilet training. Failure of either factors leads to urinary incontinence (UI). Defecation and fecal continence: Fecal continence depends on a closed and empty anal canal created by two factors, one is inherent and one is acquired. The acquired factor is keeping high sympathetic tone at the internal anal sphincter (IAS) gained in early childhood from toilet training. The inherent factor is the presence of an intact strong IAS, which is a collagen–muscle tissue cylinder surrounding the anal canal. Pathology: Childbirth trauma (CBT) causes laceration in the collagen chassis of the vagina leading to vaginal prolapse, and the intimately related IUS in front and/or the IAS posterior, causing UI and/or fecal incontinence (FI). Pathophysiology: Outlet control is how to control the sympathetic nervous system and to manage different responses according to social circumstances. Diagnosis: Structural damage is diagnosed clinically and by medical imaging: ultrasound (US), magnetic resonance imaging (MRI) and/or computed tomography (CT) scan. Structural damage will cause functional disturbance which is assessed clinically and by urodynamics. Conclusion: Ultrasound scanning of the urethra to see if it is closed or open and the state of the IUS and visualizing the lacerations are easy and cheap methods of assessment of UI. Also US assessment of the anal canal, open or closed, and the IAS, and the extent of its laceration will help very much in its diagnosis and management.

PDF Share
  1. Abdel KMEH, Laila AMM, Ahmad ME. Outlet control. J Gynecol Women's Health 2017;3(3):555-620.
  2. El Hemaly AKM, Mousa LA, Kandil IM, Hussein KS. Continence. Reprod Syst Sex Disord 2016;5:186.
  3. El Hemaly AKMA, Mousa LAE. Stress urinary incontinence, a new concept. Eur J Obstet Gynecol Reprod Biol 1996; 68:129-135.
  4. El Hemaly AKMA, Kandil IM, Kurjak A, Mousa LAS, Kamel HH, Serour AG. Ultrasonic assessment of the urethra and the vagina in normal continent women and women suffering from stress urinary incontinence and vaginal prolapse. Donald School J Ultrasound Obstet Gynecol 2011 Oct-Dec;5(4):330-338.
  5. El Hemaly AKMA, Kandil IM, Kurjak A, Serour AG, Mousa LAS, Zaied AM, El Sheikha KZ. Imaging the internal urethral sphincter and the vagina in normal women and women suffering from stress urinary incontinence and vaginal prolapse. Gynaecol Perinatol 2009 Oct-Dec;18(4):169-286.
  6. El Hemaly AKMA, Kandil IM, Kurjak A, Mousa LAS, Kamel HH, Serour AG. Ultrasound assessment of the internal anal sphincter in women with fecal incontinence and posterior vaginal wall prolapse (rectocele). Donald School J Ultrasound Obstet Gynecol 2011 Oct-Dec;5(4):330-342.
  7. El Hemaly AKMA, Mousa LAS, Kandil IM, El Sokkary FS, Serour AG, Hussein H. Fecal incontinence, a novel concept: the role of the internal anal sphincter (IAS) in defecation and fecal incontinence. Gynaecol Perinatol 2010 Apr-Jun;19(2):79-85.
  8. El Hemaly AKMA, Mousa LAS. Micturition and urinary continence. Int J Gynecol Obstet 1996;42:291-292.
  9. El Hemaly AKMA. Nocturnal enuresis: pathogenesis and treatment. Int Urogynecol J Pelvic Floor Dysfunct 1998; 9:129-131.
  10. El Hemaly AKMA, Mousa LAES, Kandil IM, Shehata KA. Imaging of the pelvic floor. Curr Med Imag Rev 2014;10(3): 205-214.
  11. El Hemaly AKM, Mousa LA, Kandil IM. The concept and pathophysiology of urinary incontinence. In: Alhasso A, Fernando A, editors. Urinary incontinence. INTECH Publication; April 2012. pp. 145-160.
  12. Kandil IM, El Hemaly AKM, Radwan MM: Ultrasonic assessment of the internal urethral sphincter in stress urinary incontinence. Int J Gynecol Obstet 2003;2(1).
  13. El Hemaly AKM, Mousa LA, and Kandil IM, Al Sayed MS, Zaher MA, Soliman MSA, Serour AG. A novel concept on the patho-physiology of defecation and fecal incontinence (FI) in women-moreover, its reconstructive surgery. In: Catto-Smith AG, editor. Fecal incontinence causes, management and outcome. INTECH Publication; April 2014. pp. 47-67.
  14. El Hemaly AKM, Mousa LA, Kurjak A, Kandil IM, Serour AG. Pelvic floor dysfunction, the role of imaging and reconstructive surgery. Donald School J Ultrasound Obstet Gynecol 2013 Jan-Mar;7(1):86-97.
  15. El Hemaly AKM, Mousa LAS, Kandil IM, El Sokkary FS, Serour AG, Hussein H. Surgical treatment of stress urinary incontinence, fecal incontinence and vaginal prolapse by a novel operation “urethro-ano-vaginoplasty”. Gynaecol Perinatol 2010 Jul-Sep;19(3):129-188.
  16. El Hemaly AKM, Mousa LAES, Kandil IM, Al-Adwani AKA. Pelvic floor dysfunction and its reconstructive surgery: novel concepts; Createspace, an ISBN 978-1-001-04115, Amazon Company; 2014.
  17. El Hemaly AKM, Mousa L, Kandil IM. Continence and Incontinence: How Can You Gain Continence? ISBN 978-3- 639-66683-0, Scholars press. November 2014.
  18. El Hemaly AKM, Mousa LAES, Kandil IM; Pelvic floor dysfunction: new concepts on its patho physiology and its reconstructive surgery. Gynecol Obstet Case Report 2016 Jan.
  19. Charnock BL, Lewis CL, Garrett WE Jr, Queen RM. Adductor longus mechanics during the maximal effort soccer kick. Sports Biomech 2009 Sep;8(3):223-234.
  20. Alcock AM, Gilleard W, Hunter AB, Baker J, Brown N. Curve and instep kick kinematics in elite female footballers. J Sports Sci 2012;30(4):387-394.
  21. Ishii H, Yanagiya T, Naito H, Katamoto S, Maruyama T. Numerical study of ball behavior in side-foot soccer kick based on impact dynamic theory. J Biomech 2009 Dec 11;42(16): 2712-2720.
  22. Chappell JD, Yu B, Kirkendall DT, Garrett WE. A comparison of knee kinetics between male and female recreational athletes in stop-jump tasks. Am J Sports Med 2002 Mar- Apr;30(2):261-267.
  23. Ferber R, Davis IM, Williams DS 3rd. Gender differences in lower extremity mechanics during running. Clin Biomech (Bristol, Avon) 2003 May;18(4):350-357.
  24. McLean SG, Lipfert SW, van den Bogert AJ. Effect of gender and defensive opponent on the biomechanics of sidestep cutting. Med Sci Sports Exerc 2004 Jun;36(6):1008-1016.
  25. Pollard CD, Davis IM, Hamill J. Influence of gender on hip and knee mechanics during a randomly cued cutting maneuver. Clin Biomech (Bristol, Avon) 2004 Dec;19(10):1022-1031.
  26. Katis A, Kellis E, Lees A. Age and gender differences in kinematics of powerful instep kicks in soccer. Sports Biomech 2015 Sep;14(3):287-299.
  27. Smith T, Gilleard W. Three-dimensional analysis of a lofted instep kick by male and female footballers. Eur J Sport Sci 2016;16(1):57-64.
  28. Sigward SM, Pollard CD, Havens KL, Powers CM. Influence of sex and maturation on knee mechanics during side-step cutting. Med Sci Sports Exerc 2012 Aug;44(8):1497-1503.
  29. Sigward SM, Pollard CD, Powers CM. The influence of sex and maturation on landing biomechanics: implications for anterior cruciate ligament injury. Scand J Med Sci Sports 2012 Aug;22(4):502-509.
  30. Karimifar M, Esmaili F, Salari A, Kachuei A, Faragzadegan Z, Karimifar M. Effects of Levothyroxine and thyroid stimulating hormone on bone loss in patients with primary hypothyroidism. J Res Pharm Pract 2014 Jul;3(3):83-87.
  31. Tárraga López PJ, López CF, de Mora FN, Montes JA, Albero JS, Mañez AN, Casas AG. Osteoporosis in patients with subclinical hypothyroidism treated with thyroid hormone. Clin Cases Miner Bone Metab 2011 Sep;8(3):44-48.
  32. Porsch M, Galm R, Hovy L, Starker M, Kerschbaumer F. Total femur replacement following multiple periprosthetic fractures between ipsilateral hip and knee replacement in chronic rheumatoid arthritis. Case report of 2 patients. Z Orthop Ihre Grenzgeb 1996 Jan-Feb;134(1):16-20.
  33. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 2012 Sep 26;308(12): 1227-1236.
  34. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001 May 16;285(19): 2486-2497.
  35. Baek SH. Identification and preoperative optimization of risk factors to prevent periprosthetic joint infection. World J Orthop 2014 Jul 18;5(3):362-367.
  36. Sehgal V, Bajwa SJ, Sehgal R, Eagan J, Reddy P, Lesko SM. Predictors of acute kidney injury in geriatric patients undergoing total knee replacement surgery. Int J Endocrinol Metab 2014 Jul 1;12(3):e16713.
  37. Bozic KJ, Bashyal RK, Anthony SG, Chiu V, Shulman B, Rubash HE. Is administratively coded comorbidity and complication data in total joint arthroplasty valid? Clin Orthop Relat Res 2013 Jan;471(1):201-205.
  38. Brattstroem H. Shape of the intercondylar groove normally and in recurrent dislocation of patella. A clinical and x-ray-anatomical investigation. Acta Orthop Scand Suppl 1964;68(Suppl 68):61-148.
  39. Davies AP, Costa ML, Shepstone L, Glasgow MM, Donell S. The sulcus angle and malalignment of the extensor mechanism of the knee. J Bone Joint Surg Br 2000 Nov;82(8): 1162-1166.
  40. Smith TO, Cogan A, Patel S, Shakokani M, Toms AP, Donell ST. The intra- and inter-rater reliability of X-ray radiological measurements for patellar instability. Knee 2013 Mar;20(2):133-138.
  41. Merchant AC, Mercer PL, Jacobsen RH, Cool CR. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 1974 Oct;56(7:1391-1396.
  42. Caton JH, Dejour D. Tibial tubercle osteotomy in patellofemoral instability and in patellar height abnormality. Int Orthop 2010 Feb;34(2):305-309.
  43. Post WR. Anterior knee pain: diagnosis and treatment. J Am Acad Orthop Surg 2005 Dec;13(8):534-543.
  44. Laurin CA Lévesque HP, Dussault R, Labelle H, Peides JP. The abnormal lateral patellofemoral angle: a diagnostic roentgenographic sign of recurrent patellar subluxation. J Bone Joint Surg Am 1978 Jan;60(1):55-60.
  45. Audi L et al. Leptin in Relation to Resumption of Menses in Women with Anorexia Nervosa. Mol Psychiatry 1998;4:544-547.
  46. Mehanna HM, Moledina J, Travis J. “Refeeding syndrome: what it is, and how to prevent and treat it”. BMJ 2008; 336: 1495 8. doi:10.1136/bmj.a301.PMC 2440847. PMID 18583681.
  47. “The Physiology and Treatment of Starvation”. US national library of medicine. Retrieved 17 August 2012. chromeextension://mhjfbmdgcfjbbpaeojofohoefgiehjai/index.html
  48. Kreipe R et al. Eating Disorders in Adolescents and Older Children. Pediatrics in Review 1999; 20:12.
  49. Pike KM et al. Cognitive Behavior Therapy in the Posthospitalization. Treatment of Anorexia Nervosa. Am J Pyschiatry 2004; 11:2046-2049.
  50. Bender DA. Carbohydrates of Physiologic Significance. Murray RK, Bender DA, Botham KM, Kenelly PJ, Rodwell VW, Weil PA.. Harpers Illustrated Biochemistry 28th ed. New York:Mc Graw Hill publications; 2009. p 113-120.
  51. Koffler M, Kisch ES. Starvation diet and very-low-calorie diets may Induce insulin resistance and overt diabetes mellitus. J Diabetes Complications.1996;10(2):109-12.
  52. Hales CN, Barker DJ The thrifty phenotype hypothesis. Br Med Bull. 2001;60:5-20.
  53. Hales CN, Barker DJ (July 1992). “Type 2 (non-insulindependent) diabetes mellitus: the thrifty phenotype hypothesis”. Diabetologia. 35 (7): 595-601.
  54. Barker, D.J.P. (1997). “Maternal Nutrition, Fetal Nutrition, and Disease in Later Life”. Nutrition, ‘13’, pp. 807.
  55. Martin, Paul; Bateson, Patrick (1999). Design for a life: How behaviour develops. London: Jonathan Cape. ISBN 0-224- 05064-8 pp. 110-111.
  56. Barker, DJP. ed. (1992). Fetal and infant origins of adult disease. London: British Medical Journal. ISBN 0-7279-0743-3.
  57. Robinson R (February 2001). “The fetal origins of adult disease: No longer just a hypothesis and may be critically important in south Asia”. Editorial
  58. Mazur A. Why were “starvation diets” promoted for diabetes in the pre-insulin period? Nutrition Journal 2011;10:23.
  59. Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated implants. J Prosthet Dent 1999 May;81(5):537-552.
  60. Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent 2004 Nov;25(11):895-900.
  61. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008 Jan;19(1):73-80.
  62. Romeo E, Lops D, Rossi A, Storelli S, Rozza R, Chiapasco M. Surgical and prosthetic management of interproximal region with single-implant restorations: 1-year prospective study. J Periodontol 2008 Jun;79(6):1048-1055.
  63. Nagaraj KR, Savadi CR, Savadi AR, Prashanth Reddy GT, Srilakshmi J, Dayalan M, John J. Gingival biotype— prosthodontic perspective. J Indian Prosthodont Soc 2010 Mar;10(1):27-30.
  64. Jung RE, Sailer I, Hämmerle CH, Attin T, Schmidlin P. In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent 2007 Jun;27(3): 251-257.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.