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.
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.
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