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Sarveazad A, Yari A, Imani F, Fayyaz F, Mokhtare M, Babaei-Ghazani A, Yousefifard M, Sarveazad S, Assar S, Shamseddin J, Bahardoust M. The effect of Trolox on the rabbit anal sphincterotomy repair. BMC Gastroenterol 2023; 23:209. [PMID: 37337166 DOI: 10.1186/s12876-023-02842-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/31/2023] [Indexed: 06/21/2023] Open
Abstract
INTRODUCTION Fecal incontinence (FI) is caused by external anal sphincter injury. Vitamin E is a potential strategy for anal sphincter muscle repair via its antioxidant, anti-inflammatory, anti-fibrotic, and protective properties against myocyte loss. Thus, we aimed to evaluate the water-soluble form of vitamin E efficacy in repairing anal sphincter muscle defects in rabbits. METHODS Twenty-one male rabbits were equally assigned to the intact (without any intervention), control (sphincterotomy), and Trolox (sphincterotomy + Trolox administration) groups. Ninety days after sphincterotomy, the resting and squeeze pressures were evaluated by manometry, and the number of motor units in the sphincterotomy site was calculated by electromyography. Also, the amount of muscle and collagen in the injury site was investigated by Mallory's trichrome staining. RESULTS Ninety days after the intervention, the resting and squeeze pressures in the intact and Trolox groups were significantly higher than in the control group (P = 0.001). Moreover, the total collagen percentage of the sphincterotomy site was significantly lower in the Trolox group than in the control group (P = 0.002), and the total muscle percentage was significantly higher in the Trolox group compared to the control group (P = 0.001). Also, the motor unit number was higher in the Trolox group than in the control group (P = 0.001). CONCLUSION Trolox administration in the rabbit sphincterotomy model can decrease the amount of collagen and increase muscle, leading to improved anal sphincter electromyography and manometry results. Therefore, Trolox is a potential treatment strategy for FI.
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Affiliation(s)
- Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abazar Yari
- Department of Anatomy, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farimah Fayyaz
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Marjan Mokhtare
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Babaei-Ghazani
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Tehran, Iran
- Department of Physical Medicine and Rehabilitation, University of Montreal Health Center, Montreal, Canada
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shahriar Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Siavash Assar
- Department of Anesthesiology, kerman university of medical sciences, kerman, Iran
| | - Jebreil Shamseddin
- Infectious and Tropical Diseases Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Shahid Chamran Boulevard, Iran.
| | - Mansour Bahardoust
- Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Velenjak 7th Floor, Bldg No.2 SBUMS, Arabi Ave, Tehran, 19839-63113, Iran.
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Subramaniam N, Dietz HP. Is posterior compartment prolapse associated with anal incontinence? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:642-648. [PMID: 36565432 DOI: 10.1002/uog.26145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 11/15/2022] [Accepted: 11/24/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVE It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. METHODS This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. RESULTS Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). CONCLUSION In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N Subramaniam
- Northern Beaches Hospital, Frenchs Forest, Sydney, Australia
| | - H P Dietz
- Sydney Urodynamic Centres, Sydney, Australia
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Swallow CH, Harvey CN, Harmanli O, Shepherd JP. Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:351-359. [PMID: 36808929 DOI: 10.1097/spv.0000000000001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
IMPORTANCE Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial. OBJECTIVE We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective. STUDY DESIGN We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios). RESULTS Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications. CONCLUSIONS Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.
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Affiliation(s)
- Christina H Swallow
- From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven
| | | | - Oz Harmanli
- From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven
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Marcellier G, Dupont A, Bourgeois-Moine A, Le Tohic A, De Carne-Carnavalet C, Poujade O, Girard G, Benbara A, Mandelbrot L, Abramowitz L. Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study. J Clin Med 2023; 12:jcm12041531. [PMID: 36836068 PMCID: PMC9967240 DOI: 10.3390/jcm12041531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22-21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.
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Affiliation(s)
- Gabriel Marcellier
- Proctology and Gastroenterology Department, APHP-Bichat Hospital, 75018 Paris, France
- Correspondence: ; Tel.: +33-6-68-97-79-05
| | - Axelle Dupont
- Biostatistics and Medical IT Department, APHP-Bichat Hospital, 75018 Paris, France
| | | | - Arnaud Le Tohic
- Department of Obstetrics and Gynecology, Versailles Hospital, 78157 Le Chesnay, France
| | | | - Olivier Poujade
- Department of Obstetrics and Gynecology, APHP-Beaujon Hospital, 92110 Clichy, France
| | - Guillaume Girard
- Department of Obstetrics and Gynecology, APHP-Armand Trousseau Hospital, 75012 Paris, France
| | - Amélie Benbara
- Department of Obstetrics and Gynecology, APHP-Jean Verdier Hospital, 93140 Bondy, France
| | - Laurent Mandelbrot
- Department of Obstetrics and Gynecology, APHP-Louis Mourier Hospital, 92700 Colombes, France
| | - Laurent Abramowitz
- Proctology and Gastroenterology Department, APHP-Bichat Hospital, 75018 Paris, France
- Proctology and Gastroenterology Department, Blomet Clinic (Ramsay GDS Group), 75015 Paris, France
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Hurni Y, Maes E, Avau F, Becu L, Buljubasic M, Danon A, Paquier L, Garofalo G, Albert V, Pastijn A. Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: An experimental study. Int Urogynecol J 2022; 33:1639-1647. [PMID: 35389056 DOI: 10.1007/s00192-022-05191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/10/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injuries are frequently missed and carry a significant risk for the development of anal incontinence. Immediate postpartum endoanal ultrasound increases identification of these injuries but is rarely employed. We hypothesize that endovaginal ultrasound could be a feasible and easily available alternative sonographic tool to improve early diagnosis of anal sphincter tears. METHODS We conducted a prospective experimental study including 160 primiparous women. Shortly after vaginal delivery, patients underwent clinical and sonographic perineal examinations. We analyzed the feasibility of anal sphincter assessment by endovaginal ultrasound and its potential contribution in the early diagnosis of anal sphincter injuries. RESULTS Sonographic assessment of the anal sphincter was analyzable for 136 patients (85.0%). Causes of non-analyzability included air artifacts (6.9%), lack of distinction between the external anal sphincter and surrounding tissues (9.4%) and distortion artifacts (9.4%). Patients in the non-analyzable ultrasound subgroup were less likely to have delivered in a dorsal lithotomy position (62.5% vs. 85.3 %) and more likely to have had an episiotomy (33.3% vs. 14.0%), and their risk of sphincter injury was more frequently classified as "improbable" on clinical examination (91.7% vs. 61.0%). Ultrasounds were analyzable for 96.4% of patients clinically reported as having "possible" or "certain" sphincter injuries. The incidence of anal sphincter injury was 16.9% for clinical observation and 20.0% with associated sonographic examination. CONCLUSIONS Endovaginal ultrasound could be used as a complementary tool in assessment of the anal sphincter in high-risk patients. Its feasibility and easy availability make this technique a promising tool for improving the management of anal sphincter tears.
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Affiliation(s)
- Yannick Hurni
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium. .,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium.
| | - Elise Maes
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium.,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Fiona Avau
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium.,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Lauren Becu
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium.,Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Marie Buljubasic
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Alix Danon
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Leila Paquier
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Giulia Garofalo
- Department of Obstetrics and Gynecology, Obstetric Unit, CHU Saint-Pierre, Brussels, Belgium.,Department of Obstetrics and Gynecology, Ultrasound Unit, CHU Saint-Pierre, Brussels, Belgium
| | - Valerie Albert
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium
| | - Ann Pastijn
- Department of Obstetrics and Gynecology, Perineal Clinic, CHU Saint-Pierre, Rue Haute 322, 1000, Brussels, Belgium
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Understanding the physiology of human defaecation and disorders of continence and evacuation. Nat Rev Gastroenterol Hepatol 2021; 18:751-769. [PMID: 34373626 DOI: 10.1038/s41575-021-00487-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.
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Speksnijder L, Oom DMJ, DE Leeuw JW, Steensma AB. Which factors are associated with anal incontinence after obstetric anal sphincter injury? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:476-482. [PMID: 33094517 DOI: 10.1002/uog.23525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI. METHODS In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter. RESULTS In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001). CONCLUSIONS Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Speksnijder
- Department of Obstetrics and Gynecology, Division of Urogynecology, Amphia Hospital, Breda, The Netherlands
| | - D M J Oom
- Department of Obstetrics and Gynecology, Division of Urogynecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - J-W DE Leeuw
- Department of Obstetrics and Gynecology, Ikazia Hospital, Rotterdam, The Netherlands
| | - A B Steensma
- Department of Obstetrics and Gynecology, Division of Urogynecology, Erasmus Medical Center, Rotterdam, The Netherlands
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Viannay P, de la Codre F, Brochard C, Thubert T, Meurette G, Legendre G, Venara A. Management and consequences of obstetrical anal sphincter injuries: Review. J Visc Surg 2021; 158:231-241. [PMID: 33454307 DOI: 10.1016/j.jviscsurg.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Obstetrical anal sphincter injuries (OASI), formerly referred to as "complete" or "incomplete" perineal tears, are a frequent complication of childbirth. They can lead to intestinal consequences (anal incontinence, ano-genital fistula) or sexual consequences (dyspareunia, genital pain). The complexity of management of OASI lies in the multi-factorial nature of these consequences but also in the frequently lengthy interval before their appearance, often long after childbirth. Indeed, while 2.4% of women in childbirth develop OASI, up to 61% of them will present with anal incontinence15 to 25 years after childbirth. Immediate or delayed repair of the sphincter and perineum within a few hours of injury is therefore the rule, but there is no consensus on longer-term management. The patient must be educated on preventive actions (avoidance of pushing or straining, regularization of stool transit, muscle strengthening, etc.). Early detection of anal incontinence leads to prompt management, which is more effective. This review aims to synthesize the information necessary to provide clear and up-to-date patient information on OASI (risk factors and prevalence), the management of OASI, and the management of eventual complications in the setting of dedicated specialty consultations. Dedicated "post-OASI" consultations by a specialist in ano-perineal pathologies could therefore become a first step in the development of care for women, particularly by removing the "shameful" nature of the symptoms.
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Affiliation(s)
- P Viannay
- Department of visceral and endocrine surgery, CHU d'Angers, 4, rue Larrey, 49933 Angers Cedex 9, France; Faculté de santé d'Angers, Department of Medicine, Angers, France
| | - F de la Codre
- Digestive and endocrine surgery clinic, IMAD, Hôtel Dieu, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France
| | - C Brochard
- Department of gastroenterology, CHU Pontchaillou, 2, rue Henri Le Guillou, 35000 Rennes, France
| | - T Thubert
- Department of Obstetrics Gynecology, CHU de Nantes, Place Alexis Ricordeau, 44000 Nantes, France
| | - G Meurette
- Digestive and endocrine surgery clinic, IMAD, Hôtel Dieu, CHU de Nantes, place Alexis-Ricordeau, 44093 Nantes cedex 01, France; UMR INSERM U1235, Faculté de médecine, 1, rue Gaston Veil, 44035 Nantes Cedex, France
| | - G Legendre
- Department of Obstetrics Gynecology, CHU d'Angers, 4, rue Larrey, 49933 Angers Cedex 9, France
| | - A Venara
- Department of visceral and endocrine surgery, CHU d'Angers, 4, rue Larrey, 49933 Angers Cedex 9, France; Faculté de santé d'Angers, Department of Medicine, Angers, France; UMR INSERM U1235, Faculté de médecine, 1, rue Gaston Veil, 44035 Nantes Cedex, France.
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Abramowitz L, Mandelbrot L, Tubach F, Roy C. Authors' reply re: Caesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetrical anal sphincter injury: the EPIC multicentre randomised trial. BJOG 2020; 128:771-772. [PMID: 33215818 DOI: 10.1111/1471-0528.16576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Laurent Abramowitz
- Department of Gastroenterology, Hopital Bichat, Proctology Unit, APHP, Paris, France.,Ramsay GDS, Clinique Blomet, Paris, France
| | - Laurent Mandelbrot
- Department of Obstetrics and Gynaecology, Hopital Louis-Mourier, APHP, Colombes, France.,Inserm IAME U1137, Paris, France
| | - Florence Tubach
- Departement de Sante Publique, INSERM, Institut Pierre Louis d'Epidemiologie et de Sante Publique, AP-HP, Hopital Pitie-Salpetriere, Sorbonne Universite, Paris, France
| | - Carine Roy
- Unite de Recherche Clinique, Hopital Bichat, APHP, Paris, France.,INSERM CIC-EC 1425, Paris, France
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Hage-Fransen MAH, Wiezer M, Otto A, Wieffer-Platvoet MS, Slotman MH, Nijhuis-van der Sanden MWG, Pool-Goudzwaard AL. Pregnancy- and obstetric-related risk factors for urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 100:373-382. [PMID: 33064839 DOI: 10.1111/aogs.14027] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 09/05/2020] [Accepted: 10/08/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Risk factors for pelvic floor disorders are often related to pregnancy and delivery. Consistent evidence is needed to develop prevention strategies targeting risk factors. The objective of this study is to identify which pregnancy- and/or obstetric-related risk factors can predict urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life by means of a systematic review and meta-analysis. MATERIAL AND METHODS Systematic review Prospero number: CRD42019131758. Literature searches of PubMed, EMBASE, CINAHL, and Cochrane Library were conducted according to PRISMA guidelines (April 2020). Prospective cohort studies describing more than two pregnancy- and/or obstetric-related risk factors on urinary incontinence, fecal incontinence (including flatal incontinence), or pelvic organ prolapse were eligible. Risk of bias was assessed (using Quality In Prognosis Studies [QUIPS]). Studies with high risk of bias were excluded. Data were extracted and checked for accuracy with the CHARMS checklist. Sub-groups were used to distinguish between a short- and long-term follow-up period: <18 months (shortterm) and >18 months (long-term) postpartum. Odds ratios were calculated from reported prevalence rates. Log odds ratios were calculated using SPSS v.24. Variables were pooled using RevMan5. RESULTS Data were extracted from nineteen studies for urinary incontinence, nine for fecal incontinence, and two for pelvic organ prolapse. Multivariate analysis was not possible because of the heterogeneity of the population and outcome measures. Pooled univariate risk factors for urinary incontinence were: urinary incontinence during pregnancy, instrumental vaginal delivery, episiotomy, tears, and constipation. Pooled univariate risk factors for fecal incontinence were: fecal incontinence during pregnancy, maternal age over 35 years, prenatal body mass index over 30 kg/m2 , instrumental vaginal delivery, a spontaneous vaginal delivery, oxytocin augmentation, and when the weight of the newborn was more than 4000 g. Both studies for pelvic organ prolapse had a short-term follow-up period and cesarean section was the only risk factor that could be pooled. CONCLUSIONS Pregnancy- and obstetric-related risk factors predicting pelvic floor disorders postpartum are multifactorial and differ between pelvic floor disorders. The strongest risk factor for incontinence later in life was incontinence during pregnancy. Better quality research with long-term follow up is needed on this topic.
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Affiliation(s)
| | - Maaike Wiezer
- Physical Therapy Practice Fysi-Unique, Amersfoort, the Netherlands
| | - Amy Otto
- Faculty of Behavior Human Movement Sciences, Amsterdam Movement Sciences, VU University Amsterdam, Amsterdam, the Netherlands
| | | | | | | | - Annelies L Pool-Goudzwaard
- Faculty of Behavior Human Movement Sciences, Amsterdam Movement Sciences, VU University Amsterdam, Amsterdam, the Netherlands.,Somt University of Physiotherapy, Amersfoort, the Netherlands
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Abramowitz L, Mandelbrot L, Bourgeois Moine A, Tohic AL, Carne Carnavalet C, Poujade O, Roy C, Tubach F. Caesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetric anal sphincter injury: the EPIC multicentre randomised trial. BJOG 2020; 128:685-693. [PMID: 32770616 DOI: 10.1111/1471-0528.16452] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether planned caesarean section (CS) for a second delivery protects against anal incontinence in women with obstetric anal sphincter lesions. DESIGN Randomised trial. SETTING Six maternity units in the Paris area. SAMPLE Women at high risk of sphincter lesions (first delivery with third-degree laceration and/or forceps) but no symptomatic anal incontinence. METHODS Endoanal ultrasound was performed in the third trimester of the second pregnancy. Women with sphincter lesions were randomised to planned CS or vaginal delivery (VD). MAIN OUTCOME MEASURES Anal incontinence at 6 months postpartum. Secondary outcomes were urinary incontinence, sexual morbidity, maternal and neonatal morbidities and worsening of external sphincter lesions. RESULTS Anal sphincter lesions were detected by ultrasound in 264/434 women enrolled (60.8%); 112 were randomised to planned VD and 110 to planned CS. At 6-8 weeks after delivery, there was no significant difference in anal continence between the two groups. At 6 months after delivery, median Vaizey scores of anal incontinence were 1 (interquartile range 0-4) in the CS group and 1 (interquartile range 0-3) in the VD group (P = 0.34). There were no significant differences for urinary continence, sexual functions or for other maternal and neonatal morbidities. CONCLUSIONS In women with asymptomatic obstetric anal sphincter lesions diagnosed by ultrasound, planning a CS had no significant impact on anal continence 6 months after the second delivery. These results do not support advising systematic CS for this indication. TWEETABLE ABSTRACT Caesarean section for the second delivery did not protect against anal incontinence in women with asymptomatic obstetric anal sphincter lesions.
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Affiliation(s)
- L Abramowitz
- Hôpital Bichat, Proctology Unit, Department of Gastroenterology, Assistance Publique-Hôpitaux de Paris, Paris, France.,Ramsay général de santé, clinique Blomet, Paris, France
| | - L Mandelbrot
- Department of Obstetrics and Gynaecology, Hôpital Louis-Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France.,Université de Paris, Paris, France.,Inserm IAME U1137, Paris, France
| | - A Bourgeois Moine
- Department of Obstetrics and Gynaecology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - A L Tohic
- Department of Obstetrics and Gynaecology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - C Carne Carnavalet
- Department of Obstetrics and Gynaecology, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - O Poujade
- Department of Obstetrics and Gynaecology Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Clichy, France.,Department of Obstetrics and Gynaecology, Hôpital des Rives de Seine, Neuilly, France
| | - C Roy
- Unité de Recherche Clinique, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM CIC-EC 1425, Paris, France
| | - F Tubach
- Département de Santé Publique, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
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12
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Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:303-312. [PMID: 32653603 DOI: 10.1016/j.ejogrb.2020.06.048] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. METHODS We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. RESULTS We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I2 = 95 %). Following primary repair of OASIS, 55 % (46-63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I2 = 98 %). INTERPRETATION Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.
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Affiliation(s)
- Michail Sideris
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.
| | - Tristan McCaughey
- Department of Surgery, School of Clinical Science at Monash Health, Monash University, 3800, VIC, Australia
| | | | - David Arroyo-Manzano
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Javier Zamora
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Swati Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Charles H Knowles
- National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Charlotte Chaliha
- Department of Obstetrics and Gynaecology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Multidisciplinary Evidence Synthesis Hub (MEsH), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
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13
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Lim CH, Kang WH, Lee YC, Ko YT, Yoo BE, Yang HK. Standardized Method of the Thiersch Operation for the Treatment of Fecal Incontinence. World J Surg 2020; 44:3141-3148. [DOI: 10.1007/s00268-020-05554-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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14
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Everist R, Burrell M, Mallitt KA, Parkin K, Patton V, Karantanis E. Postpartum anal incontinence in women with and without obstetric anal sphincter injuries. Int Urogynecol J 2020; 31:2269-2275. [PMID: 32157322 DOI: 10.1007/s00192-020-04267-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/12/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Postpartum anal incontinence is common and distressing for women. We sought to look at the prevalence of anal incontinence in women who sustained obstetric anal sphincter injuries (OASI) compared with women who did not, and factors leading to these symptoms during the postpartum period. METHODS A total of 129 primiparous women sustaining OASI were compared with 131 women who did not (controls). They were contacted at approximately 6-10 weeks postpartum to obtain information on their symptoms of anal incontinence (AI). The data underwent univariate and multivariate analysis. RESULTS There was no difference in the prevalence of AI symptoms, occurring in 30% of women with OASI, and 23% of women without at 6-10 weeks postpartum; however, in women with high-grade tears the prevalence was 59%. Severe OASI (grade 3c and 4) was associated with an increased prevalence of both AI and severe AI, whereas forceps delivery and increasing maternal age were associated with an increased prevalence of severe AI only. CONCLUSION Women with less severe (grade 3a and 3b) OASI do not experience a higher prevalence of AI than women without OASI in the postpartum period. Higher grade (3c and 4) tears, forceps delivery and increasing maternal age are associated with higher rates of AI. These factors should be avoided where possible to reduce postpartum AI. All women should be warned of the 23-30% chance of experiencing some mild AI in this period. Whether these symptoms are transient or long-lasting requires further investigation.
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Affiliation(s)
- Rebecca Everist
- Pelvic Floor Unit, St George Hospital, Sydney, New South Wales, Australia. .,University of New South Wales, Sydney, Australia.
| | | | - Kylie-Ann Mallitt
- University of New South Wales, Sydney, Australia.,NHMRC Early Career Fellow, Sydney, Australia.,Centre for Big Data Research in Health, Sydney, Australia
| | - Katrina Parkin
- Pelvic Floor Unit, St George Hospital, Sydney, New South Wales, Australia
| | | | - Emmanuel Karantanis
- Pelvic Floor Unit, St George Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, Australia
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15
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Gommesen D, Nohr EA, Qvist N, Rasch V. Obstetric perineal ruptures-risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study. Am J Obstet Gynecol 2020; 222:165.e1-165.e11. [PMID: 31449804 DOI: 10.1016/j.ajog.2019.08.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/09/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anal incontinence leads to impairment of the quality of life and lower self-esteem with implications for social, physical, and sexual health; anal incontinence after vaginal delivery is a major concern for many women. Only about half of the cases of postpartum anal incontinence can be related to anal sphincter injuries, and the remaining cases must thus be related to other factors. OBJECTIVE The aim of this study was to examine the association between maternal and obstetric characteristics, including the degree of perineal rupture and anal incontinence 12 months postpartum. Furthermore, the aim was to investigate the association between anal sphincter muscle defects, perineal length, and perineal strength and the risk of anal incontinence. MATERIALS AND METHODS We conducted a prospective cohort study at 4 Danish hospitals: Odense University Hospital, Aarhus University Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data were obtained 2 weeks postpartum in relation to an evaluation of perineal wound healing. Symptoms of anal incontinence were evaluated 12 months postpartum by a Web-based questionnaire (St. Mark's incontinence score questionnaire). In addition, defects in the anal sphincter muscles were examined using endoanal ultrasound, perineal length was measured, and perineal strength was examined using anal manometry. The main outcome measurement was anal incontinence defined as a St. Mark's score of >4. We performed multivariate analyses to investigate the risk factors for anal incontinence and to investigate the risk of anal incontinence according to endoanal ultrasound scanning and anal manometry findings. RESULTS A total of 603 primiparous women (203 with no/labia/first-degree ruptures, 200 with second-degree ruptures, and 200 with third-/fourth-degree ruptures) were included between July 2015 and January 2018. At 12 months postpartum, 575 women (95%) answered the questionnaire; 193 with no/labia/first-degree ruptures, 193 with second-degree ruptures, and 189 with third-/fourth-degree ruptures. A total of 499 women underwent an endoanal ultrasound scanning and 482 women underwent anal manometry. Anal incontinence with a St. Mark's score of >4 was reported by 7% and 9% of women with no/labia/first-degree ruptures or second-degree ruptures, respectively, and by 14%, 15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4, respectively. Compared to women with no or minor tears, women with anal sphincter ruptures had a higher risk of anal incontinence (adjusted relative risk, 2.46; 95% confidence interval, 1.28-4.71). Ruptures of degree 3c and 4 were associated with a substantial increase in risk of anal incontinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98-11.3; and adjusted relative risk, 2.23; 95% confidence interval, 1.59-11.3, respectively), especially if a defect in the external or internal anal sphincter muscle was present (adjusted relative risk, 4.74; 95% confidence interval, 1.54-14.5; and adjusted relative risk, 6.58; 95% confidence interval, 3.35-12.9, respectively). The risk of anal incontinence increased by 8% per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95% confidence interval, 1.03-1.14). CONCLUSION Obesity with body mass index of >29.9 and a high-degree rupture (3c or 4), especially with a persistent defect in the internal or external anal sphincter muscle, increased the risk of anal incontinence.
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16
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Barbosa M, Glavind-Kristensen M, Moller Soerensen M, Christensen P. Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up. Colorectal Dis 2020; 22:71-79. [PMID: 31347749 DOI: 10.1111/codi.14792] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/07/2019] [Indexed: 12/12/2022]
Abstract
AIM Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury. METHOD This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale. RESULTS Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001). CONCLUSION At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.
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Affiliation(s)
- M Barbosa
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - M Glavind-Kristensen
- Pelvic Floor Unit, Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus N, Denmark
| | - M Moller Soerensen
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - P Christensen
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
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17
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Is the extent of obstetric anal sphincter injury correlated with the severity of fecal incontinence in the long term? Tech Coloproctol 2019; 24:49-55. [DOI: 10.1007/s10151-019-02128-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 11/22/2019] [Indexed: 01/24/2023]
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18
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Relationships between the results of anorectal investigations and symptom severity in patients with faecal incontinence. Int J Colorectal Dis 2019; 34:1445-1454. [PMID: 31280351 DOI: 10.1007/s00384-019-03331-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Anorectal dysfunction is the focus of diagnostic investigations for faecal incontinence. However, severity of incontinence and anorectal investigation results can be discordant. The aim of this study was to define the relationships between anorectal investigation results and incontinence severity to determine which measures, if any, were predictive of incontinence severity. METHODS Patients presenting for investigation of faecal incontinence completed a symptom questionnaire, anorectal manometry, rectal sensation, pudendal nerve terminal motor latency, and endoanal ultrasound. Bivariate analyses were conducted between the Jorge-Wexner score and investigation results. Subgroup analyses were performed for gender and symptom subtypes (urge, passive, mixed). A multiple regression analysis was performed. RESULTS Five hundred and thirty-eight patients were included. There were weak correlations between the Jorge-Wexner score and maximal squeeze pressure [r = - 0.24, 95%CI(- 0.31, - 0.16), p < 0.001], and resting pressure [r = - 0.18, (95%CI(- 0.26, - 0.10), p < 0.001]. In men only, there were significant associations between the Jorge-Wexner score and endoanal sonography [IAS defects: t(113) = - 2.26, p = 0.03, d = 0.58, 95%CI(- 4.38, - 0.29)] and rectal sensation (MTV: rs = - 0.24, 95%CI(- 0.41, - 0.06), p = 0.01). No substantial differences were observed in the urge/passive/mixed subgroup analyses. Multiple regression analysis included three variables: age (β = 0.02, p = 0.17), maximal resting pressure (β = - 0.01, p = 0.28), and maximal squeeze pressure (β = - 0.01, p < 0.01). The variance in the Jorge-Wexner score accounted for by this model was < 10%, (R2 = 0.07, p = < 0.01, adjusted R2 = 0.06). CONCLUSION Anorectal investigations cannot predict the severity of faecal incontinence. This may be due to limitations of diagnostic modalities, the heterogeneity of anorectal dysfunction in these patients, or contributing factors which are extrinsic to the anorectum.
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19
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Tejedor P, Plaza J, Bodega-Quiroga I, Ortega-López M, García-Olmo D, Pastor C. The Role of Three-Dimensional Endoanal Ultrasound on Diagnosis and Classification of Sphincter Defects After Childbirth. J Surg Res 2019; 244:382-388. [PMID: 31325659 DOI: 10.1016/j.jss.2019.06.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 05/21/2019] [Accepted: 06/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Diagnostic tests for fecal incontinence have been improved over time. This study aims to evaluate the role of Three-dimensional endoanal ultrasound (3D-EUS) and the Starck's score in the assessment and treatment of obstetric sphincter injuries. METHODS A prospective observational study was performed including primiparous women who were evaluated at 20 wk of pregnancy and 3 mo after childbirth. Sphincter defects were classified according to the Starck's and Obstetrical Anal Sphincter Injuries classifications. Patients also completed the Fecal Incontinence Quality of Life and the Wexner questionnaires before and after childbirth. RESULTS Sphincter defects were detected in 45% of the 56 women included, although 85% had an uneventful delivery. Most defects were found isolated to the external anal sphincter except for two cases, classified by a Starck's score >8. Fecal Incontinence Quality of Life and Wexner questionnaires showed a rate of symptomatic patients of around 46%. We observed that 30% of patients with sphincter injuries remained asymptomatic. CONCLUSIONS The 3D-EUS is a useful test in assessing sphincter defects after childbirth. This method makes it possible to detect small sphincter defects that otherwise would have gone unnoticed, as 30% of patients with sphincter injuries were asymptomatic. In addition, both the 3D-EUS and the Starck's score were valuable in establishing an algorithm for the treatment of obstetric sphincter injuries.
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Affiliation(s)
- Patricia Tejedor
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain.
| | - Javier Plaza
- Department of Gynaecology and Obstetrics, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | | | - Mario Ortega-López
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Damián García-Olmo
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Carlos Pastor
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
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20
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Nelson RL, Go C, Darwish R, Gao J, Parikh R, Kang C, Mahajan A, Habeeb L, Zalavadiya P, Patnam M. Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis. Tech Coloproctol 2019; 23:809-820. [PMID: 31273486 DOI: 10.1007/s10151-019-02029-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review. METHODS Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI. RESULTS Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes. CONCLUSIONS There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.
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Affiliation(s)
- R L Nelson
- Epidemiology/Biometry Division, University of Illinois School of Public Health, Chicago, IL, USA.
| | - C Go
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Darwish
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - J Gao
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Parikh
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - C Kang
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - A Mahajan
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - L Habeeb
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - P Zalavadiya
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - M Patnam
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
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21
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Martínez Franco E, López Negre JL, Parés D, Ros Cerro C, Amat Tardiu L, Cuadras D, Espuña Pons M. Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury. Arch Gynecol Obstet 2019; 299:1001-1006. [PMID: 30729292 DOI: 10.1007/s00404-019-05070-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/25/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). METHODS This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. RESULTS 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). CONCLUSIONS The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.
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Affiliation(s)
- Eva Martínez Franco
- Obstetrics and Gynecology Department, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Camí Vell de la Colonia num 25, 08830, Sant Boi de Llobregat, Spain.
| | - José Luís López Negre
- General and Digestive Surgery Department, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Sant Boi de Llobregat, Spain
| | - David Parés
- Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Germans Trias I Pujol, Universitat Autónoma de Barcelona, Badalona, Spain
| | - Cristina Ros Cerro
- Obstetrics and Gynecology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Lluís Amat Tardiu
- Obstetrics and Gynecology Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Spain
| | - Daniel Cuadras
- Statistical and Methodological Department, Sant Joan de Déu Research Foundation, Esplugues de Llobregat, Spain
| | - Montserrat Espuña Pons
- Obstetrics and Gynecology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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22
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A systematic review of non-invasive modalities used to identify women with anal incontinence symptoms after childbirth. Int Urogynecol J 2018; 30:869-879. [DOI: 10.1007/s00192-018-3819-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/08/2018] [Indexed: 12/18/2022]
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Patton V, Kumar S, Parkin K, Karantanis E, Dinning P. The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury. Neurourol Urodyn 2018; 38:193-199. [PMID: 30387531 DOI: 10.1002/nau.23826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/31/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. METHODS Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. MAIN OUTCOME MEASURES Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. RESULTS 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. CONCLUSION The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.
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Affiliation(s)
- Vicki Patton
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Swetha Kumar
- Nepean Hospital Sydney, Department of Women and Children's Health, Sydney, New South Wales, Australia
| | - Katrina Parkin
- Department of Women and Children's Health St George Public Hospital, University of NSW St George Clinical School, Kogarah, New South Wales, Australia
| | - Emmanuel Karantanis
- Department of Women and Children's Health St George Public Hospital, University of NSW St George Clinical School, Kogarah, New South Wales, Australia
| | - Phil Dinning
- College of Medicine and Public Health and Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia.,Department of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
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24
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Le Fouler A, Hamy A, Barbieux J, Souday V, Bigot P, Le Naoures P, Jaouen R, Brochard C, Venara A. Long-term functional outcomes of perineal gangrene: worse than expected?-an observational retrospective study. Int J Colorectal Dis 2018; 33:589-592. [PMID: 29500487 DOI: 10.1007/s00384-018-2999-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE For survivors of perineal gangrene (PG), quality of life and functional prognosis of pelvic functions are probably overestimated. The aim of this study was to report long-term anal and urinary sphincter dysfunctions, sexual sequelae, and patients' quality of life after treatment of perineal gangrene. METHODS This retrospective observational study was conducted in one university hospital over 16 years. Seventy-three patients experienced PG; 22 were subject to long-term follow-up. Three questionnaires were sent to patients to assess pelvic dysfunction and quality of life: the GIQLI, the Cleveland Incontinence Score, and the USP score for urinary dysfunction. Sexual sequelae were considered if orchiectomy or penile resection for male patients and vulvar resection for female patients were performed. RESULTS Of the 72 patients included, seven died before discharge (9.7%) and at least 14 died during follow-up (19.4%), despite a mean age of 62 years (± 13). Among the surviving patients, seven experienced an alteration of their quality of life (44%) (GIQLI < 96). Six patients still had a colostomy, and among the remaining patients, 11 experienced minimal to mild incontinence (68.7%), while one experienced constipation (6.2%). One patient suffered from urinary incontinence (4.5%), and six suffered from dysuria (27.3%). Three male patients (14%) underwent an orchiectomy, and one female patient (100%) underwent a vulvar resection. CONCLUSION PG leads to a high rate of anal and urinary dysfunctions. Urinary dysfunctions are taken into account and treated; however, anal incontinence is not investigated even though it could lead to decreased quality of life.
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Affiliation(s)
- A Le Fouler
- Department of Digestive and Endocrinal Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France.,LUNAM, University of Angers, Angers, France
| | - A Hamy
- Department of Digestive and Endocrinal Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France.,LUNAM, University of Angers, Angers, France.,UMR INSERM HIFI, Angers, France
| | - J Barbieux
- Department of Digestive and Endocrinal Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France.,LUNAM, University of Angers, Angers, France
| | - V Souday
- Intensive Care Unit and Department of Hyperbaric Medicine, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - P Bigot
- LUNAM, University of Angers, Angers, France.,Department of Urology, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - P Le Naoures
- Department of Digestive and Endocrinal Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - R Jaouen
- Department of Digestive and Endocrinal Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France.,LUNAM, University of Angers, Angers, France
| | - C Brochard
- UMR INSERM U1235, TENS, Nantes, France.,Department of Gastroenterology, CHU Rennes, 2 rue Henri Le Guilloux, 35033, Rennes, France
| | - Aurélien Venara
- Department of Digestive and Endocrinal Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France. .,LUNAM, University of Angers, Angers, France. .,UMR INSERM HIFI, Angers, France. .,UMR INSERM U1235, TENS, Nantes, France.
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25
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[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]. ACTA ACUST UNITED AC 2018; 46:419-426. [PMID: 29500142 DOI: 10.1016/j.gofs.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 12/11/2022]
Abstract
Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.
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26
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Impact of systematic urinary catheterization protocol in delivery room on covert postpartum urinary retention: a before-after study. Sci Rep 2017; 7:17720. [PMID: 29255204 PMCID: PMC5735096 DOI: 10.1038/s41598-017-18065-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/05/2017] [Indexed: 11/24/2022] Open
Abstract
We investigated whether implementation of a routine catheterization procedure in labor improves covert postpartum urinary retention (cPUR) rates. We conducted a prospective before-after study. 121 women admitted to delivery room in the observational group, and 82 in the intervention group, in a tertiary university hospital in Southern France were included. All patients in the intervention group were systematically catheterized 2 hours after delivery. cPUR was screened for in both groups. The primary end-point was cPUR (post-void residual bladder volume >150 ml when voided volume is >150 mL). The rate of cPUR decreased from 50% (60 out of 121 patients) in the observational group to 17% (14/82) in the intervention group (OR = 0.21; 95% Confidence Interval [0.13;0.58]; p < 0.001). Similarly, in the subgroup of patients who underwent instrumental delivery, the rate of cPUR was lower in the intervention group (18%, 2/11) than in the observational group (65%, 15/23) (p = 0.02). Systematic intermittent bladder catheterization immediately postpartum could decrease cPUR. Further studies are necessary to assess the long-term outcomes and improve understanding of postpartum voiding dysfunction.
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27
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Persson LKG, Sakse A, Langhoff-Roos J, Jangö H. Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture. Arch Gynecol Obstet 2017; 295:1399-1406. [DOI: 10.1007/s00404-017-4368-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/05/2017] [Indexed: 12/17/2022]
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28
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Sarveazad A, Newstead GL, Mirzaei R, Joghataei MT, Bakhtiari M, Babahajian A, Mahjoubi B. A new method for treating fecal incontinence by implanting stem cells derived from human adipose tissue: preliminary findings of a randomized double-blind clinical trial. Stem Cell Res Ther 2017; 8:40. [PMID: 28222801 PMCID: PMC5320771 DOI: 10.1186/s13287-017-0489-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/23/2016] [Accepted: 01/24/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Anal sphincter defects are a major cause of fecal incontinence causing negative effects on daily life, social interactions, and mental health. Because human adipose-derived stromal/stem cells (hADSCs) are easier and safer to access, secrete high levels of growth factor, and have the potential to differentiate into muscle cells, we investigated the ability of hADSCs to improve anal sphincter incontinence. METHODS The present randomized double-blind clinical trial was performed on patients with sphincter defects. They were categorized into a cell group (n = 9) and a control group (n = 9). Either 6 × 106 hADSCs per 3 ml suspended in phosphate buffer saline (treatment) or 3 ml phosphate buffer saline (placebo) was injected. Two months after surgery, the Wexner score, endorectal sonography, and electromyography (EMG) results were recorded. RESULTS Comparing Wexner scores in the cell group and the control group showed no significant difference. In our EMG and endorectal sonography analysis using ImageJ/Fiji 1.46 software, the ratio of the area occupied by the muscle to total area of the lesion showed a 7.91% increase in the cell group compared with the control group. CONCLUSION The results of the current study show that injection of hADSCs during repair surgery for fecal incontinence may cause replacement of fibrous tissue, which acts as a mechanical support to muscle tissue with contractile function. This is a key point in treatment of fecal incontinence especially in the long term and may be a major step forward. TRIAL REGISTRATION Iranian Registry of Clinical Trials IRCT2016022826316N2 . Retrospectively registered 7 May 2016.
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Affiliation(s)
- Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Graham L Newstead
- Sydney Colorectal Associates, Prince of Wales Hospital, Randswick, NSW, Australia
| | - Rezvan Mirzaei
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Joghataei
- Cellular and Molecular Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Bakhtiari
- Cellular and Molecular Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Asrin Babahajian
- Liver and Digestive Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Bahar Mahjoubi
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Cerro CR, Franco EM, Santoro GA, Palau MJ, Wieczorek P, Espuña-Pons M. Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms. Int Urogynecol J 2016; 28:455-460. [PMID: 27613623 DOI: 10.1007/s00192-016-3136-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 08/18/2016] [Indexed: 12/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). METHODS From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (Rs) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. RESULTS A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, Rs =0.212) and Starck's (p < 0.001, Rs =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. CONCLUSIONS The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.
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Affiliation(s)
- Cristina Ros Cerro
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain. .,Pelvic Floor Unit, ICGON, Hospital Clínic, Villarroel 370, 08036, Barcelona, Spain.
| | | | | | - Maria José Palau
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Pawel Wieczorek
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - Montserrat Espuña-Pons
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
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30
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Anal incontinence and fecal urgency following vaginal delivery with episiotomy among primiparous patients. Int J Gynaecol Obstet 2016; 135:290-294. [DOI: 10.1016/j.ijgo.2016.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/18/2016] [Accepted: 08/22/2016] [Indexed: 12/12/2022]
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31
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Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study. Int Urogynecol J 2016; 27:1375-81. [DOI: 10.1007/s00192-016-2986-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
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32
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Ménard S, Poupon C, Bourguignon J, Théau A, Goffinet F, Le Ray C. [Predictive factors of 2-month postpartum anal incontinence among patients with an obstetrical anal sphincter injury]. ACTA ACUST UNITED AC 2016; 45:900-907. [PMID: 26780843 DOI: 10.1016/j.jgyn.2015.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/10/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To determine prevalence of short-term postpartum anal incontinence after obstetrical anal sphincter injury and prognostic factors. MATERIALS AND METHODS Retrospective study including every patient with an obstetrical anal sphincter injury between January 2006 and December 2012 in one tertiary maternity unit. Patients were interviewed and examined at 2-month postpartum. Anal incontinence was defined by the presence of at least one of the following symptoms: flatus incontinence, faecal incontinence and faecal urgency. RESULTS Among 17,110 patients who delivered vaginally during period study, 134 (0.8%) presented an anal sphincter injury. Postpartum obstetrical data were available for 110 of them. Among those patients, 50 women (45.5%) had at least one symptom of anal incontinence at 2-month postpartum and 8 (7.3%) had faecal incontinence. Only maternal age and second stage duration were significantly associated with anal incontinence after obstetrical anal sphincter injury. The degree of sphincter damage at delivery (IIIa, b, c, IV) was not associated with the risk of anal incontinence at 2-month postpartum. CONCLUSION Maternal age and second stage duration were the only risk factor for anal incontinence after obstetrical anal sphincter injury in this study. High prevalence of anal incontinence at 2-month postpartum of obstetrical anal sphincter injury is observed no matter what is the degree of anal sphincter damage. Our results highlight the importance to diagnose all obstetrical anal sphincter injuries whatever the degree of damage.
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Affiliation(s)
- S Ménard
- Maternité Port-Royal, groupe hospitalier Cochin-Broca-Hôtel-Dieu, Assistance publique-Hôpitaux de Paris, DHU risques et grossesse, 53, avenue de l'Observatoire, 75014 Paris, France
| | - C Poupon
- Maternité Port-Royal, groupe hospitalier Cochin-Broca-Hôtel-Dieu, Assistance publique-Hôpitaux de Paris, DHU risques et grossesse, 53, avenue de l'Observatoire, 75014 Paris, France
| | - J Bourguignon
- Maternité Port-Royal, groupe hospitalier Cochin-Broca-Hôtel-Dieu, Assistance publique-Hôpitaux de Paris, DHU risques et grossesse, 53, avenue de l'Observatoire, 75014 Paris, France
| | - A Théau
- Maternité Port-Royal, groupe hospitalier Cochin-Broca-Hôtel-Dieu, Assistance publique-Hôpitaux de Paris, DHU risques et grossesse, 53, avenue de l'Observatoire, 75014 Paris, France
| | - F Goffinet
- Maternité Port-Royal, groupe hospitalier Cochin-Broca-Hôtel-Dieu, Assistance publique-Hôpitaux de Paris, DHU risques et grossesse, 53, avenue de l'Observatoire, 75014 Paris, France
| | - C Le Ray
- Maternité Port-Royal, groupe hospitalier Cochin-Broca-Hôtel-Dieu, Assistance publique-Hôpitaux de Paris, DHU risques et grossesse, 53, avenue de l'Observatoire, 75014 Paris, France.
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Primary Adenocarcinoma of Intestinal Type Arising From a Vaginal Mass: A Case Report. J Low Genit Tract Dis 2015; 19:e52-4. [PMID: 26111042 DOI: 10.1097/lgt.0000000000000068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A patient with a history of a severe vaginal laceration during vaginal birth, unknown degree, presented with recurrent vaginal discharge and was found to have a vaginal mass. Pathologic analysis showed squamous mucosa transitioning into colonic type of mucosa with adenocarcinoma developed from colonic type of mucosa, reminiscent of anorectal junction.
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Rodríguez R, Alós R, Carceller MS, Solana A, Frangi A, Ruiz MD, Lozoya R. Incontinencia fecal posparto. Revisión de conjunto. Cir Esp 2015; 93:359-67. [DOI: 10.1016/j.ciresp.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 09/05/2014] [Accepted: 10/05/2014] [Indexed: 12/01/2022]
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35
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LaCross A, Groff M, Smaldone A. Obstetric Anal Sphincter Injury and Anal Incontinence Following Vaginal Birth: A Systematic Review and Meta-Analysis. J Midwifery Womens Health 2015; 60:37-47. [DOI: 10.1111/jmwh.12283] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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36
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Borycka-Kiciak K, Wawiernia K, Namysł J, Garstka-Namysł K, Tarnowski W. Role of electromyography and functional electrical stimulation in the treatment of anorectal diseases. POLISH JOURNAL OF SURGERY 2015; 87:194-202. [DOI: 10.1515/pjs-2015-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/15/2022]
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Bedair EM, El Hennawy HM, Moustafa AA, Meki GY, Bosat BE. Transperineal sonographic anal sphincter complex evaluation in chronic anal fissures. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1981-1989. [PMID: 25336486 DOI: 10.7863/ultra.33.11.1981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the role of transperineal sonography in assessment of pathologic changes to the anal sphincter complex in patients with chronic anal fissures. METHODS We conducted a prospective case-control study of 100 consecutive patients of any age and both sexes with chronic anal fissures who presented to a colorectal clinic between January 2012 and August 2013 (group A) and 50 healthy volunteers (group B). RESULTS The most common patterns of radiologic changes to anal sphincters associated with chronic anal fissures were circumferential thickening of the anal sphincter complex in 5 patients (5%), circumferential thickening of the internal anal sphincter in 3 patients (3%), preferential thickening of the internal anal sphincter at the 6-o'clock position in 80 patients (80%) and the 12-o'clock position in 7 patients (7%), preferential thickening of the internal and external anal sphincters in 3 patients (3%), and thinning of the internal anal sphincter in 2 patients (2%). CONCLUSIONS Chronic anal fissures cause differential thickening of both internal and external anal sphincters, with a trend toward increased thickness in relation to the site of the fissure. Routine preoperative transperineal sonography for patients with chronic anal fissures is recommended, and it is mandatory in high-risk patients.
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Affiliation(s)
- Elsaid M Bedair
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
| | - Hany M El Hennawy
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.).
| | - Ahmed Abdu Moustafa
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
| | - Gad Youssef Meki
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
| | - Bosat Elwany Bosat
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
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Soerensen MM, Pedersen BG, Santoro GA, Buntzen S, Bek K, Laurberg S. Long-term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury. Colorectal Dis 2014; 16:O347-55. [PMID: 24502361 DOI: 10.1111/codi.12579] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 10/29/2013] [Indexed: 12/24/2022]
Abstract
AIM More than 50% of women experience deteriorating continence over time following primary repair of obstetric anal sphincter injuries. The objectives of this study were to assess the function and morphology of the anal sphincters and pelvic floor in women with long-term faecal incontinence after sphincter repair (primary end-point) and to evaluate their correlation with severity of incontinence (secondary end-point). METHOD The participants in this prospective study were recruited from a cohort of all women who sustained third or fourth degree obstetric sphincter injury reconstruction (cases) from January 1976 to November 1991. The women who delivered immediately before and after each case, without sustaining obstetric damage, were included as controls. Cases and controls were stratified into three categories: (i) continent; (ii) minor incontinence; and (iii) severe incontinence. The function and morphology of the anal sphincters and pelvic floor were evaluated by MRI, three-dimensional endoanal ultrasonography and anorectal physiology tests. RESULTS Fifty-nine women (29 cases/30 controls; mean age 51/53 years; mean follow-up 23.7/24.1 years, respectively) were assessed. Morphologically, cases had a significantly shorter anterior external anal sphincter length compared with controls when evaluated by three-dimensional endoanal ultrasonography (8.6 vs 10.2 mm; P = 0.03). Functionally, cases with severe incontinence had a significantly shorter anterior sphincter length compared with cases with minor incontinence (7.7 vs 10.4 mm; P = 0.04). No correlation could be found between anal pressures and severity of incontinence in the case group. CONCLUSIONS Cases had a significantly shorter anterior external anal sphincter length. Functionally, anterior sphincter length correlated with increased severity of incontinence.
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Affiliation(s)
- M M Soerensen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Risk factors for obstetric anal sphincter injuries and postpartum anal and urinary incontinence: a case–control trial. Int Urogynecol J 2014; 26:383-9. [DOI: 10.1007/s00192-014-2478-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 06/29/2014] [Indexed: 10/25/2022]
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Abramowitz L, Benabderrahmane M, Pospait D, Philip J, Laouénan C. The prevalence of proctological symptoms amongst patients who see general practitioners in France. Eur J Gen Pract 2014; 20:301-6. [PMID: 24702041 PMCID: PMC4438346 DOI: 10.3109/13814788.2014.899578] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Patients do not often discuss anal symptoms, resulting in late diagnosis of proctological disorders and impacting health. Poor epidemiological knowledge is a contributing factor to this, which can be a significant problem in general medicine. Authors evaluated the role of family doctors in proctological disorders by assessing how many of these are spontaneously diagnosed and how many are diagnosed after questioning the patient. Methods Thirty-nine general practitioners completed a targeted questionnaire to assess all patients seen prospectively over 2.5 days of consultations. Results A total of 1079 questionnaires were completed, 621 (58%) for females and 458 (42%) for males with a median age of 54. Twenty-two patients (2%) were seen primarily for anal symptoms. Following questioning, an anal symptom was found in 153 patients (14%). Symptoms reported were: bleeding (32%), pain (31%), pruritus ani (22%), swelling (22%), oozing (14%), and anal discharge (14%). Physicians’ diagnoses were: haemorrhoids, anal fissure, anal discharge, dermatology disease, and functional disorder. In 35% of patients, questioning alone was used to make these diagnoses. Anal incontinence was the only factor associated with referral to a specialist (OR = 5; 95% CI: 1.4–17.8). Conclusion The role of proctology in the general population appears to be significant. In five out of six cases, patients conceal anal symptoms. The high proportion of unexamined patients with anal symptoms is probably multifactorial. Further studies are needed to identify these and put in place the improvement of diagnosis and treatment of anal disorder.
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Affiliation(s)
- Laurent Abramowitz
- Gastroenterology Department and Medical/Surgical Proctology Unit , Bichat UH, Paris
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Vieille P, de Tayrac R, Hudry D, Boucoiran I, Wafo E, Badiou W. [Impact of a training workshop on residents and senior registrar skill in diagnosis and repair of anal sphincter and rectal mucosae obstetrical injuries]. Prog Urol 2014; 24:240-6. [PMID: 24560293 DOI: 10.1016/j.purol.2013.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/24/2013] [Accepted: 10/25/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the impact of a training workshop on residents and senior registrar skill in repair of anal sphincter and rectal mucosae obstetrical injury. MATERIAL AND METHODS Residents and senior registrar practical and theoretical knowledge were evaluated by a questionnaire sent, using AGOF (association des gynécologues-obstétriciens en formation) mailing list. This questionnaire includes questions about epidemiology, risk factors and sutures types. Scores were compared according to the participation or not at the workshop. RESULTS There were 106 residents or senior registrar (48.4%) in the workshop group and 113 (51.6%) in the control group. Scores were significantly higher in the workshop group than in the control group for theoretical knowledge (4.1 vs. 3.7), practical knowledge (17.6 vs. 15.9) and global scores (21.7 vs. 19.7). There was no difference according to the participation before or after the third residency semester. Residents global scores were statistically higher in the workshop group compared to the control group (21.8 vs. 19.5) but there was no significant difference between the senior registrar of the two group. Participants in the workshop group estimate themselves significantly more efficient than in the control group concerning anal sphincter injury repair and rectal mucosae repair. CONCLUSION A training workshop seems to improve the theoretical and practical skill. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- P Vieille
- Service de gynécologie-obstétrique, CHU Carémeau, place du Robert-Debré, 30029 Nîmes cedex 9, France
| | - R de Tayrac
- Service de gynécologie-obstétrique, CHU Carémeau, place du Robert-Debré, 30029 Nîmes cedex 9, France.
| | - D Hudry
- Département de chirurgie oncologique, centre G.-F.-Leclerc, 31079 Dijon cedex, France
| | - I Boucoiran
- Département de gynécologie-obstétrique, CHU Sainte-Justine, université de Montréal, Montréal, Canada
| | - E Wafo
- AGOF, 9, route de la Goulée, 95510 Villers-en-Arthies, France
| | - W Badiou
- Service de gynécologie-obstétrique, CHU Purpan, 31029 Toulouse cedex 9, France
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Campbell S. Fetal macrosomia: a problem in need of a policy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:3-10. [PMID: 24395685 DOI: 10.1002/uog.13268] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Bouchard D, Abramowitz L, Castinel A, Suduca JM, Staumont G, Soudan D, Devulder F, Pigot F, Varastet M, Ganansia R. One-year outcome of haemorrhoidectomy: a prospective multicentre French study. Colorectal Dis 2013; 15:719-26. [PMID: 23216822 DOI: 10.1111/codi.12090] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/14/2012] [Indexed: 12/13/2022]
Abstract
AIM An evaluation was performed of the 1-year outcome of open haemorrhoidectomy (Milligan and Morgan alone or with posterior mucosal anoplasty [the Leopold Bellan procedure]). METHOD A prospective, multicentre, observational study included all patients having a planned haemorrhoidectomy from January 2007 to June 2008. Data were collected before surgery, and at 3 months and 1 year after surgery. Patients assessed their anal symptoms and quality of life (SF-36). RESULTS Six-hundred and thirty-three patients (median age = 48 years, 56.5% women) underwent haemorrhoidectomy either by the Milligan and Morgan procedure alone (n = 231, 36.5%) or together with the Leopold Bellan procedure (posterior mucosal anoplasty) for resection of a fourth haemorrhoid (n = 345, 54.5%), anal fissure (n = 56, 8.9%) or low anal fistula (n = 1, 0.16%). The median healing time was 6 weeks. Early complications included urinary retention (n = 3), bleeding (n = 11), local infection (n = 7) and faecal impaction (n = 9). At 1 year, the main complications included skin tags (n = 2) and anal stenosis (n = 23). There were three recurrences requiring a second haemorrhoidectomy. On a visual analogue scale, anal pain at 1 year had fallen from a median of 5.5/10 before treatment to 0.1/10 (p < 0.001), anal discomfort from 5.5/10 to 0.1/10 (P < 0.001) and the Knowles-Eckersley-Scott Symptom (KESS) constipation score from 9/45 to 6/45 (P < 0.001). The median Wexner score for anal incontinence was unchanged (2/20). De-novo anal incontinence (a Wexner score of >5) affected 8.5% of patients at 1 year, but preoperative incontinence disappeared in 16.7% of patients with this symptom. All physical and mental domains of quality of life significantly improved, and 88% of patients were satisfied or very satisfied. CONCLUSION Complications of open haemorrhoidectomy were infrequent. Anal continence was not altered. Comfort and well-being were significantly improved at 1 year after surgery. Patient satisfaction was high despite residual anal symptoms.
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Affiliation(s)
- D Bouchard
- Service de Proctologie, Hôpital Bagatelle, Talence, France.
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La Torre F, de la Portilla F. Long-term efficacy of dextranomer in stabilized hyaluronic acid (NASHA/Dx) for treatment of faecal incontinence. Colorectal Dis 2013; 15:569-74. [PMID: 23374680 DOI: 10.1111/codi.12155] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 12/15/2012] [Indexed: 02/08/2023]
Abstract
AIM Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long-term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long-term efficacy and safety of NASHA/Dx, assessed 24 months after treatment. METHOD This study was a 24-month follow-up assessment of patients treated with NASHA/Dx under open-label conditions. Data on FI episodes and quality of life measures were collected from diaries over the 28-day period immediately preceding the 24-month assessment. Adverse events were collected. RESULTS Eighty-three of 115 patients completed the 24-month follow-up assessment. At 24 months, 62.7% of patients were considered responders and experienced a ≥ 50% reduction in the total number of FI episodes. The median number of FI episodes declined by 68.8% (P < 0.001). Episodes of both solid and liquid stool incontinence decreased. The mean number of incontinence-free days increased from 14.6 at baseline to 21.7 at 24 months (P < 0.001). Incontinence scores and FI quality of life scores also showed significant improvements. The most common adverse events (AEs) were proctalgia (13.3%) and pyrexia (9.6%). The majority of AEs were mild to moderate, self-limited and resolved within 1 month of the injection. CONCLUSION NASHA/Dx is safe, effective and durable over a 24-month period with a majority of patients experiencing significant improvement in multiple symptoms associated with FI.
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Affiliation(s)
- F La Torre
- Department of Colorectal and Pelvic Surgery, Rome University, Rome, Italy.
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Abramowitz L, Bouchard D, Souffran M, Devulder F, Ganansia R, Castinel A, Suduca JM, Soudan D, Varastet M, Staumont G. Sphincter-sparing anal-fissure surgery: a 1-year prospective, observational, multicentre study of fissurectomy with anoplasty. Colorectal Dis 2013; 15:359-67. [PMID: 22776322 DOI: 10.1111/j.1463-1318.2012.03176.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM Internal sphincterotomy is the standard surgical treatment for chronic anal fissure, but is frequently complicated by anal incontinence. Fissurectomy is proposed as an alternative technique to avoid sphincter injury. We describe 1-year outcomes of fissurectomy. METHOD This was a prospective, multicentre, observational study. All patients with planned surgery for chronic anal fissure were included and had fissurectomy. Data were collected before surgery, at healing, and 1 year after fissurectomy. Patient self-assessed anal symptoms and quality of life (using the 36-item short-form health survey [SF-36] questionnaire). Presurgical and postsurgical variables were compared using the Wilcoxon signed-rank test for paired samples. RESULTS Two-hundred and sixty-four patients were included (median age, 45 years; 52% women). Anoplasty was associated with fissurectomy in 83% of the 257 documented cases. The main complications were urinary retention (n = 3), local infection (n = 4) and faecal impaction (n = 1). Healing was achieved in all patients at a median of 7.5 weeks after surgery. No recurrence occurred. At 1 year, 210 (79%) questionnaires were returned. Median anal pain had dropped from 7.3/10 to 0.1/10 (P < 0.001), anal discomfort had decreased from 5.0/10 to 0.1/10 (P < 0.001) and the Knowles-Eckersley-Scott Symptom constipation score had decreased from 9/45 to 5/45 (P < 0.001). There was a nonsignificant increase in the Wexner anal incontinence score, from 1/20 to 2/20. De-novo clinically significant anal incontinence (Wexner score > 5) affected 7% of patients at 1 year, but presurgical incontinence had disappeared in 15% of patients. All SF-36 domains significantly improved. Anoplasty did not impact any result. CONCLUSION Given its high rate of healing and low rate of de-novo anal incontinence, fissurectomy with anoplasty is a valuable sphincter-sparing surgical treatment for chronic anal fissure.
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Affiliation(s)
- L Abramowitz
- Unité de Proctologie Médico-Chirurgicale, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.
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Laalim SA, Hrora A, Raiss M, Ibnmejdoub K, Toughai I, Ahallat M, Mazaz K. [Direct sphincter repair: techniques, indications and results]. Pan Afr Med J 2013; 14:11. [PMID: 23504542 PMCID: PMC3597895 DOI: 10.11604/pamj.2013.14.11.2024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 11/21/2012] [Indexed: 12/15/2022] Open
Abstract
L'incontinence anale est un handicap physique, psychique et social majeur qui a de nombreuses causes différentes. Les méthodes actuellement disponibles pour améliorer les symptômes de cette incontinence sont les méthodes médicales et de rééducation d'une part et les méthodes chirurgicales d'autre part. Quatre techniques chirurgicales répondent à ces objectifs pour la plupart des malades: la sphinctérorraphie, la neuromodulation des racines sacrées, et les deux techniques de substitution que sont le sphincter artificiel et la graciloplastie dynamisée. La réparation sphinctérienne directe est la technique la plus utilisée dans le traitement chirurgical de l'incontinence anale (IA) par lésion sphinctérienne. Cette technique est envisageable chez les malades ayant une incontinence fécale en rapport avec des lésions limitées du sphincter anal externe. La technique chirurgicale est simple (myorraphie par suture directe ou en paletot) et bien codifiée. Les résultats fonctionnels sont imparfaits et se dégradent avec la durée du suivi. Une continence parfaite après réparation sphinctérienne est rarement acquise de façon durable: le malade candidat à cette approche thérapeutique doit en être averti.
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Affiliation(s)
- Said Ait Laalim
- Département de chirurgie générale (B), CHU Hassan II, Fès, Morocco
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PALM ANNA, ISRAELSSON LEIF, BOLIN MARIE, DANIELSSON INGELA. Symptoms after obstetric sphincter injuries have little effect on quality of life. Acta Obstet Gynecol Scand 2012; 92:109-15. [DOI: 10.1111/j.1600-0412.2012.01532.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND The predictors of the outcomes following anal sphincteroplasty have not been well documented. OBJECTIVE The aim was to evaluate age as a predictor of functional outcome and quality of life after overlapping sphincter repair. DESIGN This study is a retrospective review of chart review followed by a prospective evaluation by the use of validated questionnaires. SETTINGS Patients were assigned to group A (≤ 60 years old) or group B (>60 years). PATIENTS Included were patients with obstetric sphincter injuries who underwent overlapping sphincteroplasty between 1996 and 2007. MAIN OUTCOME MEASURES The Fecal Incontinence Quality of Life Scale, Fecal Incontinence Severity Index, the Cleveland Global Quality of Life scale, and a patient satisfaction questionnaire were used to assess outcome. RESULTS Three hundred twenty-one women underwent sphincteroplasty and 197 responded to this study, 146 (74.1%) patients in group A and 51 (25.9%) patients in group B. Median follow-up was 7.7 years (range, 4.7-10.0). The mean overall Fecal Incontinence Quality of Life Scale was 11.0 ± 3.5. Median Fecal Incontinence Severity Index score was 29.8 ± 15.9. Mean Cleveland Global Quality of Life scale was 0.7 ± 0.2. The 2 groups were comparable for BMI (p = 1.0), ethnic background (p = 0.8), smoking (p = 0.8), and follow-up duration (p = 0.9). Intergroup comparison showed no significant difference in the Fecal Incontinence Quality of Life Scale scores (p = 0.5) in all subscales: lifestyle (p = 0.8), coping behavior (p = 0.5), depression and self-perception (p = 0.2), and embarrassment (p = 0.1). No significant differences were noted in Fecal Incontinence Severity Index (p = 0.2), Cleveland Global Quality of Life scale (p =1.0), or postoperative satisfaction (p = 0.6). LIMITATIONS The study was limited by its retrospective nature. CONCLUSIONS Comparable long-term Fecal Incontinence Severity Index score and Fecal Incontinence Quality of Life Scale scores following overlapping sphincter repair suggest that age is not a predictor of outcome for overlapping sphincter repair. This procedure can be offered to both young and older patients.
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The effects of age and childbirth on anal sphincter function and morphology in 999 symptomatic female patients with colorectal dysfunction. Dis Colon Rectum 2012; 55:286-93. [PMID: 22469795 DOI: 10.1097/dcr.0b013e31823fe7f1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Conflicting data exist on the contributions of advancing age and childbirth on the structure and function of the anal sphincter. This study aimed to examine the relative contributions of age and childbirth in a large cohort of women referred for investigation of symptoms of colorectal dysfunction (fecal incontinence and constipation). SETTING This study was conducted at a specialist surgical colorectal investigation unit in a university teaching hospital. PATIENTS Retrospective analysis was performed on prospectively collected demographic, symptom profile, and physiologic data from 3686 female patients. Strict exclusion criteria were applied, leaving 999 patients for univariate, multivariate, and logistic statistical modeling. MAIN OUTCOME MEASURES The effects of independent variables alone and in combination on anal sphincter pressures (resting and squeeze increment) and the presence of sphincter defects (internal and external) were expressed as regression coefficients and odds ratios. RESULTS Median age was 42 years (range, 16-88), and parity was 2 (range, 0-11); 16% were nulliparous. Three hundred sixty patients had fecal incontinence, 352 had constipation, and 287 had combined symptoms. Anal resting tone decreased with age by 0.66 cm H2O per year, and by 4.3 cm H2O per birth, and was associated with both internal and external anal sphincter defects (p = 0.0001 for both). Squeeze increment pressures decreased by 0.3 cm H2O per year, and by 3.8 cm H2O per birth; decreased pressures were, however, only significantly associated with external anal sphincter defects (p = 0.0001) as a result of childbirth. Cesarean delivery was protective against both reduced anal pressures and sphincter defects. Pudendal nerve terminal motor latencies increased bilaterally with age and with vaginal delivery; the impact of both was greater on the left nerve. Rectal sensation was unaffected by age or parity. CONCLUSIONS Aging predominantly affects anal resting pressures; childbirth, particularly instrumental delivery, is detrimental to the structure and function of the external sphincter.
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KESMODEL ULRIKSCHIØLER, JØLVING LINERIIS. Measuring and improving quality in obstetrics - the implementation of national indicators in Denmark. Acta Obstet Gynecol Scand 2011; 90:295-304. [DOI: 10.1111/j.1600-0412.2011.01078.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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