Outcome of obstetric anal sphincter injuries (OASIS)—role of structured management

How to Avoid Becoming a Risk Factor of Fecal Incontinence Due to OASIS-A Narrative Review

Third- and fourth-degree anal sphincter injuries are among the most severe traumas women can experience during childbirth, often leading to lifelong continence issues. Despite extensive research, current repair techniques are often inadequate, failing to provide long-term efficiency. The repair of OASIS tends to worsen with time as fecal or anal incontinence increases. This article presents the risk factors for primary repair failure differently from those previously described in the literature, specifically focusing on avoidable risk factors related to obstetricians and surgeons who perform OASIS repair. After reviewing the literature, the following risk areas were identified and described: recurrent OASIS, pitfalls of the current WHO classification, surgical techniques, place in which the repair should be performed, surgical training, factors related to low volumes of patients with grade III-IV injuries, timing of the repair, and failure of primary repair.

Determination of anal sphincter injury location using impedance spectroscopy in obstetric patients

Early detection of obstetric anal sphincter injuries (OASI) presents a significant challenge due to lack of both effective and practically available diagnostic tools. Thus, ONIRY, a medical device employing electrical impedance spectroscopy combined with machine learning (ML), was introduced to detect OASI quickly after vaginal delivery. For this post-hoc analysis of the ML approach for determining the OASI location, data was utilized from a clinical study that enrolled 152 women post-vaginal delivery with varying degrees of perineal injuries or no such injuries. Both endoanal ultrasound (EUS), as the reference method, and impedance spectroscopy were performed. ML classification was also performed. The ML model developed within this analysis not only detects OASI but also suggests the location the injury detected. This location analysis had an average accuracy of 85.6% compared with the location indicated by investigators based on EUS.

Development and Validation of a Tool to Identify Anal Incontinence in Pregnant and Postnatal Women

BACKGROUND

Neuromuscular and mechanical damage to the pelvic floor because of pregnancy and birth can result in anal incontinence. Pregnant and postnatal women are rarely screened for anal incontinence by clinicians who specialize in the care of these women, and no screening tool has been developed for routine use in these women.

OBJECTIVE

To develop and validate a tool for use in everyday clinical practice in the care of pregnant and postnatal women.

DATA SOURCES

The study includes 2 test phases with separate data sources. Phase I included test and retest phases of the Bowel-Screening Questionnaire in health professionals and women who were pregnant or had recently birthed (n = 45). Phase II included a pilot of the tool compared to 2 current scoring systems (n = 358).

SETTING

Large tertiary hospital in South Australia.

PATIENTS

Phase II: prospective recruitment of 358 prenatal parous women attending a first antenatal appointment.

MAIN OUTCOMES MEASURES

To evaluate the reliability and validity of the developed tool.

RESULTS

Test-retest agreement in phase I was excellent for each of the 6 items, with each κ statistic being between 0.83 and 1.0. In phase II, agreement between new and existing tools was fair to good for the detection of anal incontinence symptoms addressed as a composite question (κ between 0.41 and 0.71). Anal incontinence was detected in 191 women (53%) using the new tool, and there was a lower prevalence reported using the Vaizey score (n = 118) and Wexner score (n = 129). Completion rates of the new tool were 99%, higher than both the Vaizey score (33%) and Wexner score (36%).

LIMITATIONS

Sample size limits the generalization of findings.

CONCLUSION

The questionnaire is reliable and valid, reporting a high incidence of bowel incontinence, with predominant symptoms of rectal urgency and flatus as precursors for worsening function.

DESARROLLO Y VALIDACIN DE UNA HERRAMIENTA PARA IDENTIFICAR LA INCONTINENCIA ANAL EN MUJERES EMBARAZADAS Y PURPERAS

ANTECEDENTES:El daño neuromuscular y mecánico del piso pélvico debido al embarazo y al parto puede resultar en incontinencia anal. Las mujeres embarazadas y puérperas rara vez son examinadas para la incontinencia anal por médicos que se especializan en el cuidado de estas mujeres, y no se ha desarrollado ninguna herramienta de detección para uso rutinario en estas mujeres.OBJETIVO:Desarrollar y validar una herramienta para uso en la práctica clínica diaria en el cuidado de las mujeres embarazadas y puérperas.FUENTES DE DATOS:El estudio incluye 2 fases de prueba con fuentes de datos separadas. Fase 1, fase test y retest del Bowel Screening Questionnaire en profesionales sanitarios y mujeres embarazadas o recién paridas (n = 45). La Fase 2 incluyó una prueba piloto de la herramienta en comparación con dos sistemas de puntuación actuales (n = 358).ENTORNO CLINICO:Gran hospital terciario en el sur de Australia.PACIENTES:Fase 2: reclutamiento prospectivo de 358 mujeres con parto prenatal que asisten a una primera cita prenatal.PRINCIPALES MEDIDAS DE VALORACIÓN:Evaluar la confiabilidad y validez de la herramienta desarrollada.RESULTADOS:La concordancia test-retest en la fase 1 fue excelente para cada uno de los 6 ítems con cada estadística kappa entre 0,83 y 1,0. En la fase 2, el acuerdo entre las herramientas nuevas y las existentes fue regular a bueno para la detección de síntomas de incontinencia anal abordados como una pregunta compuesta (kappa entre 0,41 y 0,71). Se detectó incontinencia anal en 191 (53%) de las mujeres que utilizaban la nueva herramienta, y se notificó una prevalencia más baja utilizando la puntuación de Vaizey (n = 118) y la puntuación de Wexner (n = 129). Las tasas de finalización de la nueva herramienta fueron del 99%, más altas que la puntuación de Vaizey (33%) y las puntuaciones de Wexner (36%).LIMITACIONES:El tamaño de la muestra limita la generalización de los hallazgos.CONCLUSIONES:El cuestionario es confiable y válido reportando una alta incidencia de incontinencia intestinal, con síntomas predominantes de urgencia rectal y flatos como precursores del empeoramiento de la función. (Traducción-Dr. Ingrid Melo ).

When to assess residual anal sphincter defect after OASI by ultrasound

OBJECTIVES

Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months.

STUDY DESIGN

This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation.

RESULTS

Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination.

CONCLUSIONS

In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

Enhancing the identification of anal incontinence in women of reproductive age

Anal incontinence is an unpredictable and debilitating condition that can significantly reduce quality of life. Symptoms include the involuntary loss of solid and/or liquid stool, flatus incontinence and rectal urgency. Pregnancy and childbirth are two major factors that increase the risk of anal incontinence in women of reproductive age. Women at high risk of anal incontinence include those with a known history of the condition and those who have experienced severe perineal trauma, particularly after injury to the anal sphincters (third-degree and fourth-degree tears). Routine screening for anal incontinence of women in high-risk groups during pregnancy and after childbirth appears to be limited in clinical practice. This article discusses the potential benefits of screening for anal incontinence, outlines the factors that inhibit and enable screening, describes current bowel screening tools and their limitations, and explores how the identification of anal incontinence in women of reproductive age could be improved.

Obstetric anal sphicnter injury in a Spanish hospital

OBJECTIVE

Estimation of the prevalence of obstetric anal sphincter injury (OASIS) in our environment and study of the associated risk factors.

STUDY DESING

A retrospective observational study of cases and controls of assisted deliveries at the Severo Ochoa University Hospital of Leganés during the period from January 1, 2012, to December 31, 2017. A total of 88 OASIS diagnosed in the study period is compared with a randomly selected group of 181 controls of similar characteristics, vaginal births of cephalic of 36 weeks gestation or more, occurring during the same period.

RESULTS

During the study period, a total of 8160 deliveries were attended in our hospital, of which 6187 were vaginal and we diagnosed a total of 88 OASIS at the time of delivery. The prevalence of OASIS is 1.07 % for total births and 1.42 % for total vaginal deliveries. In the case-control study, the univariate analysis shows statistical significance for nulliparity (OR 3.84; 95 % CI 2.155-6.834; p < 0.001), instrumental delivery (OR 8.73; 95 % CI 4.706-16.2016; p < 0.001), occipital posterior position (OR 7.23; 95 % CI 2.535-20.633; p < 0.001), long duration of the second stage of labor (OR 1.99; IC95 % 1,159-3,438; p 0.01), episiotomy (OR 3.51; 95 % CI 1,956-6,309; p < 0.001) and OBGYN labor assistant (<0.001). When performing the multivariate analysis, forceps delivery (OR19.68), Thierry spatulas delivery (OR 8.15), vacuum delivery (OR 2.74), nulliparity (OR 2.56) and fetal weight in grams (OR 1.12) remain significant in the final model.

CONCLUSION

The main risk factors for the onset of OASIS are instrumental delivery, nulliparity and fetal birth weight.

Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis

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.

Three-Dimensional Endoanal Ultrasound Features of the Anal Sphincter in Asian Primigravidae

OBJECTIVES

The normal parameters of 3-dimensional endoanal ultrasound (3DEAUS) of the anal sphincter have not been reported for primigravidae or pregnant women at present. 3DEAUS parameters in Asian primigravidae were assessed in this study.

METHODS

We analyzed 3DEAUS data of 101 consecutives Asian primigravidae, assessed in the early third trimester. The assessment was performed with a rigid ultrasonic probe (Olympus^® RU 12M-R1 probe and EU-ME1 ultrasound system (Olympus Corp., Shinjuku, Japan). The Wilcoxon signed-rank test was used to detect the differences in pressure in different quadrants.

RESULTS

The participants had a mean age of 24.7 (standard deviation [SD], 5.1) years. The Cleveland Clinic Incontinence Score was normal in all participants. The anal sphincter complex had 3 characteristic segments that were identifiable: upper, middle and lower. The puborectalis muscle was identified as a striated "V"-shaped sling, and its mean thickness was 7.44 (SD, 1.41) mm. The mean thickness of internal (IAS) and external (EAS) sphincters at the mid-sphincter level were 1.78 (SD, 0.59) and 5.49 (SD, 1.21) mm, respectively. The EAS measured 6.02 (SD, 1.07) mm at the lower sphincter level. The statistically significant differences seen in the in quadrants were: the IAS was thicker anteriorly (Z = -2.642; P = .008), the EAS at both midsphincter level (Z = -3.70; P < .001) and lower sphincter level (Z = -7.712; P < .001) was thicker posteriorly, and the IAS was thicker at the 9 o'clock position (Z = -2.081; P = .037). Good symmetry at all 3 levels was seen in the EAS (including the puborectalis muscle).

CONCLUSIONS

Normal values of 3DEAUS for primigravidae have been identified and may serve as reference values for other laboratories.

Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP)

OBJECTIVE

To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI).

METHODS

A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI.

RESULTS

There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy.

CONCLUSIONS

Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes.

Perineal length among Vietnamese women

OBJECTIVE

Vietnamese clinicians routinely perform episiotomies in the belief that 3rd-4th degree tears may be prevented, based partly on the view that Vietnamese women have a short perineal length that puts them at increased risk of tears. However, there is no evidence to suggest Vietnamese women have a short perineum compared with other populations. We aimed to determine the mean perineal length among Vietnamese women in early labor and in the second stage, and to compare this to findings from similar studies in other populations.

MATERIALS AND METHODS

We undertook an observational study in a tertiary obstetric hospital in Vietnam from October 2014 to June 2015. Pregnant women who presented in early labor with a live singleton cephalic presentation at ≥37 weeks gestation were eligible. Perineal length was measured early in the 1st stage of labor (≤4 cm dilation) and in 2nd stage of labor (10 cm dilation). Mean perineal length was compared to other populations using t-tests.

RESULTS

Of 395 women, 159 (40.3%) were nulliparous and 236 (59.8%) multiparous. Overall the mean perineal length in early labor was 3.4 cm (±0.4), and did not differ by parity. Mean perineal length among Vietnamese women was significantly shorter (P < 0.001) than other populations (means 3.8-4.6 cm). Among 365 women who reached 2nd stage the mean perineal length was 4.3 cm (±0.6).

CONCLUSION

The perception that Vietnamese women have a relatively shorter perineal length appears to have some basis and outcomes reported from episiotomy trials may not be generalizable to Vietnamese women.

Episiotomy Technique and Management of Anal Sphincter Tears-A Survey of Clinical Practice and Education

OBJECTIVE

To ascertain current techniques of episiotomy used by obstetrics and gynaecology faculty members and residents in an academic department and to determine the current management strategies for third and fourth degree tears.

METHOD

A 14-question anonymous online survey was circulated to all faculty members and residents in the University of Toronto Department of Obstetrics and Gynaecology between October 2015 and March 2016. Results were analyzed descriptively or with Fisher exact test.

RESULTS

The survey response rate was 65.5% (169/258) among 108 faculty members and 61 residents. A history of clinical teaching regarding episiotomy was reported by 87% of faculty members and 75.4% of residents. Right mediolateral episiotomy was the most frequently used method among faculty members (88.0%) and residents (95.1%). The majority of respondents indicated that they would use an end-to-end technique for repair in the labour and delivery room under regional anaesthesia. Prophylactic antibiotics were never prescribed by 18.5% of faculty members and 13.1% of residents for third or fourth degree tears. In analysis by type of training, respondents who had taken a workshop or formal class were significantly more likely to prescribe physiotherapy postpartum (P = 0.001).

CONCLUSION

The most common reported method of learning episiotomy was clinical experience. A substantial number of responses differed from current SOGC guidelines for episiotomy technique and repair and management of anal sphincter injury. We propose developing a workshop and/or simulation-based method of instruction for episiotomy technique and repair.

Do women of reproductive age presenting with pelvic floor dysfunction have undisclosed anal incontinence: A retrospective cohort study

BACKGROUND

Indirect and direct trauma following vaginal birth can negatively impact on the pelvic floor function increasing the risk of anal incontinence. It is often difficult for women to openly disclose that they have anal incontinence and there are limited data collection tools available for the identification of these women in a clinical setting.

AIM

This study aims to describe the prevalence of undisclosed anal incontinence in antenatal and postnatal women with pelvic floor dysfunction.

METHODS

Retrospective cohort study of 230 antenatal and postnatal women referred to a Continence Nursing Service in a large tertiary hospital in South Australia, Australia, with pelvic floor dysfunction. A criteria list was utilised to access the primary reason for referral, anal incontinence assessments and attendance to an appointment.

RESULTS

Anal incontinence was identified in 26% of women (n=59). Anal incontinence was the primary reason for referral amongst 8 women, with the remaining 51 women identified as having anal incontinence following clinical screening via phone consultation. Eighty six percent of women stated they had not previously disclosed anal incontinence to health professionals. Overall, 71% of symptomatic women (n=28 antenatal and n=14 postnatal women) attended appointments to a service specialising in pelvic floor dysfunction.

CONCLUSION

Women presenting with urinary incontinence or other markers of pelvic floor dysfunction should be actively screened for anal incontinence as the prevalence of this condition is high amongst childbearing women.

Incidence and Risk Factors of Obstetric Anal Sphincter Injuries after Various Modes of Vaginal Deliveries in Chinese Women

BACKGROUND

Obstetric anal sphincter injuries (OASIS) can cause an adverse impact on women's physical and mental health. There was lack of published data in Chinese population particularly on studying the risk of OASIS for nonrotational outlet forceps. This study was to determine the incidence and risk factors of OASIS.

METHODS

This is a retrospective cohort study carried out in a tertiary referral hospital in Hong Kong. The control group was selected randomly. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS. This study reviewed the obstetric records of OASIS women and random control from January 2011 to June 2014. Univariate and multivariate logistic regression analysis was performed to evaluate the influence of potential risk factors on OASIS.

RESULTS

Of 15,446 women delivered, 49 had OASIS. The percentage of OASIS increased from 0.3% (2011) to 0.38% (2014). There was an increasing trend of OASIS in attempted spontaneous vaginal delivery without episiotomy (P < 0.01), but it did not increase the OASIS risk (P = 0.46). Univariate analysis of 49 cases and 438 control subjects showed that forceps delivery (odds ratio [OR] =8.73, P < 0.01), prolong second stage of labor (OR = 1.43, P < 0.01) increased the risk for OASIS. In multivariate regression models, only forceps delivery (OR = 6.28, P < 0.01) proved to be independent risk factor.

CONCLUSIONS

The incidence of OASIS in Chinese women was increased after 2012, but still lower than the reported figures in the literature. Outlet forceps delivery could be a possible associated risk factor.

Correlation of three dimensional anorectal manometry and three dimensional endoanal ultrasound findings in primi gravida: a cross sectional study

Background

3-dimensional anorectal manometry (3DARM) and 3-dimensional endoanal ultrasound (3DEAUS) have not been used to assess the anal sphincter complex (ASC) in primi gravida. This study was conducted to identify any correlation that may exist between 3DARM and 3DEAUS.

Methods

We analyzed 3DARM and 3DEAUS data of 101 consecutive primi mothers assessed in the late second trimester or early 3rd trimester. 3DARM was performed using the Given Imaging^® Manoscan system and 3DEAUS was performed with the Olympus^® RU 12M-R1 probe and EU-ME1 ultrasound system.

Results

The mean age was 24.7 (SD—5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD—18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD—52.96) mmHg. The mean length of the high pressure zone was 3.67 (SD—0.52) cm. On 3DEAUS, there were three characteristic segments of the ASC that were identified; upper, middle and lower. Mean thicknesses for both internal anal sphincter (IAS) and external anal sphincter (EAS) were identified for primi gravida. IAS was thicker anteriorly and at 9 o’ clock positions and EAS was thicker posteriorly. There was good correlation in the length of the ASC at each quadrant between 3DARM and 3DEAUS. There was no correlation between either RP or SP thickness of IAS or EAS at each level and quadrant.

Conclusion

Correlation is seen only in the length of ASC at each quadrant. No correlation exist between RP or SP and thickness of IAS and EAS.

Is the risk of obstetric anal sphincter injuries increased in vaginal twin deliveries?

OBJECTIVE

Vaginal twin deliveries have a higher rate of intrapartum interventions. We aimed to determine whether these characteristics are associated with an increased rate of obstetric anal sphincter injuries compared with singleton.

STUDY DESIGN

Retrospective study of all twin pregnancies undergoing vaginal delivery trial was conducted from January 2000-September 2014. Sphincter injury rate compared with all concurrent singleton vaginal deliveries. Multivariable analysis was used to determine twin delivery association with sphincter injuries while adjusting for confounders.

RESULTS

About 717 eligible twin deliveries. Outcome was compared with 33 886 singleton deliveries. Twin pregnancies characterized by a higher rate of nulliparity (54.8% versus 49.5%, p = 0.005), labor induction (42.7% versus 29.1%, p < 0.001), and instrumental deliveries (27.5% versus 16.7%, p < 0.001), lower gestational (34.6 ± 3.3 versus 38.8 ± 2.3, p < 0.001), and lower birth weight. Total breech extraction was performed in 29.0% (208/717) of twin deliveries. Overall obstetric sphincter injury rate was significantly lower in the twins group (2.8% versus 4.4%, p = 0.03, OR = 0.6, 95% CI 0.4-0.9), due to lower rate of 3rd degree tears in twins versus singletons (2.2% versus 4.0%, p = 0.02), rate of 4th degree tears similar among the groups (0.6% versus 0.4%, p = 0.5). In multivariable analysis, sphincter injuries were associated with nulliparity (OR = 3.9, 95% CI 3.4-4.5), forceps (OR = 6.8, 95% CI 5.8-7.8), vacuum (OR = 2.9, 95% CI 2.5-3.3), earlier gestational age (OR = 0.2, 95% CI 0.1-0.3), episiotomy (OR = 0.8, 95% CI 0.7-0.9), and birth weight over 3500 g (OR = 1.8, 95% CI 1.6-2.0). However, the association between twins (versus singletons) deliveries and sphincter injuries was lost after adjustment for delivery gestational age (OR = 0.7, 95% CI 0.4-1.2).

CONCLUSION

Despite a higher rate of intrapartum interventions, the rate of sphincter injuries is lower in twins versus singleton deliveries, mainly due to a lower gestational age at delivery.

Outcome of repair of obstetric anal sphincter injuries after three years

Objective

To prospectively assess change in bowel symptoms and quality of life (QoL) approximately 3 years after primary repair of obstetric anal sphincter injuries (OASIS).

Methods

Between July 2002 and December 2007 women who attended the perineal clinic at Croydon University Hospital, UK, 9 weeks following primary repair of OASIS were asked to complete the Manchester Health Questionnaire and a questionnaire to obtain a St Mark incontinence score. All women had endoanal scans at this visit. In June 2008 all women were asked to complete the questionnaires again.

Results

Of 344 patients who responded to the questionnaires and were included in the analysis, long-term symptoms of fecal urgency, flatus incontinence, and fecal incontinence occurred in 62 (18.0%), 52 (15.1%), and 36 (10.5%), respectively. Overall, there was a significant improvement in fecal urgency (P < 0.001) and flatus incontinence (P < 0.001) from 9 weeks to 3 years. Of 31 women with fecal incontinence symptoms at early follow-up, 28 were asymptomatic at 3 years. However, 33 women developed de novo symptoms. The only predictors of fecal incontinence at 3 years were fecal urgency at 9 weeks (OR 4.65; 95% CI, 1.38–15.70) and a higher St Mark score (OR 1.40; 95% CI, 1.09–1.80).

Conclusion

Following primary repair of OASIS, the majority of symptoms and QoL significantly improve, unless there is a persistent anal sphincter defect. This highlights the importance of adequate repair.

Outcomes and follow-up after obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

To determine if the classification of obstetric anal sphincter injuries (OASIs) affected clinical and functional outcome and to assess the need for follow-up of 3a tears in secondary care

METHODS

Prospective data collection in 255 patients who sustained OASIs during repair with follow-up in a specialist clinic after 6 months.

RESULTS

One hundred and thirty-two patients (51.7 %) sustained 3a tears, 81 (31.7 %) 3b tears, 27 (10.6 %) 3c tears and 15 (5.8 %) had 4th degree tears. Twenty-three patients (9 %) reported symptoms at 6-month follow-up. Eight patients reported anal incontinence of liquid or solid stool. Among patients who sustained 3a tears, 8 patients were symptomatic: 7 had urgency and 1 had flatus incontinence. None of the patients who sustained 3a tears reported incontinence of solid/liquid stool. There appears to be no correlation with scan findings and symptoms at follow up. Most patients are asymptomatic. Urgency of faeces is the commonest symptom.

CONCLUSIONS

The vast majority of patients are asymptomatic. The necessity of seeing all these patients in secondary care for follow-up needs to be questioned. With effective primary care follow-up, there may be a place to follow up patients with 3a tears in the community during the routine 6-week postnatal check and refer the symptomatic patients to the hospital for further review.

Fecal incontinence after obstetric anal sphincter injuries

OBJECTIVE

To determine obstetric variables associated with the long-term prevalence of flatal and/or fecal incontinence among women who sustained obstetric anal sphincter injuries (OASIS).

METHODS

In a retrospective study of women who gave birth between January 1974 and December 1983 at the University Women's Hospital, Tuebingen, Germany, women with OASIS (n=460) were identified on the basis of chart review. Eligible women were recruited to participate in a telephone interview regarding symptoms and their retrospective preference about elective cesarean delivery.

RESULTS

The records of 20 999 deliveries, including all modes of delivery, within the 10-year study period were reviewed, and 99 women who sustained OASIS agreed to participate. The mean follow-up was 27.5±2.4 years. Among the participants, 39.4% reported fecal or flatal incontinence. Operative vaginal delivery (forceps and/or vacuum) was significantly associated with fecal but not flatal incontinence (odds ratio, 3.27; 95% confidence interval, 1.12-9.56, P=0.026). Only 9% of women with flatal incontinence and 13% of women with fecal incontinence would have opted retrospectively for cesarean delivery.

CONCLUSION

Operative vaginal delivery was significantly associated with fecal but not flatal incontinence. No other obstetric variables tested were associated with the long-term prevalence of fecal or flatal incontinence.

Three-dimensional transperineal ultrasound findings associated with anal incontinence after intrapartum sphincter tears in primiparous women

OBJECTIVE

Three-dimensional transperineal sonography (3D-TPS) performed in women following third- or fourth-degree intrapartum tears repaired with the overlapping technique demonstrates characteristic signs. The aim of this study was to investigate the correlation of these signs with clinical complaints of incontinence.

METHODS

This was a prospective observational study. Sixty primiparous women underwent 3D-TPS 3-42 (mean, 10.6) months after surgical repair of third- or fourth-degree postpartum sphincter tears with the overlapping technique and were evaluated for clinical degree of incontinence using the St Mark's Incontinence Score (SMIS) questionnaire. The following signs were assessed on 3D-TPS: interruption of the internal anal sphincter or external anal sphincter, 'half moon' sign, changes in the mucosal folds and thickening of the external anal sphincter in the area of sphincter repair. As a comparison group, 27 primiparous women after normal vaginal delivery, without clinically recognized anal sphincter tears, were evaluated similarly, 3-37 (mean, 9.9) months postpartum.

RESULTS

Abnormal sonographic signs were apparent in 35 (58.3%) of 60 women in the study group, and 39 (65%) of 60 had some clinical complaints of incontinence 3-42 months after delivery, most of a mild degree. Higher SMIS results were found in women of the study group than in those of the comparison group (mean (SD) 2.80 (0.481) vs. 1.15 (0.365); P = 0.018). The rates of incontinence were similar between the women in the study group with normal ultrasound findings and the women in the comparison group (9/25 vs. 10/27; relative risk (RR) = 0.97, 95% CI, 0.47-1.97).

CONCLUSIONS

Sonographic signs of anal sphincter tear and repair had disappeared at follow-up examination in almost half of the patients, and therefore this examination should be deferred from the early postpartum period. A substantial proportion of women report some complaint of incontinence after sphincter repair, most of a slight degree. Such complaints are associated with abnormal 3D-TPS findings at follow up, while in women with a normal 3D-TPS scan the rate of incontinence complaints is similar to that in women after normal delivery.