Frequency of persistent anal symptoms after first instrumental delivery

[Acceptability and results of postpartum proctological consultation for women who have had an obstetric injury of the anal sphincter]

OBJECTIVES

Early management of perineal disorders after obstetric anal sphincter injury (OASI) may improve the functional prognosis. The objective was to assess the acceptability of the consultation and to report on its results.

METHODS

This unicentric retrospective study included 64 women who had LOSA 3 or 4 and who were offered a 3-month routine postpartum proctological consultation. The proposed diagnoses and recoveries were identified.

RESULTS

Of the 5,070 women who gave birth vaginally, 64 women had LOSA (1.2%). 54 came to the clinic (84.3%). At the interview, 21 women had no complaints. A diagnosis of evacuation disorders or hemorrhoidal disease in particular was made in 10 women. A specific management was proposed to 16 women and a control consultation was proposed to 3 women. Of the 33 women with at least one symptom, 31 women were diagnosed and 27 women were offered specific management. A monitoring consultation was offered to 18 women. The main diagnoses were gas incontinence, dyschesia with or without abdominopererial asynchronism and decreased sphincter tone. The main measures undertaken were the extension of laxatives, the proposal of perineal massage and abdominal-perineal rehabilitation by biofeedback.

CONCLUSION

Systematic proctological consultation was acceptable and allows for a specific management in the majority of cases. The assessment of its long-term impact remains to be defined.

Factors associated with symptom severity in women presenting with fecal incontinence

BACKGROUND

Fecal incontinence (FI) affects 2-12% of the US population. Identification of factors associated with worsening symptoms has important implications for prevention and treatment.

OBJECTIVE

The aim of our study is to assess factors associated with symptom severity in women presenting with FI.

DATA SOURCES

This was a prospective survey study.

STUDY SELECTION

Patients presenting to the Michigan Bowel Control Program Clinic for FI were prospectively enrolled between May 2005 and May 2009.

MAIN OUTCOME MEASURES

Factors associated with fecal incontinence severity.

RESULTS

Data on 231 women was analyzed with a mean age of 59.2 years (SD = 14.2) and mean BMI of 30.0 (SD = 8.6); 92% were white. Mean FISI score was 32.4 (SD = 15.3). Two-thirds of patients had a type 1-4 stool on the Bristol stool scale. Forty-one percent of subjects complained of urinary incontinence, 56.2% had an episiotomy, 29% had an operative delivery, and 15.1% reported a severe laceration with childbirth. The majority of patients (86.1%) reported FI for greater than 1 year, and 65.4% had previously sought care for FI. Bivariate analysis revealed that diabetes, IBS, urinary incontinence, history of operative delivery or severe laceration, fecal urgency, longer history of symptoms, previous health care for FI, and belief in treatment were positively associated with worse FISI score. In multiple linear regression analysis, increased FI symptom severity was shown to be associated with fecal urgency (0.0004), history of episiotomy (0.04), urinary incontinence (0.02), and diabetes mellitus (0.004).

LIMITATIONS

This was a cross-sectional survey study performed at a Tertiary care center.

CONCLUSION

Patients with a history of episiotomy, diabetes, urinary incontinence, and fecal urgency have increased FI symptom severity. Proactive screening of patients with these medical histories is needed.

Long-term outcome after obstetric injury: a retrospective study

OBJECTIVE

To examine problems experienced by women after vaginal delivery with and without a sphincter tear and compare those with less and more severe injuries.

DESIGN

Retrospective questionnaire study. Setting. Regional hospital in Sweden.

SAMPLE

A total of 324 women with and 309 without sphincter tears.

METHODS

Questionnaires were sent out four to eight years after delivery enquiring about the existence and time course of gas incontinence, fecal incontinence, dyspareunia and perineal pain. A question about vacuum delivery was also included.

MAIN OUTCOME MEASURES

Prevalence of persisting symptoms.

RESULTS

The reply rate was 77%. About 10% of the women with a sphincter tear had fecal incontinence initially, compared with 3% among those without a sphincter tear. In women with moderate or severe tears, 20 and 31%, respectively, had gas incontinence, compared with 6% of women without a tear. Dyspareunia and perineal pain were present 18-23% of women in the tear groups compared with 9-12% of those without a tear. Almost 45% of women with initial symptoms had remaining problems after four to eight years. There was a significantly higher risk for symptoms after vacuum extraction (p < 0.001).

CONCLUSIONS

Gas incontinence, fecal incontinence, dyspareunia and perineal pain were common problems after delivery. The prevalence of persisting symptoms was high even among women without a tear. The higher prevalence after vacuum extraction delivery indicates that there are more complications associated with this mode of delivery than previously thought.

Faecal incontinence after first instrumental vaginal delivery using Thierry's spatulas

OBJECTIVE

The purpose of this study is to estimate the prevalence of faecal incontinence after first vaginal delivery and to assess the impact of Thierry's spatulas-assisted delivery.

METHODS

A prospective observational study of primiparas who underwent a vaginal delivery at term was conducted. Faecal incontinence was assessed at 2 and 6 months postpartum by a questionnaire (Wexner score >or=5 was considered significant). Univariate and multivariate analyses were performed.

RESULTS

Five hundred thirty-eight women were recruited with undergoing 176 spatulas-assisted deliveries and 362 spontaneous vaginal deliveries. The response rate was 85.9% (2 months) and 80.5% (6 months). The prevalence of faecal incontinence was similar between the two groups at 2 months (14.3% and 9.7%). Episiotomy (odds ratio [OR] = 5.0) and maternal age over 35 years (OR = 4.1) were independently associated with faecal incontinence after adjustment.

CONCLUSIONS

Anal symptoms are common after the first vaginal delivery. Thierry's spatulas do not increase the prevalence of faecal incontinence after delivery given that an episiotomy is performed.

Incidence and etiology of pelvic floor dysfunction and mode of delivery: an overview

Elective cesarean section at patient request is becoming common place. Women are requesting the intervention for preservation of the pelvic floor, but there is conflicting evidence to suggest that this mode of delivery has such benefits. The risks vs. benefits of both vaginal delivery and cesarean section need to be well understood before deciding on a surgical delivery. This review outlines the current available evidence of the risks and benefits associated with vaginal delivery and elective cesarean section and the incidence and mechanisms of injury that lead to pelvic floor dysfunction. As in most surgical conditions, a better understanding of causality of pelvic floor dysfunction may help treatment effectiveness.

Evolving therapy for fecal incontinence

BACKGROUND

Fecal incontinence is common and can be socially debilitating. Nonoperative management of fecal incontinence includes dietary modification, antidiarrheal medication, and biofeedback. The traditional surgical approach is sphincteroplasty if there is a defect of the external sphincter. Innovative treatment modalities have included sacral nerve stimulation, injectable implants, dynamic graciloplasty, and artificial bowel sphincter.

DISCUSSION

This review was designed to assess the various surgical options available for fecal incontinence and critically evaluate the evidence behind these procedures. The algorithm in the surgical treatment of fecal incontinence is shifting. Injectable therapy and sacral nerve stimulation are likely to be the mainstay in future treatment of moderate and severe fecal incontinence, respectively. Sphincteroplasty is limited to a small group of patients with isolated defect of the external sphincter. A stoma, although effective, can be avoided in most cases.

Short-term and long-term effects of obstetric anal sphincter injury and their management

PURPOSE OF REVIEW

During the past decade increasing attention has focused on the problem of obstetric anal sphincter damage. Although risk factors are now well known, the effects of such damage have received less study. This review focuses on the early and long-term problems that may arise subsequent to anal sphincter injury following childbirth and assesses therapeutic options.

RECENT FINDINGS

Up to 25% of women experience altered faecal continence after vaginal delivery, with 4% having persistent symptoms. In those women who have sustained a recognized tear to the sphincter, the quality of primary repair is crucial. Nevertheless, evidence clearly supporting the superiority of overlap over approximation repair is still lacking. The importance of pudendal nerve damage in the aetiology of postpartum faecal incontinence is gaining increasing attention. Augmented biofeedback physiotherapy is the gold standard for treatment of women with such injury, whereas sacral nerve stimulation represents a newer treatment option.

SUMMARY

The short-term and long-term effects of obstetric anal sphincter injury warrant increased attention, because with increasing longevity more women are surviving into their 80s and the prevalence of faecal incontinence in this population will increase if measures are not taken to address the problem. Prevention of such injury is not always possible and management options must be further explored. Adequate primary treatment of third-degree tears is of paramount importance.