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Bachar G, Abu-Rass H, Farago N, Zipori Y, Beloosesky R, Ginsberg Y, Vitner D, Weiner Z, Khatib N. Does delayed vacuum-assisted delivery harbor greater maternal or neonatal complications? Int J Gynaecol Obstet 2024. [PMID: 38234163 DOI: 10.1002/ijgo.15374] [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: 10/04/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries. METHODS We performed a retrospective cohort study in a single, university-affiliated medical center (2014-2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3-4 degree lacerations, and postpartum hemorrhage [PPH]). RESULTS We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2-3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant. CONCLUSION Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h.
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Affiliation(s)
- Gal Bachar
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Hiba Abu-Rass
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Naama Farago
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Oruc M, Erol T. Current diagnostic tools and treatment modalities for rectal prolapse. World J Clin Cases 2023; 11:3680-3693. [PMID: 37383136 PMCID: PMC10294152 DOI: 10.12998/wjcc.v11.i16.3680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023] Open
Abstract
Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.
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Affiliation(s)
- Mustafa Oruc
- Department of General Surgery, Hacettepe University School of Medicine, Ankara 06100, Turkey
| | - Timucin Erol
- Department of General Surgery, Hacettepe University School of Medicine, Ankara 06100, Turkey
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3
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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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4
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Spinelli A, Laurenti V, Carrano FM, Gonzalez-Díaz E, Borycka-Kiciak K. Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives. J Clin Med 2021; 10:jcm10153261. [PMID: 34362045 PMCID: PMC8347477 DOI: 10.3390/jcm10153261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries—OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Correspondence:
| | - Virginia Laurenti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Francesco Maria Carrano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Enrique Gonzalez-Díaz
- Pelvic Floor Unit, Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain;
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain
| | - Katarzyna Borycka-Kiciak
- Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, 80, Ceglowska Street, 01810 Warsaw, Poland;
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5
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Prospective comparison of obstetric anal sphincter injury incidence between an Asian and Western hospital. Int Urogynecol J 2018; 30:429-437. [PMID: 29654350 DOI: 10.1007/s00192-018-3649-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/30/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injury (OASIS) rates are reported to be higher in Asian women living in Western countries than in those living in Asia, but the reasons for the differences remain unclear. The objectives of this study were for a single examiner to prospectively compare OASIS rates in primiparous Asian women in an Asian and Western birth unit and determine potential birth factors that may influence the possible difference in OASIS incidence. METHODS This was a prospective observational study based in Hong Kong, China, and Sydney, Australia, involving primiparous women > 36 weeks gestation of Asian descent undergoing vaginal delivery. A single examiner recorded basic patient demographics, observed all the deliveries at both sites, noting birthing techniques, and then examined the women, including a rectal examination, to determine OASIS incidence. RESULTS Seventy births in Hong Kong and 66 in Sydney were studied. The incidence of OASIS was 34% in Sydney and 10% in Hong Kong (p = 0.001). Birthweight, epidural rate, body mass index, and instrumental delivery were higher in Sydney. Episiotomy rates were higher in Hong Kong (59.2% vs. 82.9%; p = 0.007). When comparing OASIS with no-OASIS, perineal length (OR = 0.36, 95% CI 0.17 to 0.76, p = 0.004) and birthweight (OR = 1.14, 95% CI 1.00 to 1.30, p = 0.039) were independent risk factors for OASIS. CONCLUSIONS The incidence of OASIS in Asian women is significantly higher in a Western than in an Asian setting. In Asian women, perineal length and birthweight can affect the risk of OASIS at the time of vaginal delivery.
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Ramage L, Yen C, Qiu S, Simillis C, Kontovounisios C, Tan E, Tekkis P. Does a missed obstetric anal sphincter injury at time of delivery affect short-term functional outcome? Ann R Coll Surg Engl 2018; 100:26-32. [PMID: 29022787 PMCID: PMC5838671 DOI: 10.1308/rcsann.2017.0140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction This study aimed to ascertain whether missed obstetric anal sphincter injury at delivery had worse functional and quality of life outcomes than primary repair immediately following delivery. Materials and methods Two to one propensity matching was undertaken of patients presenting to a tertiary pelvic floor unit with ultrasound evidence of missed obstetric anal sphincter injury within 24 months of delivery with patients who underwent primary repair at the time of delivery by parity, grade of injury and time to assessment. Outcomes compared included Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score, Short Form-36, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire and anorectal physiology results. Results Thirty-two missed anal sphincter injuries were matched two to one with sixty-two patients who underwent primary repair of an anal sphincter defect. Mean time to follow-up was 9.31 ± 6.79 months. Patients with a missed anal sphincter injury had suffered more incontinence, as seen in higher the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ; 30.56% ± 14.41% vs. 19.75% ± 15.65%, P = 0.002) and Wexner scores (6.00 ± 3.76 vs. 3.67 ± 4.06, P = 0.009). They also had a worse BBUSQ urinary domain score (28.25% ± 14.9% vs. 17.01 ± 13.87%, P = 0.001) and worse physical functioning as measured by the Short Form-36 questionnaire (P = 0.045). There were no differences in other outcomes compared, including anorectal physiology and sexual function. Discussion In the short-term, patients with a missed obstetric anal sphincter injury had significantly worse faecal incontinence and urinary function scores, however quality of life and sexual function were largely comparable between groups. Conclusions Longer-term follow-up is needed to assess the effects of missed obstetric anal sphincter injury over time.
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Affiliation(s)
- L Ramage
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - C Yen
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - S Qiu
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - C Simillis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - C Kontovounisios
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust , London , UK
| | - E Tan
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
- Department of Colorectal Surgery, Singapore General Hospital , Republic of Singapore
| | - P Tekkis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust , London , UK
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Salsi G, Cataneo I, Dodaro G, Rizzo N, Pilu G, Sanz Gascón M, Youssef A. Three-dimensional/four-dimensional transperineal ultrasound: clinical utility and future prospects. Int J Womens Health 2017; 9:643-656. [PMID: 28979167 PMCID: PMC5602462 DOI: 10.2147/ijwh.s103789] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
During the last decade, there has been a huge advancement in the use of transperineal ultrasound (TPU) in the field of obstetrics and gynecology. Its main applications in obstetrics include the monitoring of fetal progression in labor and recently the assessment of maternal pelvic dimensions, whereas in gynecology, TPU is at present widely used for the evaluation of the female pelvic floor, opening new boundaries for the assessment of pelvic floor disorders. The association of volumetric three-dimensional techniques has largely contributed to the remarkable progress that has occurred in the use of TPU. The aim of this paper is to offer an overview of the advantages, challenges and future perspectives of the use of TPU for women’s imaging.
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Affiliation(s)
- Ginevra Salsi
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Ilaria Cataneo
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gaia Dodaro
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Nicola Rizzo
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Mar Sanz Gascón
- Department of Obstetrics and Gynecology, La Fé University Hospital, University of Valencia.,Prenatal Diagnosis Unit, Casa del Salud University Hospital, Valencia, Spain
| | - Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Simic M, Cnattingius S, Petersson G, Sandström A, Stephansson O. Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study. BMC Pregnancy Childbirth 2017; 17:72. [PMID: 28222704 PMCID: PMC5320686 DOI: 10.1186/s12884-017-1251-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 02/11/2017] [Indexed: 11/20/2022] Open
Abstract
Background We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree). Methods This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008–2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree). Results Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28–1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07–2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations. Conclusions The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.
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Affiliation(s)
- Marija Simic
- Clinical Epidemiology Unit, T2, Department of Medicine Solna, Karolinska University Hospital and Institutet, Stockholm, SE 171 76, Sweden.
| | - Sven Cnattingius
- Clinical Epidemiology Unit, T2, Department of Medicine Solna, Karolinska University Hospital and Institutet, Stockholm, SE 171 76, Sweden
| | - Gunnar Petersson
- Clinical Epidemiology Unit, T2, Department of Medicine Solna, Karolinska University Hospital and Institutet, Stockholm, SE 171 76, Sweden
| | - Anna Sandström
- Clinical Epidemiology Unit, T2, Department of Medicine Solna, Karolinska University Hospital and Institutet, Stockholm, SE 171 76, Sweden.,Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska University Hospital and Institutet, Stockholm, SE-171 76, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, T2, Department of Medicine Solna, Karolinska University Hospital and Institutet, Stockholm, SE 171 76, Sweden.,Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska University Hospital and Institutet, Stockholm, SE-171 76, Sweden
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9
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Karcaaltincaba D, Erkaya S, Isik H, Haberal A. The immediate effect of vaginal and caesarean delivery on anal sphincter measurements. J Int Med Res 2016; 44:824-31. [PMID: 27353519 PMCID: PMC5536623 DOI: 10.1177/0300060516653066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/11/2016] [Indexed: 11/20/2022] Open
Abstract
Objective This study evaluated the effects of vaginal and caesarean delivery on internal and external anal sphincter muscle thickness using translabial ultrasonography (TL-US). Methods This prospective cohort study enrolled nulliparous women who either had vaginal or caesarean deliveries. The thickness of the hypoechoic internal anal sphincter (IAS) and hyperechoic external anal sphincter (EAS) at the 12, 3, 6, and 9 o’clock positions at the distal level were measured before delivery and within 24–48 h after delivery. Results A total 105 consecutive women were enrolled in the study: 60 in the vaginal delivery group and 45 in the caesarean delivery group. The IAS muscle thickness at the 12 o’clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.31 ± 0.74 mm versus 1.81 ± 0.64 mm, respectively). The EAS muscle thickness at the 12 o’clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.42 ± 0.64 mm versus 1.97 ± 0.85, respectively). Conclusions There was significant muscle thinning of both the IAS and EAS at the 12 o’clock position after vaginal delivery, but not after caesarean delivery.
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Affiliation(s)
| | - Salim Erkaya
- Department of Obstetrics and Gynaecology, Etlik Zübeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Hatice Isik
- Department of Obstetrics and Gynaecology, Zonguldak Karaelmas University, Zonguldak, Turkey
| | - Ali Haberal
- Department of Obstetrics and Gynaecology, Gazi University, Ankara, Turkey
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10
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Walsh KA, Grivell RM. Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. Cochrane Database Syst Rev 2015; 2015:CD010826. [PMID: 26513224 PMCID: PMC6465178 DOI: 10.1002/14651858.cd010826.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND During childbirth, many women sustain trauma to the perineum, which is the area between the vaginal opening and the anus. These tears can involve the perineal skin, the pelvic floor muscles, the external and internal anal sphincter muscles as well as the rectal mucosa (lining of the bowel). When these tears extend beyond the external anal sphincter they are called 'obstetric anal sphincter injuries' (OASIS). When women sustain an OASIS, they are at increased risk of developing anal incontinence either immediately following birth or later in life. Anal incontinence is associated with significant medical, hygiene and social problems. Endoanal ultrasound (EAUS) can be performed with a bedside scanner by inserting a small probe into the anus and the structures of the anal canal and perineum can be reviewed in real-time. We proposed that by examining the perineum with EAUS after the birth of the baby and before the tear has been repaired, there would be an increase in detection of OASIS. This increased detection could lead to improved primary repair of the external and internal anal sphincter resulting in reduced rates of anal incontinence and improved quality of life for women. EAUS may also have a role after perineal repair in the evaluation of residual injury and may help guide a woman's management in subsequent pregnancies and allow for early referral to specialised units, minimising long-term complications. OBJECTIVES To evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference list of the one retrieved study. SELECTION CRITERIA Randomised control trials (RCTs) comparing EAUS versus no ultrasound in women prior to repair of perineal trauma and EAUS performed after perineal repair. RCTs published in abstract form only and trials using a cluster-randomised design were eligible for inclusion, but none were identified.Trials using a cross-over design and quasi-RCTs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS The two review authors independently assessed the single trial for inclusion and assessed trial quality. Both review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS We included one trial that randomised 752 primiparous women with clinically detectable second-degree perineal tears to either further assessment with EAUS prior to perineal repair or standard care. We assessed this trial as being at a low risk of bias. The trial reported women's anal incontinence at three and 12 months as well as their pain scores and quality of life assessment. The trial authors reported outcomes at three months for 719 women (364 in the experimental group, 355 in the control group, 4% loss to follow-up), and an outcome at 12 months for 684 women (342 in the experimental group, 342 in the control group, 9% loss to follow-up). Primary outcomeCompared with clinical examination (routine care), the use of EAUS prior to perineal repair was associated with a reduction in the rate of severe anal incontinence (defined as involuntary loss of faeces or flatus that constitutes social and/or hygiene problems, or as defined by authors), at greater than six months postpartum (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.24 to 0.97, 684 women at the 12-month time point). Secondary outcomes Severe anal incontinence at less than six months was reduced with the use of EAUS prior to repair when compared with clinical examination (routine care) (RR 0.38, 95% CI 0.20 to 0.72, 719 women). However, increased perineal pain at three months was associated with the use of EAUS prior to perineal repair when compared with routine care (RR 5.86, 95% CI 1.74 to 19.72, 684 women). There was no clear difference in the number of women who reported any anal incontinence at either less than six months or equal to or greater than six months (outcomes not prespecified in our published protocol). Similarly, there was no clear difference between groups in terms of faecal incontinence, flatal incontinence, faecal urgency, or maternal quality of life. The study did not report any data on the need for secondary repair of external anal sphincter, dyspareunia, women's satisfaction with care or the planned or actual mode of birth in any subsequent pregnancy. We were unable to assess the detection rates of OASIS with EAUS from the included study because women with clinically-detected OASIS were excluded from randomisation. AUTHORS' CONCLUSIONS There is some evidence to suggest that EAUS prior to perineal repair is associated with reduced risk of severe anal incontinence but an increase in the incidence of perineal pain at three months postpartum. However, these results are based on one small study involving 752 women. The study took place in a large teaching hospital with an average to busy labour ward. The trial participants were similar to those found in most large obstetric units in developed countries, thus increasing applicability of the evidence, but were restricted to primiparous women.More research is needed to further evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS. More high-quality RCTs are needed to fully evaluate the intervention before the routine use of EAUS on the labour ward could be supported. It would be particularly useful if future trials could assess detection rates of OASIS with EAUS versus clinical examination alone as this is the basis of the theory for improved outcomes with this intervention. Cost and the training required to implement EAUS should be considered, along with maternal quality of life and individual symptoms experienced by postnatal women . It would also be useful to follow up women after their subsequent vaginal births to determine if subsequent mode of delivery affects long-term outcomes. Future studies in multiparous women may also be useful.
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Affiliation(s)
- Kate A Walsh
- Women's and Childrens HospitalDepartment of Obstetrics and Gynaecology55 King William RoadNorth AdelaideAdelaideSAAustralia5006
| | - Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and Gynaecology, Robinson Research Institute72 King William RoadAdelaideSouth AustraliaAustraliaSA 5006
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Dickinson K, Pickersgill P, Anwar S. Functional and physiological outcomes following repair of obstetrics anal sphincter injury. A case. Int J Surg 2013; 11:1137-40. [DOI: 10.1016/j.ijsu.2013.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 11/27/2022]
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Ramalingam K, Monga AK. Outcomes and follow-up after obstetric anal sphincter injuries. Int Urogynecol J 2013; 24:1495-500. [PMID: 23430073 DOI: 10.1007/s00192-013-2051-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 01/16/2013] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- K Ramalingam
- Kingston Hospital NHS trust, Galsworthy Road, Kingston, Surrey, KT2 7QB, UK.
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13
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Melamed N, Gavish O, Eisner M, Wiznitzer A, Wasserberg N, Yogev Y. Third- and fourth-degree perineal tears – incidence and risk factors. J Matern Fetal Neonatal Med 2012; 26:660-4. [DOI: 10.3109/14767058.2012.746308] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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14
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Kumar R, Ooi C, Nicoll A. Anal incontinence and quality of life following obstetric anal sphincter injury. Arch Gynecol Obstet 2011; 285:591-7. [PMID: 21800085 DOI: 10.1007/s00404-011-2003-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/08/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of our study was to identify the number of women who have long-term ano-rectal symptoms following primary repair of obstetric anal sphincter injury (OASI) and the effect on their quality of life. We also wished to determine the impact of the injury on decision for future pregnancies and mode of delivery in subsequent pregnancies. METHODS A cohort of women who sustained OASI in 2004 in Ninewells Hospital were contacted (minimum 4 years post-repair). They were sent a questionnaire about incontinence of flatus, solid stools, liquid stools, severity of incontinence, quality of life, decision for future pregnancy and mode of delivery in subsequent pregnancy. RESULTS 70/4,245 (1.7%) women sustained OASI. 42/70 (60%) women responded to the questionnaire. 15/41 (37%) experienced anal incontinence. 8/15 (53%) women had to alter their lifestyle due to their symptoms. Women who were asymptomatic had a median visual analogue score of 0.5 (range 0-4) and women who were symptomatic had a median score of 3.5 (range 2-8). 12/41 (29%) decided against further pregnancies and 8 of them were symptomatic (p 0.015). 16/41 women (39%) did not have any further pregnancy following OASI and 9 of them (56%) had anal incontinence. Of the 25 women who did have further pregnancies, 6 women (24%) had anal incontinence. 19 of them were asymptomatic. (p = 0.03). 5 out of the 6 symptomatic women had elective caesarean sections. CONCLUSIONS Long-term outcomes following OASI are not encouraging. A significant number of women decided against further pregnancy and most symptomatic women that have further pregnancy opt to deliver by caesarean section.
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Affiliation(s)
- Ranitha Kumar
- Obstetrics & Gynaecology, Wishaw General Hospital, 40, The Fairways, Bothwell, Lanarkshire G71 8PA, UK.
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15
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Kołodziejczak M, Sudoł-Szopińska I, Stefański R, Panorska AK, Gardyszewska A, Krasnodębski I. Anal endosonographic findings in women after vaginal delivery. Eur J Radiol 2011; 78:157-9. [DOI: 10.1016/j.ejrad.2009.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 10/09/2009] [Indexed: 11/28/2022]
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Lindqvist PG, Jernetz M. A modified surgical approach to women with obstetric anal sphincter tears by separate suturing of external and internal anal sphincter. A modified approach to obstetric anal sphincter injury. BMC Pregnancy Childbirth 2010; 10:51. [PMID: 20828380 PMCID: PMC2949785 DOI: 10.1186/1471-2393-10-51] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 09/09/2010] [Indexed: 11/10/2022] Open
Abstract
Background Long-term results after obstetric anal sphincter injury (OASI) are poor. We aimed to improve the long-term outcome after OASI by lessening symptoms of anal incontinence. Methods In a prospective study at Malmö University Hospital, twenty-six women with at least grade 3B OASI were classified and sutured in a systematic way, including separate suturing of the internal and external sphincter muscles with monofilament absorbable sutures. The principal outcome assessed by answers given to six questions, was a difference in anal incontinence score, between the study group and two control groups (women with prior OASI [n = 180] and primiparous women delivered vaginally without a diagnose of OASI [n = 100]). Results An anal incontinence score of zero (i.e., no symptoms) was found in 74% of the study group, 47% of the OASI control group, and 66% of the vaginal control group (p = 0.02 and 0.5, as compared to the study group). Conclusions A modified suturing technique was followed by significant improved one-year symptoms of anal incontinence as compared to historical cases.
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Affiliation(s)
- Pelle G Lindqvist
- Departments of Obstetrics and Gynecology, Clintech, Karolinska University Hospital, Huddinge, 14186 Huddinge, Sweden.
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17
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18
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Fritel X. Périnée et grossesse. ACTA ACUST UNITED AC 2010; 38:332-46. [DOI: 10.1016/j.gyobfe.2010.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Accepted: 03/16/2010] [Indexed: 01/26/2023]
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Boucoiran I, Bafghi A, Delotte J, Valerio L, Bongain A. [Learning use of spatulas: risks of perineal injuries and newborns morbidity]. ACTA ACUST UNITED AC 2010; 39:224-30. [PMID: 20299162 DOI: 10.1016/j.jgyn.2010.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 02/01/2010] [Accepted: 02/10/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the acute neonatal and maternal perineal morbidity due to resident training on spatulas assisted deliveries. MATERIAL AND METHODS We conducted a retrospective observational study of succesful spatulas-assisted deliveries at Nice University Hospital between January2003 and December2006. We performed univariate analysis and logistic regression to assess risk of severe perineal injuries, vaginal laceration and newborn hospitalization according to operator status, controlling for confounders. RESULTS Among 1004 deliveries, 86.4% were performed by residents. No significant difference was found on incidence of severe perineal tears between the 872 extractions performed by residents and the 132 performed by an attending physician (6.9% versus 7.9% p=0.706; OR=0.86 IC95% [0.41-1.81]), but extraction performed by young residents were associated to more severe perineal tears than those performed by senior residents (8.0% versus 4.5% p=0.035; OR=2.10 IC95% [1.16-3.77]). There was no difference between groups concerning newborn morbidity and hospitalisation in special care units (6.4% versus 9.8% p=0.149; OR=1.49 IC95% [0.73-304]). CONCLUSION According to our data, training of resident do not increase the incidence of severe perineal injuries, neonatal complications and hospitalisation linked to spatulas assisted delivery.
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Affiliation(s)
- I Boucoiran
- Service de gynécologie, obstétrique, reproduction et de médecine foetale, université de Nice-Sophia-Antipolis, hôpital Archet-2, CHU de Nice, 151, route de Saint-Antoine-de-Ginestière, 06202 Nice cedex 3, France.
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20
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Ononeze BO, Gleeson N, Turner MJ. Management of third degree perineal tear and choice of mode of delivery in subsequent pregnancies. J OBSTET GYNAECOL 2009; 24:148-51. [PMID: 14766450 DOI: 10.1080/01443610410001645433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study evaluates the management of third/fourth-degree obstetric tears and choice of mode of delivery in subsequent pregnancies amongst obstetricians practising in Ireland. Of the 185 obstetricians who were sent questionnaires 133 replied, giving a response rate of 72%. The consultant obstetricians were significantly more likely to suture third-degree tears in the labour ward than the non-consultant counterpart, P=0.04. There was no statistically significant difference between the two groups on the repair technique, P=0.397. The non-consultant obstetricians were significantly more likely to prescribe laxatives and diclofenac (Volterol) after repair of third/fourth-degree tears. There were significant differences between the two groups of obstetricians in terms of choice of mode of delivery in subsequent pregnancies, and the appropriate person to conduct labour, P=0.044 and 0.017, respectively. Instrumental intervention and use of episiotomies were similar in the two groups. Our study also shows that Fellows and Members of the Royal College of Obstetricians and Gynaecologists (RCOG) are not adhering to the guidelines on the repair of third/fourth-degree tears. We conclude that there is variation in the management of third-degree obstetric tears and choice of mode of delivery in subsequent pregnancies among the obstetricians.
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Affiliation(s)
- B O Ononeze
- Coombe Women's Hospital, Dolphins Barn, Dublin, Republic of Ireland.
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21
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Folch M, Parés D, Castillo M, Carreras R. Aspectos prácticos en el manejo de las lesiones obstétricas perineales de tercer y cuarto grado para minimizar el riesgo de incontinencia fecal. Cir Esp 2009; 85:341-7. [DOI: 10.1016/j.ciresp.2008.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 12/15/2008] [Indexed: 11/29/2022]
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Felt-Bersma RJF. Endoanal ultrasound in benign anorectal disorders: clinical relevance and possibilities. Expert Rev Gastroenterol Hepatol 2008; 2:587-606. [PMID: 19072406 DOI: 10.1586/17474124.2.4.587] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Endoanal ultrasound is a well-established technique used to evaluate benign anorectal disorders. The technique is easy to perform, has a short learning curve and causes very little discomfort. Reconstruction of 3D images is possible. The clinical indications for endoanal ultrasound in benign anorectal diseases are fecal incontinence and peri-anal fistula. Sphincter defects can be depicted with precision and correlate perfectly with surgical findings. Furthermore, an impression of sphincter atrophy can be established. With perianal fistula the tracts can be visualized. Introducing hydrogen peroxide via the external fistula opening improves imaging. Endoanal ultrasound and MRI have comparable results in diagnosing anorectal disorders.
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Affiliation(s)
- Richelle J F Felt-Bersma
- VU University Medical Center, Department of Gastroenterology and Hepatology, De Boelelaan 1117, 1081 HV, PO Box 7057, Amsterdam, The Netherlands.
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Abstract
Fecal incontinence (FI) has a significant social and economic impact on the patient and the community. In women, obstetric injury is commonly associated with the development of FI. Understanding FI is aided by a good knowledge of the pelvic floor anatomy and continence mechanisms. This same knowledge along with a good history and physical can guide the physician in selecting appropriate studies and treatment options. Surgical treatment of FI is currently the best option when a sphincter defect exists. The long-term prognosis of the repair is disappointing, however. Ongoing investigations continue in the hopes of getting closer to a cure and to reclaiming the patient's former quality of life.
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Fowler GE, Adams EJ, Bolderson J, Hosker G, Lowe D, Richmond DH, Alfirevic Z. Liverpool Ultrasound Pictorial Chart: the development of a new method of documenting anal sphincter injury diagnosed by endoanal ultrasound. BJOG 2008; 115:767-72. [PMID: 18355367 DOI: 10.1111/j.1471-0528.2008.01680.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop and validate a pictorial chart that documents ultrasound examination of the anal sphincter. DESIGN A new pictorial chart (Liverpool Ultrasound Pictorial Chart [LUPIC]) depicting the normal anatomy of the anal sphincter was developed. METHODS To validate LUPIC, two observers documented the findings of 296 endoanal scans. Reliability was assessed between observers using kappa agreement for presence and position of sphincter defects. To validate the use of LUPIC by different observers, a video of ten endoanal ultrasound scans was reviewed by our local expert (gold standard). Seven clinicians underwent test-retest analysis. Kappa agreement was calculated to assess intra-observer and gold standard versus observer agreement for the overall presence of sphincter defects and compared with the gold standard. Complete agreement for the position and level of sphincter defects was assessed for the five abnormal scans. MAIN OUTCOME MEASURES Excellent agreement between the two observers was found for the presence (kappa 0.99), position and level of external anal sphincter defects documented using LUPIC. The intra-observer and gold standard versus observer kappa values of experienced clinicians (A-E) showed good agreement for the overall presence of sphincter defects. Complete agreement for the position and level of sphincter defects was found in 23 of 35 (66%) observations. CONCLUSIONS LUPIC is designed and validated method of documenting anal sphincter injury diagnosed by endoanal ultrasound. Standardisation of endoanal ultrasound findings by using LUPIC may help correlate the degree of damage with patient symptoms.
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Affiliation(s)
- G E Fowler
- Department of Urodynamics, Liverpool Women's Hospital, Liverpool, UK.
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Johnson JK, Lindow SW, Duthie GS. The prevalence of occult obstetric anal sphincter injury following childbirth--literature review. J Matern Fetal Neonatal Med 2007; 20:547-54. [PMID: 17674269 DOI: 10.1080/14767050701412917] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To calculate the published prevalence of ultrasound-detected occult anal sphincter damage associated with different modes of delivery. METHODS A search of the English language literature for articles using keywords describing the prevalence of ultrasound-diagnosed anal sphincter injury following childbirth. The weighted mean prevalence of occult anal sphincter injury was calculated in the following groups: (1) primiparous women (unselected); (2) primiparous women after an unassisted normal vaginal delivery; (3) multiparous women (unselected); (4) following forceps delivery; (5) following ventouse delivery; (6) following cesarean section. RESULTS Nineteen articles described ultrasound-diagnosed occult anal sphincter injury. The prevalence in unselected primiparous women (excluding cesarean section) was 29.2% (288/983). After unassisted vaginal delivery in primiparae the prevalence was 21.7% (74/341). The incidence in multiparous women (unselected) is 32.3% (107/331); following forceps delivery 49.1% (131/267) and with ventouse delivery it is 45.2% (66/146). Only one woman (in 173 cases) had anal sphincter injury following cesarean section. CONCLUSIONS After a review of the literature, occult anal sphincter injury is mostly associated with the first vaginal delivery and is particularly high following instrumental deliveries. Ventouse is less traumatic than forceps. Cesarean section is protective to the anal sphincter.
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Affiliation(s)
- J K Johnson
- Department of Obstetrics and Gynaecology, Women and Children's Hospital - Hull Royal Infirmary, Hull, UK.
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Maslovitz S, Jaffa A, Levin I, Almog B, Lessing JB, Wolman I. The clinical significance of postpartum transperineal ultrasound of the anal sphincter. Eur J Obstet Gynecol Reprod Biol 2007; 134:115-9. [PMID: 16914253 DOI: 10.1016/j.ejogrb.2006.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2004] [Revised: 06/19/2006] [Accepted: 06/22/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the clinical significance of postpartum anal sphincter damage by transperineal ultrasonography (TPUS) performed on the day of delivery. METHODS Continence questionnaires were handed out and TPUS was performed on 154 consecutive primiparous women 6-24h after vaginal delivery. At 2 and 6 months later, complaints and sphincteric sonographic appearance were reassessed. The puerperal women's clinical status and sonographic findings in the immediate and late postpartum period were evaluated. RESULTS Thirty-five (23%) women complained of anal incontinence on the first postpartum day and anal sphincter damage was demonstrated by TPUS in 31 (89%) of them. Four women with anorectal complaints had an intact anal sphincter by TPUS. Follow-up questionnaires, 2 months later, revealed 30 symptomatic women: all of them had sonographically recognized tears on the initial TPUS and 27 of them had positive findings on the TPUS performed 2 months after birth. Six months after delivery, 27 women reported symptoms and all of them had sphincteric disruption evidenced on TPUS performed on the day of delivery. All the women with intact sphincter on the initial TPUS were asymptomatic 6 months later. CONCLUSION TPUS findings on the day of delivery are related to long-term anorectal complaints, supporting a potential role for TPUS as a screening aid for anal sphincter tears.
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Affiliation(s)
- Sharon Maslovitz
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weitzman Street, Tel Aviv 64239, Israel.
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Dupuis O. [Arguments against cesarean section to prevent anal incontinence]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2007; 35:269-71. [PMID: 17293154 DOI: 10.1016/j.gyobfe.2007.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- O Dupuis
- Service de Gynécologie-Obstétrique (Professeur-P.-Gaucherand), Centre Hospitalier Lyon-Sud (HCL), Université Claude-Bernard-Lyon, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
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Starck M, Bohe M, Valentin L. Effect of vaginal delivery on endosonographic anal sphincter morphology. Eur J Obstet Gynecol Reprod Biol 2007; 130:193-201. [PMID: 16713061 DOI: 10.1016/j.ejogrb.2006.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2005] [Revised: 01/27/2006] [Accepted: 04/10/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To describe the effect of vaginal delivery with no clinically recognized sphincter tear on endosonographic anal sphincter morphology and sphincter pressure and to relate endosonographic results to anal sphincter pressure and anal incontinence score. STUDY DESIGN Thirty-two nullipara underwent anal endosonography and anal manometry in the third trimester of pregnancy, 2 weeks and 6 months post-partum. The sphincter defect scores (1-16) and the thickness and length of the sphincters were measured by endosonography, and sphincter pressures and manometric sphincter lengths were determined. The Wexner incontinence score (1-20) was used to classify anal incontinence 6 months post-partum. RESULTS Five (16%) women had small endosonographic anal sphincter defects (score 3-4) before delivery. Eight women (25%; confidence interval 11-43%) had new defects detected post-partum, five small, one moderate (score 7), and two large (score 10-11). Six (75%) of eight women with new defects post-partum had undergone episiotomy versus five (21%) of 24 women with no new defects (p = 0.02). Six months after delivery 16 (50%) women reported anal incontinence, and there was a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score. The sphincter was significantly longer during pregnancy than 6 months post-partum. CONCLUSION New sphincter defects may arise after vaginal delivery without any clinically recognizable sphincter tear. There is a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score.
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Affiliation(s)
- Marianne Starck
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden.
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Richter HE, Fielding JR, Bradley CS, Handa VL, Fine P, FitzGerald MP, Visco A, Wald A, Hakim C, Wei JT, Weber AM. Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears. Obstet Gynecol 2007; 108:1394-401. [PMID: 17138772 DOI: 10.1097/01.aog.0000246799.53458.bc] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate whether endoanal ultrasound findings are more prevalent in primiparous women with a history of anal sphincter tear than in women without this history and whether the findings are associated with fecal incontinence symptoms. METHODS A total of 251 primiparous women at seven clinical sites underwent standardized ultrasound assessment of the internal and external anal sphincter 6-12 months after delivery. Participants were women in the three cohorts of the Childbirth and Pelvic Symptoms Study: 1) women with clinically evident third- or fourth-degree tear at vaginal delivery (n=106); 2) no tear at vaginal delivery (n=106); and 3) cesarean delivery without labor (n=39). Women completed the Fecal Incontinence Severity Index to assess fecal incontinence symptoms. RESULTS Thirty-five percent of the sphincter tear group exhibited internal sphincter gaps compared with 3% of vaginal controls (odds ratio [OR] 18.4, 95% confidence interval [CI] 5.5-62.1) and 10% of cesarean controls. External sphincter gaps were identified in 51% of the tear group compared with 31% of vaginal controls (OR 2.3, 95% CI 1.3-4.0) and 28% of cesarean controls. In the tear group, fecal incontinence severity was greater in those with internal sphincter gaps compared with those with no internal sphincter gaps (Fecal Incontinence Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well as in those with external sphincter gaps (6.1+/-8.4 compared with 2.7+/-5.0, P=.01), and greatest in those with both internal and external sphincter gaps compared with at least one gap not present (7.2+/-8.1 compared with 3.4+/-6.4, P=.003). CONCLUSION Anal sphincter gaps detected by ultrasonography are prevalent in postpartum primiparous women with a history of sphincter tear and are associated with fecal incontinence severity. LEVEL OF EVIDENCE II-2.
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Affiliation(s)
- Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama 35249-7333, and Division of Radiology, Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA.
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Boulvain M, Epiney M, Morales MA. [Fetal macrosomia and labor induction: for lack of evidence, we randomize]. ACTA ACUST UNITED AC 2006; 34:1190-3. [PMID: 17092754 DOI: 10.1016/j.gyobfe.2006.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M Boulvain
- Département de gynécologie et d'obstétrique, hôpitaux universitaires de Genève, 32, boulevard de la Cluse, 1211 Genève, Suisse
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Abstract
OBJECTIVE To review the current literature concerning anal incontinence (AI), pregnancy, and route of delivery. FINDING AI is the involuntary loss of flatus, liquid, or solid stool that is a social or hygienic problem. AI has been reported in 5% to 26% of women during the first year following vaginal delivery. AI is strongly associated with occult and overt sphincter lacerations and operative vaginal delivery. The role of pregnancy itself and the impact of cesarean delivery on AI are unclear. Elective cesarean section has not been shown to decrease the risk of AI. CONCLUSION The majority of current studies lack the power, matched controls, and long-term follow up to make recommendations concerning the mode of delivery and prevention of AI. The natural history of AI and development of symptoms as women age also remains unclear.
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Affiliation(s)
- Dee Fenner
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., L4000 Women's Hospital, Ann Arbor, MI 48109, USA.
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Faltin DL, Otero M, Petignat P, Sangalli MR, Floris LA, Boulvain M, Irion O. Women's health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. Am J Obstet Gynecol 2006; 194:1255-9. [PMID: 16647908 DOI: 10.1016/j.ajog.2005.10.797] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Revised: 09/16/2005] [Accepted: 10/21/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We studied the long-term outcome after an anal sphincter tear. STUDY DESIGN From a cohort of 4569 women who gave birth in 1982 to 1983, we identified 445 (9.7%) who sustained a sphincter tear and 445 controls. Eighteen years after the delivery, we mailed them a questionnaire and graded fecal incontinence with the Wexner score, a summary of incontinence to flatus, liquid, or solid stools; need to wear a pad; and lifestyle alterations. We predefined severe incontinence as a score above 4 of 20. RESULTS Five hundred forty of 890 women (61%) returned the questionnaire. Severe fecal incontinence was reported by 34 of 259 women (13.1%) after a sphincter tear and 22 of 281 controls (7.8%) (risk ratio 1.7, 95% confidence interval 1.0 to 2.8). Only 6.4% of the reports of fecal incontinence were attributable to a sphincter tear. CONCLUSION Fecal incontinence is frequently reported, even by women who have not sustained an anal sphincter tear. Only a small fraction of fecal incontinence can be attributed to sphincter tears.
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Affiliation(s)
- Daniel L Faltin
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Abstract
OBJECTIVES To establish the true prevalence of clinically recognisable and occult obstetric anal sphincter injuries (OASIS). DESIGN Prospective interventional study. SETTING Busy district general hospital. SAMPLE Two hundred and fifty-four women having their first vaginal delivery over a 12-month period were invited. Two hundred and forty-one (95%) participated and 208 (86%) attended follow up. METHODS Women had a clinical examination at delivery by the accoucheur and repeated by an experienced research fellow immediately after delivery. All identified OASIS were verified and repaired by the duty specialist registrar or consultant. Endoanal ultrasound was performed immediately postpartum prior to suturing and repeated seven weeks later. MAIN OUTCOME MEASURES Prevalence of recognised and occult anal sphincter injuries. RESULTS Fifty-nine (24.5%) women sustained OASIS. The prevalence of OASIS increased significantly from 11% to 24.5% when women were re-examined. Of these, 30 occurred in deliveries by midwives who missed 26 (87%) and 29 following deliveries by doctors who missed 8 (28%) injuries. All clinically apparent OASIS were also identified on endoanal ultrasound. In addition, three (1.2%) women had an occult anal sphincter injury. Two of these occult sphincter injuries were isolated to the internal anal sphincter (IAS) and would not usually be clinically detectable. CONCLUSIONS OASIS occur more frequently than previously reported. Many remain undiagnosed and are subsequently classified as occult when identified on anal endosonography. Genuine occult injuries are rare. Training in perineal anatomy and recognition of OASIS needs to be enhanced in order to increase detection of OASIS and minimise the risk of consequent anal incontinence.
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35
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Felt-Bersma RJF, Cazemier M. Endosonography in anorectal disease: an overview. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 2006:165-74. [PMID: 16782637 DOI: 10.1080/00365520600664292] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Anorectal endosonography (AE), which was introduced 20 years ago, derives from the study of urology. It was first used to evaluate rectal tumours and later also to investigate benign disorders of the anal sphincters and pelvic floor. The technique is easy to perform, it has a short learning curve and causes no more discomfort than a routine digital examination. A rotating probe with a 360 degrees radius and a frequency between 5 and 16 MHz is introduced to the rectum and then slowly withdrawn so that the pelvic floor and subsequently the sphincter complex are seen. Recently, it has become possible to reconstruct three-dimensional images. AE has been used for almost every possible disorder in the anal region and has increased our insight into anal pathology. The clinical indications for AE are: 1. Faecal incontinence in patients when surgery is an option. AE can show sphincter defects with excellent precision. There is a perfect correlation with surgical findings. Studies comparing AE with endoanal magnetic resonance imaging (MRI) have shown that both methods are equally good for demonstrating defects in the external anal sphincter; the internal anal sphincter is better visualized with AE. After sphincter repair, the effect is directly related to the decrease in the sphincter defect. 2. Perianal fistulae. AE has been shown to be accurate in staging perianal cryptoglandular fistulae and fistulae in Crohn's disease. When there is an external fistula opening, H2O2 can be introduced with a plastic infusion catheter. The tract then becomes visible as a hyperechoic lesion ("white"). It has been shown that this corresponds well with surgical findings. It is equally sensitive as endoanal MRI. Since recurrent cryptoglandular fistulae are complex in 50% and Crohn's fistula in 75%, it is mandatory to perform AE preoperatively in these patients to avoid missed tracts during surgery and subsequent recurrences. 3. Rectal tumors. In low tubulovillous adenomas or malignant polyps considered removable locally, confirming the local resectability (T0 or T1) is mandatory. Although larger rectal and more advanced tumours can be evaluated with AE, MRI is more sensitive in staging nodal involvement. 4. Anal carcinoma for staging. AE has been shown to stage better than the classical TNM classification for both local extension and prognosis. In conclusion, AE images the internal and external anal sphincter with high accuracy. It is easy to perform and is of particular value in the diagnosis of anal incontinence and perianal fistulae. It is excellent in staging anal carcinoma and can also be used in staging rectal carcinoma, especially very low large malignant polyps.
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Affiliation(s)
- R J F Felt-Bersma
- Department of Gastroenterology and Hepatology, VU University Hospital Amsterdam, The Netherlands.
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36
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Abstract
Vaginal delivery has been considered to be the main cause of pelvic static disorders since obstetric is taught. Epidemiological studies generally confirm the greater prevalence of urinary or fecal incontinence after delivery. Analysis of available data lead to the following observations. Urge urinary incontinence is not associated with the number of pregnancies or the mode of delivery. At age equivalence, stress urinary incontinence is more frequent among women who delivered by C-section compared with women without children. Also at age equivalence, stress incontinence is more frequent in women who delivered by the vaginal route compared with those who had C-section. This difference disappears with age, while stress urinary incontinence during pregnancy is a risk factor 15 days later. The only published randomized trial demonstrated a higher prevalence of stress urinary incontinence three months after delivery in the vaginal route group, but this difference disappeared at two years. Fecal incontinence is more frequent after delivery, especially in the event of forceps delivery. Nevertheless late after delivery, the prevalence of fecal incontinence is similar between spontaneous vaginal, forceps, or C-section delivery. The mode of delivery thus has an impact on continence. However, late after delivery, the influence of pregnancy and delivery fades out either due to a process of repair or via the intermediary of other predominant risk factors (age, tissue quality). The beneficial effect of programmed C-section on continence has not been demonstrated.
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Affiliation(s)
- X Fritel
- Service de Gynécologie-Obstétrique, CHD Félix-Guyon, Saint-Denis-de-la-Réunion.
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37
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Faltin DL, Boulvain M, Floris LA, Irion O. Diagnosis of anal sphincter tears to prevent fecal incontinence: a randomized controlled trial. Obstet Gynecol 2005; 106:6-13. [PMID: 15994610 DOI: 10.1097/01.aog.0000165273.68486.95] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Maternal anal sphincter tears after vaginal delivery are frequently not diagnosed clinically and are associated with subsequent fecal incontinence. This study examined whether diagnosis of these tears by ultrasonography, followed by immediate surgical repair, reduces the occurrence of incontinence. METHODS We conducted a randomized trial involving 752 primiparous women without a clinically evident anal sphincter tear to evaluate the benefit of adding endoanal ultrasonography immediately after vaginal delivery to the standard clinical examination of the perineum. When a sphincter tear was diagnosed, the perineum was surgically explored and the sphincter sutured. The main outcome evaluated was fecal incontinence 3 months postpartum graded by the Wexner incontinence scale, which measures incontinence to flatus and liquid or solid stools, need to wear a pad, and lifestyle alterations. RESULTS Among women assessed by ultrasonography, 5.6% had a sphincter tear. Severe incontinence was reported 3 months after childbirth by 3.3% of women in the intervention group compared with 8.7% in the control group (risk difference -5.4%; 95% confidence interval -8.9 to -2.0; P = .002). The benefit of the intervention persisted 1 year after delivery, with 3.2% severe incontinence in the intervention group compared with 6.7% in the control group (risk difference -3.5%; 95% confidence interval -6.8% to -0.3%; P = .03). Ultrasonography needs to be performed in 29 women to prevent 1 case of severe fecal incontinence. CONCLUSION Ultrasound examination of the perineum after childbirth improves the diagnosis of anal sphincter tears, and their immediate repair decreases the risk of severe fecal incontinence. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Daniel Ladislas Faltin
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Geneva and University Hospitals of Geneva, Switzerland.
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Wang A, Guess M, Connell K, Powers K, Lazarou G, Mikhail M. Fecal incontinence: a review of prevalence and obstetric risk factors. Int Urogynecol J 2005; 17:253-60. [PMID: 15973465 DOI: 10.1007/s00192-005-1338-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Accepted: 05/30/2005] [Indexed: 12/16/2022]
Abstract
Anal incontinence (AI) is a significant problem that causes social and hygienic inconvenience. The true prevalence of AI is difficult to estimate due to inconsistencies in research methods, but larger studies suggest a rate of 2-6% for incontinence to stool. There is a significant association between sonographically detected anal sphincter defects and symptoms of AI. The intrapartum factors most consistently associated with a higher risk of AI include: forceps delivery, third or fourth degree tears, and length of the second stage of labor. Fetal weight of > 4,000 g is also associated with AI. Repair of the sphincter can be performed in either an overlapping or an end-to-end fashion, with similar results for both methods. The role of cesarean delivery for the prevention of AI remains unclear, and further study should be devoted to this question.
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Affiliation(s)
- Andrea Wang
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, 3332 Rochambeau Ave, 1st Floor Suite C, Bronx, NY 10467, USA.
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39
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Abstract
BACKGROUND To describe an operative technique for the repair of anovaginal fistulae secondary to obstetric injury and to assess its functional outcome and patient satisfaction. METHODS An operative repair involving division of the anovaginal fistula, closure of rectal and vaginal walls, anterior levatoplasty and overlapping sphincteroplasty is described. Postoperative complications and recurrence were recorded. A telephone interview was carried out to assess the functional outcome and the satisfaction score. RESULTS Seven consecutive patients had a repair of an obstetric-related anovaginal fistula. Their mean age was 34 years (range: 22-72). They had a mean duration of symptoms of 14 months (range: 1.5-54). Four patients did not have any previous repair and no stoma was necessary in any of the seven patients. There was no significant postoperative complication and only one recurrence. Telephone interviews were conducted for six patients and one was lost to follow-up. The mean follow-up period was 24 months (11-35). The Wexner's continence score improved from a mean preoperative score of 13.4 to a mean postoperative score of 5.6. With satisfaction scores ranging from +3 to -3 (+3 indicating complete satisfaction and -3 indicating complete dissatisfaction), five patients scored 1 and one scored 0. CONCLUSION This technique is straightforward and effective in healing obstetric-related anovaginal fistula. It achieves improved continence and reasonable satisfaction.
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Affiliation(s)
- Simon S B Chew
- Colorectal Unit, University Department of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
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40
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Fornell EU, Matthiesen L, Sjödahl R, Berg G. Obstetric anal sphincter injury ten years after: subjective and objective long term effects. BJOG 2005; 112:312-6. [PMID: 15713145 DOI: 10.1111/j.1471-0528.2004.00400.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To establish the long term effects of obstetric anal sphincter rupture. DESIGN Prospective observational study. SETTING University hospital in Sweden. POPULATION Eighty-two women from a prospective study from 1990 to compare anorectal function after third degree tear. METHODS Women completed a structured questionnaire, underwent a clinical examination and anorectal manometry, endoanal ultrasound (EAUSG) with perineal body measurement. MAIN OUTCOME MEASURES Symptoms of anal incontinence, sexual symptoms, anal manometry scores and evidence of sphincter damage on EAUSG. RESULTS Five women had undergone secondary repair and three were lost to follow up. Fifty-one women (80%) completed the questionnaire. Twenty-six out of 46 (57%) of the original study group and 6/28 (20%) of the original controls were examined. Incontinence to flatus and liquid stool was more severe in the study group than in controls. Flatus incontinence was significantly more pronounced among women with subsequent vaginal deliveries. Mean maximal anal squeeze pressures were 69 mmHg in the partial rupture group and 42 mmHg in the complete rupture group (P= 0.04). Study group women with signs of internal sphincter injury reported more pronounced faecal incontinence and had lower anal resting pressures (24 mmHg) than those with intact internal sphincters (40 mmHg) (P= 0.01). Perineal body thickness of less than 10 mm was associated with incontinence for flatus and liquid stools, less lubrication during sex and lower anal squeeze pressures (58 mmHg vs 89 mmHg, P= 0.04). CONCLUSIONS Subjective and objective anal function after anal sphincter injury deteriorates further over time and with subsequent vaginal deliveries. Thin perineal body and internal sphincter injury seem to be important for continence and anal pressure.
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Affiliation(s)
- Eva Uustal Fornell
- Department of Molecular and Clinical Medicine, Division of Obstetrics and Gynecology, University Hospital, S-581 85 Linköping, Sweden
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41
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Pinta TM, Kylänpää ML, Teramo KAW, Luukkonen PS. Sphincter rupture and anal incontinence after first vaginal delivery. Acta Obstet Gynecol Scand 2004; 83:917-22. [PMID: 15453886 DOI: 10.1111/j.0001-6349.2004.00346.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this prospective study was to establish the incidence of anal incontinence and sphincter defects after first vaginal delivery. METHODS A total of 99 nulliparous and pregnant women were examined prospectively 4 weeks (mean) before delivery and 4 months (mean) after delivery. Of the study population, 75 (76%) women had vaginal delivery and 24 (24%) had cesarean section. Vacuum extraction was necessary in 20 (20%) cases. The symptoms of anal incontinence were asked about using a standard questionnaire. Clinical examination, endoanal ultrasound (EAUS) and anal manometry were performed before and after delivery. RESULTS The symptoms of mild anal incontinence, mainly gas incontinence, increased after vaginal delivery more than after cesarean section (P < 0.032). Occult anal sphincter defects were noted in 17 (23%) of the 75 women after vaginal delivery by using EAUS. After vacuum extraction, anal sphincter defects were noted in nine (45%) out of 20 women. No new sphincter defects were found in the cesarean section group. The maximal squeezing pressures were significantly decreased in the patients with external anal sphincter (EAS) defects (P = 0.0025). Vacuum extraction leads to more sphincter defects but does not significantly increase anal incontinence or decrease mean anal sphincter pressures. CONCLUSIONS The first vaginal delivery can result in occult sphincter defects and the use of vacuum extraction increases the risk.
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Affiliation(s)
- Tarja M Pinta
- Department of Surgery, Helsinki University Central Hospital, Haartmaninkatu, Helsinki, Finland.
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42
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Abstract
Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.
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Affiliation(s)
- Robert D Madoff
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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43
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Abstract
Faecal incontinence is a distressing and socially debilitating problem. Nurses are ideally placed to support patients and assist them in improving their quality of life. In order to provide the necessary holistic care the nurse needs to understand the nature of the patient's symptoms and be aware of a variety of management interventions. In this article the author outlines the various causes of faecal incontinence and highlights the importance of a thorough nursing assessment which takes into account the physical, psychological and social aspects of the symptoms. Planned care should be based on a firm knowledge base, but should reflect the needs of the individual. A good nurse-patient interaction facilitates this process and should be valued.
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Affiliation(s)
- Lesley Butcher
- Department of Physiology and Intestinal Imaging, St Mark's Hospital, Harrow, Middlesex
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44
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Mínguez Pérez M. [Functional digestive disorders from beginning to end. Anal incontinence]. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:161-6. [PMID: 14998469 DOI: 10.1016/s0210-5705(03)79117-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Miguel Mínguez Pérez
- Servicio de Gastroenterología, Hospital Clínico de Valencia, Universidad de Valencia, Spain
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45
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Savoye-Collet C, Savoye G, Koning E, Sassi A, Leroi AM, Dacher JN. Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear. Scand J Gastroenterol 2003; 38:1149-53. [PMID: 14686718 DOI: 10.1080/00365520310005631] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Disruption of the anal sphincter occurs in 0.6%-6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third-degree obstetric tear in order to compare the findings with the clinical outcome. METHODS Twenty-one women aged 27-41 (mean 31.5 years) who had undergone primary suture of a third-degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery. RESULTS Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P < 0.01). The presence of an external sphincter defect was associated with anal incontinence in 91.7%. Surgical repair was identified on endosonography in 88% continent women and in 25% incontinent women (P < 0.03). The combination of a visible surgical repair and absence of defect was highly associated with normal continence (91.7%). Squeezing pressures were higher in continent women (87 +/- 23 cm H2O) than in incontinent women (48 +/- 36 cm H2O; P = 0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome. CONCLUSION After primary repair of a third-degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.
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Affiliation(s)
- C Savoye-Collet
- Dept. of Radiology, Research Unit QUANT-IF, Rouen University Hospital, Rouen, France.
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46
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Abstract
PURPOSE OF REVIEW Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking. RECENT FINDINGS Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor. SUMMARY Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.
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Affiliation(s)
- Mira Lal
- Department of Obstetrics and Gynaecology, Wordsley Hospital, Dudley Group of Hospital NHS Trust, Tourbridge, Wesst Midlands, UK.
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47
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Richter HE, Brumfield CG, Cliver SP, Burgio KL, Neely CL, Varner RE. Risk factors associated with anal sphincter tear: a comparison of primiparous patients, vaginal births after cesarean deliveries, and patients with previous vaginal delivery. Am J Obstet Gynecol 2002; 187:1194-8. [PMID: 12439502 DOI: 10.1067/mob.2002.126977] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study was conducted to identify obstetric risk factors for anal sphincter tear in primiparous patients, patients with a previous cesarean delivery (VBAC), and patients with a previous vaginal delivery (PVD). STUDY DESIGN An obstetrics automated record system was accessed to retrospectively review records of all singleton vaginal deliveries at greater than 36 weeks' gestation (excluding breech and stillbirth) from 1995 through 2000 (n = 10,928). A number of potential risk factors for anal sphincter tear (third- and fourth-degree episiotomy extensions and lacerations) were tested with use of multivariate logistic regression analysis. RESULTS The risk of anal sphincter tear was significantly increased with primiparity (relative risk [RR] 4.08) and VBAC (RR 5.46) compared with PVD, birth weight greater than 4000 g (RR 2.41), forceps delivery (RR 6.00), vacuum delivery (RR 2.18), shoulder dystocia (RR 3.28), and episiotomy (RR 2.59). CONCLUSION Efforts to prevent anal sphincter tear might include reconsideration of modifiable risk factors such as episiotomy, operative vaginal delivery, and VBAC.
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Affiliation(s)
- Holly E Richter
- Division of Medical and Surgical Gynecology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 35249-7333, USA
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48
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Abstract
Pelvic organ prolapse repair poses a unique challenge to the reconstructive pelvic surgeon. Traditional levator plication has been promoted for the past century and has recently been shown to create unsatisfactory functional results, among them dyspareunia. In an attempt to improve both functional and quality-of-life outcomes, new methods for posterior vaginal wall defect repair have been developed and are now undergoing critical evaluation. We present a review of posterior vaginal wall repair with a focus on new anatomic concepts and site-specific rectocele repair.
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Affiliation(s)
- Emily S Lukacz
- Department of Reproductive Medicine, University of California, San Diego, 200 West Arbor Drive, #8433, San Diego, CA 92103, USA.
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Cornelia L, Stephan B, Michel B, Antoine W, Felix K. Trans-perineal versus endo-anal ultrasound in the detection of anal sphincter tears. Eur J Obstet Gynecol Reprod Biol 2002; 103:79-82. [PMID: 12039471 DOI: 10.1016/s0301-2115(02)00021-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare endo-anal and trans-perineal ultrasonography in the detection of anal sphincter lesions. STUDY DESIGN Sixty-four patients sent for a uro-gynaecological consultation were given tests by two ultrasound methods using the same apparatus (Aloka) with different probes. The endo-anal ultrasound (EAUS) was carried out in a supine position using a rotary circular probe at 7.5 MHz. The trans-perineal ultrasound (TPUS) was carried out using a curved linear probe at 5 MHz, applied to the perineum in the transverse direction, allowing a proximal view of the sphincter. For each image the thicknesses of the two components of the sphincter (internal and external) were noted, as well as the presence of any ultrasonographic tear, its position, and its width on the sphincterian circumference. RESULTS The average of the internal and external thickness of the sphincters was of 2.8 and 5.6 mm, respectively for the TPUS, and 2.1 and 6.2 mm for the EAUS. Among the 64 patients, 15 external lesions of the anal sphincter were found with the TPUS, and 14 with the EAUS. The kappa correlation coefficient was 48%, with a confidence interval of 95%. CONCLUSION The endo-anal technique, which provides a staged analysis of the anal sphincter muscle, remains the benchmark of sphincterian imaging. TPUS is a useful method, in that it gives good visualisation of anatomical structures, but its sensitivity in detecting sphincter lesions remain to be demonstrated.
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Affiliation(s)
- Lohse Cornelia
- Department of Gynaecology, University Hospital of Geneva, Geneva, Switzerland
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