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Roper JC, Thakar R, Sultan AH. UK survey of colorectal surgeons on the management of acute obstetric anal sphincter injuries. Colorectal Dis 2024; 26:130-136. [PMID: 38148521 DOI: 10.1111/codi.16820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/03/2023] [Accepted: 09/21/2023] [Indexed: 12/28/2023]
Abstract
AIM The role of colorectal surgeons in the management of acute obstetric anal sphincter injury (OASI) is an ongoing debate. Their expertise in operating in the anorectal region lends itself to assisting in OASI repair. The aim of this study was to establish the current involvement and recommended management of acute OASI by colorectal surgeons. METHOD An online survey of consultant colorectal surgeons was sent to members of the Pelvic Floor Society to assess current involvement in acute OASI management and repair. RESULTS Forty completed surveys were collated and analysed. Sixty-five per cent of respondents had seen an acute OASI since being a consultant and 50% stated they were involved in the repair of OASI less than once per year. 37.5% felt that a de-functioning stoma was still necessary sometimes. Many agreed with current guidelines for OASI repair in terms of antibiotics, laxatives and follow-up. CONCLUSIONS Colorectal surgeons have varied opinions on the management of OASI. We suggest that multidisciplinary training of obstetricians and colorectal surgeons could lead to more collaboration regarding the management of women with acute OASI.
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Affiliation(s)
- Joanna C Roper
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
- St George's University of London, London, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
- St George's University of London, London, UK
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2
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Roper JC, Thakar R, Hurt KJ, Sultan AH. Diagnosis, management and training in perineal trauma: a UK national survey of obstetricians. Int Urogynecol J 2023; 34:2873-2883. [PMID: 37498432 PMCID: PMC10756863 DOI: 10.1007/s00192-023-05590-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Perineal trauma during vaginal delivery is very common. Training in diagnosis and repair of trauma, including obstetric anal sphincter injuries, varies in the UK. We aimed to investigate the current knowledge and training received by obstetric physicians. METHODS A national, validated survey was conducted online, using Qualtrics. The National Trainees Committee distributed the survey. It was also sent directly to consultants via email. RESULTS A total of 302 physicians completed the survey and were included in the analysis. 3.9% of participants described their training in obstetric perineal trauma as "very poor" or "poor". 20.5% said they have not received training. 8.6% of physicians practising for more than 10 years had not had training for over 10 years. 70.5% responded "somewhat agree" or "strongly agree" when asked if they would like more training. Identification of first, second, third-, and fourth-degree tears from images and descriptions was very good (more than 80% correct for all categories). Classification of other perineal trauma was less consistent, with many incorrectly using the Sultan Classification. "Manual perineal support" and "Controlled or guided delivery" were the most frequently selected methods for the prevention of obstetric anal sphincter injury (OASI). CONCLUSIONS Training experience for physicians in obstetric perineal trauma varies. Further improvement in training and education in perineal trauma, particularly in OASI, is needed for physicians. Perineal trauma that is not included in the Sultan Classification is often misclassified.
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Affiliation(s)
- Joanna C Roper
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
- St George's University of London, London, UK
| | - K Joseph Hurt
- Divisions of Maternal Fetal Medicine and Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK.
- St George's University of London, London, UK.
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3
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Okeahialam NA, Taithongchai A, Thakar R, Sultan AH. The incidence of anal incontinence following obstetric anal sphincter injury graded using the Sultan classification: a network meta-analysis. Am J Obstet Gynecol 2023; 228:675-688.e13. [PMID: 36379266 DOI: 10.1016/j.ajog.2022.11.1279] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aimed to systematically determine and compare the incidence of anal incontinence between those with different grades of obstetric anal sphincter injury. DATA SOURCES Ovid MEDLINE, Embase, and the Cochrane Library were searched from January 2000 to April 2021. STUDY ELIGIBILITY CRITERIA Observational studies investigating the incidence of anal incontinence following an obstetric anal sphincter injury that was graded using the Sultan classification were eligible for inclusion. To allow comparison between individual tear grades (3a, 3b, 3c, fourth), a network meta-analysis was performed using Stata (version 15.1). METHODS For binary outcomes, odds ratios with corresponding 95% confidence intervals were reported. Obstetric anal sphincter injury grades were ranked from the best clinical outcome to the worst clinical outcome. The percentage chance of each grade taking each rank with regards to outcome was calculated. Study quality and risk of bias was assessed using the relevant tool from the Joanna Briggs Institute. RESULTS Of the 696 studies identified, 10 were eligible for inclusion and were included in the network meta-analysis (n=2467 women). The mean incidence of anal incontinence among those with 3a tears was 22.4% (range, 6.1%-51.2%), 24.9% (range, 6.9%-46.7%) among those with 3b tears, 26.8% (range, 0%-55.6%) among those with 3c tears, and 28.6% (0%-71.4%) among those with fourth-degree tears. Anal incontinence incidence was found to be significantly higher among those with 3c (odds ratio, 1.79; 95% confidence interval, 1.09-2.94) and fourth-degree tears (odds ratio, 2.37; 95% confidence interval, 1.40-4.02) than among those with 3a tears. In addition, anal incontinence incidence was significantly higher among those with fourth-degree tears (odds ratio, 1.89; 95% confidence interval, 1.10-3.22) than among those with 3b tears. Those with 3a tears had the highest probability of having the best clinical outcome; those with 3b; second-, 3c; third- and fourth-degree tears had the highest probability of having the worst clinical outcome. Overall, all studies had a high or unclear risk of bias across 1 or more assessed element. CONCLUSION This was a network meta-analysis comparing the incidence of anal incontinence among those with different grades of obstetric anal sphincter injury. Increasing tear-grade severity is associated with worse clinical outcomes. This study provides useful, clinically applicable information that can assist clinicians in the counseling of women following an obstetric anal sphincter injury. In addition, it highlights the importance of accurately diagnosing the obstetric anal sphincter injury grade and subsequently performing the appropriate repair.
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Affiliation(s)
| | | | - Ranee Thakar
- Croydon University Hospital, Thornton Heath, London, United Kingdom
| | - Abdul H Sultan
- Croydon University Hospital, Thornton Heath, London, United Kingdom; St George's University of London, London, United Kingdom.
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4
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Barg M, Rotem R, Weintraub AY, Grisaru-Granovsky S, Michaelson-Cohen R, Rottenstreich M. Use of antibiotics in women undergoing correction of an obstetric anal sphincter injury: Results from a national Israeli survey. Int J Gynaecol Obstet 2023; 160:195-201. [PMID: 35617218 PMCID: PMC10084148 DOI: 10.1002/ijgo.14286] [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: 01/04/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Obstetric anal sphincter injures (OASIS) have long-term implications on women's health. Administration of antibiotic prophylaxis and treatment following OASIS repair is controversial. We conducted a national survey to provide data about practice routines regarding antibiotic prophylaxis and treatment following OASIS repair in Israeli labor and delivery units. METHODS A national survey was performed among obstetricians and gynecologists from 24 university-affiliated delivery centers within the jurisdiction of the Israeli Ministry of Health during 2020. Representatives from each center completed the "Google form" electronic survey. For each questionnaire item, the most common answer was chosen to represent the center's answer. RESULTS The number of physicians who responded per center varied from 1 to 14 (median, 3.5). Preoperative and postoperative antibiotic treatment was given in 75% and 92% of the centers, respectively. While most centers (58.3%) recommend pelvic floor physical therapy on release, recommendations about functional radiologic tests vary. In all centers, there is a designated clinic for postpartum follow-up of OASIS. Most centers (83%) allow trial of vaginal delivery in the subsequent pregnancy, on an individual basis. CONCLUSION Heterogeneity exists in managing OASIS in Israel, particularly regarding administration of antibiotics. Further studies are needed to examine the consequences of different management protocols.
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Affiliation(s)
- Moshe Barg
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel
| | - Reut Rotem
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel
| | - Rachel Michaelson-Cohen
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel.,Medical Genetics Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University School of Medicine, Jerusalem, Israel.,Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
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Hubka P, Dvorak J, Lincova M, Masata J, Martan A, Svabik K. When to assess residual anal sphincter defect after OASI by ultrasound. Eur J Obstet Gynecol Reprod Biol 2022; 277:8-11. [PMID: 35964398 DOI: 10.1016/j.ejogrb.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months. STUDY DESIGN This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation. RESULTS Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination. CONCLUSIONS In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.
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Affiliation(s)
- Petr Hubka
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and Na Bulovce Faculty Hospital, Charles University, Prague, Czech Republic.
| | - Jan Dvorak
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Marcela Lincova
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and Na Bulovce Faculty Hospital, Charles University, Prague, Czech Republic.
| | - Jaromir Masata
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Alois Martan
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
| | - Kamil Svabik
- Department of Obstetrics and Gynaecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
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Barba M, Bernasconi DP, Manodoro S, Frigerio M. Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta-analysis. Int J Gynaecol Obstet 2022; 158:27-34. [PMID: 34559892 PMCID: PMC9298380 DOI: 10.1002/ijgo.13950] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence. OBJECTIVE We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs. SEARCH STRATEGY Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science. SELECTION CRITERIA Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded. DATA COLLECTION AND ANALYSIS Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model. MAIN RESULTS The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery. CONCLUSION Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.
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Affiliation(s)
- Marta Barba
- Department of Obstetrics and GynecologyUniversity Milano‐BicoccaMonzaItaly
| | | | - Stefano Manodoro
- Department of Obstetrics and GynecologyASST Santi Paolo e Carlo, San Paolo HospitalMilanoItaly
| | - Matteo Frigerio
- Department of Obstetrics and GynecologyASST Monza, San Gerardo HospitalMonzaItaly
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7
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Schwertner-Tiepelmann N, Lorenz K, Schwab F, Beilecke K, Marschke J, Tunn R. Berlin survey on obstetric anal sphincter injury (OASI). Arch Gynecol Obstet 2022; 306:1117-1125. [DOI: 10.1007/s00404-022-06627-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
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8
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Macedo MD, Ellström Engh M, Siafarikas F. Detailed classification of second-degree perineal tears in the delivery ward: an inter-rater agreement study. Acta Obstet Gynecol Scand 2022; 101:880-888. [PMID: 35546433 DOI: 10.1111/aogs.14369] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Second-degree perineal tears can vary widely as to the extent of trauma, which may be relevant for women's pelvic floor health postpartum. However, the short- and long-term consequences of second-degree perineal tears are poorly understood, likely due to the lack of a detailed classification system. Such a classification system for second-degree tears has been suggested but the inter-rater agreement has not yet been assessed. The aim of this study was to assess the inter-rater agreement of the already established classification system for perineal tears recommended by the Royal College of Obstetricians and Gynaecologists (RCOG classification) among midwives. Further, we aimed to assess the inter-rater agreement of a classification system that provides three sub-categories for second-degree perineal tears. MATERIAL AND METHODS This was an inter-rater agreement study, conducted at Akershus University Hospital in Norway from 31 August to 29 November 2020. All midwives working in the delivery ward participated in the study. Midwives classified the integrity of the perineum of all women delivering vaginally within the study period. During the first month of the study, tears were classified by two midwives who were blinded to each other's findings, and the agreement of the RCOG classification was assessed. The following month, the detailed classification system was introduced to the midwifery staff. The last month, perineal tears were classified by two midwives using the detailed classification system, and the agreement was assessed. Inter-rater agreement was measured using Fleiss multirater kappa (k) and Kendall's coefficient of concordance (KCCw ). RESULTS The inter-rater agreement for the RCOG classification was good to very good, with k = 0.705 (95% confidence interval [CI] 0.62-0.79, P < 0.001), KCCw = 0.928 (P < 0.001). The inter-rater agreement for the detailed classification system was good to very good, with k = 0.748 (95% CI 0.67-0.83, P < 0.001), KCCw = 0.956 (P < 0.001). CONCLUSIONS The inter-rater agreement among midwives using both the RCOG classification and the detailed classification system among midwives was good to very good. The detailed classification system provides additional information about the extent of tissue trauma in second-degree tears, warranted for future research on women's pelvic floor health postpartum.
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Affiliation(s)
- Marthe Dalevoll Macedo
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway.,Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Franziska Siafarikas
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway.,Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
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9
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Ong F, Phan-Thien KC. How to do it: delayed sphincteroplasty for obstetric anal sphincter injury. ANZ J Surg 2022; 92:1208-1210. [PMID: 35332987 PMCID: PMC9311690 DOI: 10.1111/ans.17650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ferdinand Ong
- Department of Colorectal Surgery, St George Public Hospital, Kogarah, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Kensington, New South Wales, Australia
| | - Kim-Chi Phan-Thien
- Department of Colorectal Surgery, St George Public Hospital, Kogarah, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Kensington, New South Wales, Australia
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10
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Uebergang J, Hiscock R, Hastie R, Middleton A, Pritchard N, Walker S, Tong S, Lindquist A. Risk of obstetric anal sphincter injury among women who birth vaginally after a prior caesarean section: A state-wide cohort study. BJOG 2021; 129:1325-1332. [PMID: 34913246 DOI: 10.1111/1471-0528.17063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small, or used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. DESIGN State-wide retrospective cohort study. SETTING Victoria, Australia. POPULATION All births (455,000) between 2009-2014. METHODS The risk of severe perineal injury between first vaginal birth and first vaginal birth after previous caesarean section was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and Stata v16 multiple imputation and teffects suites. RESULTS Women having a VBAC (n=5,429) were significantly more likely than primiparous women (n=123,353) to sustain a 3rd or 4th degree tear during vaginal birth (7.1 vs 5.7%, p<0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (relative risk 1.21 (95%CI 1.07 - 1.38)). CONCLUSIONS Women having their first vaginal birth after caesarean section have a significant increased risk of sustaining a 3rd or 4th degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.
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Affiliation(s)
| | - Richard Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Department of Anaesthesia, Mercy Hospital for Women, Melbourne, Australia
| | - Roxanne Hastie
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Anna Middleton
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Natasha Pritchard
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Susan Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Anthea Lindquist
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
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11
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Okeahialam NA, Thakar R, Sultan AH. Healing of disrupted perineal wounds after vaginal delivery: a poorly understood condition. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2021; 30:S8-S16. [PMID: 34781764 DOI: 10.12968/bjon.2021.30.sup20.s8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Perineal injury following childbirth can result in complications such as wound infection and dehiscence. The reported incidence of these complications in the literature range between 0.1-23.6% and 0.2-24.6%, respectively. However, the healing of disrupted perineal wounds is poorly understood. In addition, it is a neglected area in maternity services. In this review, the authors explore the process of wound healing in the context of infected perineal wounds following childbirth. In addition, the authors describe the management of complications including hypergranulation, perineal pain and dyspareunia.
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Affiliation(s)
| | - Ranee Thakar
- Consultant Obstetrician and Urogynaecologist, Croydon University Hospital, London, and Honorary Senior Lecturer, St George's University of London
| | - Abdul H Sultan
- Consultant Obstetrician and Urogynaecologist, Croydon University Hospital, London, and Honorary Reader, St George's University of London
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12
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Hammond RK, Naidoo TD. The knowledge and perceptions of healthcare workers regarding obstetrical anal sphincter injuries. A practice audit from a resource-constrained setting. AJOG GLOBAL REPORTS 2021; 1:100021. [PMID: 36277460 PMCID: PMC9563464 DOI: 10.1016/j.xagr.2021.100021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND OBJECTIVE STUDY DESIGN RESULTS CONCLUSION
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Affiliation(s)
- Randall Kegan Hammond
- Department of Obstetrics and Gynaecology, Greys Hospital, Pietermaritzburg, South Africa
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Corresponding author: Randall Kegan Hammond, MbChB, FCOG, MMed.
| | - Thinagrin Dhasarathun Naidoo
- Department of Obstetrics and Gynaecology, Greys Hospital, Pietermaritzburg, South Africa
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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13
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Young R, Nippita TAC. Training in obstetric anal sphincter injuries in Australia and New Zealand: A survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees. Aust N Z J Obstet Gynaecol 2021; 62:250-254. [PMID: 34585741 DOI: 10.1111/ajo.13437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/08/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Training in obstetric anal sphincter injuries (OASIS) in Australia and New Zealand relies upon consultant teaching and has not previously been assessed. AIMS The aims of this study are to establish if training in OASIS is consistent and optimal in Australia and New Zealand and to evaluate trainee perspectives on supervision and teaching, along with confidence in repairing OASIS. MATERIALS AND METHODS A descriptive cross-sectional study was performed. Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees were sent a 21-question survey. The survey was distributed to 725 trainees, and 132 trainees provided complete responses (18.2%). The main outcome measures were (i) comparison of confidence in performing a caesarean section versus OASIS repair and (ii) descriptive analysis of views towards training and suggestions for improvement. RESULTS Trainees were significantly more confident in performing a caesarean section independently compared to OASIS repair (P < 0.05). This was the case for all year groups. Confidence increased with each year of training. Only 62% reported credentialing at their site. Whereas 50% reported training at the time of first unsupervised repair as good or excellent, 22.7% felt it was suboptimal and 2.3% unsatisfactory; 75.8% had attended a workshop; 38.6% requested mandatory workshops. Requests included that workshops be yearly, include video training and be required at consultant level. Trainees asked for supervision despite credentialing and for separate credentialing for 3A/B- and 3C/4th-degree tears. CONCLUSIONS Trainees have increasing confidence in their ability to independently perform OASIS repairs throughout training. They requested that improvements be made to training and that there be an increase in structured teaching.
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Affiliation(s)
- Rebecca Young
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia.,Department of Urogynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Tanya A C Nippita
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia.,Department of Urogynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine and Health, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Women and Babies Research, Kolling Institute, Royal North Shore Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia
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14
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Gyhagen M, Ellström Engh M, Husslein H, Koelbl H, Nilsson IEK, Schulz J, Wagg A, Milsom I. Temporal trends in obstetric anal sphincter injury from the first vaginal delivery in Austria, Canada, Norway, and Sweden. Acta Obstet Gynecol Scand 2021; 100:1969-1976. [PMID: 34435349 DOI: 10.1111/aogs.14244] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC). MATERIAL AND METHODS Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2-O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004-2016. RESULTS The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (β 0.49) and 6.2% (β -1.15) (trend, all p < 0.001) in 2016. CONCLUSIONS This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy.
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Affiliation(s)
- Maria Gyhagen
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Heinrich Husslein
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Heinz Koelbl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Ida E K Nilsson
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Jane Schulz
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ian Milsom
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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15
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Lindquist AC, Hastie RM, Hiscock RJ, Pritchard NL, Walker SP, Tong S. Risk of major labour-related complications for pregnancies progressing to 42 weeks or beyond. BMC Med 2021; 19:126. [PMID: 34030675 PMCID: PMC8145839 DOI: 10.1186/s12916-021-01988-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Post-term gestation beyond 41+6 completed weeks of gestation is known to be associated with a sharp increase in the risk of stillbirth and perinatal mortality. However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks. METHODS We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression. RESULTS The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55-2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89-2.78) following instrumental birth and 1.44 (95% CI 1.17-1.78) following emergency caesarean section; 1.43 (95% CI 1.16-1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03-1.45) for 3rd or 4th degree perineal tear (all women). The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26-12.57) among nulliparous women and 4.71 (95% CI 3.90-5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86-2.06) following any labour and 1.47 (95% CI 1.38-1.56) following induction of labour. CONCLUSIONS Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation.
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Affiliation(s)
- Anthea C Lindquist
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia. .,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia.
| | - Roxanne M Hastie
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Richard J Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Natasha L Pritchard
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
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16
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Fourth degree perineal tears: Surgical repair technique in 10 steps. J Gynecol Obstet Hum Reprod 2021; 50:102151. [PMID: 33887534 DOI: 10.1016/j.jogoh.2021.102151] [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: 03/08/2021] [Revised: 03/26/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
Obstetrical anal sphincter injury (OASIS) may lead to significant comorbidities, including anal incontinence, rectovaginal fistula, and pain. A correct repair is required to avoid improper healing, as a persistent defect in the external anal sphincter after delivery can increase the risk of complications and worsening of symptoms following subsequent vaginal deliveries. Herein is described the surgical repair technique for a fourth degree perineal tear. Regarding resident education, there are challenges associated with the proper training in OASIS repair. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform with step-by-step explanations.
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17
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Gong M, Mann GK, Koenig N, Geoffrion R. Documenting Perineal and Obstetrical Anal Sphincter Injury Care at Childbirth: A Cross-Sectional Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:1164-1169. [PMID: 33684531 DOI: 10.1016/j.jogc.2021.02.120] [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: 10/04/2020] [Revised: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study evaluates whether maternity care providers document guideline-based recommendations for the prevention and care of obstetrical anal sphincter injuries (OASIS) for their labour and delivery patients. METHODS We performed a cross-sectional study, aiming for a convenience sample of 60 primiparous women, over 19 years of age, equally representative of patients who experienced severe (third- and fourth-degree) and minimal (intact or first-degree) tears during vaginal birth. Information on patient demographics, delivery details, and guideline-endorsed preventative and management measures were collected. Descriptive statistics were used when appropriate. RESULTS We enrolled a total of 73 women, 34 of whom had severe tears and 39 of whom had minimal tears. Preventative measures, including fetal head control and perineal support during delivery, were documented for 1 out of 73 patients. The use of perineal massage and warm compress to the perineum was not documented. A rectal exam after delivery was documented for 30% (22/73) of all patients and 62% (21/34) of patients with OASIS. Sixty-five percent (22/34) of patients with OASIS received intravenous antibiotics, 88% (30/34) received laxatives, and 100% received nonsteroidal anti-inflammatory drugs. Post-void residual was not documented for any patients. Patients recalled being informed about their OASIS in 68% (23/34) of cases and being referred to pelvic physiotherapy in 47% (16/34) of cases. CONCLUSION In our study, perineal care practices during and after childbirth, as detailed in the national OASIS guideline, were incompletely documented. This may indicate partial guideline adherence or suboptimal medical record-keeping.
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Affiliation(s)
- Merry Gong
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC.
| | - Gurkiran K Mann
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC
| | - Nicole Koenig
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC
| | - Roxana Geoffrion
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC
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18
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Oh D, Wright C, Young CJ. Management of obstetric anal sphincter injury: Colorectal surgeons' perspectives in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2020; 61:16-21. [PMID: 33058142 DOI: 10.1111/ajo.13261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIs) are a significant complication of vaginal delivery, and a leading cause of anal incontinence in women. AIMS The aims were to explore the management of OASIs in Australia and New Zealand (ANZ) by colorectal surgeons and how this compares with current recommendations and international experience, and to identify the deterrents to the provision of best-practice care among colorectal surgeons. MATERIALS AND METHODS Three hundred colorectal surgeons of the Colorectal Surgical Society of ANZ were mailed questionnaires. Areas of interest included: surgeon demographics; exposure to OASIs; understanding of current recommendations; and opinions regarding the importance of symptoms and assessment tools in OASIs. RESULTS There were 94 completed questionnaires (response rate 31.3%). Fifty-seven surgeons (60.6%) reported low exposure to OASIs during their fellowship training. Greater than 90% believed patients with grade three tears and above should have anal sphincter assessment. Sixty-six (70.2%) reported that they routinely review women who have had OASIs. However, 56.4% were unaware if their obstetrics department followed a standard protocol for OASIs. Surgeons practising in metropolitan centres reported higher rates of their obstetrics department following a protocol (P = 0.013), and greater access to investigative tools (P < 0.001), when compared to rural-based surgeons. CONCLUSIONS Most ANZ colorectal surgeons have had minimal training in OASI management. Colorectal surgeons are more commonly involved with OASI patients in the non-acute setting. Management protocols involving a multidisciplinary team of both colorectal surgeons and obstetricians should be clearly defined, and the gap between metropolitan and rural centres needs to be reviewed.
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Affiliation(s)
- Daniel Oh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Caroline Wright
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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19
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Roper JC, Thakar R, Sultan AH. Isolated rectal buttonhole tears in obstetrics: case series and review of the literature. Int Urogynecol J 2020; 32:1761-1769. [PMID: 32930849 PMCID: PMC8295104 DOI: 10.1007/s00192-020-04502-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/13/2020] [Indexed: 12/26/2022]
Abstract
Introduction and hypothesis The management of isolated rectal buttonhole tears is not standardised and can be challenging in an acute obstetric setting. Our aim was to review the published literature and describe management and repair techniques in a case series. Methods A literature search was carried out. All results were screened and reviewed. Rectal buttonhole tears following vaginal delivery between April 2012 and January 2020 in our institution were identified. Repair technique and post-operative management were recorded. Results There were nine published case reports (four instrumental deliveries, two vaginal breech and three normal vaginal deliveries). Four case reports described a two-layer closure and five described a three-layer closure. Two cases were repaired in collaboration with colorectal surgeons. All nine cases made an uneventful recovery. We identified three patients with buttonhole tears all of whom had instrumental deliveries. A colorectal surgeon repaired the tear in two layers in one case, and an obstetrician performed the repair in the other two cases, one in three layers and the other in two layers. One patient had a de-functioning stoma at a later date due to a second breakdown of the recto-vaginal fistula repair. Conclusion Buttonhole tears are rare but techniques of repair vary. Most cases reviewed had an uneventful recovery after repair. We provide standardised steps for repair and management of isolated rectal buttonhole tears along with a video demonstrating the repair technique in an animal tissue (pig) model. Electronic supplementary material The online version of this article (10.1007/s00192-020-04502-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanna C Roper
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
- St George's University of London, London, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK.
- St George's University of London, London, UK.
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20
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Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:303-312. [PMID: 32653603 DOI: 10.1016/j.ejogrb.2020.06.048] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. METHODS We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. RESULTS We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I2 = 95 %). Following primary repair of OASIS, 55 % (46-63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I2 = 98 %). INTERPRETATION Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.
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Affiliation(s)
- Michail Sideris
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.
| | - Tristan McCaughey
- Department of Surgery, School of Clinical Science at Monash Health, Monash University, 3800, VIC, Australia
| | | | - David Arroyo-Manzano
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Javier Zamora
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Swati Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Charles H Knowles
- National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Charlotte Chaliha
- Department of Obstetrics and Gynaecology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Multidisciplinary Evidence Synthesis Hub (MEsH), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
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21
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Diko S, Sheeder J, Guiahi M, Nacht A, Reeves S, Connell KA, Hurt KJ. Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: a national survey of nurse-midwives. Int Urogynecol J 2020; 32:1745-1753. [PMID: 32399907 DOI: 10.1007/s00192-020-04304-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/21/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Clinical quality improvement relies on accurate understanding of current practice. We performed a cross-sectional national survey of certified nurse-midwives (CNMs) assessing classification and identification of obstetric anal sphincter injury (OASI) and other delivery lacerations. We hypothesized laceration diagnoses are frequently inaccurate, and delivery records for obstetric lacerations may be of questionable quality. METHODS We emailed 6909 American College of Nurse Midwives members an internet-based survey link. Of respondents, we included clinically active CNMs who perform at least one delivery per month. We evaluated laceration knowledge and application using standard descriptive text and images and asked about processes for recording lacerations in the delivery record. RESULTS We received 1070 (15.5%) completed surveys and 832 (77.8%) met inclusion criteria. Over 50% characterized their OASI training and ability to identify OASI as good/excellent. Most (79%) had never attended education review on OASI. The overall accuracy for classification and identification of perineal lacerations ranged from 49 to 99%. Non-perineal lacerations were frequently categorized using the perineal/OASI system. Half of respondents (51%) document their deliveries in an electronic medical record but a quarter (28%) are not personally responsible for approving delivery data. Younger participants without a doctoral degree, with self-assessed good/excellent laceration training, and caring for < 50% publicly insured patients had higher accuracy for laceration identification and diagnosis. CONCLUSIONS We found high rates of inaccurate laceration diagnosis and inappropriate application of the perineal OASI degree system, suggesting education and training are needed. Clinical studies that rely on delivery diagnosis of OASI may not be reliable.
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Affiliation(s)
- Sindi Diko
- Department of Surgery, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Jeanelle Sheeder
- Division of Family Planning, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Maryam Guiahi
- Division of Family Planning, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Amy Nacht
- Nurse Midwifery Program, College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Shane Reeves
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Kathleen A Connell
- Division of Urogynecology, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Reproductive Sciences, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - K Joseph Hurt
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA.
- Division of Reproductive Sciences, Department of Obstetrics & Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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22
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Pregnancy in Women With Prior Treatments for Pelvic Floor Disorders. Female Pelvic Med Reconstr Surg 2020; 26:299-305. [DOI: 10.1097/spv.0000000000000822] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Jardine JE, Knight HE, Carroll FE, Gurol-Urganci I. Risk of obstetric anal sphincter injury in women having a vaginal birth after a previous caesarean section: A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2019; 236:7-13. [DOI: 10.1016/j.ejogrb.2019.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 01/21/2023]
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Şimsek A, Ateş M, Dirican A, Özgör D. A surgical technique for secondary repair of obstetric anal sphincter injuries; sphinctero-vagino-perineoplasty. Turk J Obstet Gynecol 2019; 15:249-253. [PMID: 30693141 PMCID: PMC6334249 DOI: 10.4274/tjod.12369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/05/2018] [Indexed: 01/16/2023] Open
Abstract
Objective: This study was conducted to present the preliminary results of seven patients treated with sphinctero-vagino-perineoplasty for secondary repair of obstetric anal sphincter injuries. Materials and Methods: This retrospective study was conducted on the records of seven patients who underwent secondary repair of obstetric anal sphincter injuries at the colorectal surgery unit of a tertiary care center between February 2015 and December 2017. Results: All patients with solid stool incontinence were fully recovered at postoperative month 3. The Wexner incontinence score was significantly improved (decreased from 14.12 [range: 8-20] to 2.28 [range: 1-4]). The complication rate was 85.7% (wound infection, abscess, hematoma, detachment). Conclusion: Combined repair of anal sphinchters, perineal body, superficial transverse perineal muscles, and bulbospongious muscles, which contribute to anal continence, may improve surgical outcomes in patients with obstetric anal sphincter injuries.
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Affiliation(s)
- Arife Şimsek
- İnönü University Faculty of Medicine, Department of General Surgery, Malatya, Turkey
| | - Mustafa Ateş
- İnönü University Faculty of Medicine, Department of General Surgery, Malatya, Turkey
| | - Abuzer Dirican
- İnönü University Faculty of Medicine, Department of General Surgery, Malatya, Turkey
| | - Dinçer Özgör
- İnönü University Faculty of Medicine, Department of General Surgery, Malatya, Turkey
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25
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Obstetrical Anal Sphincter Injuries and the Need for Adequate Care. Female Pelvic Med Reconstr Surg 2019; 25:109-112. [DOI: 10.1097/spv.0000000000000684] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Thubert T, Cardaillac C, Fritel X, Winer N, Dochez V. [Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. ACTA ACUST UNITED AC 2018; 46:913-921. [PMID: 30385355 DOI: 10.1016/j.gofs.2018.10.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors. METHODS A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice. RESULTS To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C). CONCLUSION It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.
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Affiliation(s)
- T Thubert
- Service de gynécologie-obstétrique, hôpitaux de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; Université de Nantes, 1, rue Gaston-Veil, 44000 Nantes, France; GMC-UPMC 01, GREEN (Groupe de recherche clinique en neurourologie), 4, rue de la Chine, 75020 Paris, France.
| | - C Cardaillac
- Service de gynécologie-obstétrique, hôpitaux de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; Université de Nantes, 1, rue Gaston-Veil, 44000 Nantes, France
| | - X Fritel
- Service de gynécologie-obstétrique, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - N Winer
- Service de gynécologie-obstétrique, hôpitaux de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; Université de Nantes, 1, rue Gaston-Veil, 44000 Nantes, France
| | - V Dochez
- Service de gynécologie-obstétrique, hôpitaux de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; Université de Nantes, 1, rue Gaston-Veil, 44000 Nantes, France
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Cassis C, Giarenis I, Mukhopadhyay S, Morris E. Mode of delivery following an OASIS and caesarean section rates. Eur J Obstet Gynecol Reprod Biol 2018; 230:28-31. [PMID: 30237137 DOI: 10.1016/j.ejogrb.2018.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/23/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES While the rate of obstetric anal sphincter injury (OASIS) is increasing, there is a lack of evidence on how best to advise women on mode of delivery (MOD) afterwards. The objectives of this study were to assess the clinical value of bowel symptoms, endoanal ultrasound and anorectal manometry in the management of pregnancies after an OASIS and evaluate the performance of different algorithms. STUDY DESIGN This was a retrospective analysis of prospectively collected data in a university hospital perineal clinic. Women with OASIS undergoing endoanal ultrasound scan (EAUS) and anorectal manometry (AM) were included in this study (all women with an OASIS, except the asymptomatic 3a tears). A number of published algorithms were theoretically applied in this cohort to define recommended MOD after an OASIS. RESULTS Out of the 233 women included in the study, 51 (21.9%) were symptomatic, 141 (60.5%) had persistent sphincter defects on EAUS and 124 (53.2%) had abnormal AM. One asymptomatic and five symptomatic women were found to have isolated internal anal sphincter (IAS) defects without external anal sphincter (EAS) defects. There were no women with low resting pressure and normal incremental squeeze pressure. The application of the algorithm requiring only one abnormal investigation to be recommended caesarean would have led to an 81.5% caesarean rate. If women with symptoms of anal incontinence or abnormal investigations would be advised for caesarean the rate would be 85.0%. Using the local protocol where symptomatic women only needed one of the two investigations to be abnormal but asymptomatic women were required to have both investigations being abnormal, 94 were considered for caesarean (40.3%). CONCLUSION There is a wide range in the number of patients recommended to have caesarean section after an OASIS, depending on the used criteria and management algorithms. There is minimal additional information gained from identifying internal anal sphincter defects and measuring low resting pressures at manometry.
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Affiliation(s)
| | | | | | - Edward Morris
- Norfolk and Norwich University Hospital, United Kingdom
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Ali-Masri H, Hassan S, Ismail K, Zimmo K, Zimmo M, Fosse E, Vikanes Å, Laine K. Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study. BMJ Open 2018; 8:e020983. [PMID: 29921684 PMCID: PMC6009514 DOI: 10.1136/bmjopen-2017-020983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To explore the impact of a training intervention on obstetric anal sphincter injuries' (OASIS) detection rate. DESIGN Prospective quality improvement interventional study. SETTING Six secondary and tertiary maternity units in Palestine. POPULATION Women having singleton vaginal births ≥23 weeks' gestation or babies weighing ≥500 g (n=22 922). Caesarean births (n=5431), multiple gestations (n=443) and vaginal births of unregistered perineum status (n=800) were excluded. INTERVENTIONS Training programme for enhancing OASIS detection was conducted between 31 January and 31 December 2015. International experts delivered 2-day standardisation workshop teaching OASIS diagnosis and repair to each maternity unit. They also provided additional training to three research fellows employed in three of the maternity units. This was followed by 13-week period of data collection (phase 1). Research fellows then delivered training intervention over 15-week interval (phase 2), including theoretical teaching and 'onsite' training in perineal trauma assessment within the six maternity units. Finally, 13-week postintervention observation (phase 3) followed. PRIMARY OUTCOME MEASURE OASIS rates were used as surrogate for OASIS recognition. OASIS rates were compared between different phases and between the two maternity unit groups (research fellow and non-research fellow based) using Pearson's χ² test. RESULTS A total 22 922 women were included. Among primiparous women, OASIS rate was higher in phase 2 (2.8%, p<0.001) and phase 3 (3.1%, p<0.001) than phase 1 (0.5%). However, no significant differences were detected in the rates of severe OASIS (third-degree 3c and fourth-degree tears) between phase 1 and 2 (0.5% vs 0.3%), because this would have required at least 103 women with severe OASIS to be included in each phase. Among parous women, OASIS rate was significantly higher in phase 2 (0.6%, p=0.002) but not in phase 3 (0.4%, p=0.071) compared with phase 1 (0.2%). Research fellows' maternity units showed higher OASIS rates among primiparous women in phase 2 (3.6% vs 1.4%, p=0.001) and phase 3 (4.3% vs 0.8%, p<0.001) than non-research fellows' maternity units. CONCLUSIONS This work is basically an epidemiological study which has identified the prevalence of perineal lacerations and their severity on a large sample of women representative of an entire geographical ethnic region. The quality improvement intervention improved OASIS detection mainly in the research fellows' maternity units. Regular mandatory national programmes in obstetric perineal trauma assessment and management by local champions are essential to mitigate the risk of missing significant degrees of trauma.
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Affiliation(s)
- Hadil Ali-Masri
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Palestine Medical Complex, Ramallah, Palestine
| | - Sahar Hassan
- Faculty of Pharmacy, Nursing and Health Professions, Birzeit University, Ramallah, Palestine
- Institute of Community and Public Health, Birzeit University, Ramallah, Palestine
| | - Khaled Ismail
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kaled Zimmo
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Al Aqsa Martyrs Hospital, Gaza, Palestine
| | - Mohammed Zimmo
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics, Al Shifa Hospital, Gaza, Palestine
| | - Erik Fosse
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Åse Vikanes
- The Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Katariina Laine
- Department of Obstetrics, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Health Management and Health Economics, Institute for Health and Society, University of Oslo, Oslo, Norway
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Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. Int Urogynecol J 2018; 29:1579-1588. [PMID: 29600403 PMCID: PMC6208957 DOI: 10.1007/s00192-018-3601-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 02/14/2018] [Indexed: 01/06/2023]
Abstract
Introduction and hypothesis Our primary objective was to prospectively evaluate anorectal symptoms, anal manometry and endoanal ultrasound (EAUS) in women who followed the recommended mode of subsequent delivery following index obstetric anal sphincter injuries (OASIs) using our unit’s standardised protocol. Our secondary objectives were to evaluate the role of internal anal sphincter defects and also to compare outcomes in a subgroup of symptomatic women with normal anorectal physiology. Methods This is a prospective follow-up study of pregnant women with previous OASIs who were counselled regarding subsequent mode of delivery between January 2003 and December 2014. Assessment involved the St Mark’s Incontinence Score (SMIS), anal manometry and EAUS at both antepartum and 3-month postpartum visits. Data were analysed using Wilcoxon and Mann–Whitney U tests. Results Three hundred and fifty women attended the perineal clinic over the study period, of whom 122 met the inclusion criteria (99 vaginal delivery [VD], 23 caesarean section). No significant worsening of anorectal symptoms was observed following subsequent delivery in the VD group (p = 0.896), although a reduced squeeze pressure was observed at 3 months postpartum (p < 0.001). There were no new defects on EAUS in either group. Conclusions This study showed no significant worsening of bowel symptoms and sphincter integrity apart from lower squeeze pressures at 3 months postpartum in the VD group when our standardised protocol was used to recommend subsequent mode of delivery. In the absence of a randomised study, use of this protocol can aid clinicians in their decision-making.
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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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Sioutis D, Thakar R, Sultan AH. Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:642-647. [PMID: 27643513 DOI: 10.1002/uog.17306] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/31/2016] [Accepted: 09/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine the accuracy of clinical diagnosis of obstetric anal sphincter injuries (OASIS) using three-dimensional (3D) endoanal ultrasound (EA-US) and to compare symptoms and anal manometry measurements between women with anal sphincters adequately repaired and those with persistent anal sphincter defects. METHODS The EA-US images of women with clinically diagnosed and repaired OASIS, defined as third- or fourth-degree perineal tear, who attended the perineal clinic at Croydon University Hospital over a 10-year period (2003-2013) were reanalyzed by a single expert blind to symptoms and the results of clinical examination. St Mark's Incontinence Scores (SMIS) and anal manometry measurements were obtained and compared between women with an intact anal sphincter and those with an anal sphincter scar and between those with an intact anal sphincter and those with a defect. Anal manometry measurements were compared between women with an external anal sphincter (EAS) defect and those with an internal anal sphincter (IAS) defect. RESULTS The images of 908 women were reanalyzed. No evidence of OASIS was found in 64 (7.0%) women, an EAS scar alone was detected in 520 (57.3%) and an anal sphincter defect in 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect, 90 had an IAS defect and 122 had a combined IAS and EAS defect. SMIS results were significantly higher in women with an anal sphincter defect compared with those with no evidence of OASIS (P = 0.018), but there was no significant difference in scores between women with an intact sphincter and those with an EAS scar only. Women with a defect had a significantly lower maximum resting pressure (median (range), 44 (8-106) vs 55 (29-86) mmHg; P < 0.001) and maximum squeeze pressure (median (range), 74 (23-180) vs 103 (44-185) mmHg; P < 0.001) compared with those in the intact group. Similar, but less marked, differences were observed in women with an EAS scar compared with those who had an intact anal sphincter. The anal length was significantly shorter in women with a defect compared with those in the intact group (median (range), 20 (10-40) vs 25 (10-40) mm; P = 0.003). CONCLUSIONS Seven percent of women with a clinical diagnosis of OASIS were wrongly diagnosed. We believe that this rate may differ from that of other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of EA-US in the immediate postpartum period needs further evaluation as the accurate interpretation of the images is dependent on the expertise of the staff involved. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Sioutis
- Department of Obstetrics and Urogynaecology, Croydon University Hospital, Croydon, UK
| | - R Thakar
- Department of Obstetrics and Urogynaecology, Croydon University Hospital, Croydon, UK
| | - A H Sultan
- Department of Obstetrics and Urogynaecology, Croydon University Hospital, Croydon, UK
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Fourth-Degree Perineal Laceration in Nonconsenual Fisting: A Case Report, Brief Review of the Literature, and Medicolegal Issues. Am J Forensic Med Pathol 2017; 38:258-261. [PMID: 28665832 DOI: 10.1097/paf.0000000000000324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present the case of an 18-year-old girl who was sexually assaulted with transanal forearm penetration resulting in a fourth-degree perineal laceration. Fisting is an uncommon sexual practice consisting in the penetration of the vagina, anus, or both of them with fingers, hand (fist) or forearm.Perineal lacerations are a relatively common finding in both consensual and nonconsensual fisting victims. Even though cases of fisting with first-, second-, and third-degree lacerations have been reported in literature, only one previous case of fourth-degree perineal laceration has been described in a woman, who died after anal fisting.The clinical and morphological findings related to this sexual practice have been presented. No previous reports concerning nonfatal cases of fourth-degree perineal laceration, due to anal fisting, exists in literature. We report a case in which the forensic evaluation and the identification of the sexual assault were delayed because of both the atypical and uncommon pattern of injury and the unconsciousness of the patient. The information gathered thanks to this article would support forensic pathologists and sexual assault forensic examiners in recognizing doubtful cases, and this is particularly important when the suspect of sexual assault arise.
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Ramage L, Yen C, Qiu S, Simillis C, Kontovounisios C, Tekkis P, Tan E. Functional and quality of life outcomes following obstetric anal sphincter injury (OASI): does the grade of injury affect outcomes? Int Urogynecol J 2017; 28:1709-1717. [PMID: 28523401 PMCID: PMC5655560 DOI: 10.1007/s00192-017-3334-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/30/2017] [Indexed: 12/17/2022]
Abstract
Introduction and hypothesis The aim of this study was to compare functional and quality of life data in patients with increasing grades of obstetric anal sphincter injury (OASI) presenting to a tertiary colorectal pelvic floor clinic within 24 months of delivery. Methods Prospective data were collected from the patients for the period 2009–2016 and included data on functional outcomes and motor anorectal manometry parameters. The instruments used for the evaluation of functional outcomes were the Birmingham Bowel and Urinary Symptoms Questionnaire, the Wexner Incontinence Score, Short Form 36, and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. OASI grade of injury was based on the postdelivery endoanal ultrasound scan. Data from patients with a grade 3a, 3b, 3c or 4 OASI were compared using one-way ANOVA for parametric data and the Kruskal-Wallis test for nonparametric data overall and for separate time periods (3–6 months, 6–12 months, 12–24 months). Results Functional patient data were available in 177 patients: 29 with grade 3a, 55 with grade 3b, 77 with grade 3c and 16 with grade 4 OASI. There was no discernible trend in worsening function with increasing severity of OASI overall, nor for the specified time periods of 3–6 months 58 patients), 6–12 months (85 patients) or 12–24 months (18 patients). Conclusions Our series demonstrated no significant differences in functional outcomes or quality of life in patients with different OASI grades. Longer-term follow-up is required to ascertain any later functional differences which may become apparent with time.
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Affiliation(s)
- Lisa Ramage
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Clarence Yen
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Shengyang Qiu
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Constantinos Simillis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK.
- Department of Colorectal Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
| | - Paris Tekkis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
- Department of Colorectal Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Emile Tan
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust, 369 Fulham Road, London, SW10 9NH, UK
- Department of Colorectal Surgery, Singapore General Hospital, Bukit Merah, Republic of Singapore
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Zimmo K, Laine K, Vikanes Å, Fosse E, Zimmo M, Ali H, Thakar R, Sultan AH, Hassan S. Diagnosis and repair of perineal injuries: knowledge before and after expert training-a multicentre observational study among Palestinian physicians and midwives. BMJ Open 2017; 7:e014183. [PMID: 28389490 PMCID: PMC5558821 DOI: 10.1136/bmjopen-2016-014183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 03/02/2017] [Accepted: 03/06/2017] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess whether a 2 days training with experts teaching on diagnosis and repair of perineal injuries among Palestinian midwives and physicians could change their level of knowledge towards the correct diagnosis and treatment. STUDY DESIGN Multicentre observational study. SETTING Obstetric departments in 6 government Palestinian hospitals. PARTICIPANTS All physicians and midwives who attended the training. METHODS A questionnaire comprising of 14 questions on the diagnosis and repair of perineal tears was distributed to all participants before the training (n=150; 64 physicians and 86 midwives) and 3 months after the training (n=124, 53 and 71, respectively). Characteristics, differences of the study population and level of knowledge before and after the training were presented as frequencies and percentages. Consistency in responses was tested by estimating the p value of McNemar test. RESULTS Among physicians only 11.4% had accurate knowledge on perineal anatomy before the training compared with 78.85% after the training (p<0.001). For midwives, the corresponding numbers were 9.8% and 54.2%, respectively (p<0.001). Before the training, 5.8% of the physicians were aware that rectal examination is mandatory before and after suturing of episiotomies compared with 45.8% after the training (p<0.001). The corresponding numbers for midwives were 0% and 18% (p<0.001), respectively. Physicians knowledge of best practice of skin repair following episiotomy improved from 36.5% to 64.5% (p=0.008) and among midwives from 26.1% to 50.7% (p<0.001). Physicians knowledge of the overlap technique in the repair of full thickness external anal sphincter tears improved from 28.5% to 42.8% (p=0.05), whereas knowledge of repairing torn internal anal sphincter separately improved from 12.8% to 86.8% (p<0.001). CONCLUSIONS Improvement in the level of knowledge on diagnosis and repair of perineal tears was observed for all physicians and midwives who attended the 2 days' expert training. Regular ongoing training will serve to maintain the newly acquired knowledge.
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Affiliation(s)
- Kaled Zimmo
- Department of Obstetrics, Al Aqsa Hospital, Gaza, Palestine
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Katariina Laine
- Department of Obstetrics, Oslo University Hospital, Oslo, Norway
| | - Åse Vikanes
- The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Erik Fosse
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Mohammed Zimmo
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Obstetrics, Al Shifa Hospital, Gaza, Palestine
| | - Hadil Ali
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Obstetrics, Palestine Medical Complex Hospital, Ramallah, Palestine
| | | | | | - Sahar Hassan
- Faculty of Nursing, Pharmacy and Health Professions, Birzeit University, Ramallah, Palestine
- Institute of Community and Public Health, Birzeit University, Ramallah, Palestine
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Arkel E, Torell K, Rydhög S, Rikner Å, Neymark Bachmeier H, Gutke A, Fagevik Olsén M. Effects of physiotherapy treatment for patients with obstetric anal sphincter rupture: a systematic review. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2017. [DOI: 10.1080/21679169.2016.1263872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elisabeth Arkel
- Department of Physical Therapy Norra Älvsborgs Länssjukhus, Trollhättan, Sweden
| | - Karin Torell
- Department of Physical Therapy, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Sofia Rydhög
- Department of Women’s Health/Physical Therapy, Skånes University Hospital, Malmö, Sweden
| | - Åsa Rikner
- Department of Physical Therapy, Akademiska sjukhuset, Uppsala, Sweden
| | | | - Annelie Gutke
- Department of Health and Rehabilitation/Physical Therapy, Gothenburg University/Sahlgrenska Academy, Gothenburg, Sweden
| | - Monika Fagevik Olsén
- Department of Physical Therapy, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Health and Rehabilitation/Physical Therapy, Gothenburg University/Sahlgrenska Academy, Gothenburg, Sweden
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Harvey MA, Pierce M. Lésions obstétricales du sphincter anal (LOSA) : Prévention, identification et réparation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S740-S761. [PMID: 28063577 DOI: 10.1016/j.jogc.2016.09.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Harvey MA, Pierce M, Alter JEW, Chou Q, Diamond P, Epp A, Geoffrion R, Harvey MA, Larochelle A, Maslow K, Neustaedter G, Pascali D, Pierce M, Schulz J, Wilkie D, Sultan A, Thakar R. Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 37:1131-48. [PMID: 26637088 DOI: 10.1016/s1701-2163(16)30081-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. OPTIONS Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. OUTCOMES The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. EVIDENCE Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.
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Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis. Int Urogynecol J 2015; 27:849-57. [PMID: 26676912 PMCID: PMC4879153 DOI: 10.1007/s00192-015-2893-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/11/2015] [Indexed: 11/12/2022]
Abstract
Objectives The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis. Data sources A review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings. Methods of study selection Observational studies (cohort/case–control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3. Tabulation, integration and results From the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42–4.01) or ventouse (OR 2.44, 95 % CI 1.83–3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24–2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06–2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1–1.35). Conclusion The overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery. Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2893-4) contains supplementary material, which is available to authorized users.
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Parmar N, Kumar L, Emmanuel A, Day RM. Prospective regenerative medicine therapies for obstetric trauma-induced fecal incontinence. Regen Med 2015; 9:831-40. [PMID: 25431918 DOI: 10.2217/rme.14.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Fecal incontinence is a major public health issue that has yet to be adequately addressed. Obstetric trauma and injury to the anal sphincter muscles are the most common cause of fecal incontinence. New therapies are emerging aimed at repair or regeneration of sphincter muscle and restoration of continence. While regenerative medicine offers an attractive option for fecal incontinence there are currently no validated techniques using this approach. Although many challenges are yet to be resolved, the advent of regenerative medicine is likely to offer disruptive technologies to treat and possibly prevent the onset of this devastating condition. This article provides a review on regenerative medicine approaches for treating fecal incontinence and a critique of the current landscape in this area.
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Affiliation(s)
- Nina Parmar
- Applied Biomedical Engineering Group, University College London, 21 University Street, London, WC1E 6JJ, UK
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Rodríguez R, Alós R, Carceller MS, Solana A, Frangi A, Ruiz MD, Lozoya R. Incontinencia fecal posparto. Revisión de conjunto. Cir Esp 2015; 93:359-67. [DOI: 10.1016/j.ciresp.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 09/05/2014] [Accepted: 10/05/2014] [Indexed: 12/01/2022]
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Ismail SIMF. The management of obstetric anal sphincter injuries (OASIS): A national postal questionnaire survey in hospitals in the UK. J OBSTET GYNAECOL 2015; 35:229-34. [DOI: 10.3109/01443615.2014.954098] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ozyurt S, Aksoy H, Gedikbasi A, Yildirim G, Aksoy U, Acmaz G, Ark C. Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial. Arch Gynecol Obstet 2015; 292:853-9. [DOI: 10.1007/s00404-015-3708-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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Pelvic floor in females with anorectal malformations--findings on perineal ultrasonography and aspects of delivery mode. J Pediatr Surg 2015; 50:622-9. [PMID: 25840075 DOI: 10.1016/j.jpedsurg.2014.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/15/2014] [Accepted: 08/06/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Advice on the mode of delivery to females born with anorectal malformation (ARM) is needed. The primary aim was to evaluate the anatomy of the pelvic floor muscles in females with ARM operated with posterior sagittal anorectal plasty (PSARP). The second aim was to correlate the extent of muscle defects to the bowel symptoms. METHODS This interventional study with perineal 4D/3D ultrasonography describes the smooth muscles in the intestinal wall (neo-IAS), external sphincter, levators and anal canal using a muscle score (0-6 worst). The bowel symptoms were prospectively registered with Krickenbeck criteria score (0-7 worst). RESULTS Forty females with different subtypes of ARM, median age 13 (4-21), were followed up regarding bowel symptoms. Seventeen were examined with ultrasonography. Bowel symptoms were similar for those examined with ultrasonography and those not, median score 5 and 3 (1-7) respectively, (p=0.223, Fisher's exact test). All the females had at least one muscular defect. There was no significant correlation between muscle defects and bowel symptoms (p=0.094, Spearman's correlation). CONCLUSION Females with ARM have considerable defects in the pelvic floor without any significant correlation to bowel symptoms. All women with ARM would benefit from individualized predelivery evaluations and caesarian section should be considered.
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Franz HBG, Erxleben CWJ. Is the Outcome Indicator "3rd/4th Degree Perineal Tear in Spontaneous Singleton Births" a Reliable Quality Parameter in Obstetrics? Geburtshilfe Frauenheilkd 2015; 75:145-147. [PMID: 25797957 DOI: 10.1055/s-0035-1545703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Obstetric sphincter damage is the most common cause of fecal incontinence in women. Between one-third and two-thirds of women who sustain a recognized third-degree tear during delivery subsequently suffer from fecal incontinence. We should therefore try to reduce the rate of high-grade tears as much as possible. But this rate can only be used as an outcome indicator for the quality of obstetric departments if the recognition and classification of sphincter injury is similar across departments in different hospitals.
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Affiliation(s)
- H B G Franz
- Frauenklinik Klinikum Braunschweig, Braunschweig
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Review of the Diagnosis, Management and Treatment of Fecal Incontinence. Female Pelvic Med Reconstr Surg 2015; 21:8-17. [DOI: 10.1097/spv.0000000000000102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Temtanakitpaisan T, Bunyacejchevin S, Koyama M. Obstetrics anal sphincter injury and repair technique: a review. J Obstet Gynaecol Res 2014; 41:329-33. [PMID: 25545893 DOI: 10.1111/jog.12630] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/03/2014] [Indexed: 12/01/2022]
Abstract
The Urogynecology Committee of the Asia and Oceania Federation of Obstetrics and Gynaecology (AOFOG) has held seminars and workshops on various urogynecological problems in each country in the Asia-Oceania area in order to encourage young obstetricians and gynecologists. In 2013, we organized the operative seminar for obstetrical anal sphincter injuries (OASIS) in which we prepared porcine models to educate young physicians in a hands-on workshop at the 23rd Asian and Oceanic Congress of Obstetrics and Gynaecology in Bangkok, Thailand. Laceration of the anal sphincter mostly occurs during vaginal delivery and it can develop into anal sphincter deficiency, which causes fecal incontinence, if an appropriate suture is not performed. OASIS has become an important issue, especially in developing countries. The prevalence of OASIS of more than the third degree is around 5% in primary parous women and the frequency is higher when detected by ultrasonographic evaluation. Several risk factors, such as macrosomia, instrumental labor, perineal episiotomy and high maternal age, have been recognized. In a society where pregnant women are getting older, OASIS is becoming a more serious issue. An intrapartum primary appropriate stitch is important, but the 1-year outcome of a delayed operation after 2 weeks postpartum is similar. A randomized controlled study showed that overlapping suture of the external sphincter is better than that of end-to-end surgical repair. The Urogynecology Committee of the AOFOG would like to continue with educative programs about the appropriate therapy for OASIS.
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Affiliation(s)
- Teerayut Temtanakitpaisan
- Division Female Pelvic Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Siproudhis L, Jones D, Shing RNK, Walker D, Scholefield JH. Libertas: rationale and study design of a multicentre, Phase II, double-blind, randomised, placebo-controlled investigation to evaluate the efficacy, safety and tolerability of locally applied NRL001 in patients with faecal incontinence. Colorectal Dis 2014; 16 Suppl 1:59-66. [PMID: 24499497 DOI: 10.1111/codi.12546] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/29/2013] [Indexed: 12/27/2022]
Abstract
AIMS Faecal incontinence affects up to 8% of adults. Associated social isolation and subsequent depression can have devastating effects on quality of life (QoL). Faecal incontinence is an underreported health problem as the social isolation and stigma that patients experience makes it difficult for sufferers to discuss their condition with a physician. There have been few well-designed, placebo-controlled clinical trials of treatment for faecal incontinence and little clinical evidence is available to inform the most appropriate management strategies. Libertas, a robustly designed study will investigate the efficacy and safety of NRL001 (1R,2S-methoxamine), an α1 -adrenoceptor agonist, in the treatment of faecal incontinence. METHODS Libertas is a multicentre, Phase II, double-blind, randomised, placebo-controlled, parallel group study. Patient recruitment took place across 55 study centres in Europe. Patients suffering with faecal incontinence were randomised into four groups (approximately 110 each) to receive once daily self-administered doses of NRL001 (5, 7.5 or 10 mg or placebo in a suppository formulation) for 8 weeks. The primary objective of Libertas is to assess the impact of once daily administration of NRL001 on the severity and frequency of incontinence episodes as assessed by the Wexner score at 4 weeks, compared with placebo. Secondary outcomes include measures of efficacy of NRL001 compared with placebo following 8 weeks treatment; safety and tolerability; evaluation of plasma pharmacokinetics; establishment of any pharmacokinetic/pharmacodynamic relationship to adverse events; dose-response relationship; the efficacy of NRL001 therapy at 4 and 8 weeks assessed by the Vaizey score; and QoL using the Faecal Incontinence Quality of Life and the EQ-5D-5L Healthcare Questionnaires following 4 and 8 weeks NRL001 therapy. Overall patient satisfaction with the treatment will also be evaluated. DISCUSSION This is the first randomised controlled study to investigate the efficacy and safety of a selective α1 -adrenoceptor agonist for the treatment of faecal incontinence. Furthermore, this is the first time the impact of NRL001 on assessments of QoL, health outcomes and patient satisfaction will be assessed. Innovative strategies were developed to meet the challenge of recruiting patients for this study, for example, media advertising, posters and mailshots as allowed by each study centre.
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Affiliation(s)
- L Siproudhis
- Gastroenterology Unit, CHU Pontchaillou, Rennes, France
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Severe Perineal Lacerations in Obstetric Practice: The Effect of Institutional Practice Guidelines on Repair Failures in a Single Centre. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:131682. [PMID: 27350967 PMCID: PMC4897495 DOI: 10.1155/2014/131682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 09/10/2014] [Indexed: 11/24/2022]
Abstract
Background. There is a high incidence of failure after repair of severe perineal lacerations (SPLs). A tertiary referral hospital in the Caribbean introduced guidelines in an attempt to improve outcomes. We performed an audit of SPL repairs at this centre in an attempt to determine the effect on repair failure. Methods. All patients with SPL repairs between November 1, 2007, and December 30, 2012, were identified. The primary aim was to determine the incidence of failed repairs (wound dehiscence, anal sphincter disruption, rectovaginal fistula, and/or faecal incontinence). The Cleveland Clinic Incontinence Score (CCIS) was used to assess continence at discharge and 24 weeks after repair. Data were analyzed with SPSS version 12. Results. There were 8108 vaginal deliveries, 23 third-degree injuries, and 3 fourth-degree injuries. Three patients experienced a repair failure. Notably, 69% of surgeons chose an inappropriate suture for sphincter repair. Conclusions. Experienced operators are performing repairs, but there is a high prevalence of inappropriate suture choice for repairs. A targeted educational campaign may be necessary to remind clinicians of the best practice in repair techniques.
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Oliveira LS, Brito LGO, Quintana SM, Duarte G, Marcolin AC. Perineal trauma after vaginal delivery in healthy pregnant women. SAO PAULO MED J 2014; 132:231-8. [PMID: 25055069 PMCID: PMC10496741 DOI: 10.1590/1516-3180.2014.1324710] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 08/30/2013] [Accepted: 09/17/2013] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Despite all the medical care provided during delivery labor, perineal injury is still prevalent and may lead to diverse pelvic floor disorders. The aim here was to investigate the prevalence of obstetric and anal sphincter injuries (OASIS) in healthy pregnant women after vaginal delivery. DESIGN AND SETTING Cross-sectional study involving 3,034 patients with singletons in a secondary hospital for low-risk cases. METHODS A standardized questionnaire was prepared and applied to medical files that had been completely filled out (classification of the Royal College of Obstetricians and Gynecologists, RCOG) in order to identify OASIS and analyze risk factors associated with mild and severe perineal lacerations. RESULTS The women's mean age was 25 years; more than half (54.4%) were primiparae. Almost 38% of the participants had perineal lacerations; these were severe in 0.9% of the cases. Previous vaginal delivery (odds ratio, OR: 1.64 [1.33-2.04]) and forceps delivery (OR: 2.04 [1.39-2.97]) were risk factors associated with mild perineal injuries (1st and 2nd OASIS classifications). Only remaining standing for prolonged periods during professional activity (OR: 2.85 [1.34-6.09]) was associated with severe perineal injuries. CONCLUSION The prevalence of severe perineal injuries was concordant with data in the literature. The variable of standing position was considered to be a risk factor for severe perineal injury and should be further investigated.
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Affiliation(s)
- Larissa Santos Oliveira
- MD. Physician, Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Luiz Gustavo Oliveira Brito
- MD, PhD. Attending Physician, Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Silvana Maria Quintana
- MD, PhD. Associate Professor, Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Geraldo Duarte
- MD, PhD. Full Professor, Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Alessandra Cristina Marcolin
- MD, PhD. Professor, Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
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Abstract
BACKGROUND Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair. OBJECTIVES To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS. DATA COLLECTION AND ANALYSIS Trial quality was assessed independently by all authors. MAIN RESULTS Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women). AUTHORS' CONCLUSIONS The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.
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Affiliation(s)
- Ruwan J Fernando
- Department of Urogynaecology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, UK, W2 1NY
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