Symptoms and anal sphincter morphology following primary repair of third-degree tears

Risk of Fecal Incontinence Following Receptive Anal Intercourse: Survey of 21,762 Men Who Have Sex With Men

BACKGROUND

The prevalence of receptive anal intercourse (RAI) is increasing. A few studies, with heterogeneous designs, have investigated the associated risk of fecal incontinence (FI).

AIM

The primary objective of this study was to determine FI prevalence in a population of men who have sex with men (MSM) engaging in RAI. The secondary objective was to identify risk factors for severe FI.

METHODS OUTCOMES

An online survey of 24,308 MSM was performed in 2019. Demographic and socioeconomic data were collected, together with information about RAI sexual practices, and FI defined by: "During the last month, have you experienced any involuntary leakage of stools?"

RESULTS CLINICAL IMPLICATIONS

In total, 1,734 (8%) of the 21,762 participants reported FI. Mean age was 35.3 years. The prevalence of FI was correlated with RAI frequency: 12.7% (if RAI ≥ 1 /wk) versus 5.7% (if no RAI). In multivariate analysis, the factors associated with FI were age (OR: 1.01), low socioeconomic status (OR 1.32 to 1.40), HIV-seropositivity (OR: 1.78), high RAI frequency (OR: 1.64), chemsex (OR: 1.67) and fist-fucking (OR: 1.61).

STRENGTHS AND LIMITATIONS

Main strengths of our study are population size and assessment of detailed modalities of sexual practices. Main limitations are the use of a convenience non-random sample and the assessment of FI only during the past month.

CONCLUSION

This study of a large MSM population, highlights risk factors for FI among RAI practices: RAI ≥ 1 /wk, chemsex, fist-fucking, low socioeconomic status. Garros A, Bourrely M, Sagaon-Teyssier L, et al. Risk of Fecal Incontinence Following Receptive Anal Intercourse: Survey of 21,762 Men Who Have Sex With Men. J Sex Med 2021;18:1880-1890.

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

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review.

METHODS

We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI.

RESULTS

We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I² = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I² = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I² = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I² = 95 %). Following primary repair of OASIS, 55 % (46-63, I² = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I² = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I² = 98 %).

INTERPRETATION

Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.

Prevalence of anal incontinence in a working population within a healthcare environment

OBJECTIVES

Anal incontinence is a devastating affliction with several considerations that make it difficult to define in terms of epidemiology with good precision. The aim of the present work is to study the prevalence of an important disorder such as anal incontinence in a healthy working population within a sanitary environment.

MATERIAL AND METHODS

A cluster of easy understanding and filling inquiry forms are distributed to 910 apparently healthy individuals at our hospital. This questionnaires include filiation data, passed medical history, presence or not of Incontinence and other symptoms such as urgency. The Cleveland Clinic Incontinence Score is also registered.

RESULTS

Anal incontinence is present in a 21.2% of subjects when considered in any of it forms (flatus, liquid or solid faeces). A Clevleand Clinic Incontinence Score higher than 6 was obtained in a 7.3% of the sample and higher than 10 in 1.2%. No gender predominance has been identified. A slightly higher severity is recognised with increasing age. Obstetric and anal surgical background are the only related factors identified in the studied sample.

CONCLUSIONS

Faecal incontinence is a high prevalent affliction, even among apparently healthy population. Considering the aetiologic factors that have been established, prevention during obstetric and anal surgical procedures is absolutely mandatory.

Long-term impact of full-thickness rectal prolapse treatment on fecal incontinence

BACKGROUND

Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse.

OBJECTIVE

We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse.

DESIGN

A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010).

MAIN OUTCOME MEASURES

Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score.

RESULTS

Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017).

LIMITATIONS

Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias.

CONCLUSION

Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies.

Incontinence in full-thickness rectal prolapse: low level of improvement after laparoscopic rectopexy

AIM

The study aimed to quantify incontinence before and after laparoscopic rectopexy in patients suffering from rectal prolapse.

METHOD

Eighty-five patients underwent laparoscopic rectopexy to treat rectal prolapse between 2003 and 2009. Symptomatic and functional data were collected prospectively before and after surgery by self-administered questionnaires including the Cleveland Clinic Fecal Incontinence Score (CCIS) and constipation, gastrointestinal quality of life and urinary incontinence questionnaires. Incontinence was considered to be present when the CCIS remained at ≥ 5 after surgery.

RESULTS

After a mean follow-up period of 36 months after surgery, 83% of the patients reported good to excellent results. Continence was improved in 58 (68%), with a significant decrease in the continence score (-3.4 ± 5.8, P = 0.001). However, 50 (58.9%) patients remained incontinent: 47 (55%) reported urge incontinence and 27 (32%) had passive leakage. Incontinence for liquid stool, incontinence for solid stool and the need for protection was seen in 43 (51%), 35 (41%) and 43 (51%) patients. Manometry, defaecography and ultrasonography were not associated with any improvement. In contrast, the patients' average age (60.2 ± 15.8 vs 46.9 ± 15.5 years; P = 0.003), symptom duration before surgery (58.1 ± 70.1 vs 29.5 ± 33.3 months; P = 0.011), preoperative urinary incontinence score (10.7 ± 10.8 vs 4.2 ± 5.7; P = 0.0131) and faecal incontinence score (12.9 ± 4.9 vs 7.1 ± 6; P < 0.0001) were significantly higher in patients suffering from postoperative incontinence.

CONCLUSION

Despite some continence improvement in two-thirds of patients who underwent surgery for rectal prolapse, the level of improvement remained low in more than half of the patients.

Sacral nerve stimulation for fecal incontinence improves symptoms, quality of life and patients' satisfaction: results of a monocentric series of 119 patients

PURPOSE

Sacral nerve stimulation (SNS) is validated as an efficient treatment for fecal incontinence (FI). However, long-term results are scarce in the literature. The goal of this study was to assess the impact of SNS on FI symptoms and quality of life, based on a retrospective analysis of prospectively collected data.

METHODS

From 2001 to 2009, 119 patients (six men, mean age 61 years) underwent SNS testing for FI after an extensive diagnostic workup. Permanent implantation was realized when FI symptoms improved during testing, and follow-up visits were performed every 12 months thereafter. This follow-up evaluated morbidity and efficacy, based on clinical data and self-administered questionnaires including Jorge and Wexner FI score, urinary incontinence score (urinary distress inventory-6, UDI-6), gastrointestinal quality of life index (GIQLI), and auto-evaluation scale.

RESULTS

A permanent stimulator was implanted after a positive test in 102 patients (91 %). Ten patients were explanted during follow-up (pain in one case and absence of efficacy in nine), and 29 had the stimulator and/or the electrode changed. The mean follow-up was 48 months (range 12-84): there was a significant improvement of FI score (9 ± 1 vs 14 ± 3, p < 0.0001), UDI-6 score (8 ± 4 vs 11 ± 5, p < 0.05), and GIQLI index (p < 0.002). The improvement was present at 12 months follow-up and remained stable. Eighty percent of patients were satisfied with the treatment at the last point of follow-up. None of the pretreatment variables were predictive of SNS efficacy.

CONCLUSIONS

SNS improved FI and quality of life, and this efficacy remained over time. Although a complete disappearance of FI was rare, most patients were satisfied.

[Direct sphincter repair: techniques, indications and results]

L'incontinence anale est un handicap physique, psychique et social majeur qui a de nombreuses causes différentes. Les méthodes actuellement disponibles pour améliorer les symptômes de cette incontinence sont les méthodes médicales et de rééducation d'une part et les méthodes chirurgicales d'autre part. Quatre techniques chirurgicales répondent à ces objectifs pour la plupart des malades: la sphinctérorraphie, la neuromodulation des racines sacrées, et les deux techniques de substitution que sont le sphincter artificiel et la graciloplastie dynamisée. La réparation sphinctérienne directe est la technique la plus utilisée dans le traitement chirurgical de l'incontinence anale (IA) par lésion sphinctérienne. Cette technique est envisageable chez les malades ayant une incontinence fécale en rapport avec des lésions limitées du sphincter anal externe. La technique chirurgicale est simple (myorraphie par suture directe ou en paletot) et bien codifiée. Les résultats fonctionnels sont imparfaits et se dégradent avec la durée du suivi. Une continence parfaite après réparation sphinctérienne est rarement acquise de façon durable: le malade candidat à cette approche thérapeutique doit en être averti.

The effect of concealed concomitant anal incontinence symptoms in patients with urinary incontinence on their quality of life

INTRODUCTION AND HYPOTHESIS

We evaluated the bother of concomitant anal incontinence (AI) in women with urinary incontinence (UI) who do not primarily report their anal symptoms.

METHODS

This prospective study assessed patients with complaings of primary UI without initially reporting anal symptoms. After urogynecological assessment, all patients were asked to complete the validated versions of the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Pelvic Floor and Incontinence Sexual Impact Questionnaire (PISQ-12), Wexner Incontinence Scale (WIS) score, and Beck Anxiety Inventory (BAI). Patients who scored nil in the WIS constituted the group of only UI, and patients with scores ≥1 were grouped as double incontinence (DI)., and the groups were compared.

RESULTS

Among 136 women, 69.1 % (94) had only UI, whereas 30.9 % (42) had DI. There were no differences in age, parity, body mass index (BMI), and prolapse status between patients with UI and those with DI, except menopausal status. Women with DI scored worse for IIQ-7, PISQ-12, and BAI questionnaires compared with women with UI. This difference was not statistically significant for IIQ-7 only.

CONCLUSIONS

Our data show that concealed AI symptoms may contribute to the anxiety of the patient and even alter the perception of urinary symptoms. Actually, a significant number of women suffer from DI without reporting their anal symptoms, which results in underdiagnosing of concomitant AI. To prevent the suboptimal management of patients with lower urinary tract symptoms, standardized questionnaires for AI should be included in the evaluation of all patients with lower urinary tract symptoms.

Underlying functional bowel disorder may explain patient dissatisfaction after haemorrhoidal surgery

AIM

The aim of this study was to assess patient dissatisfaction and functional symptoms following haemorrhoid surgery, aspects of which are seldom covered in other published series.

METHOD

A self-administered questionnaire was mailed to 359 consecutive patients (prospective database; 198 men, 161 women; median follow up, 59 [1-120] months) who underwent either Milligan-Morgan haemorrhoidectomy (n=205) or stapled haemorrhoidopexy (n=154).

RESULTS

The response rate was 72%; 2.4% of patients had no opinion, 13.6% were dissatisfied, 33.0% were satisfied, and 51.0% were very satisfied with the treatment. Dissatisfied patients were more likely to be women and more likely to have a long history of constipation and irritable bowel syndrome. The duration of surgery and the rates of pre- and postoperative complications did not differ between groups. Residual bleeding (49% vs 32%), prolapse (67% vs 31%) and pain (91% vs 55%) occurred more frequently in the dissatisfied group compared with the satisfied group (P<0.001). Incontinence (4 [0-16] vs 1 [0-15]; P=0.0003) and constipation (19 [1-34] vs 8 [0-31]; P<0.0001) scores were significantly higher in the dissatisfied group compared with satisfied patients. Anal pain was the predominant symptom associated with dissatisfaction in a logistic regression model.

CONCLUSION

Persistent pain remains the major long-term factor associated with dissatisfaction after surgery for haemorrhoids.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term anal continence and quality of life following postpartum anal sphincter injury

OBJECTIVE

Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long-term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3).

METHOD

In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound.

RESULTS

Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3.

CONCLUSION

Our study indicates that long-term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).

Intraoperative mapping of anal and perineal anatomy using an electrostimulator

OBJECTIVE

To present a new technique to identify perineal and anal sphincter anatomy using an electrostimulator in order to facilitate anatomical repair.

METHODS

A neglected perineal tear was repaired using the technique described.

RESULTS

The patient's St Mark's incontinence score improved from 22 out of 24 to 6 out of 24.

CONCLUSIONS

This technique may be practical and useful for intraoperative mapping of distorted perineal and anal anatomy to assist surgical repair.

[What are the risk factors of anal incontinence after vaginal delivery?]

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.

Clinical, sonographic and manometric characteristics and impact on quality of life of fecal incontinence in 92 men referred for endoanal ultrasonography

Anal incontinence (AI) is a frequent symptom with considerable impact on quality of life. The aim of this study was to describe the clinical, sonographic and manometric characteristics of a male population with AI.

MATERIALS AND METHODS

Endoanal ultrasonography (EAU) was performed in 92 men referred for exploration of AI. Anal incontinence severity was evaluated by the Jorge and Wexner score (JW). The gastrointestinal quality-of-life index (GIQLI) was determined in 57% of patients. Anorectal manometry was performed in 62.6% of patients.

RESULTS

The average JW score was 11+/-1. Anal incontinence had considerable impact on quality of life: average GIQLI=81+/-4. Seventeen patients presented an anal sphincter defect on EAU, 16 of whom had a history of coloproctological surgery. Prior surgery was significantly more common among patients who had a defect on ultrasonography; manometry showed significantly lower resting anal pressure.

CONCLUSION

Our study confirms the severity of AI in a male population and its impact on quality of life. It also highlights the high prevalence of anal sphincter defects in patients with a history of anal surgery.

Overlap technique improves results of primary surgery after obstetric anal sphincter tear

PURPOSE

This study was designed to evaluate prospectively the results of the overlap technique in primary sphincter reconstruction after obstetric tear.

METHODS

Obstetric tears in 44 women were operated on with primary overlap reconstruction. These women were investigated six to nine months after the operation. Results were compared with those of a historical control group of 52 women whose obstetric sphincter rupture had been treated with the end-to-end technique.

RESULTS

The overlap group had significantly more incontinence symptoms after delivery and repair of the sphincter tear than before delivery (P < 0.0001); however, their incontinence symptoms were significantly fewer than those of the end-to-end group (P = 0.004). The prevalence of persistent rupture of the external anal sphincter was significantly lower in the overlap group (6/44, 13.6 percent) than in the end-to-end group (39/52, 75 percent; P < 0.0001). Internal anal sphincter rupture occurred in 5 patients (11.4 percent) in the overlap group and in 40 patients (76.9 percent) in the end-to-end group (P < 0.0001).

CONCLUSIONS

The overlap technique should be adopted as the method of choice for primary sphincter repair after obstetric tear.

Obstetric anal sphincter injury: incidence, risk factors, and management

BACKGROUND AND AIMS

Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management.

METHOD

This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists.

RESULTS

A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality.

CONCLUSIONS

Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

Early results of immediate repair of obstetric third-degree tears: 65% are completely asymptomatic despite persistent sphincter defects in 61%

OBJECTIVE

The outcome of immediate repair of obstetric third-degree tears is poorly documented. Immediate repair may give better functional results than delayed repair because scarring is reduced. This aim of this prospective study was to examine the early outcome of immediate repair of third-degree tears.

METHOD

A total of 121 women who had immediate repair of obstetric third-degree tears underwent interview, anal ultrasonography and anorectal physiology.

RESULTS

At review, 79 (65%) were completely asymptomatic (score = 0), 23 (19%), had minor flatus incontinence or mild urgency causing no compromise to their quality of life (score 1-4), and 19 (16%) had clinically embarrassing faecal incontinence (score 5-24). Thirty-nine (32%) had an intact internal anal sphincter (IAS) and external anal sphincter (EAS) (i.e. a successful repair), eight (7%) had a defect in the IAS alone but the EAS was intact (i.e. a successful repair but a residual IAS defect), 43 (35%) had a residual defect in the EAS alone (IAS intact) and 31 (26%) had a persistent defect in the IAS and EAS. Residual defects in either or both of the sphincters were associated with a significantly higher incidence of abnormal resting and squeeze anal pressures. Anal manometry had no correlation with symptoms. The highest proportion of severe incontinence was in those with an IAS defect alone (37%) and when there was a residual IAS and EAS defect (24%). Only 2 of 39 (5%) with an intact IAS and EAS had severe incontinence and only 8 of 43 (18%) with a residual EAS defect alone had severe faecal incontinence.

CONCLUSION

These results indicate a good outcome following immediate repair of third-degree obstetric tears and emphasize the role of the IAS in providing continence.

Postpartum evaluation of the anal sphincter by transperineal three-dimensional ultrasound in primiparous women after vaginal delivery and following surgical repair of third-degree tears by the overlapping technique

OBJECTIVE

Intrapartum damage to the anal sphincter is an important factor in fecal incontinence. Recognized lacerations occur in 0.36-8.4% of vaginal deliveries, and occult sphincter damage in up to 35% of primiparous women. We examined the role of three-dimensional transperineal ultrasound (3DTUS) in the evaluation of the anal sphincter in primiparous women after vaginal delivery and after surgical repair of third-degree intrapartum tears by the overlapping technique.

METHODS

During 2004-2005 139 primiparous women without clinically recognized third- to fourth-degree anal sphincter tears were prospectively studied 24-72 h postpartum (Group 1) and 13 primiparous women were examined 48 h to 4 months following surgical repair of third-degree tears with the overlapping technique (Group 2). A 3D 5-9-MHz transvaginal probe was placed in the area of the fourchette and perineal body in transverse and sagittal planes and 2-4 volumes were stored. The parameters studied were: examination duration; continuity of the internal and external sphincters; occult sphincter damage; internal sphincter and external sphincter width-measured 1.5 cm from the distal margin of the anus-at the '12, 3, 6 and 9 o'clock positions'; length of the posterior internal sphincter.

RESULTS

Scanning was possible in all women and the stored volumes were adequate in 127/139 (91.4%) cases. Mean examination time was 3.5 min. In Group 1, occult sphincter defect was suspected in 10/127 women (7.9%). These patients were excluded from measurement calculations, leaving 117 cases for analysis. The internal sphincter was consistently visualized in all the remaining patients (n = 117), while the external sphincter was fully visualized in 99/117 women (84.6%), and partially visualized in the remainder. Mean internal sphincter thickness was 2.60, 2.55, 2.60 and 2.72 mm at the 12, 3, 6 and 9 o'clock positions, respectively, and mean internal sphincter length was 3.34 cm. Mean external sphincter thickness was 4.15, 4.20, 4.21 and 4.20 mm at the 12, 3, 6 and 9 o'clock measurement points. In Group 2, 3DTUS confirmed anatomic abnormalities in all the women in the area surrounding the 12 o'clock position. Evaluation of sphincter tears and their position and length was possible using the longitudinal view. Thinning of the internal sphincter in the area of damage and thickening on the opposite side, the 'half moon sign', sphincter discontinuity, thickening of the external sphincter in the area of repair and abnormality of mucous folds, seemed to be common signs of third-degree intrapartum sphincter tears, even after repair.

CONCLUSIONS

3DTUS is an accessible and promising method for postpartum sphincter evaluation, that is apparently well tolerated by patients. Reference data for sphincter anatomy representative of findings at transperineal ultrasound in primiparous women in the postpartum period have been established.

Risk factors for obstetric anal sphincter injury: a prospective study

BACKGROUND

Anal incontinence is an embarrassing condition that is largely underreported. Obstetric anal sphincter injuries are the major etiological factor. Recognition of risk factors may minimize the development of sphincter injuries. The objective of this study was to identify risk factors for sphincter injuries and measure dimensions of mediolateral episiotomies.

METHODS

Women expecting their first vaginal delivery were invited to participate, and an experienced research fellow performed a perineal and rectal examination and classified tears according to the new international classification. Dimensions of episiotomies were measured and obstetric variables recorded prospectively.

RESULTS

Of the 241 women recruited, 59 (25%) sustained sphincter injuries. Univariate analysis revealed that forceps delivery OR 4.03 (1.63-9.92), vacuum extraction OR 2.64 (1.25-5.54), gestation > 40 weeks OR 3.18 (2.35-4.29), and mediolateral episiotomy OR 5.0 (2.64-9.44) were associated with these injuries. In addition, compared with women who had no injuries, sphincter injuries were more common with higher birthweight (3.51 vs 3.17 kg, p < 0.01), larger head circumference (34.3 vs 33.3 cm, p < 0.01), and longer second stage of labor (76 vs 51 min, p < 0.01). Multiple logistic regression revealed higher birthweight and mediolateral episiotomy OR 4.04 (1.71-9.56) as independent risk factors. Episiotomies angled closer to the midline were significantly associated with such injuries (26 vs 37 degrees, p = 0.01). No midwife and only 13 (22%) doctors performed truly mediolateral episiotomies.

CONCLUSIONS

Mediolateral episiotomy is an independent risk factor for anal sphincter injuries. Although a liberal policy of mediolateral episiotomy does not appear to reduce the risk of such injuries, it may be related to inappropriate technique. A concerted approach to educate trainees in appropriate episiotomy technique and identification of sphincter injuries is imperative to enable reexamination of the true merits or disadvantages of mediolateral episiotomy.

How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial

OBJECTIVE

To compare two surgical techniques and two types of suture material for anal sphincter repair after childbirth-related injury.

DESIGN

Factorial randomised controlled trial.

SETTING

Tertiary referral maternity unit.

POPULATION

Women with an anal sphincter injury sustained during childbirth.

METHOD

Women were randomised into four groups: overlap repair with polyglactin (Vicryl); end-to-end repair with polyglactin (Vicryl); overlap repair with polydioxanone (PDS); and end-to-end repair with PDS. All repairs were completed as a primary procedure by staff trained in both methods.

MAIN OUTCOME MEASURES

Suture-related morbidity at six weeks. Bowel symptoms at 3, 6 and 12 months. Anorectal physiology at three months. Quality of life scores at 3 and 12 months.

RESULTS

One hundred and fifty women (1.5% of deliveries) were eligible and 112 (75%) were randomised. One hundred and three (92%) attended follow up visit at 6 weeks, 89 (80%) at 3 months, 79 (71%) at 6 months and 60 (54%) at 12 months. At six weeks, there was no difference in suture-related morbidity between groups (P=0.11) and 70% patients were completely asymptomatic. Incidence of bowel symptoms and quality of life disturbances were low, with no differences between the four groups.

CONCLUSION

Obstetric anal sphincter repair carried out by appropriately trained staff is associated with low morbidity, irrespective of the suture material and repair method used.

Prevalence of anal incontinence in adults and impact on quality-of-life

OBJECTIVE

To investigate the prevalence of anal incontinence in the general population and in patients consulting gastroenterologist and gynecologist practices in the Rhône Alpes area.

METHODS

For the first study a questionnaire was sent to a sample of 2800 people selected randomly from the electoral roll. Another study of patients selected randomly among patients attending gynecology and gastroenterology consultations was performed. A Jorge & Wexner score above or equal to 5 was used to define anal incontinence.

RESULTS

For the first study, a total of 706 questionnaires was analyzed: the prevalence of anal incontinence was 5.1% [95% CI: 3.6-7.0] and the scores of each dimension of the SF-12 Health Survey were significantly lower among incontinent people than among continent people. The prevalence was significantly higher for women (7.5% [5.0-10.7]) than for men (2.4% [1.1-4.7]). Eighty-four physicians returned 835 valid questionnaires. The prevalence was 13.1% [10.1-16.6] among patients attending gastroenterology consultations and 5.0% [3.1-7.6] among those attending gynecology consultations. For 84.8% of the incontinent patients, the physician was unaware of the patient's disorder.

CONCLUSION

The prevalence figures we obtained coincide with data in the literature. This disorder is common and affects the patient's quality-of-life, but remains underestimated and under-diagnosed.

Risk scoring system for prediction of obstetric anal sphincter injury

OBJECTIVE

The objective was to begin the process of developing an antenatal risk scoring system, as a first step towards examining whether elective Caesarean section for women at high risk of injury could be an effective and acceptable intervention.

DESIGN

Retrospective study.

SETTING

Tertiary maternity unit in the UK.

POPULATION

One hundred and twenty-three women who sustained an obstetric anal sphincter injury (OASI) and 123 controls without OASI.

METHODS

Case notes of women with a third or fourth degree tear between 1997 and 1999 were examined for risk factors. Controls matched for age and week of delivery were identified from the maternity record database and case records reviewed for the presence of risk factors. Unweighted and weighted risk scores were produced using odds ratios, and compared between cases and controls. Receiver operating characteristics (ROC) curve analysis of the risk scores was performed to discriminate between cases and controls and to calculate the sensitivity and specificity of each scoring system.

MAIN OUTCOME MEASURES

Odds ratio (OR) and 95% confidence interval (CI) for each risk factor. Sensitivity and specificity from ROC curves for weighted and unweighted risk score.

RESULTS

Among the cases there were more nulliparous women (OR 1.77; CI 1.05-2.99) and a trend towards more women with an episiotomy (OR 1.57; CI 0.99-2.47). Among women with sphincter injury, trends towards more epidurals (OR 1.64; CI 0.97-2.75), and more babies weighing more than 4000 g among (OR 1.45; CI 0.85-2.49) were noted. The median unweighted risk score was 2 for cases and 2 for controls (P= 0.05), while the weighted risk score was 2.1 and 1.37 (P= 0.03), respectively. The ROC curves approximated to a straight line demonstrating very poor discrimination between cases and controls.

CONCLUSION

The predictive test performed poorly, suggesting that the risk factors identified do not exert a large enough effect in a cohort of this size.

Is it possible to predict or prevent third degree tears?

OBJECTIVES

This paper reviews the causes anal sphincter injury during vaginal delivery. It emphasises that they are not usually the result of poor obstetric care. The role of the colorectal surgeon in their management is discussed.

METHODS

Medline was searched using the key words third degree tears, pregnancy, risk factors, prevention and recurrence risk. A hand search of journals and located articles was made. Two hundred and twenty three papers were identified, 84 are referenced.

RESULTS

The reported incidence of anal sphincter tears is usually between 0.5% and 2.5% of vaginal deliveries. Maternal factors such as parity and age and obstetric factors such as mode of presentation, the use of forceps and the size of the baby all influence the incidence of sphincter tears. Predicting tears in individual women is inaccurate and midwifery practices can do little to prevent them. Reducing pelvic floor morbidity by increasing the caesarean section rate would require that a large number of caesarean sections be done to prevent a small number of tears. The recognition of perineal trauma is improved by training. Accurate apposition of the sphincters with antibiotic cover and post-operative laxatives are the important technical aspects of the repair. Colorectal follow up helps to identify those women with symptoms and allows advice about the advisability of subsequent vaginal deliveries. A previous third degree tears increases the risk of a subsequent one, although the overall risk remains low. A second vaginal delivery after a third degree tear that has resulted in a functional deficit predisposes to worsening function. When there is no residual anatomical defect and no functional loss, there is no evidence of increased risk of incontinence following another vaginal delivery.

CONCLUSION

Vaginal delivery will continue to be the main method of delivery and will continue to generate a low incidence of pelvic floor morbidity. The management of injury to the anal sphincter is facilitated by close co-operation between obstetricians and colorectal surgeons.

Combined urinary and faecal incontinence

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9-19% (urinary) and 5-10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.