The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury

Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS)

INTRODUCTION

Obstetric anal sphincter injuries (OASIS) predispose to development of anorectal symptoms that affect women's quality of life.

METHODS

A retrospective cohort study was conducted for all women with singleton vaginal deliveries who had a primary OASIS repair and attended the Postpartum Perineal Clinic between July 1st 2017 and December 31st 2020. This study was approved by the Research Ethics Board. The purpose of this study was (1) to determine correlation between endoanal ultrasound (EAUS) findings and anorectal symptoms quantified by the St. Mark's Incontinence Score (SMIS), (2) to determine the incidence of residual anal sphincter defects, and (3) to determine the rate of clinical overdiagnosis of OASIS. Pearson correlation coefficient was used to assess correlation between anorectal symptoms and EAUS findings.

RESULTS

A total of 247 participants with clinical diagnosis of OASIS met the inclusion criteria. A 3rd-degree tear was identified in 126 (51.0%) and 4th-degree tear was identified in 30 (12.1%) participants. In participants with sonographic evidence of OASIS, there was a statistically significant weak positive correlation between the size of residual defect and SMIS for both external anal sphincter (EAS) (r = .3723, p < .0001) and internal anal sphincter (IAS) (r = .3122, p = .0180). Residual defect in the anorectal sphincter of greater than 1 hour (> 30°) in width was present in 64.3% participants with 3rd-degree tear and 86.7% participants with 4th-degree tear. The rate of overdiagnosis was 36.8%.

CONCLUSION

The size of residual defect of EAS and IAS has a weak positive correlation with anorectal symptoms, emphasizing the importance of EAUS for counselling regarding mode of subsequent delivery.

Anal incontinence following obstetric anal sphincter injury: Is there a difference between subtypes? A systematic review

AIMS

Obstetric anal sphincter injury (OASI) is associated with long-term anal incontinence (AI). We aimed to address the following questions: (a) are women with major OASI (grade 3c and 4) at higher risk of developing AI when compared to women with minor OASI (grade 3a and 3b)? (b) is a fourth-degree tear more likely to cause AI over a third-degree tear?

METHODS

A systematic literature search from inception until September 2022. We considered prospective and retrospective cohort studies, cross-sectional and case-control studies without language restrictions. The quality was assessed by the Newcastle-Ottawa Scale and the Joanna Briggs Institute critical appraisal checklist. Risk ratios (RRs) were calculated to measure the effect of different grades of OASI.

RESULTS

Out of 22 studies, 8 were prospective cohort, 8 were retrospective cohort, and 6 were cross-sectional studies. Length of follow-up ranged from 1 month to 23 years, with the majority of the reports (n = 16) analysing data within 12-months postpartum. Third-degree tears evaluated were 6454 versus 764 fourth-degree tears. The risk of bias was low in 3, medium in 14 and high in 5 studies, respectively. Prospective studies showed that major tears are associated with a twofold risk of AI for major tears versus minor tears, while retrospective studies consistently showed a risk of fecal incontinence (FI) which was two- to fourfold higher. Prospective studies showed a trend toward worsening AI symptoms for fourth-degree tears, but this failed to reach statistical significance. Cross-sectional studies with long-term (≥5 years) follow-up showed that women with fourth-degree tear were more likely to develop AI, with an RR ranging from 1.4 to 2.2. Out of 3, 2 retrospective studies showed similar findings, but the follow-up was significantly shorter (≤1 year). Contrasting results were noted for FI rates, as only 5 out of 10 studies supported an association between fourth-degree tear and FI.

CONCLUSIONS

Most studies investigate bowel symptoms within few months from delivery. Data heterogeneity hindered a meaningful synthesis. Prospective cohort studies with adequate power and long-term follow-up should be performed to evaluate the risk of AI for each OASI subtype.

Risk factors accounting for anal incontinence during the first year after vaginal delivery-A case control study in China

Introduction and hypothesis

Anal incontinence (AI) is a prevalent postpartum disorder. This study aims to investigate and quantify the risk factors for AI in the Chinese population during the first year following vaginal delivery.

Methods

The case control study was conducted at Peking University Third Hospital, including all women who delivered vaginally between January 1, 2014, and June 30, 2018. Participants were followed up by telephone interviews 1 year after delivery. AI was defined as the involuntary loss of flatus or feces using a retrospective Jorge and Wexner score above 0. Clinical data were retrieved from the medical record system. Univariate and multivariate analyses were applied to identify potential risk factors accounting for AI. Based on the logistic regression model, a nomogram was constructed to predict the probability of AI postpartum. Restricted cubic spline was utilized to explore potential non-linear relationships between birth weight and AI postpartum.

Results

Among the 140 AI and 421 none AI cases, we observed antepartum factors like every 100 g of birth weight gain (OR 1.39, 95% CI 1.30-1.49), while intrapartum factors like forceps-assisted vaginal delivery (OR 7.11, 95% CI 2.60-19.45), midline episiotomy (OR 13.11, 95% CI 1.71-100.89), second-degree perineal tear (OR 6.51, 95% CI 1.16-36.68), and third to fourth-degree perineal tear were independent risk factors for postpartum AI. Significantly, infant weighing over 3,400 g at birth increased the risk of AI postpartum. Based on logistic regression model, we constructed a nomogram to estimate the risk of AI 1 year after vaginal delivery.

Conclusion

Our findings indicated that during the first year following vaginal delivery, infant with birth weight of 3,400 g or more, forceps-assisted vaginal delivery, midline episiotomy, and second to fourth-degree perineal tear increased the risk of AI. As a result, it is essential to limit the routine use of forceps and midline episiotomy and to monitor fetal weight during prenatal care.

Short and long term results of anatomical reconstruction of perineal body and sphincter complex in obstetric anal sphincter injuries

OBJECTIVES

The effective way to reduce the risk of fecal incontinence (FI) in primary repaired obstetric anal sphincter injuries (OASIS) patients is to accurately detect the injury and provide complete anatomical reconstruction. The aim of the study was to evaluate the short-term and long-term results of OASIS cases that were diagnosed by an experienced surgical team and whose perineal body and anal sphincters were reconstructed separately.

MATERIAL AND METHODS

Sixteen patients that required consultations due to anal sphincter damage during vaginal delivery and underwent anatomical reconstruction due to Grade 3c and Grade 4 sphincter damage between 2007 and 2019 were included in the study. These cases were divided into three groups [Group 1 (≤12 months), Group 2 (12-60 months), Group 3 (≥60 months)] according to the time elapsed until anal manometry, and incontinence questionnaires were conducted in the postoperative period. Recto-anal inhibitory reflex (RAIR), mean resting (IB) and squeezing (SB) pressures were measured by anal manometry. Anal incontinence (AI) and FI rates were determined by questionnaires. Anal sphincter damage repair techniques (overlapping, end-to-end) were determined. These parameters were compared between the three groups.

RESULTS

Mean age of the patients was 27.5 (16-35) years. Six (37.5%) patients had Grade 3c, while 10 (62.5%) had Grade 4 injury. The overall mean RP and SP were 35 (26-56) mmHg and 67 (31-100) mmHg, respectively. Mean RP and SP were 46/67 mmHg, 33.5/75.5 mmHg, and 37.5/70.5 mmHg in Groups 1, 2, and 3 respectively. There was no difference between the three groups in terms of mean RP and SP (p= 0.691, p= 0.673). The rate of AI and FI in all patients were 18.75% and 12.5%, respectively while the rate of severe AI incontinence was 6%. Severe AI was observed in 1 (16.7%) case in Group 1, mild AI was observed in 1 (25%) case in group 2, and in 1 (16.7%) case in Group 3. RAIR was positive in all patients. In Group 1, 5 (83.3%) patients underwent overlapping repair, and in Group 3, 6 (100%) patients underwent end-to-end repair. This difference was statistically significant (p= 0.011).

CONCLUSION

In vaginal births, evaluation of anal sphincter damage, determination of perineal body structures and anal sphincters separately and performing anatomical reconstruction when needed significantly reduce the rate of FI in the short and long term.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

OBJECTIVES

Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI.

METHODS

In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter.

RESULTS

In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001).

CONCLUSIONS

Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

REAL CLINICAL PRACTICE OF POSTPARTUM ANAL INCONTINENCE TREATMENT IN RUSSI

Aim: To evaluate the medical care quality provided to patients with fecal incontinence in practice; to investigate the patient care effectiveness; to identify the problems the patient and the doctor are faced during the postpartum anal incontinence (AI) treatment.

Methods: A questionnaire for surgeons was created using Google forms. It includes 22 questions about medical characteristics of patients with AI, used diagnostic methods, and treatment results. The answers were analyzed and presented as histograms.

Results: Totally 134 (17.4%) questionnaires were completed from September to November 2020. Labor was the most common AI cause (74.4%). The median age was 20-40 years, 37% of patients was >40 years, 8% – >60 years. The most common complaints were incontinence (70%) and decreased life quality (72%). Rectovaginal fistulas were diagnosed in 28% of cases. The sphincter complex lesion size, age and anorectal manometry results determined the treatment strategy. Only 8.8% of surgeons suggested sacral neurostimulation in case of the other methods inefficiency. Up to 16.7% of patients were offered to create stoma as the final treatment method.

Discussion: Our study is the first major survey for proctologists and surgeons in Russia, assessing the medical care of patients with postpartum AI. The results indicate insufficient attention to this problem; it requires educational and organizational solutions. Regional or federal centers where obstetrician and surgeons can work cooperatively could be extremely helpful to provide appropriate medical care to these patients and to improve the treatment quality for women with postpartum AI.

[Surgical reconstruction of traumatic sphincter muscle defects]

BACKGROUND

Traumatic anal sphincter muscle defects often occur after childbirth and surgery and can lead to fecal incontinence that requires further treatment.

OBJECTIVE

The aim of this article is to illustrate the etiology of traumatic sphincter muscle defects, the treatment options of subsequent fecal incontinence and their evaluation on the basis of current studies.

MATERIAL AND METHODS

Selected studies are presented.

RESULTS

Fecal incontinence presenting with a traumatic sphincter muscle defect is often due to multiple factors especially in the aged and makes the use of extended diagnostic tools necessary; however, the subjective complaints do not always correlate with morphological or functional diagnostic findings. Besides reconstructive procedures, such as sphincteroplasty and graciloplasty, sphincter augmentation techniques and sacral nerve stimulation can also be applied in traumatic sphincter muscle defects that are often associated with a loss of efficacy in the long term or a high rate of adverse events.

CONCLUSION

The fecal incontinence associated with traumatic sphincter insufficiency represents a diagnostic and therapeutic challenge due to the multifactorial origin. It is not uncommon that patients have to undergo several surgical and conservative interventions.

Obstetric perineal ruptures-risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study

BACKGROUND

Anal incontinence leads to impairment of the quality of life and lower self-esteem with implications for social, physical, and sexual health; anal incontinence after vaginal delivery is a major concern for many women. Only about half of the cases of postpartum anal incontinence can be related to anal sphincter injuries, and the remaining cases must thus be related to other factors.

OBJECTIVE

The aim of this study was to examine the association between maternal and obstetric characteristics, including the degree of perineal rupture and anal incontinence 12 months postpartum. Furthermore, the aim was to investigate the association between anal sphincter muscle defects, perineal length, and perineal strength and the risk of anal incontinence.

MATERIALS AND METHODS

We conducted a prospective cohort study at 4 Danish hospitals: Odense University Hospital, Aarhus University Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data were obtained 2 weeks postpartum in relation to an evaluation of perineal wound healing. Symptoms of anal incontinence were evaluated 12 months postpartum by a Web-based questionnaire (St. Mark's incontinence score questionnaire). In addition, defects in the anal sphincter muscles were examined using endoanal ultrasound, perineal length was measured, and perineal strength was examined using anal manometry. The main outcome measurement was anal incontinence defined as a St. Mark's score of >4. We performed multivariate analyses to investigate the risk factors for anal incontinence and to investigate the risk of anal incontinence according to endoanal ultrasound scanning and anal manometry findings.

RESULTS

A total of 603 primiparous women (203 with no/labia/first-degree ruptures, 200 with second-degree ruptures, and 200 with third-/fourth-degree ruptures) were included between July 2015 and January 2018. At 12 months postpartum, 575 women (95%) answered the questionnaire; 193 with no/labia/first-degree ruptures, 193 with second-degree ruptures, and 189 with third-/fourth-degree ruptures. A total of 499 women underwent an endoanal ultrasound scanning and 482 women underwent anal manometry. Anal incontinence with a St. Mark's score of >4 was reported by 7% and 9% of women with no/labia/first-degree ruptures or second-degree ruptures, respectively, and by 14%, 15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4, respectively. Compared to women with no or minor tears, women with anal sphincter ruptures had a higher risk of anal incontinence (adjusted relative risk, 2.46; 95% confidence interval, 1.28-4.71). Ruptures of degree 3c and 4 were associated with a substantial increase in risk of anal incontinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98-11.3; and adjusted relative risk, 2.23; 95% confidence interval, 1.59-11.3, respectively), especially if a defect in the external or internal anal sphincter muscle was present (adjusted relative risk, 4.74; 95% confidence interval, 1.54-14.5; and adjusted relative risk, 6.58; 95% confidence interval, 3.35-12.9, respectively). The risk of anal incontinence increased by 8% per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95% confidence interval, 1.03-1.14).

CONCLUSION

Obesity with body mass index of >29.9 and a high-degree rupture (3c or 4), especially with a persistent defect in the internal or external anal sphincter muscle, increased the risk of anal incontinence.