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Worrall AP, O'Leary BD, Salameh F. Obstetric anal sphincter injury (OASI) in the presence of an intact perineum. BMJ Case Rep 2023; 16:e253922. [PMID: 37848273 PMCID: PMC10583107 DOI: 10.1136/bcr-2022-253922] [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] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
Obstetric anal sphincter injury (OASI) in the absence of concurrent injury to the perineal skin is not a common diagnosis. A primiparous woman delivered a healthy male infant by spontaneous vertex delivery. At time of delivery, a compound presentation of the fetal hand with the head was noted. Initial examination revealed a presumed second-degree tear; however, a small laceration above the anal verge was noted, which on exploration revealed a perineal injury through the anal sphincter complex. In the operating theatre, the perineal skin was incised to reveal a 3c OASI, which was repaired appropriately. While atypical OASI has been reported previously, this specific injury has never been described in detail in the literature. Awareness of atypical perineal injuries is needed and while careful perineal examination is required in all cases, this is especially important where the perineal skin appears intact to ensure appropriate diagnosis of any concurrent OASI.
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Affiliation(s)
- Amy P Worrall
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Bobby D O'Leary
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Fadi Salameh
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Zhang M, Wu J, Lin X, Mu L, Ma G, Zhang Z, Shi J, He S, Ma Y, Shang N, Wang H, Ran S, Wang X, Tian J, Qu E, Zhang X. Quality assessment of transperineal ultrasound in Chinese tertiary medical centers: a multicenter study. Quant Imaging Med Surg 2023; 13:6952-6964. [PMID: 37869356 PMCID: PMC10585525 DOI: 10.21037/qims-23-176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/14/2023] [Indexed: 10/24/2023]
Abstract
Background Transperineal ultrasound (TPUS) is a vital examination method for diagnosing pelvic floor diseases. However, the quality of TPUS largely relies on the operator's experience, and there is a lack of studies on the evaluation of TPUS quality. Therefore, the objective of this study was to assess the quality of TPUS examinations in Chinese tertiary medical centers. Methods This multicenter study conducted in 44 Chinese tertiary medical centers recruited postpartum women between September 2020 and September 2021. All participants underwent a standardized inquiry and TPUS examination. The participating centers were required to submit 5 parts of ultrasound data to the National Ultrasound Quality Control Center: 2-dimensional images at rest, 2-dimensional images at strain; 4-dimensional images of the levator ani hiatus; 4-dimensional images of the levator ani muscle; and 4-dimensional images of the anal sphincter. Quality assessment was performed by 2 experts with more than 5 years of experience in TPUS, and the reasons for nonqualification were stated. Results In this study, 31 hospitals that were distributed across 20 provinces in China were included, submitting 2,251 cases in total. The overall qualified rate ranged from 12.00% to 86.92%. In each part, the qualified rate of 2-dimensional images at rest, 2-dimensional images at straining, levator ani hiatus, levator ani muscle, and anal sphincter was 94.27% (2,122/2,251), 78.54% (1,768/2,251), 85.52% (1,925/2,251), 93.03% (2,094/2,251), and 88.09% (1,983/2,251), respectively. Most of the nonqualified images belonged to 2-dimensional images at strain, and the errors in image acquisition (221/483, 45.76%) and measurement (262/483, 54.24%) were the main reasons for nonqualification. For levator ani hiatus images, error in image acquisition (275/326, 84.36%) was the main reason for nonqualification. Reconstruction error was the most common reason for nonqualification for levator ani muscle (133/157, 84.71%) and anal sphincter images (133/268, 49.63%). Conclusions This multicenter study assessed the quality of TPUS in tertiary medical centers in China and identified the common reasons for nonqualification in each part. These findings can aid in forming the basis for quality control management and training for TPUS.
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Affiliation(s)
- Man Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiawei Wu
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xin Lin
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liang Mu
- Department of Ultrasound, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Guifeng Ma
- Department of Ultrasound, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Zhikun Zhang
- Department of Ultrasound, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Jing Shi
- Department of Ultrasound, Guiyang Maternal and Child Health Care Hospital, Guiyang, China
| | - Shaozheng He
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yanan Ma
- Department of Ultrasound, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Ning Shang
- Department of Ultrasound, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hongyan Wang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Suzhen Ran
- Department of Ultrasound, Women and Children’s Hospital of Chongqing Medical University, Chongqing Health Center for Women and Children, Chongqing, China
| | - Xudong Wang
- Department of Ultrasound, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiawei Tian
- Department of Ultrasound, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Enze Qu
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xinling Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Zhao B, Li Y, Tang Y, Guo Y, Yang Y, Wen L, Dietz HP. Assessing Obstetric Anal Sphincter Injuries: A Comparison of Exoanal and Endoanal Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2031-2038. [PMID: 36916688 DOI: 10.1002/jum.16221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/12/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms. METHODS A group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A "significant sphincter defect" was diagnosed by TPUS and EAUS using "2/3 rules." Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms. RESULTS Of 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty-one (10.7%) "significant defects" were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k = 0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and "significant sphincter defects" seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for "significant defects" on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively. CONCLUSIONS "Significant defects" diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.
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Affiliation(s)
- Baihua Zhao
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yinbo Li
- Department of Drug Evaluation and Adverse Drug Reaction Monitoring, Drug Administration of Hunan Province, Hunan, China
| | | | - Yuyang Guo
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yalin Yang
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lieming Wen
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, Changsha, China
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Lieming W, Baihua Z, Yingchun T, Yuyang G, Xian X. Morphological differences in the female anal sphincter complex between endoanal and exoanal ultrasound. Int Urogynecol J 2023; 34:545-551. [PMID: 36063193 DOI: 10.1007/s00192-022-05341-z] [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: 06/14/2022] [Accepted: 08/07/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This study was aimed at describing the morphological characteristics of the normal female anal sphincter complex (ASC) by high-resolution transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS). METHODS Thirty volunteers, including 19 nulliparous and 11 women who had only given birth by Cesarean section, were recruited. The ASC was shown in a set of five slices by EAUS and 8 slices by TPUS. EAUS slices 1 and 5 matched TPUS slices 1 and 8; EAUS slices 2, 3, and 4 were approximately at the levels of TPUS slices 3, 5, and 7. The anterior and lateral EAS and IAS thicknesses were measured and the two methods were compared. RESULTS The median age was 29 years. The mean body mass index (BMI) was 20.6 kg/m2. All measured values obtained by TPUS were normally distributed. The EAS thickness on EAUS slice 2 and the IAS thickness on EAUS slices 2 and 3 were not normally distributed. The mean anterior EAS thickness was 2.51 mm, 2.96 mm, and 3.53 mm in slices 3, 5, and 7 on TPUS and was significantly thinner than that in slices 2 (2.62 mm), 3 (3.77 mm), and 4 (4.62 mm) on EAUS. In contrast, the IAS was markedly thicker on TPUS. The ratio of sphincter thickness anteriorly to laterally was similar using the two methods. CONCLUSIONS The morphological characteristics of EAS shown by TPUS and EAUS were similar. EAS was thinner, and IAS was thicker on TPUS. The IAS seems to be distorted on endoanal imaging.
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Affiliation(s)
- Wen Lieming
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, 410011, Hunan, China.
| | - Zhao Baihua
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, 410011, Hunan, China
| | | | - Guo Yuyang
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, 410011, Hunan, China
| | - Xiao Xian
- Department of Ultrasound Diagnosis, Second Xiangya Hospital, Central South University, 139 Renmin Road (M), Changsha, 410011, Hunan, China
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O'Leary BD, Kelly L, Fitzpatrick M, Keane DP. Underdiagnosis of internal anal sphincter trauma following vaginal delivery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:251-256. [PMID: 36722430 PMCID: PMC10108077 DOI: 10.1002/uog.26049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic. METHODS This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane. RESULTS In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001). CONCLUSIONS One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B. D. O'Leary
- Perineal ClinicNational Maternity HospitalDublinIreland
- UCD Perinatal Research CentreNational Maternity HospitalDublinIreland
| | - L. Kelly
- Perineal ClinicNational Maternity HospitalDublinIreland
| | | | - D. P. Keane
- UCD Perinatal Research CentreNational Maternity HospitalDublinIreland
- Royal College of Surgeons IrelandNational Maternity HospitalDublinIreland
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Dietz HP, Shek KL. Re: Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:818. [PMID: 36454634 DOI: 10.1002/uog.26103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/07/2022] [Indexed: 05/27/2023]
Affiliation(s)
- H P Dietz
- Sydney Urodynamic Centres, Penrith, NSW, Australia
| | - K L Shek
- Western Sydney University, Liverpool, NSW, Australia
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Okeahialam NA, Thakar R, Sultan AH. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:818-819. [PMID: 36454635 DOI: 10.1002/uog.26104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 05/27/2023]
Affiliation(s)
| | - R Thakar
- Croydon University Hospital, Croydon, UK
- St George's University of London, London, UK
| | - A H Sultan
- Croydon University Hospital, Croydon, UK
- St George's University of London, London, UK
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