Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture

Development and Validation of a Tool to Identify Anal Incontinence in Pregnant and Postnatal Women

BACKGROUND

Neuromuscular and mechanical damage to the pelvic floor because of pregnancy and birth can result in anal incontinence. Pregnant and postnatal women are rarely screened for anal incontinence by clinicians who specialize in the care of these women, and no screening tool has been developed for routine use in these women.

OBJECTIVE

To develop and validate a tool for use in everyday clinical practice in the care of pregnant and postnatal women.

DATA SOURCES

The study includes 2 test phases with separate data sources. Phase I included test and retest phases of the Bowel-Screening Questionnaire in health professionals and women who were pregnant or had recently birthed (n = 45). Phase II included a pilot of the tool compared to 2 current scoring systems (n = 358).

SETTING

Large tertiary hospital in South Australia.

PATIENTS

Phase II: prospective recruitment of 358 prenatal parous women attending a first antenatal appointment.

MAIN OUTCOMES MEASURES

To evaluate the reliability and validity of the developed tool.

RESULTS

Test-retest agreement in phase I was excellent for each of the 6 items, with each κ statistic being between 0.83 and 1.0. In phase II, agreement between new and existing tools was fair to good for the detection of anal incontinence symptoms addressed as a composite question (κ between 0.41 and 0.71). Anal incontinence was detected in 191 women (53%) using the new tool, and there was a lower prevalence reported using the Vaizey score (n = 118) and Wexner score (n = 129). Completion rates of the new tool were 99%, higher than both the Vaizey score (33%) and Wexner score (36%).

LIMITATIONS

Sample size limits the generalization of findings.

CONCLUSION

The questionnaire is reliable and valid, reporting a high incidence of bowel incontinence, with predominant symptoms of rectal urgency and flatus as precursors for worsening function.

DESARROLLO Y VALIDACIN DE UNA HERRAMIENTA PARA IDENTIFICAR LA INCONTINENCIA ANAL EN MUJERES EMBARAZADAS Y PURPERAS

ANTECEDENTES:El daño neuromuscular y mecánico del piso pélvico debido al embarazo y al parto puede resultar en incontinencia anal. Las mujeres embarazadas y puérperas rara vez son examinadas para la incontinencia anal por médicos que se especializan en el cuidado de estas mujeres, y no se ha desarrollado ninguna herramienta de detección para uso rutinario en estas mujeres.OBJETIVO:Desarrollar y validar una herramienta para uso en la práctica clínica diaria en el cuidado de las mujeres embarazadas y puérperas.FUENTES DE DATOS:El estudio incluye 2 fases de prueba con fuentes de datos separadas. Fase 1, fase test y retest del Bowel Screening Questionnaire en profesionales sanitarios y mujeres embarazadas o recién paridas (n = 45). La Fase 2 incluyó una prueba piloto de la herramienta en comparación con dos sistemas de puntuación actuales (n = 358).ENTORNO CLINICO:Gran hospital terciario en el sur de Australia.PACIENTES:Fase 2: reclutamiento prospectivo de 358 mujeres con parto prenatal que asisten a una primera cita prenatal.PRINCIPALES MEDIDAS DE VALORACIÓN:Evaluar la confiabilidad y validez de la herramienta desarrollada.RESULTADOS:La concordancia test-retest en la fase 1 fue excelente para cada uno de los 6 ítems con cada estadística kappa entre 0,83 y 1,0. En la fase 2, el acuerdo entre las herramientas nuevas y las existentes fue regular a bueno para la detección de síntomas de incontinencia anal abordados como una pregunta compuesta (kappa entre 0,41 y 0,71). Se detectó incontinencia anal en 191 (53%) de las mujeres que utilizaban la nueva herramienta, y se notificó una prevalencia más baja utilizando la puntuación de Vaizey (n = 118) y la puntuación de Wexner (n = 129). Las tasas de finalización de la nueva herramienta fueron del 99%, más altas que la puntuación de Vaizey (33%) y las puntuaciones de Wexner (36%).LIMITACIONES:El tamaño de la muestra limita la generalización de los hallazgos.CONCLUSIONES:El cuestionario es confiable y válido reportando una alta incidencia de incontinencia intestinal, con síntomas predominantes de urgencia rectal y flatos como precursores del empeoramiento de la función. (Traducción-Dr. Ingrid Melo ).

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.

Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries

BACKGROUND

The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory.

OBJECTIVE

This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries.

STUDY DESIGN

Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components.

RESULTS

The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204).

CONCLUSION

The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.

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.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up

AIM

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury.

METHOD

This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale.

RESULTS

Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001).

CONCLUSION

At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

Anal incontinence after vaginal delivery or cesarean section

INTRODUCTION

Uncertainties remain as to whether a cesarean section is protective for the short-term and long-term development of anal incontinence. Our aim was to explore whether women who had delivered only vaginally were at greater risk of anal incontinence than nulliparous women and women who had undergone cesarean sections only.

MATERIAL AND METHODS

Background information, medical history, and data on anal incontinence (defined as fecal or flatus incontinence weekly or more) reported by women participating in a large population-based health survey in Norway (the Nord-Trøndelag Health Study 3) during the period October 2006 to June 2008 were collected and linked to data from the Medical Birth Registry of Norway. The prevalence of anal incontinence was calculated and multivariate logistic regression analyses were applied.

RESULTS

The mean age of the 12 567 women was 49.9 years. The age and educational level of women who had cesarean sections only were similar to those who had a vaginal delivery and obstetric anal sphincter injuries (OASIS). Nulliparous women and those who had a vaginal delivery and no OASIS were older and had higher educational achievements than women who had delivered by cesarean section exclusively, and women with OASIS. One in four women with OASIS reported anal incontinence compared with one in six of the other women (P < .001). Age, educational level, diarrhea, constipation, birthweight, and OASIS increased the risk of anal incontinence in all women. Parity was associated with anal incontinence in parous women only. No differences were found for fecal urgency.

CONCLUSIONS

Women with vaginal deliveries complicated by OASIS are at increased risk of anal incontinence. However, no increased risk of anal incontinence was found in nulliparous women or women who had cesarean sections only or vaginal deliveries not complicated by OASIS.