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Sartore A, Scalia MS, Mangino FP, Savastano G, Magni E, Ricci G. Pelvic floor function after third and fourth degree perineal lacerations: a case-control study on quality of life. BMC Womens Health 2024; 24:12. [PMID: 38172805 PMCID: PMC10765914 DOI: 10.1186/s12905-023-02739-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 10/28/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The primary aim of this study was to compare the quality of life between women with obstetric anal sphincter injury (OASI) and women with intact perineum or minor vaginal tears following their first vaginal birth through a validated urogynaecological questionnaire. As a secondary aim, we wanted to identify the specific symptoms for pelvic floor dysfunction after a vaginal birth. METHODS One hundred thirty-three cases (III- and IV-degree vaginal tears) and 133 controls (intact perineum or I- and II-degree vaginal tear) were asked to fill the PFDI-20 condition-specific and quality of life survey at three and 12 months after vaginal delivery. The survey evaluates pelvic floor dysfunction symptoms through three subsections: the Pelvic Organ Prolapse Distress Inventory (POPDI), the Colorectal-Anal Distress Inventory (CRADI), and Urinary Distress Inventory, (UDI). The scoring system ranges from 0 (no distress) to 100 (maximum distress) for each subsection, subsequently summed up to obtain the summary score (0 to 300). The patients recruited were asked to complete the survey at 3- and 12-months follow-up visit. Accordingly, data collection started. Categorical variables were subjected to Chi-square test or Fisher's Exact test. Quantitative variables were compared through Student's t-test or Mann-Whitney test. RESULTS All surveys have shown statistically significant differences when comparing the cases to the control group. Consequently, PFDI-20 has shown a strong correlation between III- and IV-grade lacerations and pelvic floor dysfunction persistence at 12 months after delivery. Intestinal symptoms were the most reported disturbances among women with previous OASI. CONCLUSIONS Major vaginal tears have demonstrated to have a strong impact on women's quality of life up to a follow-up of 12 months. The use of PFDI-20 questionnaire is a useful and valid tool in the diagnosis and follow-up of genital prolapse, fecal and urinary incontinence in primiparous women with a history of OASI. Thus, its application in clinical practice can help offering the most adequate rehabilitative treatment.
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Affiliation(s)
- Andrea Sartore
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137, Trieste, Italy
| | - Maria Sole Scalia
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137, Trieste, Italy.
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127, Trieste, Italy.
| | | | - Giulia Savastano
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127, Trieste, Italy
| | - Elena Magni
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Giuseppe Ricci
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127, Trieste, Italy
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Frigerio M, D'Alessandro G, Re I, Cola A, Vergani P, Barba M. Clinical, ultrasonographic, and functional outcomes after obstetric anal sphincter injury primary repair: A single-center experience. Int J Gynaecol Obstet 2023; 163:234-242. [PMID: 37128949 DOI: 10.1002/ijgo.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/14/2022] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To present clinical and instrumental sequelae after obstetric anal sphincter injuries (OASIS), evaluating correlations between intrapartum severity of lesions, postpartum symptoms, and sonographic and manometric findings; outcomes during subsequent deliveries were also evaluated. METHODS This retrospective study evaluated all consecutive women who sustained an OASIS between 2015 and 2020. Postpartum symptoms, anorectal manometry (ARM), and three-dimensional endoanal ultrasonography (3D-EAUS) were analyzed. RESULTS A total of 107 women underwent OASIS primary repair; 84 (78.5%) of them were asymptomatic after 1 month. The presence and severity of symptoms showed a great correlation with instrumental outcomes in terms of maximum resting pressure, squeeze pressure increment (SPI), circumferential extension of defect for both external anal sphincter (EAS) and internal anal sphincter (IAS), and EAS, IAS and total Starck scores. There was a significant correlation between ARM and 3D-EAUS findings, with the exception of SPI, for which the abnormalities were not predictable based on EAUS results. CONCLUSION Both ARM and EAUS findings after OASIS are directly related to each other, and associated with symptoms. These instrumental tools may be useful for OASIS assessment and counseling.
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Affiliation(s)
| | | | - Ilaria Re
- University of Milano-Bicocca, Monza, Italy
| | - Alice Cola
- ASST Monza, Ospedale San Gerardo, Monza, Italy
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Kropshofer S, Aigmüller T, Beilecke K, Frudinger A, Krögler-Halpern K, Hanzal E, Helmer H, Hölbfer S, Huemer H, Van MK, Kronberger I, Kuhn A, Pfeifer J, Reisenauer C, Tamussino K, Umek W, Kölle D, Abou-Dakn M, Gabriel B, Schwandner O, Pristauz-Telsnigg G, Welskop P, Bader W. Management of Third and Fourth-Degree Perineal Tears After Vaginal Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/079, December
2020). Geburtshilfe Frauenheilkd 2022; 83:165-183. [PMID: 37151735 PMCID: PMC10155200 DOI: 10.1055/a-1933-2647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
Purpose This guideline provides recommendations for the diagnosis, treatment and follow-up care of 3rd and 4th degree perineal tears which occur during vaginal birth. The aim is to
improve the management of 3rd and 4th degree perineal tears and reduce the immediate and long-term damage. The guideline is intended for midwives, obstetricians and physicians involved in
caring for high-grade perineal tears.
Methods A selective search of the literature was carried out. Consensus about the recommendations and statements was achieved as part of a structured process during a consensus
conference with neutral moderation.
Recommendations After every vaginal birth, a careful inspection and/or palpation by the obstetrician and/or the midwife must be carried out to exclude a 3rd or 4th degree perineal
tear. Vaginal and anorectal palpation is essential to assess the extent of birth trauma. The surgical team must also include a specialist physician with the appropriate expertise (preferably
an obstetrician or a gynecologist or a specialist for coloproctology) who must be on call. In exceptional cases, treatment may also be delayed for up to 12 hours postpartum to ensure that a
specialist is available to treat the individual layers affected by trauma. As neither the end-to-end technique nor the overlapping technique have been found to offer better results for the
management of tears of the external anal sphincter, the surgeon must use the method with which he/she is most familiar. Creation of a bowel stoma during primary management of a perineal tear
is not indicated. Daily cleaning of the area under running water is recommended, particularly after bowel movements. Cleaning may be carried out either by rinsing or alternate cold and warm
water douches. Therapy should also include the postoperative use of laxatives over a period of at least 2 weeks. The patient must be informed about the impact of the injury on subsequent
births as well as the possibility of anal incontinence.
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Affiliation(s)
- Stephan Kropshofer
- Frauenheilkunde und Geburtshilfe, Tirol Kliniken GmbH, Innsbruck, Austria
| | | | - Kathrin Beilecke
- Klinik für Urogynäkologie, Alexianer Sankt Hedwig Kliniken Berlin GmbH, Berlin, Germany
| | - Andrea Frudinger
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | | | - Engelbert Hanzal
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Hanns Helmer
- Department of Obstetrics and Maternal-fetal Medicine, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Annette Kuhn
- Urogynaecology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Johann Pfeifer
- Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Karl Tamussino
- Department of Gynecology, Medical University of Graz, Graz, Austria
| | - Wolfgang Umek
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Dieter Kölle
- Abteilung Gynäkologie, Sanatorium Hera, Vienna, Austria
| | - Michael Abou-Dakn
- Klinik für Gynäkologie, St Joseph Krankenhaus Berlin-Tempelhof, Berlin, Germany
| | - Boris Gabriel
- Klinik für Gynäkologie und Geburtshilfe, Josefs Hospital Wiesbaden, Wiesbaden, Germany
| | | | - Gunda Pristauz-Telsnigg
- Abteilung Frauenheilkunde und Geburtshilfe, Landeskrankenhaus Feldbach Fürstenfeld, Feldbach, Austria
| | - Petra Welskop
- Österreichisches Hebammengremium, Innsbruck, Austria
| | - Werner Bader
- Gynäkologie und Geburtshilfe, Klinikum Bielefeld, Bielefeld, Germany
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Evidence-based labor management: third stage of labor (part 5). Am J Obstet Gynecol MFM 2022; 4:100661. [PMID: 35537683 DOI: 10.1016/j.ajogmf.2022.100661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022]
Abstract
During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) immediately after delivery of the neonate are recommended. Single-dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations with continuous synthetic suture technique is recommended. No repair of first-degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third-degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth-degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single-dose second-generation cephalosporin at the time of third- or fourth-degree laceration repairs can be considered. Skin-to-skin contact after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.
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Meyer I, Richter HE. Accidental Bowel Leakage/Fecal Incontinence: Evidence-Based Management. Obstet Gynecol Clin North Am 2021; 48:467-485. [PMID: 34416932 DOI: 10.1016/j.ogc.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA.
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
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Doumouchtsis SK, Loganathan J, Fahmy J, Falconi G, Rada M, Elfituri A, Haddad JM, Pergialiotis V, Betschart C. Patient-reported outcomes and outcome measures in childbirth perineal trauma research: a systematic review. Int Urogynecol J 2021; 32:1695-1706. [PMID: 34143238 DOI: 10.1007/s00192-021-04820-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/18/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION AND HYPOTHESIS In evaluating the effectiveness of interventions in perineal trauma research, outcomes reported by patients should have a prominent focus. There is no international consensus regarding the use of either patient-reported outcomes (PROs) or tools used to determine these outcomes (patient-reported outcome measures, PROMs). The objective was to evaluate the selection, reporting and geographical variations of PROs and PROMs in randomised controlled trials (RCTs) on perineal trauma. METHODS We performed a systematic review of RCTs in perineal trauma research evaluating outcome and outcome measure reporting. We identified PROs and PROMs and grouped PROs into domains and themes, a classification system based on a medical outcome taxonomy. RESULTS Of 48 included RCTs, 47 reported PROs. In total, we identified 51 PROs. Outcome reporting consistency was low, with 27 PROs reported only once. Nine PROs were reported more than five times, the most frequent being perineal pain, with no geographical variation in reporting. Four themes encompassing 12 domains were identified. The most frequently reported theme was "Clinical", with 25 PROs grouped within four domains. "Resource use" and "Adverse events" themes were rarely reported, with only five PROs. PROMs also exhibited variation. Most common were visual analogue scale (VAS; 100 mm), Cleveland Clinic Continence Score, The Faecal Incontinence Quality of Life scale, VAS (0-10) and the McGill Pain Questionnaire. CONCLUSIONS Significant heterogeneity in PROs and PROMs was observed among RCTs. Despite inconsistency, PROs are the most prevalent outcome in perineal trauma research. Patient-reported adverse events are underreported. Their use in determining the effectiveness and safety of interventions makes their integration important in perineal trauma core outcome sets. Identification and grouping of outcomes will assist future core outcome consensus studies.
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Affiliation(s)
- Stergios K Doumouchtsis
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, Dorking Road, London, UK.,St George's University of London, London, UK.,Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens, Medical School, Athens, Greece.,School of Medicine, American University of the Caribbean, Cupecoy, Sint Maarten.,School of Medicine, Ross University, Miramar, Florida, United States
| | - Jemina Loganathan
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, Dorking Road, London, UK.
| | - John Fahmy
- St George's University of London, London, UK
| | - Gabriele Falconi
- Department of Obstetrics and Gynaecology, San Bortolo Hospital, Vicenza, Italy
| | - Maria Rada
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hatieganu", University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Abdullatif Elfituri
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, Dorking Road, London, UK
| | - Jorge Milhem Haddad
- Department of Obstetrics and Gynecology, School of Medicine, University of São Paulo, Butanta, Brazil
| | - Vasilios Pergialiotis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, Athens University Medical School, Athens, Greece
| | - Cornelia Betschart
- Department of Gynecology, University Hospital of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
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7
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Gehrich AP, McClellan E, Gillern S. Surgical repair of an obstetric cloaca with review of the literature. BMJ Case Rep 2021; 14:14/1/e234321. [PMID: 33500293 PMCID: PMC7839897 DOI: 10.1136/bcr-2020-234321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.
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Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:303-312. [PMID: 32653603 DOI: 10.1016/j.ejogrb.2020.06.048] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. METHODS We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. RESULTS We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I2 = 95 %). Following primary repair of OASIS, 55 % (46-63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I2 = 98 %). INTERPRETATION Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.
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Affiliation(s)
- Michail Sideris
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.
| | - Tristan McCaughey
- Department of Surgery, School of Clinical Science at Monash Health, Monash University, 3800, VIC, Australia
| | | | - David Arroyo-Manzano
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Javier Zamora
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Swati Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Charles H Knowles
- National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Charlotte Chaliha
- Department of Obstetrics and Gynaecology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Multidisciplinary Evidence Synthesis Hub (MEsH), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
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Marty N, Verspyck E. Déchirures périnéales obstétricales et épisiotomie : aspects techniques. RPC prévention et protection périnéale en obstétrique CNGOF. ACTA ACUST UNITED AC 2018; 46:948-967. [DOI: 10.1016/j.gofs.2018.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 10/27/2022]
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Pergialiotis V, Durnea C, Elfituri A, Duffy J, Doumouchtsis SK. Do we need a core outcome set for childbirth perineal trauma research? A systematic review of outcome reporting in randomised trials evaluating the management of childbirth trauma. BJOG 2018; 125:1522-1531. [PMID: 30009461 DOI: 10.1111/1471-0528.15408] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Selecting appropriate outcomes to reflect both beneficial and harmful effects is a critical step in designing childbirth trauma trials. OBJECTIVE To evaluate the outcomes and outcome measures reported in randomised controlled trials evaluating interventions for childbirth trauma. SEARCH STRATEGY Randomised trials were identified by searching bibliographical databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. SELECTION CRITERIA Randomised trials evaluating the efficacy and safety of different techniques in the management of perineal lacerations. DATA COLLECTION AND ANALYSIS Two researchers independently assessed studies for inclusion, evaluated methodological quality, and extracted the relevant data. Spearman's ρ correlation and multivariate linear regression analysis using the backward stepwise model were used for analysis. MAIN RESULTS Forty-eight randomised trials, reporting data from 20 308 women, were included. Seventeen different interventions were evaluated. Included trials reported 77 different outcomes and 50 different outcome measures. Commonly reported outcomes included pain (34 trials; 70%), wound healing (20 trials; 42%), and anorectal dysfunction (16 trials, 33%). In the multivariate analysis, no relationship was demonstrated between the quality of outcome reporting and year of publication (P = 0.31), journal impact factor (P = 0.49), and methodological quality (P = 0.13). CONCLUSION Outcome reporting in childbirth trauma research is heterogeneous. Developing, disseminating, and implementing a core outcome set in future childbirth trauma research could help address these issues. TWEETABLE ABSTRACT Developing @coreoutcomes for childbirth trauma research could help to reduce #research waste.
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Affiliation(s)
- V Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research NS Christeas, Athens University Medical School, Athens, Greece
| | - C Durnea
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK.,St George's University of London, London, UK
| | - A Elfituri
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK.,St George's University of London, London, UK
| | - Jmn Duffy
- Balliol College, University of Oxford, Oxford, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - S K Doumouchtsis
- Laboratory of Experimental Surgery and Surgical Research NS Christeas, Athens University Medical School, Athens, Greece.,Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, London, UK.,St George's University of London, London, UK
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11
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Epidemiology, Pathophysiology and Management of Fecal Incontinence in the Older Woman. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0201-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Muhleman MA, Aly I, Walters A, Topale N, Tubbs RS, Loukas M. To cut or not to cut, that is the question: A review of the anatomy, the technique, risks, and benefits of an episiotomy. Clin Anat 2017; 30:362-372. [PMID: 28195378 DOI: 10.1002/ca.22836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/03/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Mitchel Alan Muhleman
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Islam Aly
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Andrew Walters
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Nitsa Topale
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | | | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
- Department of Anatomy, Faculty of Medicine; University of Warmia and Mazury in Olsztyn; Poland
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13
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Leeman L, Rogers R, Borders N, Teaf D, Qualls C. The Effect of Perineal Lacerations on Pelvic Floor Function and Anatomy at 6 Months Postpartum in a Prospective Cohort of Nulliparous Women. Birth 2016; 43:293-302. [PMID: 27797099 PMCID: PMC5125543 DOI: 10.1111/birt.12258] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine the effect of perineal lacerations on pelvic floor outcomes, including urinary and anal incontinence, sexual function, and perineal pain in a nulliparous cohort with low incidence of episiotomy. METHODS Nulliparous women were prospectively recruited from a midwifery practice. Pelvic floor symptoms were assessed with validated questionnaires, physical examination, and objective measures in pregnancy and 6 months postpartum. Two trauma groups were compared, those with an intact perineum or only 1st degree lacerations and those with second-, third-, or fourth-degree lacerations. RESULTS Four hundred and forty-eight women had vaginal deliveries. One hundred and fifty-one sustained second-degree or deeper perineal trauma and 297 had an intact perineum or minor trauma. Three hundred and thirty-six (74.8%) presented for 6-month follow-up. Perineal trauma was not associated with urinary or fecal incontinence, decreased sexual activity, perineal pain, or pelvic organ prolapse. Women with trauma had similar rates of sexual activity; however, they had slightly lower sexual function scores (27.3 vs 29.1). Objective measures of pelvic floor strength, rectal tone, urinary incontinence, and perineal anatomy were equivalent. The subgroup of women with deeper (> 2 centimeter) perineal trauma demonstrated increased likelihood of perineal pain (15.5% vs 6.2%) and weaker pelvic floor muscle strength (61.0% vs 44.3%) compared with women with more superficial trauma. CONCLUSION Women having second-degree lacerations are not at increased risk for pelvic floor dysfunction other than increased pain, and slightly lower sexual function scores at 6 months postpartum.
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Affiliation(s)
- Lawrence Leeman
- Departments of Family and Community Medicine, and Obstetrics and Gynecology at the University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Rebecca Rogers
- Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine, Albuquerque, NM, USA
| | | | - Dusty Teaf
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Clifford Qualls
- Clinical and Translational Research Center, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Abstract
Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA.
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, USA
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Benezech A, Bouvier M, Vitton V. Faecal incontinence: Current knowledges and perspectives. World J Gastrointest Pathophysiol 2016; 7:59-71. [PMID: 26909229 PMCID: PMC4753190 DOI: 10.4291/wjgp.v7.i1.59] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/31/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Faecal incontinence (FI) is a disabling and frequent symptom since its prevalence can vary between 5% and 15% of the general population. It has a particular negative impact on quality of life. Many tools are currently available for the treatment of FI, from conservative measures to invasive surgical treatments. The conservative treatment may be dietetic measures, various pharmacological agents, anorectal rehabilitation, posterior tibial nerve stimulation, and transanal irrigation. If needed, patients may have miniinvasive approaches such as sacral nerve modulation or antegrade irrigation. In some cases, a surgical treatment is proposed, mainly external anal sphincter repair. Although these different therapeutic options are available, new techniques are arriving allowing new hopes for the patients. Moreover, most of them are non-invasive such as local application of an α1-adrenoceptor agonist, stem cell injections, rectal injection of botulinum toxin, acupuncture. New more invasive techniques with promising results are also coming such as anal magnetic sphincter and antropylorus transposition. This review reports the main current available treatments of FI and the developing therapeutics tools.
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Pucciani F, Altomare DF, Dodi G, Falletto E, Frasson A, Giani I, Martellucci J, Naldini G, Piloni V, Sciaudone G, Bove A, Bocchini R, Bellini M, Alduini P, Battaglia E, Galeazzi F, Rossitti P, Usai Satta P. Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists. Dig Liver Dis 2015; 47:628-45. [PMID: 25937624 DOI: 10.1016/j.dld.2015.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 03/08/2015] [Accepted: 03/28/2015] [Indexed: 02/06/2023]
Abstract
Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.
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Affiliation(s)
| | - Filippo Pucciani
- Department of Surgery and Translational Medicine, University of Florence, Italy.
| | | | - Giuseppe Dodi
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Ezio Falletto
- I Division of Surgical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Italy
| | - Alvise Frasson
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Iacopo Giani
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | - Jacopo Martellucci
- General, Emergency and Minimally Invasive Surgery, Careggi University Hospital, Florence, Italy
| | - Gabriele Naldini
- Proctological and Perineal Surgical Unit, University Hospital of Pisa, Italy
| | | | - Guido Sciaudone
- General and Geriatric Surgery Unit, School of Medicine, Second University of Naples, Italy
| | | | - Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology - AORN "A. Cardarelli", Naples, Italy
| | - Renato Bocchini
- Gastrointestinal Physiopathology, Gastroenterology Department, Malatesta Novello Private Hospital, Cesena, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Gastroenterology, University of Pisa, Italy
| | - Pietro Alduini
- Digestive Endoscopy Unit, San Luca Hospital, Lucca, Italy
| | - Edda Battaglia
- Gastroenterology and Endoscopy Unit, Cardinal Massaia Hospital, Asti, Italy
| | | | - Piera Rossitti
- Gastroenterology Unit, S.M. della Misericordia University Hospital, Udine, Italy
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Meyer I, Richter HE. Evolving Surgical Treatment Approaches for Fecal Incontinence in Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0116-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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19
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Rodríguez R, Alós R, Carceller MS, Solana A, Frangi A, Ruiz MD, Lozoya R. Incontinencia fecal posparto. Revisión de conjunto. Cir Esp 2015; 93:359-67. [DOI: 10.1016/j.ciresp.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 09/05/2014] [Accepted: 10/05/2014] [Indexed: 12/01/2022]
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20
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Aigmueller T, Bader W, Beilecke K, Elenskaia K, Frudinger A, Hanzal E, Helmer H, Huemer H, van der Kleyn M, Koelle D, Kropshofer S, Pfeiffer J, Reisenauer C, Tammaa A, Tamussino K, Umek W. Management of 3rd and 4th Degree Perineal Tears after Vaginal Birth. German Guideline of the German Society of Gynecology and Obstetrics (AWMF Registry No. 015/079, October 2014). Geburtshilfe Frauenheilkd 2015; 75:137-144. [PMID: 26157195 PMCID: PMC4477621 DOI: 10.1055/s-0034-1396323] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- T. Aigmueller
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | | | - K. Beilecke
- Klinik St. Hedwig, KH Barmherzige Brüder, Regensburg
| | | | - A. Frudinger
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | - E. Hanzal
- Medizinische Universität Wien, Wien, Österreich
| | - H. Helmer
- Medizinische Universität Wien, Wien, Österreich
| | - H. Huemer
- Klinikum Wels-Grieskirchen, Österreich
| | | | | | - S. Kropshofer
- Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - J. Pfeiffer
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | | | - A. Tammaa
- Wilhelminenspital Wien, Wien, Österreich
| | - K. Tamussino
- Universitätsklinik für Frauenheilkunde und Geburtshilfe Graz, Österreich
| | - W. Umek
- Medizinische Universität Wien, Wien, Österreich
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21
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Abstract
Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.
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Affiliation(s)
- Kathleen Chin
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, UT Southwestern School of Medicine, Dallas, Texas
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22
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Abstract
Anal incontinence (AI) can be a debilitating condition for women following vaginal delivery. Operative vaginal delivery and anal sphincter laceration are important risk factors for the development of postpartum AI. Obtaining a comprehensive delivery history, along with a thorough physical examination of the perineum, vagina and rectum may aid the clinician in the diagnosis of an anal sphincter defect. Sonographic imaging can also assist in identifying sphincter defects. The treatment of AI may include a combination of dietary modification, medications that promote constipation, pelvic floor physical therapy, biofeedback, anal sphincteroplasty, and/or sacral neuromodulation.
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Affiliation(s)
- Kathleen Chin
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, UT Southwestern School of Medicine, Dallas, Texas
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23
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Best C, Drutz HP, Alarab M. Obstetric anal sphincter injuries: a survey of clinical practice among Canadian obstetricians. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 34:747-754. [PMID: 22947406 DOI: 10.1016/s1701-2163(16)35338-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the current practice, experience, and confidence of Canadian obstetricians in the management of obstetric anal sphincter injuries (OASIS) and to explore the need for national practice guidelines on this topic. METHODS We conducted a cross-sectional, Internet-based survey between December 2010 and March 2011. The survey was initially tested among a sample population and then distributed electronically to 665 Canadian obstetricians. Data were analyzed descriptively. The main outcome measures were the self-reported confidence and experience of Canadian obstetricians in OASIS management and the frequency of performing specific OASIS management steps. RESULTS The survey response rate was 28.7%. The majority of the respondents (95%) reported confidence in performing OASIS repairs. In the event of a perineal laceration, 47.9% of respondents routinely performed a rectal examination. Most OASIS repairs were performed in the delivery room (89.4%) under local anaesthesia (60.6%) when regional anaesthesia was not already present. If lacerated, the internal anal sphincter was repaired separately by 63.4% of respondents, and intraoperative antibiotics were ordered by 51.1% of respondents. Most (92%) reported the absence of a local protocol to guide OASIS repair. CONCLUSION The confidence of Canadian obstetricians who participated in this survey in performing OASIS repairs was high. However, their experience in performing repairs and their use of management steps varied. The need for national guidelines and an increase in awareness is suggested.
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Affiliation(s)
- Carolyn Best
- Division of Urogynaecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
| | - Harold P Drutz
- Division of Urogynaecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
| | - May Alarab
- Division of Urogynaecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
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Meyer I, Richter HE. An Evidence-Based Approach to the Evaluation, Diagnostic Assessment and Treatment of Fecal Incontinence in Women. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2014; 3:155-164. [PMID: 25505643 PMCID: PMC4258837 DOI: 10.1007/s13669-014-0085-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Fecal incontinence (FI) is a debilitating disorder which negatively impacts quality of life. The etiology is often multifactorial and although most women with FI are able to be treated, many remain untreated because a significant proportion of women do not report their symptoms and seek care. The evaluation and treatment of FI can be also hindered by a lack of understanding of the mechanisms and current options. This article provides a review on the evidence-based evaluation and management for FI.
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Affiliation(s)
- Isuzu Meyer
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, ,
| | - Holly E Richter
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, 1700 6th Avenue South, Suite 10382, Birmingham, AL 35233, ,
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25
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Vitton V, Soudan D, Siproudhis L, Abramowitz L, Bouvier M, Faucheron JL, Leroi AM, Meurette G, Pigot F, Damon H. Treatments of faecal incontinence: recommendations from the French national society of coloproctology. Colorectal Dis 2014; 16:159-66. [PMID: 24521273 DOI: 10.1111/codi.12410] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 06/09/2013] [Indexed: 12/13/2022]
Abstract
Faecal incontinence is common and significantly affects quality of life. Its treatment involves dietary manipulation, medical treatments, perineal rehabilitation or surgery. In this paper, the French National Society of Coloproctology offers recommendations based on the data in the current literature, including those on recently developed treatments. There is a lack of high quality data and most of the recommendations are therefore based either on grade of recommendation B or expert recommendation (Level 4). However, the literature supports the construction of an algorithm based on the available scientific evidence and expert recommendation which may be useful in clinical practice. The French National Society of Coloproctology proposes a decision-making algorithm that includes recent developments of treatment. The current recommendations support sacral nerve modulation as the key treatment for faecal incontinence. They do not support the use of sphincter substitutions except in certain circumstances. Transanal irrigation is a novel often successful treatment of faecal incontinence due to neurological disorders.
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Affiliation(s)
- V Vitton
- Service de Gastroentérologie, Hôpital Nord, AP-HM, Interface de recherche translationnelle en neurogastroentérologie, CRN2M, UMR 7286, Aix-Marseille Université, Marseille, France
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26
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Rogers RG, Leeman LM, Borders N, Qualls C, Fullilove AM, Teaf D, Hall RJ, Bedrick E, Albers LL. Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women. BJOG 2014; 121:1145-53; discussion 1154. [PMID: 24548705 DOI: 10.1111/1471-0528.12571] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Maternal expulsive efforts are thought to damage the pelvic floor. We aimed to compare pelvic floor function and anatomy between women who delivered vaginally (VB) versus those with caesarean delivery (CD) prior to the second stage of labour. DESIGN Prospective cohort. SETTING University Hospital Midwifery practice. POPULATION Nulliparas. METHODS Pregnant nulliparas were recruited during pregnancy and women who underwent CD prior to the 2nd stage of labour at birth were recruited immediately postpartum. Both groups were followed prospectively to 6 months postpartum. MAIN OUTCOME MEASURES POPQ, perineal ultrasound (U/S) and Paper Towel Test (PTT), an objective measure of stress incontinence; Incontinence Severity Index (ISI), Pelvic Floor Impact Questionnaire (PFIQ-7), Wexner Fecal Incontinence Scale (W) and Female Sexual Function Index (FSFI). RESULTS 336/448 (75%) VB and 138/224 (62%) CD followed up. The VB group was younger (23.9 ± 4.9 versus 26.6 ± 6.1 years, P < 0.001) and less overweight/obese (38 versus 56%, P < 0.001); baseline functional measures were similar (all P > 0.05). At follow-up, urinary incontinence (UI) (55 versus 46% ISI > 0, P = 0.10), fecal incontinence (FI) (8 versus 13% FI on W, P = 0.12), sexual activity rates (88 versus 92%, P = 0.18) and PFIQ-seven scores were similar. Positive PTT tests (17 versus 6%, P = 0.002) and ≥ Stage 2 prolapse (22 versus 15%, P = 0.03) were higher with VB; differences were limited to points Aa and Ba. U/S findings were not different between groups. Stepwise multivariate analyses controlling for age, body mass index, and non-Hispanic White race for prolapse of points Aa and Ba did not alter conclusions (all P < 0.004). CONCLUSIONS VB resulted in prolapse changes and objective UI but not in increased self-report pelvic floor dysfunction at 6 months postpartum compared with women who delivered by CD prior to the second stage of labour. The second stage of labour had a modest effect on postpartum pelvic floor function.
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Affiliation(s)
- R G Rogers
- Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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27
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Abstract
BACKGROUND Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair. OBJECTIVES To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS. DATA COLLECTION AND ANALYSIS Trial quality was assessed independently by all authors. MAIN RESULTS Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women). AUTHORS' CONCLUSIONS The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.
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Affiliation(s)
- Ruwan J Fernando
- Department of Urogynaecology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, UK, W2 1NY
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28
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Abstract
BACKGROUND Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (for example pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex. OBJECTIVES To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques. SEARCH METHODS Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 6 March 2013), the Cochrane Colorectal Cancer Group Specialised Register (searched 6 March 2013), CENTRAL (2013, issue 1) and EMBASE (1 January 1998 to 6 March 2013) were undertaken. The British Journal of Surgery (1 January 1995 to 6 March 2013), Colorectal Diseases (1 January 2000 to 6 March 2013) and the Diseases of the Colon and Rectum (1 January 1995 to 6 March 2013) were specifically handsearched. The proceedings of the Association of Coloproctology of Great Britain and Ireland annual meetings held from 1999 to 2012 were perused. Reference lists of all relevant articles were searched for further trials. SELECTION CRITERIA All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse). DATA COLLECTION AND ANALYSIS Three review authors independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency. MAIN RESULTS Nine trials were included with a total sample size of 264 participants. Two trials included a group managed non-surgically. One trial compared levatorplasty with anal plug electrostimulation and one compared an artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but the numbers were small. The other trial showed no difference in the primary outcome measures.Seven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, and total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures. AUTHORS' CONCLUSIONS The review is striking for the lack of high quality randomised controlled trials on faecal incontinence surgery that have been carried out in the last 10 years. Those trials that have been carried out have focused on sacral neuromodulation and injectable bulking agents, both reported in separate reviews. The continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.
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Affiliation(s)
- Steven R Brown
- Surgery, Sheffield Teaching Hospitals, Sheffield S7, UK.
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29
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Morris OJ, Smith S, Draganic B. Comparison of bulking agents in the treatment of fecal incontinence: a prospective randomized clinical trial. Tech Coloproctol 2013; 17:517-23. [PMID: 23525964 DOI: 10.1007/s10151-013-1000-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 03/01/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND We sought to compare two synthetic injectable bulking agents, with known efficacy (PTQ™: a silicone biomaterial and Durasphere(®): pyrolytic carbon-coated beads), in the form of a randomised clinical trial. METHODS Circumferential injection of either agent was performed under local anesthesia and sedation as a day-case procedure. The primary outcome measure was the Wexner incontinence scale. Secondary measures were the short-form 36 (SF-36) quality of life assessment and manometry (maximum resting and squeeze pressures). Follow-up was at 6 weeks, 6 and 12 months. RESULTS Thirty-five patients were randomised, 17 to PTQ(®) and 18 to Durasphere(®). Early closure of the trial occurred, due to the removal of the agent PTQ(®), from the Australian Pharmaceutical Benefits scheme. Wexner incontinence scores were significantly better than baseline, in both groups, at 6 weeks and 6 months (P < 0.05), although the improvements were not significant at 12 months. There was no significant improvement for either agent, from baseline, in mean SF-36 scores at any follow-up sessions. There was no significant difference between the two bulking agents, with regard to both Wexner and SF-36 scores, at any of the follow-up sessions. Complications occurred in one patient in the PTQ group (perianal abscess) and did not occur in any of the patients in the Durasphere group. CONCLUSIONS This trial appears to show that both synthetic agents PTQ(®) and Durasphere(®) are effective and safe, although long-term improvement is limited. In this trial, there appears to be no difference in efficacy between the two agents, over a 12-month follow-up period.
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Affiliation(s)
- O J Morris
- Hunter Colorectal Research, Newcastle Hospital Private Suites, New Lambton Heights, NSW, 2305, Australia,
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Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial. Obstet Gynecol 2013; 120:803-8. [PMID: 22955309 DOI: 10.1097/aog.0b013e31826ac4bb] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report on a 3-year follow-up of women who underwent overlapping repair of a complete third-degree or fourth-degree obstetric tear. METHODS Primiparous women sustaining a complete third-degree or a fourth-degree tear of the perineum were randomized to a primary sphincter repair using either an end-to-end or an overlapping surgical technique. At 1, 2, and 3 years, questionnaires on rates of flatal and fecal incontinence were mailed to participants. RESULTS At 1 year, women who underwent an end-to-end repair reported lower rates of flatal and fecal incontinence than women who had an overlapping repair. For flatal incontinence the rates were 31% compared with 56% (95% confidence interval for the rate difference 6-43%, P=.012). For fecal incontinence, the rates were 7% compared with 16% (95% confidence interval for the rate difference -4% to 21%, P=.17). The difference between the two methods of surgical repair had largely disappeared by the end of year 2. CONCLUSION At 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is associated with significantly lower rates of anal incontinence when compared with overlapping repair. There is no long-term benefit associated with either technique over the other. CLINICAL TRIAL REGISTRATION ISRCTN Register, http://isrctn.org, ISRCTNO 4149919. LEVEL OF EVIDENCE I.
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Laalim SA, Hrora A, Raiss M, Ibnmejdoub K, Toughai I, Ahallat M, Mazaz K. [Direct sphincter repair: techniques, indications and results]. Pan Afr Med J 2013; 14:11. [PMID: 23504542 PMCID: PMC3597895 DOI: 10.11604/pamj.2013.14.11.2024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 11/21/2012] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Said Ait Laalim
- Département de chirurgie générale (B), CHU Hassan II, Fès, Morocco
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Aigmueller T, Umek W, Elenskaia K, Frudinger A, Pfeifer J, Helmer H, Huemer H, Tammaa A, van der Kleyn M, Tamussino K, Koelle D. Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group. Int Urogynecol J 2012; 24:553-8. [PMID: 23160871 DOI: 10.1007/s00192-012-1982-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 10/15/2012] [Indexed: 01/25/2023]
Abstract
The purpose of this guideline is to provide a decision aid for diagnosis, treatment, and follow-up of patients with major perineal tears and thus minimize the risk of persistent symptoms. In 2007, the "Guideline for the management of third and fourth degree perineal tears after vaginal birth" was established by members of the Austrian Urogynecologic Working Group (AUB). The guideline was updated in 2011, including literature published up to 30 November 2011. The DELPHI method was used to reach consensus. Evidence-based and consensus-based statements were defined for epidemiology, risk factors, classification, diagnosis, surgery, and follow-up of major perineal lacerations at vaginal birth.
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Affiliation(s)
- T Aigmueller
- Department of Gynecology, Medical University of Graz, Graz, Austria.
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Overlapping compared with end-to-end repair of third and fourth degree obstetric anal sphincter tears. Curr Opin Obstet Gynecol 2012; 23:386-90. [PMID: 21836509 DOI: 10.1097/gco.0b013e32834a91e8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW There is a significant risk of anal incontinence in women who sustain a third or fourth degree tear of the external anal sphincter (EAS) at the time of delivery. Optimizing the surgical correction of these injuries should result in the best functional outcome for women. The purpose of this review is to examine recent evidence. RECENT FINDINGS The results of randomized trials are conflicting. Four trials have found no difference between the overlapping and end-to-end repairs. One trial found the overlapping procedure superior and one found the end-to-end procedure to be superior. Repair of the internal anal sphincter is an important part of the surgical repair. Surgeon experience with specific surgical procedures does not significantly affect outcomes. Methodological limitations have compromised the conclusions of the majority of the studies and longer-term follow-up is still needed. SUMMARY At present, the bulk of the evidence (follow-up to 12 months) finds that there is no difference in symptomatic outcomes between the end-to-end or the overlapping repair of EAS defects. A surgeon should use the technique with which they are most familiar. Obstetricians should familiarize themselves with the most up-to-date evidence concerning the anatomy of the EAS and take care to identify and repair both the internal anal sphincter and EAS at the time of an obstetrical injury. Surgeon experience with specific repair procedures does not affect outcomes of EAS defect repair.
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Fowler G, Williams A, Murphy G, Taylor K, Wood C, Adams E. How to set up a perineal clinic. ACTA ACUST UNITED AC 2011. [DOI: 10.1576/toag.11.2.129.27487] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Obstetric anal sphincter injury in the UK and its effect on bowel, bladder and sexual function. Eur J Obstet Gynecol Reprod Biol 2010; 154:223-7. [PMID: 21055866 DOI: 10.1016/j.ejogrb.2010.09.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Revised: 08/19/2010] [Accepted: 09/24/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the incidence and factors associated with the development of bowel, urinary and sexual symptoms following obstetric anal sphincter injury (OASIS). STUDY DESIGN A prospective cohort study involving 435 women who sustained OASIS, over a five-year period, in a large UK teaching hospital. Details of bowel, urinary and sexual function were documented using a structured questionnaire. The outcome measures included the incidence of symptoms following OASIS and factors which modify the risk of developing symptoms. RESULTS The majority (96%) of women were faecally continent three months after primary OASIS repair. Nevertheless, 34.2% reported faecal urgency, 25% suffered poor flatal control, and nearly 30% reported pain and bleeding on defaecation. Sixteen percent of women reported stress urinary incontinence, 15% experienced urgency and 20% reported urinary frequency. Fifty-seven percent of women had resumed intercourse but 32% of those women reported dyspareunia. Women who developed faecal symptoms were significantly more likely to develop urinary symptoms. Advancing maternal age and the use of forceps, in particular rotational forceps, significantly increase the risk of developing faecal and urinary symptoms. CONCLUSIONS Obstetric anal sphincter injuries continue to be responsible for significant morbidity, with approximately 30% of women reporting faecal, urinary or sexual symptoms, three months postpartum. This large prospective UK study provides up-to-date information relating to factors which increase the likelihood of such symptoms occurring. These data are useful for counselling and targeting more intensive follow up to women at higher risk of developing symptoms.
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Lindqvist PG, Jernetz M. A modified surgical approach to women with obstetric anal sphincter tears by separate suturing of external and internal anal sphincter. A modified approach to obstetric anal sphincter injury. BMC Pregnancy Childbirth 2010; 10:51. [PMID: 20828380 PMCID: PMC2949785 DOI: 10.1186/1471-2393-10-51] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 09/09/2010] [Indexed: 11/10/2022] Open
Abstract
Background Long-term results after obstetric anal sphincter injury (OASI) are poor. We aimed to improve the long-term outcome after OASI by lessening symptoms of anal incontinence. Methods In a prospective study at Malmö University Hospital, twenty-six women with at least grade 3B OASI were classified and sutured in a systematic way, including separate suturing of the internal and external sphincter muscles with monofilament absorbable sutures. The principal outcome assessed by answers given to six questions, was a difference in anal incontinence score, between the study group and two control groups (women with prior OASI [n = 180] and primiparous women delivered vaginally without a diagnose of OASI [n = 100]). Results An anal incontinence score of zero (i.e., no symptoms) was found in 74% of the study group, 47% of the OASI control group, and 66% of the vaginal control group (p = 0.02 and 0.5, as compared to the study group). Conclusions A modified suturing technique was followed by significant improved one-year symptoms of anal incontinence as compared to historical cases.
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Affiliation(s)
- Pelle G Lindqvist
- Departments of Obstetrics and Gynecology, Clintech, Karolinska University Hospital, Huddinge, 14186 Huddinge, Sweden.
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Abstract
BACKGROUND Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex. OBJECTIVES To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques. SEARCH STRATEGY Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 26 November 2009), the Cochrane Colorectal Cancer Group Specialised Register (searched 26 November 2009), CENTRAL (The Cochrane Library 2009) and EMBASE (1 January 1998 to 30 June 2009) were undertaken. The British Journal of Surgery (1 January 1995 to 30 June 2009) Colorectal Diseases (1 January 2000 to 30 June 2009) and the Diseases of the Colon and Rectum (1 January 1995 to 30 June 2009) were specifically handsearched. The proceedings of the UK Association of Coloproctology meeting held from 1999 to 2009 were perused. Reference lists of all relevant articles were searched for further trials. SELECTION CRITERIA All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse). DATA COLLECTION AND ANALYSIS Three reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency. MAIN RESULTS Thirteen trials were included with a total sample size of 440 participants. Two trials included a group managed non-surgically. One trial compared levator with anal plug electrostimulation and one compared artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but numbers were small. The other trial showed no difference in primary outcome measures.Eleven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, injection of silicone, hydrogel, physiological saline, carbon beads or collagen bulking agents, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are also considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures. AUTHORS' CONCLUSIONS Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.
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Affiliation(s)
- Steven R Brown
- Surgery, Sheffield Teaching Hospitals, Dept Surgery, Northern General Hospital, Herried Road, Sheffield S7, South Yorkshire, UK, S5 7AU
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The increased incidence of obstetric anal sphincter rupture--an emerging trend in Finland. Prev Med 2009; 49:535-40. [PMID: 19850070 DOI: 10.1016/j.ypmed.2009.10.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 10/07/2009] [Accepted: 10/11/2009] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe recent trends in the prevalence and risk factors of obstetric anal sphincter ruptures during between 1997 and 2007 in Finland. METHOD We analyzed a population-based register of 514,741 women with singleton vaginal deliveries recorded in the Finnish Medical Birth Register. Primiparous (n=2315) and multiparous women (n=534) with anal rupture compared in terms of possible risk factors to primiparous (n=215,463) and multiparous (n=296,429) women without anal rupture, respectively, using stepwise logistic regression analysis. RESULTS The occurrence of anal rupture increased from 0.5% in 1997-1999 to 1.8% in 2006-2007 among primiparous women, and from 0.1% in 1997-2001 to 0.3% in 2006-2007 among multiparous women. Over the study period, the likelihood of women having anal rupture in these groups increased by a factor of 3.28 (95% CI 2.86-3.76) and 2.83 (95% CI 2.19-3.67), respectively, after adjustments for strong associations with many known risks. Changes in population characteristics and in the use of interventions were small, and these did not cause the increased anal rupture rate. The only exception was vacuum-assisted deliveries, which explained about 9% of the rising anal rupture risk. CONCLUSIONS The current obstetric practice is not optimal for protecting the perineum and reflects the need to standardise obstetric care.
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Folch M, Parés D, Castillo M, Carreras R. Aspectos prácticos en el manejo de las lesiones obstétricas perineales de tercer y cuarto grado para minimizar el riesgo de incontinencia fecal. Cir Esp 2009; 85:341-7. [DOI: 10.1016/j.ciresp.2008.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Accepted: 12/15/2008] [Indexed: 11/29/2022]
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Nordenstam J, Mellgren A, Altman D, López A, Johansson C, Anzén B, Li ZZ, Zetterström J. Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial. BJOG 2008; 115:857-65. [PMID: 18485164 DOI: 10.1111/j.1471-0528.2008.01726.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up. DESIGN Randomised controlled trial. SETTING University hospital in Sweden. POPULATION A total of 165 women diagnosed with a third- to fourth-degree perineal tear. METHODS The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up. MAIN OUTCOME MEASURES Anal incontinence measured by the validated Pescatori incontinence score. RESULTS A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces. CONCLUSION Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.
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Affiliation(s)
- J Nordenstam
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to outline optimum practice in diagnosis and management of obstetric anal sphincter injury. The review focuses briefly on prevention of the problem before outlining diagnosis of sphincter injury as well as immediate and long-term management of patients who have sustained such injuries. RECENT FINDINGS Increasing vigilance is vital in order that sphincter injury is not overlooked; immediate radiological assessment may play a role in diagnosis. Optimum anal sphincter repair should be followed by oral laxative administration to maintain sphincter integrity. Biofeedback physiotherapy and sacral nerve stimulation show great promise in treatment of persistent symptoms. Optimum mode of delivery in future pregnancies is not clearly defined, and decisions should be individualized. SUMMARY Because obstetric injury to the anal sphincter mechanism cannot always be prevented, efforts must focus on limiting its occurrence, documenting its severity and providing optimum therapy to women who have sustained it. Management includes routine postnatal review of at-risk women and antenatal assessment in future pregnancies to limit deterioration in continence after future deliveries.
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Affiliation(s)
- Maeve Eogan
- UCD School of Medicine and Medical Science, Department of Obstetrics and Gynaecology, National Maternity Hospital, Holles St, Dublin 2, Ireland
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Faucheron JL. [Anal incontinence]. Presse Med 2008; 37:1447-62. [PMID: 18555639 DOI: 10.1016/j.lpm.2008.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Revised: 01/26/2008] [Accepted: 04/21/2008] [Indexed: 12/15/2022] Open
Abstract
Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.
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Affiliation(s)
- Jean-Luc Faucheron
- Unité de chirurgie colorectale, Clinique universitaire de chirurgie digestive et de l'urgence, Hôpital Albert Michallon, F-38043 Grenoble cedex 9, France.
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Abramov Y, Feiner B, Rosen T, Bardichev M, Gutterman E, Lissak A, Auslander R. Primary repair of advanced obstetric anal sphincter tears: should it be performed by the overlapping sphincteroplasty technique? Int Urogynecol J 2008; 19:1071-4. [PMID: 18385917 DOI: 10.1007/s00192-008-0592-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 02/14/2008] [Indexed: 11/25/2022]
Abstract
Advanced obstetric anal sphincter tears are often associated with a high incidence of fecal and flatus incontinence. We aimed to assess the clinical outcome of these repairs when done by the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. Between August 2005 and December 2006, all grades 3 and 4 obstetric anal sphincter tears in our department were repaired by a reconstructive pelvic surgeon, primarily using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. All women were followed every 6 months using the Colorectal Anal Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, a physical examination of the anal sphincter, anal manometry, and transperineal anal sonography. There were 3,478 deliveries of which 22 (0.63%) anal sphincter tears were repaired in women aged 22-41 years. Two women were diagnosed with Royal College of Obstetricians and Gynecologists grade 3a, eight with grade 3b, nine with grade 3c, and three with grade 4 anal sphincter tears. Postoperatively, 21 patients attended the outpatient clinic, with an average follow-up time of 9.2+/-1.4 months. Only two women (9.5%) complained of flatus incontinence and fecal urgency and had mildly decreased anal sphincter squeeze pressure and a small sonographic anal sphincter defect. None of the women complained of fecal incontinence. Two women (9.5%) reported on transient perineal pain and one (4.8%) on transient dyspareunia. All other women were asymptomatic and had normal anal manometry and sonographic evaluation. Repair of obstetric anal sphincter tears using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum seems to carry favorable clinical outcome and reduced risk for anal incontinence, perineal pain, and sexual dysfunction.
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Affiliation(s)
- Yoram Abramov
- Division of Urogynecology and Reconstructive Pelvic Surgery, Haifa, Israel.
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Lorenzi B, Pessina F, Lorenzoni P, Urbani S, Vernillo R, Sgaragli G, Gerli R, Mazzanti B, Bosi A, Saccardi R, Lorenzi M. Treatment of experimental injury of anal sphincters with primary surgical repair and injection of bone marrow-derived mesenchymal stem cells. Dis Colon Rectum 2008; 51:411-20. [PMID: 18224375 DOI: 10.1007/s10350-007-9153-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 07/16/2007] [Accepted: 08/25/2007] [Indexed: 12/15/2022]
Abstract
PURPOSE Sphincter injury is a common cause of anal incontinence. Surgical repair remains the operation of choice; however, the outcome often is poor. We investigated the ability of injected bone marrow-derived mesenchymal stem cells to enhance sphincter healing after injury and primary repair in a preclinical model. METHODS Twenty-four inbred Wistar Furth rats were divided into three groups. As a control, Group A underwent sham operation. Group B had sphincterotomy and repair of both anal sphincters plus saline injections. The study group (Group C) underwent sphincterotomy and repair followed by intrasphincteric injections of syngenic bone marrow-derived mesenchymal stem cells. A further group (Group D) of outbred Wistar rats treated with mesenchymal stem cells and immunosuppressive therapy also was evaluated. At 30 days, histologic and morphometric analysis and in vitro contractility testing was performed. RESULTS A significant decrease of muscle tissue was observed at the site of repair after sphincter injury. However, in Groups C and D, histologic examination demonstrated new muscle fibers and morphometric analysis revealed a significantly greater muscle area fraction than in Group B (P < 0.05). Moreover, mesenchymal stem cells injection improved contractility of sphincters strips compared with Group B (P < 0.05). No significant differences were found between Groups C and D. CONCLUSIONS In our experimental model, bone marrow-derived mesenchymal stem cells injection improved muscle regeneration and increased contractile function of anal sphincters after injury and repair. Therefore, mesenchymal stem cells may represent an attractive tool for treating anal sphincter lesions in humans. Investigations into the biologic basis of this phenomenon should increase our knowledge on underlying mechanisms involved in sphincter repair.
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Affiliation(s)
- Bruno Lorenzi
- Department of Surgery, University of Siena, Viale Bracci, 53100 Siena, Italy.
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Lepistö A, Pinta T, Kylänpää ML, Halmesmäki E, Väyrynen T, Sariola A, Stefanovic V, Aitokallio-Tallberg A, Ulander VM, Molander P, Luukkonen P. Overlap technique improves results of primary surgery after obstetric anal sphincter tear. Dis Colon Rectum 2008; 51:421-5. [PMID: 18213488 DOI: 10.1007/s10350-007-9182-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 08/31/2007] [Accepted: 10/17/2007] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- A Lepistö
- Department of Surgery, Helsinki University Central Hospital, PL 340, 00029 HUS, Helsinki, Finland.
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Abstract
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.
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