Impact of pregnancy and parturition on the anal sphincters and pelvic floor

Association of Constipation with Modes of Delivery: A Retrospective Questionnaire-based Study

INTRODUCTION AND HYPOTHESIS

Pelvic floor damage can contribute to pelvic floor dysfunction, including constipation. Most studies focus on constipation during pregnancy, whereas information regarding the mode of delivery in relation to constipation is limited. We hypothesise that women with a history of vaginal delivery report constipation more often than women with a history of caesarean section.

METHODS

This was a retrospective cross-sectional multicentre study conducted in the Netherlands. All included patients (n = 2,643) completed the Groningen Defecation and Fecal Continence questionnaire to assess bowel problems of the last 6 months. Parametric tests, Chi-squared, univariable and multivariable regression analyses were performed.

RESULTS

Among 2,643 parous women, 2,248 delivered vaginally (85.1%) and 395 (14.9%) by caesarean section. Altogether, 649 women (24.6%) suffered from constipation. Women in the vaginal delivery group were constipated more often than women in the caesarean section group (25.5% versus 19.0%, p = 0.005). For women who had delivered vaginally, multivariable regression analysis showed an odds ratio for constipation of 1.47 (95% confidence interval, 1.109-1.938, p = 0.007). The odds ratio for constipation in women with a spontaneous perineal tear was 1.4 times higher than in women with an intact perineum (p = 0.030). Furthermore, the vaginal delivery group reported difficulties regarding bowel emptying (p = 0.048), straining (p = 0.027), incomplete defecation (p = 0.043), not able to defecate daily (p = 0.018), manually assisted defecation (p = 0.015) and had higher Renzi scores (p = 0.043) more often.

CONCLUSIONS

Women in the vaginal delivery group have higher prevalences and odds ratios for constipation. Furthermore, a perineal tear during vaginal delivery increases the odds ratio for constipation.

Does parity impact obstructed defecation in women with normal anorectal anatomy?

INTRODUCTION AND HYPOTHESIS

Obstructed defecation (OD) is often associated with trauma to pelvic connective tissue and nerves sustained during pregnancy and childbirth. Although there are multiple potential etiologies of defecatory dysfunction, the pathophysiology of this symptom complex is not well understood. The purpose of this study is to determine the role of parity in the development of obstructed defecatory symptoms in women with normal anorectal anatomy in a search for evidence of a presumptive neuropathic effect of pregnancy and childbirth.

METHODS

This study retrospectively evaluated the records of 754 women presenting at a tertiary urogynecology unit for pelvic floor dysfunction with no anatomical abnormalities of the anorectum on imaging. They were stratified according to parity. The authors determined the prevalence of obstructed defecation symptoms in these groups. Chi-squared test was performed for statistical analysis.

RESULTS

Median age was 51 (range 16-88) years, and median vaginal parity was 2 (0-8); 399 (53%) women reported symptoms of OD. When anatomical abnormalities of the anorectum were excluded, parity did not seem to have a major effect on the prevalence of symptoms of OD.

CONCLUSIONS

In this cohort, parity is unlikely to be a cause of OD in women with normal anorectal anatomy.

Fecal incontinence and oral regurgitation during duodenal endoscopic submucosal dissection using the water pressure method

OBJECTIVES

Endoscopic submucosal dissection (ESD) in the duodenum is challenging. The water pressure method (WP-ESD) has been developed with a decreased rate of perforation. However, details of perioperative adverse events of WP-ESD are unknown. The purpose of this study was to clarify the frequency and related factors of fecal incontinence and oral regurgitation during WP-ESD.

METHODS

A chart-based retrospective analysis was performed on 43 patients who underwent duodenal WP-ESD. The saline volume given into the body was calculated in all cases. All adverse events during WP-ESD until 6 weeks were extracted, and factors related to intraoperative fecal incontinence or oral regurgitation were analyzed. The frequency of fecal incontinence and oral regurgitation was also compared to those of 83 conventional ESD cases.

RESULTS

In WP-ESD, intraoperative fecal incontinence occurred in 12 (28%), oral regurgitation in six (14%), and aspiration pneumonia in one patient. For fecal incontinence, the infusion speed (saline volume divided by resection time) around 17 mL/min was a significant factor in multivariable analysis. For oral regurgitation, only tumor size was a significant factor in univariate analysis (P = 0.027). Significant difference was observed in the frequency of fecal incontinence between WP-ESD and conventional ESD (28% vs. 0%, P < 0.001), but no difference was observed in oral regurgitation or aspiration pneumonia.

CONCLUSIONS

Intraoperative fecal incontinence is a unique adverse event of WP-ESD related to the infusion speed. WP-ESD did not pose a risk for oral regurgitation, but we should be aware of the risk in large tumor cases.

Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods

Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.

Validation of the Dutch-Language Version of the Neurogenic Bowel Dysfunction Score in Patients with Multiple Sclerosis

Background: Neurogenic bowel dysfunction (NBD), like fecal incontinence and constipation, is a common symptom of disease in patients with multiple sclerosis (MS). The NBD score is a validated symptom-based questionnaire consisting of ten multiple-choice questions. The aim of this study was to validate the Dutch version of the NBD score in patients with MS, creating an objective measuring tool of bowel dysfunction.

Methods: Translation and validation of the NBD score was performed according to standardized guidelines. Adult patients with MS visiting a urology department completed a set of questionnaires (test): the NBD score, the Fecal Incontinence Quality of Life scale (FIQL), the Fecal Incontinence Severity Index (FISI), and the EQ-5D 3-Level questionnaire (EQ-5D-3L). After 1 to 2 weeks, the questionnaires were completed again (retest). A control group recruited at a general practitioner’s practice completed the questionnaires once. Data were analyzed for measurement properties.

Results: Sixty-one patients and 50 controls were included. Content validity was adequate, internal consistency was moderate (Cronbach α = 0.57 and 0.41), and reproducibility was excellent (interclass correlation coefficient = 0.78). Criterion validity was confirmed; the NBD score correlated moderately/strongly with the FIQL, FISI, and EQ-5D-3L. The NBD scores in the patient group were significantly higher than those in the control group, demonstrating good construct validity.

Conclusions: The Dutch version of the NBD score showed moderate-to-good validity and good reliability for assessment of NBD in patients with MS.

Anal fissure management by the gastroenterologist

PURPOSE OF REVIEW

Anal fissures are very common. They are easy to diagnose and treat in the office setting. They may coexist with hemorrhoids. In fact 20% of patients with hemorrhoids have anal fissures also. The purpose of this review is to highlight current diagnosis and treatment of anal fissures using diet, ointments and botulinum toxin to enable healing. Medical treatment relies on reducing anal sphincter spasm to allow improved blood flow and healing.

RECENT FINDINGS

Many anorectal disorders can be managed in the office. Most anal fissures can be managed without the need for surgery. The need for anorectal examination, including use of anoscopy is stressed in the current literature. The use of calcium channel blockers in preference to nitroglycerin is highlighted as well as the use of botulinum toxin when ointments don't work.

SUMMARY

Anal fissure can be managed nonsurgically most of the time and gastroenterologists should be able to manage them. This article should help in preventing unnecessary surgery and its complications, mainly incontinence in a small but significant number. The search for more effective drugs and options for managing this disorder continues.

Pregnancy and postpartum bowel changes: constipation and fecal incontinence

Pregnancy and the postpartum period are often associated with many gastrointestinal complaints, including nausea, vomiting, and heartburn; however, the most troublesome complaints in some women are defecatory disorders such as constipation and fecal incontinence, especially postpartum. These disorders are often multifactorial in etiology, and many studies have looked to see what risk factors lead to these complications. This review discusses the current knowledge of pelvic floor and anorectal physiology, especially during pregnancy, and reviews the current literature on causes and treatments of postpartum bowel symptoms of constipation and fecal incontinence.

Joint hypermobility and rectal evacuatory dysfunction: an etiological link in abnormal connective tissue?

BACKGROUND

  Previous studies report an association between joint hypermobility (JHM), as a clinical feature of underlying connective tissue (CT) disorder, and pelvic organ prolapse. However, its association with rectal evacuatory dysfunction (RED) has not been evaluated. To investigate the prevalence of JHM in the general population and in patients with symptoms of RED referred for anorectal physiological investigation.

METHODS

Bowel symptom and Rome III questionnaires to detect irritable bowel syndrome were sent to 273 patients with RED. Patients then underwent full investigation, including evacuation proctography. A validated 5-point self-reported questionnaire was used to assess JHM in both the patient group and 100 age- and sex-matched controls [87 female, median age 55 (range 28-87)].

KEY RESULTS

Seventy-three patients were excluded from analysis (incomplete questionnaire or investigation). Of 200, 65 patients [32%: 63 female, median age 52 (range 15-80)] and 14% of controls (P = 0.0005 vs patients) had features satisfying criteria for JHM. Overall constipation score (P < 0.0001), abdominal pain (P = 0.003), need for manual assistance (P = 0.009), and use of laxatives (P = 0.03) were greater in the JHM group than the non-JHM group. On proctography, 56 of JHM patients (86%) were found to have significant morphological abnormalities (e.g. functional rectocoele), compared with 64% of the non-JHM group (P = 0.001).

CONCLUSIONS & INFERENCES

The greater prevalence of JHM in patients with symptoms of RED, and the demonstration of significantly higher frequencies of morphological abnormalities than those without JHM, raises the possibility of an important pathoaetiology residing in either an enteric or supporting pelvic floor abnormality of CT.

What is the natural history of internal rectal prolapse?

AIM

The nature and clinical significance of internal rectal prolapse is controversial. Its natural history is unclear. Longitudinal cohort studies show rare progression to external prolapse but lack adequate follow-up. We aimed to study the relationship of age to various stages of internal rectal prolapse using the Oxford Rectal Prolapse Grade (ORPG) and evaluate the influence of sex and vaginal delivery on this relationship.

METHOD

Internal rectal prolapsed (IRP) diagnosed at proctography and external rectal prolapse were graded using the ORPG. Age, sex and obstetric history were documented. Mean age of each prolapse grade (1-5) was analysed and regression analysis performed for age and prolapse. Subgroup analyses were made for males, and females with (V+) and without (V0) history of vaginal delivery.

RESULTS

Sixty males (11%) and 471 females (89%) were studied. The difference in the mean ages of each group was statistically significant (grade 1,38.6; grade 2, 52.1; grade 3, 56.0; grade 4, 60.3 and grade 5, 66.5, P < 0.0001). On average male (8.7 years) and V0-group (8.0 years) were younger than V+ group (95% CI difference 4.5-12.9 years, P < 0.0001, and 3.8-12.2 years, P < 0.0001, respectively). Males and V0-group had weaker correlation between age and prolapse grade (r = 0.16 and r = 0.17, respectively, vs 0.41), and a faster prolapse progression rate than the V+ group.

CONCLUSION

These data demonstrate a strong relationship between age and prolapse grade, supporting the view of internal rectal prolapse as a precursor to external prolapse in the spectrum of rectal prolapse disease.