A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears

Guideline No. 457: Obstetrical Anal Sphincter Injuries (OASIS) Part I: Prevention, Recognition, and Immediate Management

OBJECTIVE

The purpose of this guideline is to promote recognition and preventive strategies for obstetrical anal sphincter injuries. Furthermore, it provides guidance on primary repair and immediate postpartum management for obstetrical anal sphincter tears in order to minimize further negative sequelae.

TARGET POPULATION

All patients having a vaginal delivery and those who have sustained an obstetrical anal sphincter injury.

OUTCOMES

Certain preventive strategies have been associated with lower rates of obstetrical anal sphincter injuries (e.g., fetal head flexion and control, appropriate use of mediolateral episiotomy). Management strategies, including appropriate diagnosis and repair of obstetrical anal sphincter injuries, antibiotic prophylaxis, and bowel and bladder function management can decrease associated short- and long-term complications.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline may increase detection, prevention, and appropriate management of obstetrical anal injuries, thus limiting the future burden associated with these injuries. Implementation of the recommended classification of obstetrical anal sphincter injuries will improve national and international research efforts.

EVIDENCE

Published literature was retrieved through searches of PubMed, Ovid, Medline, Embase, Scopus, and the Cochrane Library from September 1, 2014, through November 30, 2023, using appropriate MeSH terms (delivery, obstetrics, obstetric surgical procedures, obstetric labor complications, anal canal, episiotomy) and keywords (OASIS, obstetrical anal sphincter injury, anal injury, anal sphincter, vaginal delivery, suture, fecal incontinence, anal incontinence, overlap repair, end-to-end repair, bladder protocol, analgesia). Results were restricted to systematic reviews, meta-analyses, randomized controlled trials/controlled clinical trials, observational studies, and clinical practice guidelines. Results were limited to English- or French-language materials. Evidence was supplemented with references from the 2015 Society of Obstetricians and Gynaecologists of Canada guideline no. 330.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

Obstetrical care providers.

TWEETABLE ABSTRACT

Updated Canadian guideline on recognition, prevention and management of obstetrical anal sphincter injuries (OASIS).

SUMMARY STATEMENTS

RECOMMENDATIONS.

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)

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.

Evidence-based labor management: third stage of labor (part 5)

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.

End-to-end anal Sphincter Repair in Treatment of Post-traumatic Fecal Incontinence

The present report describes the end-to-end technique of anal sphincter repair in a 36-year-old female patient with post-vaginal delivery fecal incontinence (FI). The patient had a history of two vaginal deliveries and the symptoms of FI were observed after the second delivery. On assessment of the severity of FI using the Wexner incontinence score, the patient had a score of 12. Endoanal ultrasonography revealed an anterior defect of the external anal sphincter extending from 11 to 3 o'clock. The patient had no previous anal surgery and did not have any medical comorbidities.

The operation time was 45 minutes. No intraoperative complications were recorded. At 12 months of follow-up, the patient showed significant improvement in the continence state, with her Wexner score dropping to 4. No postoperative complications were recorded. We can conclude that end-to-end anal sphincter repair is a technically feasible operation that confers satisfactory improvement in the continence state without imposing much tension on the site of sphincter repair.

Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis

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.

A retrospective review of 1495 patients with obstetric anal sphincter injuries referred for assessment of function and endoanal ultrasonography

AIM

Obstetric anal sphincter injuries are a significant risk factor for faecal incontinence. Correct identification and successful primary repair are important. The aim of this study was to review the outcome of all patients, with an obstetric anal sphincter injury, referred to our unit.

METHOD

This is a retrospective review of 1495 patients over a 12-year period. All had a third or fourth degree tear and were referred at 4-months postpartum.

RESULTS

Endoanal ultrasonography demonstrated residual sphincter defect in 792 (53%) and normal sphincters, with no evidence of repair, in 661 (44%). The majority of injuries involved both the external and internal sphincters (n = 501). Significant reductions in resting pressure and voluntary squeeze pressures were seen when those with a sphincter defect were compared to those with intact sphincters. However, there was no significant difference in the mean (SD) Cleveland Clinic faecal incontinence scores (5.8 (5.8) and 4.3 (5.5), p = 0.8).

CONCLUSION

Third and fourth degree tears appear to be over diagnosed. Primary repair appears to be unsuccessful in the majority of cases. There appears to be poor correlation between objective and subjective assessment of sphincter function.

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair

OBJECTIVE

To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS.

OPTIONS

Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies.

OUTCOMES

The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth.

EVIDENCE

Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

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.

[Management of third and fourth degree perineal tears: A systematic review]

This was a comprehensive literature review using Pubmed, Medline, Embase and Cochrane, whose aim was to analyse the prevalence of anal sphincter injuries, their risk factors, their management and their functional prognosis. The prevalence of 3rd and 4th degree perineal tears varies between studies from 2.95% regardless the parity to 25% in nulliparous women. Twenty-eight percent to 48% of these lacerations were clinically occult. Perineal tears were associated with (multivariate analysis) forceps (6.021 [IC 95% 1.23-19.45]), nulliparity (OR 9.8 [IC 95% 3.6-26.2]), gestational age over 42 SA (OR 2.5 [IC 95% 1-6.2]), fundal pressure (OR 4.6 [IC 95% 2.3-7.9]), midline episiotomy (OR 5.5 [IC 95% 1.4-18.7]) or fetal weight in interval of 250g (OR 1.3 [IC 95% 1.1-1.6]). There was no difference between the sphincter repair techniques. Post-partum laxative use showed less painful bowel motion and earlier postnatal discharge. Data concerning rehabilitation were contradictory. The rate of anal incontinence 6 months after vaginal delivery were 3.6% following third degree of perineal tear and 30.8% in case of fourth degree of perineal tear. Thirty years after anal sphincter disruption, the prevalence of fecal incontinence reached 6.9%.

Obstetric anal sphincter injuries: a survey of clinical practice among Canadian obstetricians

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.

Methods of repair for obstetric anal sphincter injury

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.

Surgery for faecal incontinence in adults

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.

Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third-degree tears (EBAPT Trial)

OBJECTIVE

To compare early home biofeedback physiotherapy with pelvic floor exercises (PFEs) for the initial management of women sustaining a primary third-degree tear.

DESIGN

Single centre, randomised trial.

SETTING

National Maternity Hospital, Dublin, Ireland.

POPULATION

A total of 120 women sustaining a primary third-degree tear.

METHODS

Women were randomised in a one to three ratio: 30 to early postpartum home biofeedback physiotherapy and 90 to PFEs.

MAIN OUTCOME MEASURES

Differences in anorectal manometry results, Cleveland Clinic continence scores and Rockwood faecal incontinence quality of life scale scores after 3 months of postpartum treatment.

RESULTS

The mean anal resting pressure was 39 ± 13 mmHg in the early biofeedback physiotherapy group and 43 ± 17 mmHg in the PFE group. The mean anal squeeze pressure was 64 ± 17 mmHg in the biofeedback group and 62 ± 23 mmHg in the PFE group. There was no significant difference in anal resting and squeeze pressure values between the groups (P = 0.123 and P = 0.68, respectively). There were no differences in symptom score and quality of life measurements between the groups.

CONCLUSIONS

This study demonstrates no added value in using early home biofeedback physiotherapy in the management of women sustaining third-degree tears. Poor compliance may have contributed because women found it difficult to designate time to using biofeedback.

Outcomes and follow-up after obstetric anal sphincter injuries

INTRODUCTION AND HYPOTHESIS

To determine if the classification of obstetric anal sphincter injuries (OASIs) affected clinical and functional outcome and to assess the need for follow-up of 3a tears in secondary care

METHODS

Prospective data collection in 255 patients who sustained OASIs during repair with follow-up in a specialist clinic after 6 months.

RESULTS

One hundred and thirty-two patients (51.7 %) sustained 3a tears, 81 (31.7 %) 3b tears, 27 (10.6 %) 3c tears and 15 (5.8 %) had 4th degree tears. Twenty-three patients (9 %) reported symptoms at 6-month follow-up. Eight patients reported anal incontinence of liquid or solid stool. Among patients who sustained 3a tears, 8 patients were symptomatic: 7 had urgency and 1 had flatus incontinence. None of the patients who sustained 3a tears reported incontinence of solid/liquid stool. There appears to be no correlation with scan findings and symptoms at follow up. Most patients are asymptomatic. Urgency of faeces is the commonest symptom.

CONCLUSIONS

The vast majority of patients are asymptomatic. The necessity of seeing all these patients in secondary care for follow-up needs to be questioned. With effective primary care follow-up, there may be a place to follow up patients with 3a tears in the community during the routine 6-week postnatal check and refer the symptomatic patients to the hospital for further review.

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

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.

[Direct sphincter repair: techniques, indications and results]

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.

Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group

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.

A randomized trial of birthing with and without stirrups

OBJECTIVE

The objective of the study was to determine whether bed delivery without stirrups reduces the incidence of perineal lacerations compared with delivery in stirrups.

STUDY DESIGN

In this randomized trial, we compared bed delivery without stirrups with delivery in stirrups in nulliparous women. The primary outcome was any perineal laceration (first through fourth degree).

RESULTS

One hundred eight women were randomized to delivery without stirrups and 106 to stirrups. A total of 82 women randomized to no stirrups (76%) sustained perineal lacerations compared with 83 in women allocated to stirrups (78%) (P = .8). There was no significant difference in the severity of lacerations or in obstetric outcomes such as prolonged second stage of labor, forceps delivery, or cesarean birth. Similarly, infant outcomes were unaffected.

CONCLUSION

Our results do not incriminate stirrups as a cause of perineal lacerations. Alternatively, our findings of no difference in perineal lacerations suggest that delivering in bed without stirrups confers no advantages or disadvantages.

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study

OBJECTIVE

To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed.

METHODS

Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score.

RESULTS

Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007).

CONCLUSION

Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair.

Overlapping compared with end-to-end repair of third and fourth degree obstetric anal sphincter tears

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.

Anal incontinence and quality of life following obstetric anal sphincter injury

PURPOSE

The objective of our study was to identify the number of women who have long-term ano-rectal symptoms following primary repair of obstetric anal sphincter injury (OASI) and the effect on their quality of life. We also wished to determine the impact of the injury on decision for future pregnancies and mode of delivery in subsequent pregnancies.

METHODS

A cohort of women who sustained OASI in 2004 in Ninewells Hospital were contacted (minimum 4 years post-repair). They were sent a questionnaire about incontinence of flatus, solid stools, liquid stools, severity of incontinence, quality of life, decision for future pregnancy and mode of delivery in subsequent pregnancy.

RESULTS

70/4,245 (1.7%) women sustained OASI. 42/70 (60%) women responded to the questionnaire. 15/41 (37%) experienced anal incontinence. 8/15 (53%) women had to alter their lifestyle due to their symptoms. Women who were asymptomatic had a median visual analogue score of 0.5 (range 0-4) and women who were symptomatic had a median score of 3.5 (range 2-8). 12/41 (29%) decided against further pregnancies and 8 of them were symptomatic (p 0.015). 16/41 women (39%) did not have any further pregnancy following OASI and 9 of them (56%) had anal incontinence. Of the 25 women who did have further pregnancies, 6 women (24%) had anal incontinence. 19 of them were asymptomatic. (p = 0.03). 5 out of the 6 symptomatic women had elective caesarean sections.

CONCLUSIONS

Long-term outcomes following OASI are not encouraging. A significant number of women decided against further pregnancy and most symptomatic women that have further pregnancy opt to deliver by caesarean section.

Overlapping compared with end-to-end repair of third- and fourth-degree obstetric anal sphincter tears: a randomized controlled trial

OBJECTIVE

To compare overlapping repair with end-to-end repair of obstetric tears and to investigate which procedure results in a higher rate of flatal incontinence.

METHODS

One-hundred forty-nine primiparous women sustaining a complete third- or a fourth-degree tear of the perineum were assigned randomly to a primary sphincter repair using either an end-to-end (n=75) or an overlapping surgical technique (n=74) using 3-0 polyglyconate. Outcome measures at 6 months included rates of flatal and fecal incontinence, quality-of-life scores, integrity of the internal and external anal sphincters by anal ultrasonography, and anal sphincter function as reflected by anal manometry.

RESULTS

Women who underwent overlapping repair compared with end-to-end repair had higher rates of flatal incontinence, 61% compared with 39% (odds ratio [OR] 2.44, confidence interval [CI] 1.2-5.0). The rate of fecal incontinence was also higher, 15% compared with 8% (OR 1.97, CI 0.62-6.3) but did not attain statistical significance. Rates of internal and external anal sphincter defects did not differ significantly between groups and did not correlate with anal incontinence symptoms. Fecal incontinence was higher when there was a defect in both sphincter muscles. Anal sphincter function as assessed by manometry did not differ significantly between groups.

CONCLUSION

End-to-end repair of third- or fourth-degree obstetric anal sphincter tears is associated with lower rates of anal incontinence when compared with overlapping repair.

CLINICAL TRIAL REGISTRATION

ISRCTN Register, isrctn.org, ISRCTN04149919.

LEVEL OF EVIDENCE

I.

Obstetric anal sphincter injury in the UK and its effect on bowel, bladder and sexual function

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.

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

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.

Surgery for faecal incontinence in adults

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.

Overlapping sphincteroplasty: is it the standard of care?

Anal sphincter injury secondary to obstetric trauma during vaginal delivery occurs in nearly one of every five women. Episiotomy, forceps delivery, and prolonged second stage of labor have all been shown to increase the risk of sphincter disruption. One third of these women will go on to have alterations in anal continence ranging from occasional incontinence to gas to severely debilitating incontinence to solid stool. Symptoms often arise many years after delivery, suggesting that factors such as nerve damage and progressive degeneration of muscle fibers contribute to incontinence. Surgical treatment of fecal incontinence secondary to sphincter injury has been varied and creative attempts have been made to find the repair with the greatest durability and fewest complications. Over the past few decades, overlapping sphincteroplasty emerged as such a repair with many reports of excellent short-term outcomes. Recently, however, published reports of long-term data reveal decreased function over time, causing many to question whether this repair truly is the best possible treatment. Several controversies have arisen. These include (1) optimum timing from injury to repair; (2) how best to perform the repair; (3) whether or not fecal diversion, either medical or surgical, is beneficial; (4) whether or not pudendal neuropathy predicts outcome; and finally, (5) if patient's age at the time of repair affects outcome. Randomized controlled trials are lacking, so any conclusions drawn from reviewing current literature must be evaluated with this in mind. Nonetheless, important information can be gleaned from the available literature and future studies designed with the hope of improving treatment for this life-altering condition.

Evaluation and treatment of anal incontinence, constipation, and defecatory dysfunction

Posterior compartment disorders include anal incontinence, constipation, and defecatory dysfunction. These disorders cause considerable morbidity, and are typically underreported by patients and undertreated by providers. The purpose of this article is outline the approach to diagnosis and treatment of anal incontinence, constipation, and defecatory dysfunction with a brief description of the nature of the problem and approaches to evaluation and diagnosis, as well as medical and surgical management.

Management of third degree perineal tear and choice of mode of delivery in subsequent pregnancies

This study evaluates the management of third/fourth-degree obstetric tears and choice of mode of delivery in subsequent pregnancies amongst obstetricians practising in Ireland. Of the 185 obstetricians who were sent questionnaires 133 replied, giving a response rate of 72%. The consultant obstetricians were significantly more likely to suture third-degree tears in the labour ward than the non-consultant counterpart, P=0.04. There was no statistically significant difference between the two groups on the repair technique, P=0.397. The non-consultant obstetricians were significantly more likely to prescribe laxatives and diclofenac (Volterol) after repair of third/fourth-degree tears. There were significant differences between the two groups of obstetricians in terms of choice of mode of delivery in subsequent pregnancies, and the appropriate person to conduct labour, P=0.044 and 0.017, respectively. Instrumental intervention and use of episiotomies were similar in the two groups. Our study also shows that Fellows and Members of the Royal College of Obstetricians and Gynaecologists (RCOG) are not adhering to the guidelines on the repair of third/fourth-degree tears. We conclude that there is variation in the management of third-degree obstetric tears and choice of mode of delivery in subsequent pregnancies among the obstetricians.

Third-degree perineal tears: risk factors and outcome after primary repair

This study aimed to determine the incidence of obstetric anal sphincter tears and to determine the risk factors and outcome after primary repair. This was an audit of third- and fourth-degree tears in 1997-99, occurring in a tertiary obstetric unit with 5000 deliveries per annum. The study involved 75 women with a third-degree tear occurring between 1997 and 1999. A total of 10,307 women delivered vaginally without third-degree tear during this period, and they acted as controls. Obstetric risk factors for tears and the number of patients with ongoing symptoms after repair were studied. Cases were identified from the hospital database. Notes were reviewed to obtain clinical data. Odds ratios were calculated for potential risk factors. The incidence of sphincter tears was 0.6%. The mean age was 27 years and mean birth weight 3532 g; 72% were primiparous and 72% had a spontaneous vaginal delivery. A total of 68% of repairs were performed in theatre, and 76% of repairs were carried out under general or regional anaesthesia. Identified risk factors were nulliparity (OR 1.83), mediolateral episiotomy (OR 2.58), and forceps delivery (OR 3.81); 78% of patients attended for follow-up in the perineal clinic. Forty-four per cent of these women were symptomatic and 75% of the women had evidence of anal sphincter defect on ultrasound. The incidence of obstetric sphincter injury was similar to reports in the literature. Forceps and episiotomy were significant risk factors. Obstetric sphincter injury is associated with significant morbidity as 44% of our patients were symptomatic after repair.

Long-term anal continence and quality of life following postpartum anal sphincter injury

OBJECTIVE

Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long-term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3).

METHOD

In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound.

RESULTS

Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3.

CONCLUSION

Our study indicates that long-term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).