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Cerdán Miguel J, Arroyo Sebastián A, Codina Cazador A, de la Portilla de Juan F, de Miguel Velasco M, de San Ildefonso Pereira A, Jiménez Escovar F, Marinello F, Millán Scheiding M, Muñoz Duyos A, Ortega López M, Roig Vila JV, Salgado Mijaiel G. Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology. Cir Esp 2024; 102:158-173. [PMID: 38242231 DOI: 10.1016/j.cireng.2023.07.008] [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: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 01/21/2024]
Abstract
Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.
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Affiliation(s)
| | - Antonio Arroyo Sebastián
- Servicio de Cirugía General y Aparato Digestivo, Unidad de Coloproctología, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - Antonio Codina Cazador
- Servicio de Cirugía General y Digestiva, Unidad de Coloproctología, Hospital Universitario de Girona, Girona, Spain
| | | | | | | | | | - Franco Marinello
- Unidad de Cirugía Colorrectal, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mónica Millán Scheiding
- Unidad de Coloproctología, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Arantxa Muñoz Duyos
- Unidad de Coloproctología, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Mario Ortega López
- Unidad de Coloproctología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Worrall AP, O'Leary BD, Salameh F. Obstetric anal sphincter injury (OASI) in the presence of an intact perineum. BMJ Case Rep 2023; 16:e253922. [PMID: 37848273 PMCID: PMC10583107 DOI: 10.1136/bcr-2022-253922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
Obstetric anal sphincter injury (OASI) in the absence of concurrent injury to the perineal skin is not a common diagnosis. A primiparous woman delivered a healthy male infant by spontaneous vertex delivery. At time of delivery, a compound presentation of the fetal hand with the head was noted. Initial examination revealed a presumed second-degree tear; however, a small laceration above the anal verge was noted, which on exploration revealed a perineal injury through the anal sphincter complex. In the operating theatre, the perineal skin was incised to reveal a 3c OASI, which was repaired appropriately. While atypical OASI has been reported previously, this specific injury has never been described in detail in the literature. Awareness of atypical perineal injuries is needed and while careful perineal examination is required in all cases, this is especially important where the perineal skin appears intact to ensure appropriate diagnosis of any concurrent OASI.
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Affiliation(s)
- Amy P Worrall
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Bobby D O'Leary
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Fadi Salameh
- Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Bordeianou LG, Thorsen AJ, Keller DS, Hawkins AT, Messick C, Oliveira L, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Fecal Incontinence. Dis Colon Rectum 2023; 66:647-661. [PMID: 37574989 DOI: 10.1097/dcr.0000000000002776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
| | - Amy J Thorsen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Deborah S Keller
- Colorectal Center, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Alexander T Hawkins
- Section of Colon and Rectal Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lucia Oliveira
- Anorectal Physiology Department of Rio de Janeiro, CEPEMED, Rio de Janeiro, Brazil
| | - Daniel L Feingold
- Division of Colon and Rectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Markaryan DR, Lukyanov AM, Garmanova TN, Agapov MA, Kubyshkin VA. [Postpartum fecal incontinence. State of the problem]. Khirurgiia (Mosk) 2022:127-132. [PMID: 35658144 DOI: 10.17116/hirurgia2022061127] [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: 11/17/2022]
Abstract
A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.
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Affiliation(s)
| | - A M Lukyanov
- Lomonosov Moscow State University, Moscow, Russia
| | | | - M A Agapov
- Lomonosov Moscow State University, Moscow, Russia
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Ong F, Phan-Thien KC. How to do it: delayed sphincteroplasty for obstetric anal sphincter injury. ANZ J Surg 2022; 92:1208-1210. [PMID: 35332987 PMCID: PMC9311690 DOI: 10.1111/ans.17650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ferdinand Ong
- Department of Colorectal Surgery, St George Public Hospital, Kogarah, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Kensington, New South Wales, Australia
| | - Kim-Chi Phan-Thien
- Department of Colorectal Surgery, St George Public Hospital, Kogarah, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Kensington, New South Wales, Australia
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Nóbrega MA, Pereira GMV, Brito LGO, Luz AG, Lajos GJ. Severe Perineal Trauma in a Brazilian Southeastern Tertiary Hospital: A Retrospective Cohort Study. Female Pelvic Med Reconstr Surg 2021; 27:e301-e305. [PMID: 32576733 DOI: 10.1097/spv.0000000000000910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence of severe perineal trauma (obstetric and anal sphincter injury [OASIS]) in a tertiary high-risk pregnancy facility and the associated factors. METHODS A retrospective electronic chart review on perineal lacerations was performed from the period of April 2017 to February 2019. Obstetric and anal sphincter injury was diagnosed by a rectal examination. Primary outcome was the prevalence of OASIS (third- and fourth-degree perineal tear). Independent variables were maternal, intrapartum, and neonatal characteristics. Univariate and multivariate analyses with logistic regression models were performed. A P value lower than 0.05 was considered significant. RESULTS The prevalence of OASIS (third/fourth-degree laceration) was 1.51% (43/2846) in our population. Our population was mostly white (66.3%) and mostly primiparous (52.1%). By comparison, the prevalence of first/second-degree laceration was 43% (1223/2846). Selective episiotomy occurred in 18.73% (517/2761) of patients, and it was not associated with OASIS (P = 0.211). Advanced maternal age (P = 0.196), higher number of vaginal examinations (P = 0.169), fetal presentation (P = 0.533), and duration of second stage (P = 0.757) were not associated with OASIS. Univariate analysis has found that forceps delivery (odds ratio [OR], 3.68 [1.74-7.79]; P = 0.001), neonatal macrossomy (OR, 3.42 [1.02-11.43]; P = 0.045), and larger head circumference (OR, 1.15 [1.02-1.32]; P = 0.026) were risk factors for OASIS, whereas higher gravidity reduced the risk (OR, 0.61 [0.42-0.91] for OASIS. However, after multivariate analysis, only head circumference (OR, 1.86 [1.10-3.14]; P = 0.020) remained as a risk factor. CONCLUSIONS Larger neonatal head circumference increased in 86% the risk for severe perineal trauma in this cohort of women.
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Affiliation(s)
- Marina Augusto Nóbrega
- From the Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Maeda K, Yamana T, Takao Y, Mimura T, Katsuno H, Seki M, Tsunoda A, Yoshioka K. Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version. J Anus Rectum Colon 2021; 5:52-66. [PMID: 33537501 PMCID: PMC7843140 DOI: 10.23922/jarc.2020-057] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022] Open
Abstract
Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).
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Affiliation(s)
- Kotaro Maeda
- International Medical Center Fujita Health University Hospital, Toyoake, Japan
| | - Tetsuo Yamana
- Department of Coloproctology, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshihiko Takao
- Division of Colorectal Surgery, Department of Surgery, Sanno Hospital, Tokyo, Japan
| | - Toshiki Mimura
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Mihoko Seki
- Nursing Division, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Kazuhiko Yoshioka
- Department of Surgery, Kansai Medical University Medical Center, Osaka, Japan
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Gillor M, Shek KL, Dietz HP. How comparable is clinical grading of obstetric anal sphincter injury with that determined by four-dimensional translabial ultrasound? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:618-623. [PMID: 32149422 DOI: 10.1002/uog.22011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the agreement between grading of obstetric anal sphincter injuries (OASI) on translabial ultrasound (TLUS), using a newly developed algorithm, and grading on postpartum examination. A secondary aim was to assess the correlation between tear severity, as defined on ultrasound, and symptoms of anal incontinence and/or fecal urgency. METHODS This was a retrospective study of patients seen at a perineal clinic between 2012 and 2018, after recent primary repair of OASI. All patients underwent a standardized interview including the St Mark's anal incontinence test and four-dimensional TLUS. Post-processing of ultrasound volume data was performed blinded to all other data. Using tomographic ultrasound imaging, a set of eight slices was obtained, and the central six slices were evaluated for sphincter abnormalities. Slices with distortion, thinning or defects were rated as abnormal. The following algorithm was used to grade OASI: a Grade-3a tear was diagnosed if the external anal sphincter (EAS) was abnormal in < 4/6 slices; a Grade-3b tear was diagnosed if the EAS was abnormal in ≥ 4/6 slices; and a Grade-3c/4 tear was diagnosed if both the EAS and internal anal sphincter were abnormal in ≥ 4/6 slices. Clinical grading of OASI was determined according to the Royal College of Obstetricians and Gynaecologists guidelines. Agreement between clinical and TLUS diagnosis of OASI was evaluated using weighted κ. RESULTS Of the 260 women seen during the study period, 45 (17%) were excluded owing to missing data or a repeat OASI, leaving 215 complete datasets for analysis. The average follow-up interval was 2.4 months (range, 1-11 months) after OASI and the mean age of the women was 29 years (range, 17-42 years). One hundred and seventy-five (81%) women were vaginally primiparous. OASI was graded clinically as Grade 3a in 87 women, Grade 3b in 80, Grade 3c in 29 and Grade 4 in 19. On imaging, full agreement between clinical and TLUS grading was noted in 107 (50%) women, with a weighted κ of 0.398. In 96 (45%) women, there was disagreement by one category, with a weighted κ of 0.74 and in 12 (6%) there was disagreement by two categories. Twenty-four (11%) women were found to have a normal anal sphincter on imaging. Overall, potential clinical over-diagnosis was noted in 72 (33%) women and potential under-diagnosis in 36 (17%). The seniority of the diagnosing obstetrician did not significantly alter agreement between clinical and sonographic OASI grading (κ 0.44, 0.43, and 0.34, for specialists and senior and junior residents, respectively). The association between symptoms of anal incontinence and/or fecal urgency and TLUS grading did not reach significance (P = 0.052). CONCLUSIONS Clinical and TLUS-based grading of OASI showed fair agreement. Clinical over-diagnosis may be increasingly common in our population, although under-diagnosis may still occur in a significant minority. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Gillor
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Kaplan Medical Centre, Rehovot, Affiliated to the Hebrew University and Hadassah School of Medicine, Jerusalem, Israel
| | - K L Shek
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Liverpool Clinical School, Western Sydney University, Sydney, Australia
| | - H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
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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: 41] [Impact Index Per Article: 10.3] [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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10
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Berg MR, Sahlin Y. Anal incontinence and unrecognized anal sphincter injuries after vaginal delivery- a cross-sectional study in Norway. BMC WOMENS HEALTH 2020; 20:131. [PMID: 32571291 PMCID: PMC7310077 DOI: 10.1186/s12905-020-00989-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 06/12/2020] [Indexed: 11/10/2022]
Abstract
Background Aim of the study was to estimate the prevalence of postpartum anal incontinence among women who delivered vaginally, and to assess the extent to which obstetric injuries to the anal sphincters are missed. Methods All women (both primiparous and multiparous) who delivered vaginally and received any kind of sutures in the perineal area at Innlandet Hospital Trust Elverum in Norway between January 1, 2015 and June 30, 2016 were invited to answer a questionnaire on St. Mark’s incontinence score and to participate in a clinical examination of the pelvic floor including endoanal sonography. Results In total 52,3% (n = 207) of the 396 invited women participated in the study. Mean St. Mark’s score was 1.8 points (95% CI 1.4 to 2.1) at examination 14 months (mean) postpartum, and none of the participants suffered from weekly fecal leakage. Fecal urgency affected 11.7% (95% CI 7.1 to 16.3) of the participants, and 8.7% (95%CI 5.1 to 12.8) had weekly involuntary leakage of flatus. Nine women (9.3%, 95% CI 4.1 to 15.5) had a previously undetected third degree obstetric anal sphincter injury. Conclusion The prevalence of anal incontinence among women who have delivered vaginally and received sutures due to 1st and 2nd degree perineal lacerations is low. Some obstetric anal sphincter injuries remain unrecognized at the time of delivery, but the symptoms of anal incontinence due to these injuries are in the lower half of the St. Mark’s incontinence score. Women with persistent symptoms like fecal urgency or leakage of gas and/or feces should be referred to evaluation by a colorectal surgeon in order to achieve optimal treatment.
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Affiliation(s)
- Matilde Risopatron Berg
- Department of Colorectal Surgery, Innlandet Hospital Trust Hamar, Hamar, Norway. .,University of Oslo, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway.
| | - Ylva Sahlin
- Innlandet Hospital Trust Hamar, Hamar, Norway
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Risk factors and outcome of repair of obstetric anal sphincter injuries as followed up in a dedicated perineal clinic. Int Urogynecol J 2019; 30:1649-1655. [DOI: 10.1007/s00192-019-03960-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/17/2019] [Indexed: 12/17/2022]
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Wickramasinghe DP, Senaratne S, Senanayake H, Samarasekera DN. Three-Dimensional Endoanal Ultrasound Features of the Anal Sphincter in Asian Primigravidae. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2821-2827. [PMID: 29665089 DOI: 10.1002/jum.14640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The normal parameters of 3-dimensional endoanal ultrasound (3DEAUS) of the anal sphincter have not been reported for primigravidae or pregnant women at present. 3DEAUS parameters in Asian primigravidae were assessed in this study. METHODS We analyzed 3DEAUS data of 101 consecutives Asian primigravidae, assessed in the early third trimester. The assessment was performed with a rigid ultrasonic probe (Olympus® RU 12M-R1 probe and EU-ME1 ultrasound system (Olympus Corp., Shinjuku, Japan). The Wilcoxon signed-rank test was used to detect the differences in pressure in different quadrants. RESULTS The participants had a mean age of 24.7 (standard deviation [SD], 5.1) years. The Cleveland Clinic Incontinence Score was normal in all participants. The anal sphincter complex had 3 characteristic segments that were identifiable: upper, middle and lower. The puborectalis muscle was identified as a striated "V"-shaped sling, and its mean thickness was 7.44 (SD, 1.41) mm. The mean thickness of internal (IAS) and external (EAS) sphincters at the mid-sphincter level were 1.78 (SD, 0.59) and 5.49 (SD, 1.21) mm, respectively. The EAS measured 6.02 (SD, 1.07) mm at the lower sphincter level. The statistically significant differences seen in the in quadrants were: the IAS was thicker anteriorly (Z = -2.642; P = .008), the EAS at both midsphincter level (Z = -3.70; P < .001) and lower sphincter level (Z = -7.712; P < .001) was thicker posteriorly, and the IAS was thicker at the 9 o'clock position (Z = -2.081; P = .037). Good symmetry at all 3 levels was seen in the EAS (including the puborectalis muscle). CONCLUSIONS Normal values of 3DEAUS for primigravidae have been identified and may serve as reference values for other laboratories.
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Affiliation(s)
| | | | - Hemantha Senanayake
- Department of Obstetrics and Gynaecology Faculty of Medicine, University of Colombo, Sri Lanka
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13
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Long-Term Outcomes After Overlapping Sphincteroplasty for Cloacal-Like Deformities. Female Pelvic Med Reconstr Surg 2018; 25:271-278. [DOI: 10.1097/spv.0000000000000543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Emile SH, Magdy A, Youssef M, Thabet W, Abdelnaby M, Omar W, Khafagy W. Utility of Endoanal Ultrasonography in Assessment of Primary and Recurrent Anal Fistulas and for Detection of Associated Anal Sphincter Defects. J Gastrointest Surg 2017; 21:1879-1887. [PMID: 28895031 DOI: 10.1007/s11605-017-3574-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/30/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tridimensional endoanal ultrasonography (3D-EAUS) has been used for the assessment of various anorectal lesions. Previous studies have reported good accuracy of 3D-EAUS in preoperative assessment of fistula-in-ano (FIA). This study aimed to assess the diagnostic utility of 3D-EAUS in preoperative evaluation of primary and recurrent FIA and its role in detection of associated anal sphincter (AS) defects. PATIENTS AND METHODS Prospectively collected data of patients with FIA who were investigated with 3D-EAUS were reviewed. The findings of EAUS were compared with the intraoperative findings, the reference standard, to find the degree of agreement regarding the position of the internal opening (IO) and primary tract (PT), and presence of secondary tracts using kappa (k) coefficient test. A subgroup analysis was performed to compare the accuracy and sensitivity of EAUS for primary and recurrent FIA. RESULTS Of the patients, 131 were included to the study. EAUS had an overall accuracy of 87, 88.5, and 89.5% in detection of IO, PT, and AS defects, respectively. There was very good concordance between the findings of EAUS and intraoperative findings for the investigated parameters (kappa = 0.748, 0.83, 0.935), respectively. Accuracy and sensitivity of EAUS in recurrent FIA were insignificantly lower than primary cases. EAUS detected occult AS defects in 5.3% of the patients studied. CONCLUSION The diagnostic utility of 3D-EAUS was comparable in primary and recurrent FIA. 3D-EAUS was able to detect symptomatic and occult AS defects with higher accuracy than clinical examination.
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Affiliation(s)
- Sameh Hany Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt.
| | - Alaa Magdy
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Mohamed Youssef
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Waleed Thabet
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Mahmoud Abdelnaby
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Waleed Omar
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
| | - Wael Khafagy
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura City, Egypt
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Kargın S, Çifçi S, Kaynak A, Ataseven H, Kadıyoran C, Çakır M. The relationship between fecal incontinence and vaginal delivery in the postmenopausal stage. Turk J Obstet Gynecol 2017; 14:37-44. [PMID: 28913133 PMCID: PMC5558316 DOI: 10.4274/tjod.56650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/04/2017] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Obstetric anal sphincter injuries are one of the most significant complications of vaginal delivery that give way to fecal incontinence, which is defined as the involuntary leakage of gas, fluid or solid stool. Although sphincter injuries are seen in 0.5-9% of all deliveries. It has been reported that 20-41% of women who had vaginal deliveries had occult anal sphincter injuries as endoanal ultrasonography began to be used by physicians. The aim of our study was to investigate the relationship between fecal incontinence, whose incidence increases dramatically during the postmenopausal stage, and occult anal sphincter injuries. MATERIALS AND METHODS Two hundred healthy female patients with no history of anal sphincter injury, aged between 18 and 70 years were included in the study. The participants were divided into 4 groups according to their menopausal stages and mode of delivery; premenopausal (group 1) and postmenopausal (group 2) vaginal delivery, and premenopausal (group 3) and postmenopausal (group 4) cesarean section. Wexner incontinence scores were determined. The participants' defects were assessed using endoanal ultrasound and their status of fecal incontinence using anorectal manometric measurements. RESULTS Anorectal manometric measurement results were found significantly lower in group 1 than in group 3 (p<0.01). The Wexner scores of groups 1 and 3 were similar. The anorectal manometric measurement results of group 2 were significantly lower than those of group 4, and the Wexner score of group 2 was significantly higher than other groups (p=0.03). CONCLUSION Anal sphincter injuries formed after vaginal delivery may be one of the reasons that increase the incidence of postmenopausal fecal incontinence and cause the formation of fecal incontinence symptoms in women.
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Affiliation(s)
- Süleyman Kargın
- Medova Private Hospital, Clinic of General Surgery, Konya, Turkey
| | - Sami Çifçi
- Karaman State Hospital, Clinic of Gastroenterology, Karaman, Turkey
| | - Adnan Kaynak
- Necmettin Erbakan University Meram Faculty of Medicine, Department of General Surgery, Konya, Turkey
| | - Hüseyin Ataseven
- Necmettin Erbakan University Meram Faculty of Medicine, Department of Gastroenterology, Konya, Turkey
| | | | - Murat Çakır
- Necmettin Erbakan University Meram Faculty of Medicine, Department of General Surgery, Konya, Turkey
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González MS, Garriga JC, Capel CD, Roda OP, Capó JP, Saladich IG. Is obstetric anal sphincter injury a risk factor for levator ani muscle avulsion in vaginal delivery? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:257-262. [PMID: 26701063 DOI: 10.1002/uog.15847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 12/17/2015] [Accepted: 12/21/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To analyze whether women who sustain obstetric anal sphincter injury (OASI) in their first vaginal delivery have a higher incidence of levator ani muscle (LAM) avulsion than do women without OASI. METHODS We conducted a prospective observational cohort study of 80 primiparous women who gave birth at our tertiary obstetric unit between September 2011 and July 2013. The women were divided into two groups: women diagnosed with OASI during vaginal delivery (n = 40) and women without OASI (n = 40), matched by mode of delivery and newborn birth weight. Four-dimensional (4D) transperineal ultrasound was performed in all participants at 6-12 months after delivery to assess for integrity or avulsion of the LAM. Ultrasound images were evaluated by two observers who were blinded to group assignment and clinical data. Interobserver agreement was assessed to determine the reproducibility of 4D transperineal ultrasound for diagnosing LAM avulsion. RESULTS We found no statistically significant differences between the two groups. The incidence of LAM avulsion was 24.3% in the OASI group and 34.2% in the control group (P = 0.448). Interobserver agreement in the diagnosis of LAM avulsion in the study population using 4D transperineal ultrasound was 89.5%, with a kappa index of 0.76. CONCLUSIONS Our findings do not support OASI as a risk factor for LAM avulsion. Prospective studies in larger populations are needed to establish the biomechanical relationships of the pelvic floor structures involved in vaginal delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Simó González
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - J Cassadó Garriga
- Department of Gynecology and Obstetrics, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - C Dosouto Capel
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - O Porta Roda
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - J Perelló Capó
- Gynecology and Obstetrics Department, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
| | - I Gich Saladich
- Clinical Epidemiology Unit, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
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van Limbeek S, Davis D, Currie M, Wong N. Non-surgical intrapartum practices for the prevention of severe perineal trauma: a systematic review protocol. ACTA ACUST UNITED AC 2016; 14:30-40. [PMID: 27532307 DOI: 10.11124/jbisrir-2016-2473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this review is to determine the effectiveness of non-surgical intrapartum practices in reducing the incidence of severe perineal trauma (third and fourth degree tears) during childbirth.
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Affiliation(s)
- Sophie van Limbeek
- 1ACT Health, Canberra, Australia 2Disciplines of Nursing and Midwifery, Faculty of Health, University of Canberra, Australia 3Australian Capital Regional Center for Evidence-Based Nursing and Midwifery Practice: an Affiliate Center of the Joanna Briggs Institute
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Karcaaltincaba D, Erkaya S, Isik H, Haberal A. The immediate effect of vaginal and caesarean delivery on anal sphincter measurements. J Int Med Res 2016; 44:824-31. [PMID: 27353519 PMCID: PMC5536623 DOI: 10.1177/0300060516653066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/11/2016] [Indexed: 11/20/2022] Open
Abstract
Objective This study evaluated the effects of vaginal and caesarean delivery on internal and external anal sphincter muscle thickness using translabial ultrasonography (TL-US). Methods This prospective cohort study enrolled nulliparous women who either had vaginal or caesarean deliveries. The thickness of the hypoechoic internal anal sphincter (IAS) and hyperechoic external anal sphincter (EAS) at the 12, 3, 6, and 9 o’clock positions at the distal level were measured before delivery and within 24–48 h after delivery. Results A total 105 consecutive women were enrolled in the study: 60 in the vaginal delivery group and 45 in the caesarean delivery group. The IAS muscle thickness at the 12 o’clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.31 ± 0.74 mm versus 1.81 ± 0.64 mm, respectively). The EAS muscle thickness at the 12 o’clock position in the vaginal delivery group was significantly thicker before compared with after delivery (mean ± SD: 2.42 ± 0.64 mm versus 1.97 ± 0.85, respectively). Conclusions There was significant muscle thinning of both the IAS and EAS at the 12 o’clock position after vaginal delivery, but not after caesarean delivery.
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Affiliation(s)
| | - Salim Erkaya
- Department of Obstetrics and Gynaecology, Etlik Zübeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Hatice Isik
- Department of Obstetrics and Gynaecology, Zonguldak Karaelmas University, Zonguldak, Turkey
| | - Ali Haberal
- Department of Obstetrics and Gynaecology, Gazi University, Ankara, Turkey
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Shek KL, Zazzera VD, Atan IK, Rojas RG, Langer S, Dietz HP. The evolution of transperineal ultrasound findings of the external anal sphincter during the first years after childbirth. Int Urogynecol J 2016; 27:1899-1903. [DOI: 10.1007/s00192-016-3055-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/12/2016] [Indexed: 12/31/2022]
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Ashwal E, Aviram A, Wertheimer A, Krispin E, Kaplan B, Hiersch L. The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial. J Matern Fetal Neonatal Med 2015; 29:3024-9. [PMID: 26669965 DOI: 10.3109/14767058.2015.1114079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity. METHODS Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4 cm dilation). The primary measured outcome was the length of second stage of labor. RESULTS Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery. CONCLUSION Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.
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Affiliation(s)
- Eran Ashwal
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Amir Aviram
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Avital Wertheimer
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Eyal Krispin
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Boris Kaplan
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Liran Hiersch
- a Helen Schneider Hospital for Women, Rabin Medical Center , Petach Tikva , Israel and.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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Walsh KA, Grivell RM. Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. Cochrane Database Syst Rev 2015; 2015:CD010826. [PMID: 26513224 PMCID: PMC6465178 DOI: 10.1002/14651858.cd010826.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND During childbirth, many women sustain trauma to the perineum, which is the area between the vaginal opening and the anus. These tears can involve the perineal skin, the pelvic floor muscles, the external and internal anal sphincter muscles as well as the rectal mucosa (lining of the bowel). When these tears extend beyond the external anal sphincter they are called 'obstetric anal sphincter injuries' (OASIS). When women sustain an OASIS, they are at increased risk of developing anal incontinence either immediately following birth or later in life. Anal incontinence is associated with significant medical, hygiene and social problems. Endoanal ultrasound (EAUS) can be performed with a bedside scanner by inserting a small probe into the anus and the structures of the anal canal and perineum can be reviewed in real-time. We proposed that by examining the perineum with EAUS after the birth of the baby and before the tear has been repaired, there would be an increase in detection of OASIS. This increased detection could lead to improved primary repair of the external and internal anal sphincter resulting in reduced rates of anal incontinence and improved quality of life for women. EAUS may also have a role after perineal repair in the evaluation of residual injury and may help guide a woman's management in subsequent pregnancies and allow for early referral to specialised units, minimising long-term complications. OBJECTIVES To evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015) and reference list of the one retrieved study. SELECTION CRITERIA Randomised control trials (RCTs) comparing EAUS versus no ultrasound in women prior to repair of perineal trauma and EAUS performed after perineal repair. RCTs published in abstract form only and trials using a cluster-randomised design were eligible for inclusion, but none were identified.Trials using a cross-over design and quasi-RCTs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS The two review authors independently assessed the single trial for inclusion and assessed trial quality. Both review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS We included one trial that randomised 752 primiparous women with clinically detectable second-degree perineal tears to either further assessment with EAUS prior to perineal repair or standard care. We assessed this trial as being at a low risk of bias. The trial reported women's anal incontinence at three and 12 months as well as their pain scores and quality of life assessment. The trial authors reported outcomes at three months for 719 women (364 in the experimental group, 355 in the control group, 4% loss to follow-up), and an outcome at 12 months for 684 women (342 in the experimental group, 342 in the control group, 9% loss to follow-up). Primary outcomeCompared with clinical examination (routine care), the use of EAUS prior to perineal repair was associated with a reduction in the rate of severe anal incontinence (defined as involuntary loss of faeces or flatus that constitutes social and/or hygiene problems, or as defined by authors), at greater than six months postpartum (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.24 to 0.97, 684 women at the 12-month time point). Secondary outcomes Severe anal incontinence at less than six months was reduced with the use of EAUS prior to repair when compared with clinical examination (routine care) (RR 0.38, 95% CI 0.20 to 0.72, 719 women). However, increased perineal pain at three months was associated with the use of EAUS prior to perineal repair when compared with routine care (RR 5.86, 95% CI 1.74 to 19.72, 684 women). There was no clear difference in the number of women who reported any anal incontinence at either less than six months or equal to or greater than six months (outcomes not prespecified in our published protocol). Similarly, there was no clear difference between groups in terms of faecal incontinence, flatal incontinence, faecal urgency, or maternal quality of life. The study did not report any data on the need for secondary repair of external anal sphincter, dyspareunia, women's satisfaction with care or the planned or actual mode of birth in any subsequent pregnancy. We were unable to assess the detection rates of OASIS with EAUS from the included study because women with clinically-detected OASIS were excluded from randomisation. AUTHORS' CONCLUSIONS There is some evidence to suggest that EAUS prior to perineal repair is associated with reduced risk of severe anal incontinence but an increase in the incidence of perineal pain at three months postpartum. However, these results are based on one small study involving 752 women. The study took place in a large teaching hospital with an average to busy labour ward. The trial participants were similar to those found in most large obstetric units in developed countries, thus increasing applicability of the evidence, but were restricted to primiparous women.More research is needed to further evaluate the effectiveness of EAUS in the detection of OASIS following vaginal birth and in reducing the risk of anal sphincter complications related to OASIS. More high-quality RCTs are needed to fully evaluate the intervention before the routine use of EAUS on the labour ward could be supported. It would be particularly useful if future trials could assess detection rates of OASIS with EAUS versus clinical examination alone as this is the basis of the theory for improved outcomes with this intervention. Cost and the training required to implement EAUS should be considered, along with maternal quality of life and individual symptoms experienced by postnatal women . It would also be useful to follow up women after their subsequent vaginal births to determine if subsequent mode of delivery affects long-term outcomes. Future studies in multiparous women may also be useful.
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Affiliation(s)
- Kate A Walsh
- Women's and Childrens HospitalDepartment of Obstetrics and Gynaecology55 King William RoadNorth AdelaideAdelaideSAAustralia5006
| | - Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and Gynaecology, Robinson Research Institute72 King William RoadAdelaideSouth AustraliaAustraliaSA 5006
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Milsom I. Can we predict and prevent pelvic floor dysfunction? Int Urogynecol J 2015; 26:1719-23. [PMID: 26493692 DOI: 10.1007/s00192-015-2868-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/01/2015] [Indexed: 01/27/2023]
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Wickramasinghe DP, Perera CS, Senanayake H, Samarasekera DN. Correlation of three dimensional anorectal manometry and three dimensional endoanal ultrasound findings in primi gravida: a cross sectional study. BMC Res Notes 2015; 8:387. [PMID: 26318733 PMCID: PMC4553000 DOI: 10.1186/s13104-015-1346-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 08/12/2015] [Indexed: 12/13/2022] Open
Abstract
Background 3-dimensional anorectal manometry (3DARM) and 3-dimensional endoanal ultrasound (3DEAUS) have not been used to assess the anal sphincter complex (ASC) in primi gravida. This study was conducted to identify any correlation that may exist between 3DARM and 3DEAUS. Methods
We analyzed 3DARM and 3DEAUS data of 101 consecutive primi mothers assessed in the late second trimester or early 3rd trimester. 3DARM was performed using the Given Imaging® Manoscan system and 3DEAUS was performed with the Olympus® RU 12M-R1 probe and EU-ME1 ultrasound system. Results The mean age was 24.7 (SD—5.1) years. All patients had a normal Cleveland Clinic Incontinence Score. The mean resting pressure (RP) was 87.02 (SD—18.43) mmHg and the maximum squeeze pressure (SP) was 179.21 (SD—52.96) mmHg. The mean length of the high pressure zone was 3.67 (SD—0.52) cm. On 3DEAUS, there were three characteristic segments of the ASC that were identified; upper, middle and lower. Mean thicknesses for both internal anal sphincter (IAS) and external anal sphincter (EAS) were identified for primi gravida. IAS was thicker anteriorly and at 9 o’ clock positions and EAS was thicker posteriorly. There was good correlation in the length of the ASC at each quadrant between 3DARM and 3DEAUS. There was no correlation between either RP or SP thickness of IAS or EAS at each level and quadrant. Conclusion Correlation is seen only in the length of ASC at each quadrant. No correlation exist between RP or SP and thickness of IAS and EAS.
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Affiliation(s)
| | - Chamila Sudarshi Perera
- Department of Surgery, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka.
| | - Hemantha Senanayake
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka.
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Does preoperative anal physiology testing or ultrasonography predict clinical outcome with sacral neuromodulation for fecal incontinence? Int Urogynecol J 2015; 26:1613-7. [PMID: 26017894 DOI: 10.1007/s00192-015-2746-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/14/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND HYPOTHESIS To determine the value of preoperative anal physiology testing and transanal ultrasonography in predicting clinical response to sacral neuromodulation for fecal incontinence. METHODS We report a retrospective study of all patients treated with sacral neuromodulation for fecal incontinence in a single practice between 2011 and 2014 was performed. Patient demographics included age, gender, comorbidities, presence of an ultrasound-defined external sphincter defect, and history of prior anal sphincter repair. Cleveland Clinic Florida (CCF) scores were used to assess the severity of fecal incontinence at baseline, and at 3, 6 and 12 months. Pearson's correlation coefficient was used to evaluate the relationship between preoperative physiology testing and ultrasonography and patient outcome. RESULTS Sacral neuromodulation was trialed in 60 patients, of whom 31 had anorectal physiology testing and 29 did not. Patients who were tested were younger (60.9 vs. 71.4 years, p = 0.013) and more likely to have had a prior overlapping sphincteroplasty (40.5% vs. 15%, p = 0.043). Among patients who progressed to complete system implantation, CCF scores at 3 and 12 months were similar whether they had physiology testing or not. Likewise, patient outcome did not correlate with the finding of an ultrasound-defined external sphincter defect. Pearson's correlation coefficient was used to evaluate the relationship between the test results and the 3-month CCF scores. CCF scores 3 months after full system implantation did not correlate with the presence or size of an external sphincter defect, resting or squeeze pressure, pudendal nerve terminal motor latency, rectoanal inhibitory reflex, or minimum detectable volume. CONCLUSIONS Anal physiology testing and ultrasonography were not predictive of clinical outcomes among patients treated with sacral neuromodulation for fecal incontinence.
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Long-term outcome of obstetric anal sphincter injury repaired by experienced obstetricians. Int J Gynaecol Obstet 2014; 126:130-5. [PMID: 24866049 DOI: 10.1016/j.ijgo.2014.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/03/2014] [Accepted: 04/22/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the long-term outcomes of women with obstetric anal sphincter injury (OASI) repaired by obstetricians without the involvement of colorectal surgeons. METHODS A retrospective cohort study was undertaken of women who had been admitted for delivery between 2004 and 2012. All OASIs had been repaired by experienced obstetricians using the end-to-end technique. An unexposed group (no OASI) was matched at a ratio of 1:1. Fecal incontinence was graded using a modified Wexner questionnaire. RESULTS Overall, 113 OASIs were recorded. Sixty-seven (59.3%) and 71 (62.8%) women from the exposed and unexposed groups, respectively, agreed to participate in the study (P=0.9). Continence to both stool and gas was reported by 48 (71.6%) and 64 (90.1%) women in the exposed and unexposed groups, respectively (P=0.03). The incidence of urgency, dyspareunia, and use of a pad or constipating agents was the same in both groups. CONCLUSION The long-term outcome of OASI repair performed by experienced obstetricians is comparable to that reported in the literature. Some women who did not sustain an OASI reported fecal incontinence, which suggests that only a proportion of fecal incontinence can be attributed to OASI.
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Wilson D, Dornan J, Milsom I, Freeman R. UR-CHOICE: can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? Int Urogynecol J 2014; 25:1449-52. [DOI: 10.1007/s00192-014-2376-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 03/13/2014] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To examine problems experienced by women after vaginal delivery with and without a sphincter tear and compare those with less and more severe injuries. DESIGN Retrospective questionnaire study. Setting. Regional hospital in Sweden. SAMPLE A total of 324 women with and 309 without sphincter tears. METHODS Questionnaires were sent out four to eight years after delivery enquiring about the existence and time course of gas incontinence, fecal incontinence, dyspareunia and perineal pain. A question about vacuum delivery was also included. MAIN OUTCOME MEASURES Prevalence of persisting symptoms. RESULTS The reply rate was 77%. About 10% of the women with a sphincter tear had fecal incontinence initially, compared with 3% among those without a sphincter tear. In women with moderate or severe tears, 20 and 31%, respectively, had gas incontinence, compared with 6% of women without a tear. Dyspareunia and perineal pain were present 18-23% of women in the tear groups compared with 9-12% of those without a tear. Almost 45% of women with initial symptoms had remaining problems after four to eight years. There was a significantly higher risk for symptoms after vacuum extraction (p < 0.001). CONCLUSIONS Gas incontinence, fecal incontinence, dyspareunia and perineal pain were common problems after delivery. The prevalence of persisting symptoms was high even among women without a tear. The higher prevalence after vacuum extraction delivery indicates that there are more complications associated with this mode of delivery than previously thought.
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