Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment

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Abstract

Background

The aim of the present study was to evaluate the subjective outcome of primary repair of obstetric anal sphincter injury (OASIS) at 6 months, the factors associated with the symptoms of anal incontinence (AI), and the role of a simple survey consisting in one question with three answer choices, combined with the Wexner incontinence score for the assessment of this patient population.

Methods

A retrospective cohort study was conducted on patients with third- or fourth-degree OASIS operated on between January 2007 and December 2013 inclusive at Tampere University Hospital, Finland. At 6 months, the patients were asked to report their Wexner’s score as well as the three-choice assessment regarding AI symptoms. Based on this assessment, the patients were divided into three groups: those, asymptomatic, those with mild symptoms who did not want further treatment and those with severe symptoms who were willing to undergo further evaluation and treatment.

Results

There were 325 patients (median age 30 years). A total of 310 patients answered the questionnaire. Of which, one hundred and ninety-eight (63.9%) patients were asymptomatic, 85 (27.4%) had mild AI, and 27 (8.7%) experienced severe symptoms. There was no statistical difference in the results between the two techniques used (overlapping vs. end-to-end), or the stage of specialization of the operating physician. Persistent symptoms were associated with instrumental vaginal delivery (OR 2.12, 95% CI 1.32–3.41), severity of the injury (OR 1.64, 95% CI 1.20–2.25), and increased maternal age (OR 1.07, 95% CI 1.02–1.13). The correlation between the three-choice symptom evaluation and the Wexner score was good (Spearman’s rho 0.82).

Conclusions

After 6 months, severe symptoms after OASIS repair were present in 9% of women and were more frequent in older women, women with high-degree tears and after instrumental vaginal delivery. A three-choice assessment of AI symptoms correlated well with the Wexner score and might be useful to triage patients who need further evaluation.

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Most cited references 30

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Anal-sphincter disruption during vaginal delivery.

Ali A Sultan, C Bartram, M. Kamm … (1993)

Lacerations of the anal sphincter or injury to sphincter innervation during childbirth are major causes of fecal incontinence, but the incidence and importance of occult sphincter damage during routine vaginal delivery are unknown. We sought to determine the incidence of damage to the anal sphincter and the relation of injury to symptoms, anorectal physiologic function, and the mode of delivery. We studied 202 consecutive women six weeks before delivery, 150 of them six weeks after delivery, and 32 with abnormal findings six months after delivery. Symptoms of anal incontinence and fecal urgency were assessed, and anal endosonography, manometry, perineometry, and measurement of the terminal motor latency of the pudendal nerves were performed. Ten of the 79 primiparous women (13 percent) and 11 of the 48 multiparous women (23 percent) who delivered vaginally had anal incontinence or fecal urgency when studied six weeks after delivery. Twenty-eight of the 79 primiparous women (35 percent) had a sphincter defect on endosonography at six weeks; the defect persisted in all 22 women studied at six months. Of the 48 multiparous women, 19 (40 percent) had a sphincter defect before delivery and 21 (44 percent) afterward. None of the 23 women who underwent cesarean section had a new sphincter defect after delivery. Eight of the 10 women who underwent forceps delivery had sphincter defects, but none of the 5 women who underwent vacuum extractions had such defects. Internal-sphincter defects were associated with a significantly lower mean (+/- SD) resting anal pressure (61 +/- 11 vs. 48 +/- 10 mm Hg, P < 0.001) six weeks post partum, and external-sphincter defects were associated with a significantly lower squeeze pressure (increase above resting pressure, 70 +/- 38 vs. 44 +/- 13 mm Hg; P < 0.001). There was a strong association (P < 0.001) between sphincter defects and the development of bowel symptoms. Occult sphincter defects are common after vaginal delivery, especially forceps delivery, and are often associated with disturbance of bowel function.

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Obstetric anal sphincter injury: incidence, risk factors, and management.

Michael Kamm, Thomas Dudding, Carolynne J Vaizey (2008)

Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management. This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists. A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality. Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

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Changing incidence of anal sphincter tears in four Nordic countries through the last decades.

Katariina Laine, Mika Gissler, Jouko Pirhonen (2009)

Anal sphincter rupture is a serious complication of a vaginal delivery. A considerable number of women suffer permanent anal incontinence after this type of injury. The incidence of sphincter tears is believed to have increased over several decades in Denmark, Norway, Sweden and Finland, but there seem to be significant differences in the incidence rates among these countries. The aim of this study is to compare frequency of anal sphincter tears among the four Nordic countries, and to discuss the possible reasons for the development. Ecological register study. Anal sphincter ruptures are registered as third and fourth degree perineal tears in the national birth and hospital registries in the Nordic countries. Data from these registries were sampled from Denmark, Finland, Norway and Sweden. The incidences of anal sphincter ruptures were calculated as percentages of all vaginal deliveries and caesarean sections were excluded. The test of relative proportions, Chi-square and linear regression modelling were used to study the difference between countries and time trends. The frequency of anal sphincter rupture was significantly higher in three countries, Denmark 3.6%, Norway 4.1% and Sweden 4.2%, compared to Finland 0.6%. The trend was clearly increasing from the early 1970s in all countries. There is a significant difference in the Nordic countries in the incidence of anal sphincter tears and a significant increment in the incidence over three decades. Our hypothesis is that change in the routines during labour may be one reason for this increment. Higher episiotomy frequency in Finland may be one contributing reason. We assume that there has been a change in the conduct of labour during the last decades, and protecting the perineum may have lost its importance in the three Nordic countries, while the classic method of protecting perineum is still in use in Finland.

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Author and article information

Contributors

K. Kuismanen: kirsi.kuismanen@pshp.fi

Journal

Journal ID (nlm-ta): Tech Coloproctol

Journal ID (iso-abbrev): Tech Coloproctol

Title: Techniques in Coloproctology

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1123-6337

ISSN (Electronic): 1128-045X

Publication date (Electronic): 15 March 2018

Publication date PMC-release: 15 March 2018

Publication date (Print): 2018

Volume: 22

Issue: 3

Pages: 209-214

Affiliations

[1 ]ISNI 0000 0004 0628 2985, GRID grid.412330.7, Department of Obstetrics and Gynecology, , Tampere University Hospital, ; Tampere, Finland

[2 ]ISNI 0000 0001 2314 6254, GRID grid.5509.9, Faculty of Medicine and Life Sciences, , University of Tampere, ; Tampere, Finland

[3 ]ISNI 0000 0001 1013 0499, GRID grid.14758.3f, National Institute for Health and Welfare, ; Helsinki, Finland

[4 ]ISNI 0000 0004 0628 2985, GRID grid.412330.7, Department of Gastroenterology and Alimentary Tract Surgery, , Tampere University Hospital, ; Tampere, Finland

Article

Publisher ID: 1770

DOI: 10.1007/s10151-018-1770-9

PMC ID: 5862944

PubMed ID: 29546469

SO-VID: be7e6bf6-c26f-4110-858b-f8cc151207d0

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 15 February 2017

Date accepted : 15 January 2018

Custom metadata

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: anal sphincter,anal incontinence,fecal incontinence,obstetric anal sphincter injury

Data availability:

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: anal sphincter, anal incontinence, fecal incontinence, obstetric anal sphincter injury

Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment

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Abstract

Background

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Conclusions

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Karger: Gastroenterology

Most cited references 30

Anal-sphincter disruption during vaginal delivery.

Obstetric anal sphincter injury: incidence, risk factors, and management.

Changing incidence of anal sphincter tears in four Nordic countries through the last decades.

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