Anal Sphincter Rupture Research Articles

Surgery for female dyspareunia after perineal trauma

Perineal trauma during labor and vulvo-vaginal surgery is common and entails pain, dyspareunia, and other quality of life issues. Herein we describe common pitfalls, reconstruction problems and considerations illustrated by two cases. Diagnosis: A thorough conversation with the woman about her history concerning trauma and present symptoms including sex life before the trauma. Examination: Visual traces of the trauma and palpation for persisting trigger points in accordance with the history. CASE 1: Had previously had two operations for Bartholinitis and two operations for vulvo-vaginal fistulas. She had severe external dyspareunia and not been able to engage in intercourse for 1 ½ year when referred. CASE 2: Suffered a total obstetric anal sphincter rupture during first delivery. Primary suturing was performed in the delivery room. The patient suffered from severe dysparunia and soiling during intercourse three months after the delivery. A low perineum and a low rectocele were seen. By 3D ultrasound a very short external anal sphincter was seen. The transverse perineal and bulbocavernose muscle were still torn. Surgery: Removal of scar tissue. Identifying affected anatomical structures. Usually, the superficial and deep transverse perineal muscle, the bulbocavernosus muscle and the rectovaginal fascia are traumatized. Examples of anatomical correct reconstruction are presented. Postoperative: Weekly Low Level Laser therapy (LLLT) for three weeks was applied, and pain killers were used. Scar tissue massage after four weeks. Recommendation of no intercourse for six weeks. After a longer period with dyspareunia, sex is usually connected with an expectation of pain even when the trigger is removed. This is partially caused by strong pelvic muscle contractions. Supportive consultations about sexual issues are usually necessary to obtain a complete recovery with a healed body and mind. Anatomical correct reconstructive surgery after long term dyspareunia is best treated in a bio-psycho-social frame. No conflict of interest

Induction of labor in breech presentations - a retrospective cohort study.

There is limited evidence on the safety and outcome of induction of breech labor. In this study, we aimed to compare the outcomes of spontaneous and induced breech deliveries and to describe variations in induction rates. This was a retrospective cohort study comprising 1054 singleton live fetuses in breech presentation at Trondheim University Hospital from 2012 to 2019. The main outcome was intrapartum cesarean section, and secondary outcomes were postpartum hemorrhage, anal sphincter ruptures, Apgar scores, pH in the umbilical artery, and metabolic acidosis. All data were obtained from the hospital birth journal. Induction of labor was performed in 127/606 (21.0%) women with planned vaginal birth. The frequency of intrapartum cesarean section was 48.0% for induced labor vs 45.7% for spontaneous labor (P=.64). We found no differences in the frequency of postpartum hemorrhage or anal sphincter ruptures between induced and spontaneous births. The median pH in the umbilical artery was significantly lower in neonates with induced labor compared with neonates with spontaneous labor (7.22 vs 7.25; P=.02). The frequency of pH <7.05 was 7.0% for induced labor vs 2.9% (P=.05) for spontaneous labor, but the frequency of pH <7.0 was not significantly different: 2.6% vs 0.8% (P=.14), respectively. Three neonates with planned vaginal birth had metabolic acidosis: two with spontaneous labors and one with induced labor. Three fetuses with planned vaginal birth died during labor: two with spontaneous onset of labor and one with induced labor. All three were extremely preterm: two were delivered in week 23 and one in week 25. We did not observe any significant trend in induction rates in either parous or nulliparous women. The induction rates were stable during the study period. We did not observe any significant difference in intrapartum cesarean section rates, in the frequency of pH <7.0 in the umbilical artery, or in the frequency of metabolic acidosis when comparing induced and spontaneous breech deliveries.

Induction of labour in nulliparous women- quick or slow: a cohort study comparing slow-release vaginal insert with low-dose misoprostol oral tablets

BackgroundThis study was undertaken with the objective of comparing efficacy and safety for two different regimens using misoprostol for induction of labour.MethodsThe study was set in two different hospitals in the region of Zeeland, Denmark, and designed as a prospective cohort study. Nulliparous women with unripe cervix, eligible for vaginal delivery and medical induction of labour were included. Exclusion criteria were a previous uterine scar, suspicion of growth restriction of the fetus and prelabour rupture of membranes.One department used 25 mcg oral misoprostol tablets and the other department used 200 mcg slow-release misoprostol vaginal insert, for induction of labour.Primary outcomes were predefined as frequency of cesarean section, tachysystole and delivery within 24 h. Secondary outcomes were: time from induction to delivery, use of additional methods for induction, postpartum hemorrhage, anal sphincter rupture, epidural, pyrexia (rectal temperature > 38.5 °C), prolonged rupture of membranes, and use of tocolysis.ResultsNo significant differences in women achieving vaginal delivery was found. However, a significantly increased risk of tachysystole for the vaginal administration route was observed; 28.4% compared with 2.3%. There were no events of serious neonatal asphyxia. Half of the women induced with vaginal insert delivered within 24 h, compared with 16.8% of the women induced with oral misoprostol.ConclusionsInduction with vaginal slow-release misoprostol leads to quicker delivery with an increased risk of tachysystole but with similar perinatal outcomes and rates of cesarean sections. Low-dose oral misoprostol appears to be safe, however it leads to an increased use of secondary methods and a tendency of more intrapartum pyrexia.Trial registrationClinicaltrials.gov ID: NCT02693587 on February 262,016.EudraCT number 2020–000366-42 on 23 January 2020, retrospectively registered.

Anal/anogenital lesion revealing child sexual abuse: A case series of an unusual situation in a black African setting

IntroductionChild sexual abuse (CSA) remains a big taboo in black Africa with an underestimated prevalence. In our context, the majority of cases are known by revelations of the child at least one year after the facts. Presentation of casesWe report three cases of CSA revealed by an anal/anogenital lesion requiring surgery. All of these patients were female with ages ranging from 20 months to 8 years. The lesions encountered were: an anal abscess, a fissure-in-ano with permanent anal mucosal eversion and a complex perineal tear including partial anal sphincter rupture with partial section of the rectovaginal septum. The outcome was favorable in all cases after surgery. The abuser was subsequently able to be identified after the statements of two of these three children. DiscussionDetection of anogenital lesions during a pediatric consultation should make practitioners aware of the possibility of sexual abuse. Surgical repair of these lesions can be simple or complex, requiring major reconstructions. In such cases, it’s important to listening to the child’s voice. ConclusionAnogenital lesions discovered during pediatric consultation must evoke sexual abuse. The silence and the taboo surrounding these abuses in Africa must be break down.

Obstetric perineal ruptures—risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study

Anal incontinence leads to impairment of the quality of life and lower self-esteem with implications for social, physical, and sexual health; anal incontinence after vaginal delivery is a major concern for many women. Only about half of the cases of postpartum anal incontinence can be related to anal sphincter injuries, and the remaining cases must thus be related to other factors. The aim of this study was to examine the association between maternal and obstetric characteristics, including the degree of perineal rupture and anal incontinence 12 months postpartum. Furthermore, the aim was to investigate the association between anal sphincter muscle defects, perineal length, and perineal strength and the risk of anal incontinence. We conducted a prospective cohort study at 4 Danish hospitals: Odense University Hospital, Aarhus University Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data were obtained 2 weeks postpartum in relation to an evaluation of perineal wound healing. Symptoms of anal incontinence were evaluated 12 months postpartum by a Web-based questionnaire (St. Mark's incontinence score questionnaire). In addition, defects in the anal sphincter muscles were examined using endoanal ultrasound, perineal length was measured, and perineal strength was examined using anal manometry. The main outcome measurement was anal incontinence defined as a St. Mark's score of >4. We performed multivariate analyses to investigate the risk factors for anal incontinence and to investigate the risk of anal incontinence according to endoanal ultrasound scanning and anal manometry findings. A total of 603 primiparous women (203 with no/labia/first-degree ruptures, 200 with second-degree ruptures, and 200 with third-/fourth-degree ruptures) were included between July 2015 and January 2018. At 12 months postpartum, 575 women (95%) answered the questionnaire; 193 with no/labia/first-degree ruptures, 193 with second-degree ruptures, and 189 with third-/fourth-degree ruptures. A total of 499 women underwent an endoanal ultrasound scanning and 482 women underwent anal manometry. Anal incontinence with a St. Mark's score of >4 was reported by 7% and 9% of women with no/labia/first-degree ruptures or second-degree ruptures, respectively, and by 14%, 15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4, respectively. Compared to women with no or minor tears, women with anal sphincter ruptures had a higher risk of anal incontinence (adjusted relative risk, 2.46; 95% confidence interval, 1.28-4.71). Ruptures of degree 3c and 4 were associated with a substantial increase in risk of anal incontinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98-11.3; and adjusted relative risk, 2.23; 95% confidence interval, 1.59-11.3, respectively), especially if a defect in the external or internal anal sphincter muscle was present (adjusted relative risk, 4.74; 95% confidence interval, 1.54-14.5; and adjusted relative risk, 6.58; 95% confidence interval, 3.35-12.9, respectively). The risk of anal incontinence increased by 8% per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95% confidence interval, 1.03-1.14). Obesity with body mass index of >29.9 and a high-degree rupture (3c or 4), especially with a persistent defect in the internal or external anal sphincter muscle, increased the risk of anal incontinence.

Incidence and risk factors for obstetric anal sphincter ruptures, OASIS, following the introduction of preventive interventions. A retrospective cohort study from a Norwegian hospital 2012–2017

ObjectiveA decrease of obstetric anal sphincter injuries (OASIS) was observed after preventive interventions were implemented at a Norwegian university hospital. The aim was to investigate whether the improvement had sustained over the following years. Materials and methodsWe performed a retrospective cohort study of 18 258 singleton vaginal cephalic births, ≥37 + 0 weeks of gestation during 2012–2017, examining data from the hospital’s birth journals and separate registration forms. Interventions to prevent OASIS were implemented in 2011, and training in practical skills was repeated each year. Main outcome measuresThe main outcome was OASIS (n = 377). ResultsFrequency of OASIS overall decreased from 3.6% prior to 2011 to 2.1% after the intervention and sustained at that level throughout the study period. A trend of fewer OASIS among spontaneous deliveries, decreasing from 2.1% to 1.2% (p = 0.01) was observed, but no trend was seen for instrumental deliveries (p = 0.37), where the incidence fluctuated between 4.0% and 9.3% with an average of 6.5%. Primiparity, increased maternal age and increased fetal head circumference were associated with more OASIS in spontaneous deliveries. In instrumental deliveries, primiparity, occiput posterior position and increased fetal head circumference were associated with more OASIS, whilst episiotomy was associated with fewer OASIS. ConclusionThe incidence of obstetric anal sphincter injuries maintained at a similar level of around 2.1% during the six following years after introducing preventive interventions. Regularly repetition and practical training seemed to be effective.

Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture.

To evaluate prevalence and risk factors for long-term anal incontinence in women with two prior vaginal deliveries without obstetric anal sphincter injury (OASIS) and to assess the impact of anal incontinence-related symptoms on quality of life. This is a nation-wide cross-sectional survey study. One thousand women who had a first vaginal delivery and a subsequent delivery, both without OASIS, between 1997 and 2008 in Denmark were identified in the Danish Medical Birth Registry. Women with more than two deliveries in total till 2012 were excluded at this stage. Of the 1000 women randomly identified, 763 were eligible and received a questionnaire. Maternal and obstetric data were retrieved from the national registry. The response rate was 58.3%. In total, 394 women were included for analysis after reviewing responses according to previously defined exclusion criteria. Median follow-up time was 9.8years after the first delivery and 6.4years after the second. The prevalence of flatal incontinence, fecal incontinence and fecal urgency were 11.7, 4.1, and 12.3%, respectively. Overall, 20.1% had any degree of anal incontinence and/or fecal urgency. In 6.3% these symptoms affected their quality of life. No maternal or obstetric factors including episiotomy and vacuum extraction were consistently associated with altered risk of anal incontinence in the multivariable analyses. Anal incontinence and fecal urgency is reported by one fifth of women with two vaginal deliveries without OASIS at long-term follow-up. Episiotomy or vacuum extraction did not alter the risk of long-term anal incontinence.

Severe perineal morbidity of instrumental deliveries using Thierry's spatulas and vacuum extraction: A prospective observational cohort study

To evaluate the risk of severe perineal tear following instrumental vaginal delivery (IVD) performed with spatulas and vacuum extraction. Secondary objectives were to estimate the impact of episiotomy on this risk. From December2008 to October2012, women who underwent spatulas or vacuum were prospectively included. Each spontaneous vaginal delivery (SVD) following each included IVD were included as control cases (1-1ratio). Careful perineal examination was systematically performed. Severe perineal tear was defined by the occurrence of anal sphincter rupture with or without anal mucosa tear. A total of 761patients were included in the current study: 248 (64%) spatulas, 137 (36%) vacuums and 381 (49%) SVDs. Severe perineal tear was diagnosed in 19 (2.5%) cases. Episiotomy had been performed in 276 (36.9%) patients. Only spatulas extraction was found to significantly increase the risk of severe perineal tear (AOR=7.66; 95% CI: 2.06-28; P=0.02). Although vacuum extraction seemed to increase this risk, it was not found to be significant (AOR=3.25; 95% CI: 0.65-16.24; P=0.15). No significant difference was observed between the risk of severe perineal tear following spatulas and vacuum (AOR=2.36; 95% CI: 0.63-8.82; P=0.202). Finally, neither foetal macrosomia, nor episiotomy, nor foetal extraction with the head in the deep pelvis, nor delivery at night had a significant impact on the probability of severe perineal tear. Spatulas extraction is an independent risk factor for severe perineal tear. The practice of episiotomy was not shown to have any significant impact on this risk.

State-of-the-art review.

State-of-the-art review.

A five year follow-up of women with obstetric anal sphincter rupture at their first delivery

ObjectivesObstetric anal sphincter rupture (OASR) is considered a risk factor for subsequent fecal incontinence and suspected to be a risk factor for urinary incontinence and sexual dysfunction. The aims of this study were to assess risk factors for the different grades of OASR and to evaluate the clinical outcome five years after birth using validated questionnaires. Study designA five year follow-up study was performed on 82 women with OASR during their first delivery in 2009. Case records were reviewed for known risk factors for OASR. Three questionnaires were mailed to the women: The St. Marks fecal incontinence score, The Danish anal sphincter rupture questionnaire (DASRQ) and a short supplemental questionnaire. The data were analyzed using Wilcoxon rank sum test, Fisher's exact test and Kruskal–Wallis test. ResultsFifty percent had an OASR 3a, 32% an OASR 3b, and 18% OASR 4. None of the investigated risk factors showed statistically significant difference according to the degree of rupture. Seventy-four percent of the women had some degree of fecal incontinence with a significantly higher frequency of fecal incontinence in rupture group 4 than in 3a. Forty-four percent had urinary incontinence and 50% had some sort of sexual dysfunction with no significant differences between the rupture groups. ConclusionNone of the investigated risk factors increased the incidence of more severe grades of rupture. Ninety-one percent of women with OASR at their first delivery had some degree of fecal or urinary incontinence or sexual dysfunction five years after. The symptoms of fecal incontinence showed a tendency to be more severe in women with more advanced sphincter rupture.

The Incidence of Anal Sphincter Ruptures and Risk Factors

Objective: To analyze the incidence of anal sphincter ruptures and&#x0D; to evaluate risk factors of obstetric anal sphincter ruptures in Dr.&#x0D; Cipto Mangunkusumo Hospital.&#x0D; Method: We reviewed 2009 vaginal deliveries based on the analysis&#x0D; of obstetric data base and patient records of our department during&#x0D; 2012. Cases and control subjects were chosen randomly and patient’s&#x0D; records were reviewed for the following variable: maternal&#x0D; age, parity, gestational age, labor induction, duration of 2nd stage labor,&#x0D; use of forceps, use of vacuum, use of episiotomy, birth weight,&#x0D; and presentation of the baby.&#x0D; Result: There were 91 (4.53%) anal sphincter ruptures during period&#x0D; of study (91 of 2009 patients). An univariate analysis of these&#x0D; 91 case and 91 randomly selected control subjects show that primiparity&#x0D; (p = .000), gestational age (p = .016), duration of second-stage&#x0D; labor (p = .000), forceps delivery (p = .000), vacuum delivery (p =&#x0D; .001), episiotomy (p = .000), and birth weight (p = .000) increased&#x0D; the risk for anal sphincter ruptures. In multivariate re-gression models,&#x0D; only 5 of the 10 predictor variables were significantly related&#x0D; to the likelihood of having a severe perineal trauma greater than second&#x0D; degree. Primiparity (p = .023; OR 2.74, 95% [CI], 1.15-6.51),&#x0D; forceps delivery (p = .000; OR 18.18, 95% [CI] 3.84-86.07), vacuum&#x0D; delivery (p = .005; OR 6.83, 95% [CI] 1.77-26.42), episiotomy (p =&#x0D; .015; OR 2.86, 95% [CI] 1.23-6.65), and birth weight (p = .000; OR&#x0D; 0.99, 95% [CI] 0.997-0.999).&#x0D; Conclusion: Damage of the anal sphincter resulting in a third- or&#x0D; fourth- degree perineal tear is a relatively rare but severe complication&#x0D; of vaginal delivery. We found that factors as sociated with anal&#x0D; sphincter ruptures were primiparity, forceps, vacuum, episiotomy&#x0D; and birth weight.&#x0D; [Indones J Obstet Gynecol 2016; 1: 31-36]&#x0D; Keywords: anal sphincter ruptures, third- or fourth- degree perineal&#x0D; tear, vaginal delivery

Feeling old in a young body: Women’s experiences of living with severe consequences of an obstetric anal sphincter rupture: An interview study

Background: The incidence of obstetric anal sphincter rupture (OASR) is increasing. It may cause anal incontinence and dyspareunia,leading to reduced quality of life and wellbeing. Qualitative studies are lacking. The aim was to describe experiencesof living with ongoing severe consequences of an OASR 8 weeks after childbirth. Method: Twenty women with ongoing severe consequences of an OASR 8 weeks after delivery were interviewed usingqualitative content analysis. Results: The experience of complications of an OASR is described in the overall theme ”Feeling old in a young body” andfour categories: The body as injured; isolation; inability to function sexually, and anxiety for the future. Participants describedhow the consequences of OASR totally occupied their lives, making them feel old in a young body. They told of repercussionsfor their physical, psychological, sexual and social lives; how it affected their roles of mothers and partners, making them fearfuture childbirths. Diet, use of medicines, coal filters in incontinence pads, timing of toilet visits, use of the environment andmobile phones to conceal flatus and/or feces were strategies participants described. Conclusions: This study can contribute to increased understanding of how women can be affected by an OASR, and may enablehealthcare personnel and authorities to meet their needs and organize care so that adequate support is available. It would alsobe beneficial if the women’s physical strategies were integrated into the information provided by health caregivers involved infollow-up. However, more research in this area is warranted.

Is a low episiotomy rate associated with increased risk of obstetric anal sphincter rupture? An ecological study from 20 European countries in 2010

Background The incidence of obstetric anal sphincter ruptures (OASR) is considered a good indicator of the quality of obstetric care because of its impact on anal incontinence for women and its association with obstetric practices. OASR rates have increased in some countries. The dramatic decrease in episiotomies, after publication of a meta-analysis favouring restrictive use, might contribute to this trend. We compared OASR rates in European countries and investigated …

A perineal protection device designed to protect the perineum during labor: a multicenter randomized controlled trial

ObjectiveThe objective of this study was to evaluate the protective effects of a new device for reducing perineal tears during vaginal childbirth. Study designA multicenter open randomized controlled trial (RCT) was performed in Helsingborg, Lund and Malmö, Sweden consisting of 1148 women. Women anticipating a vaginal delivery were either randomized to the intervention group (n=574 in which the perineal protection device was used, or a control group (n=574), in which the perineal protection device was not used. The main outcome measurements were incidence of vaginal and perineal tears (1st to 4th degree tears) and adverse effects on the parturient and newborn. ResultsThe incidences of first- and second-degree tears of the vagina (p=0.018) and perineum (p=0.005) were significantly reduced in the intervention group compared with the controls. In the intervention- and control group, 184 women (34.9%) and 142 (26.6%) showed no perineal tearing, respectively (p=0.034). Numbers needed to treat to avoid any perianal tearing was 12. The incidence of anal sphincter rupture (ASR) was the same in both groups (n=19; 3.4%). No negative effects on mother or child from using the device were observed. ConclusionsThe perineal protective device significantly reduced the incidence of first- and second-degree tears in the vagina and perineum during vaginal birth and also significantly increased the number of parturients with a fully intact posterior commissure. No significant reduction of ASR and no negative effects of the device were observed

Anal incontinence in women with recurrent obstetric anal sphincter rupture: a case control study

Objectives: To determine the risk of recurrent anal sphincter rupture (ASR), and compare the risk of anal incontinence (AI) after recurrent ASR, with that seen in women with previous ASR who deliver by caesarean section or vaginally without sustaining a recurrent ASR.Methods: Women with recurrent ASR between January 2000 and June 2011 were identified at two delivery wards in Copenhagen. The women answered a questionnaire with a validated scoring system for AI (St. Mark`s score), and the results were compared with those obtained in two control groups: women with subsequent uncomplicated vaginal delivery or caesarean section.Results: There were 93 437 vaginal deliveries. ASR occurred in 5.5% (n = 2851) of the nulliparous and 1.5% (n = 608) of the multiparous women. Recurrent ASR occurred in 8% (n = 49) of whom 50% reported symptoms of AI. We found no difference in the occurrence of AI between women with recurrent ASR, and those who delivered vaginally without repeat ASR (p = 0.37; OR = 2.0) or by caesarean section (p = 0.77; OR = 1.3).Conclusion: Women with a past history of ASR have an 8% risk of recurrence. AI affects half of the women with recurrent ASR. Larger studies are required to confirm our findings.

Complete Obstetric Anal Sphincter Tear and Risk of Long-term Fecal Incontinence

Women with anal sphincter injuries have an increased risk of developing fecal incontinence despite surgical intervention. The aim of this study was to evaluate the long-term risk of fecal incontinence after primary anal sphincter reconstruction and its impact on quality of life. This was a cohort study. This study was performed at Aarhus University Hospital. Women with complete anal sphincter rupture (exposed) from 1976 to 1991 and a control group of parous women (nonexposed) were included. The primary outcomes measured were fecal incontinence, Wexner score, St Mark incontinence score, and quality of life. A total of 363 women were included (125 exposed and 238 nonexposed). The mean age was 50.4 years (95%CI: 49.8-51.0), with 22.2 years (95% CI: 21.7-22.6) of follow-up. At the time of follow-up, 49% of exposed women and 74% of nonexposed women were continent. Complete anal sphincter tear increases the risk of fecal incontinence twofold (relative risk = 2.00; 95%CI: 1.52-2.63). No other risk factors were identified. The mean Wexner score was 1.7 (95%CI: 1.3-2.1) vs 1.1 (95%CI: 0.7-1.4) (p = 0.02), and the mean St Mark score was 2.8 (95% CI: 2.1-3.4) vs 1.4 (95%CI: 1.0-1.9) (p < 0.001) in the exposed and nonexposed groups. Severity of fecal incontinence had a significant impact on the quality of life independent of exposure. The cohort is relatively young; a short postmenopausal period limits the assessment of hormonal status and the effect of postmenopausal hormone replacement therapy. Complete obstetric anal sphincter tear increases the long-term risk of fecal incontinence twofold. When present, the severity of the incontinence symptoms is minor and the risk of incontinence for solid stool is not increased in comparison with the general population. Anal sphincter rupture is the only independent risk factor for fecal incontinence. The severity of fecal incontinence had the same impact on quality of life in both groups.

Sa2044 Anal Incontinence, Sexual Complaints, and Anorectal Function in Patients With a Third Degree Anal Sphincter Rupture: Long Term Follow-up

Sa2044 Anal Incontinence, Sexual Complaints, and Anorectal Function in Patients With a Third Degree Anal Sphincter Rupture: Long Term Follow-up

Successful implantation of autologous muscle-derived stem cells in treatment of faecal incontinence due to external sphincter rupture

Dear Editor:The most common pathological mechanism of faecalincontinence is the insufficiency of the external anal sphinc-ter (EAS) caused by neurological or myogenic dysfunction.The myogenic mechanism of EAS insufficiency is usuallydue to direct mechanical damage during childbirth, traumaor surgery in anorectal region, whereas neurologicalaetiology involves either spinal or peripheral nerves disrup-tion—in most cases the pudendal nerve. Unfortunately, co-incidence of sphincter rupture with damage to pudendalnerves is quite common.Each skeletal muscle, including EAS, has the ability toregenerate to some degree and repair sustained damage. Inresponse to injury and/or muscle damage, so-called satellitecells are activated and become myoblasts—capable of in-tense proliferation. Myoblasts then differentiate and fusetogether to form new muscle fibres and connect withexisting ones, adding new portions of contractile tissue toexisting motoric units [1].Attempts of autotransplantation of myoblasts into dam-aged skeletal muscle were already made in animal models ofmuscular dystrophy, post-infarction myocardial dysfunctionand urethral sphincter insufficiency [2]. The results showedthat the transplanted myoblasts differentiate into musclefibres, connect with host motoric units, increase the amountof contractile elements in the muscle and improve its con-tractile activity. In 2001, Menasche et al. first transplantedautologous myoblasts into the post-infarction myocardialscar in human patients with cardiac failure, with significantimprovements in contractile function and clinical condition[3]. In Poland, the method of treating post-infarction heartfailure was performed for the first time a year later, withsimilar results [4].Basedonthose encouraging results,a pioneerexperimen-tal study was designed in attempt to enhance the function ofexternal anal sphincter using injections of autologousmuscle-derived stem cells. The study is designed as a pro-spective experimental study. It is being conducted by twocooperating research centres—the 3rd Department of Gen-eral Surgery, Jagiellonian University in Cracow and theDepartment of Reproductive Biology and Stem Cells, Insti-tute of Human Genetics, Polish Academy of Sciences inPoznan. We would like to present a case of the representa-tive patient enrolled to our study.A 20-year old male withfaecal incontinenceduetoanoldexternal anal sphincter rupture in a road accident was en-rolled to the study. Sphincter rupture had been repairedsurgically right after the accident (with an end-to-endsphincteroplasty). The patient underwent 6 months of bio-feedback training after the wounds were healed. At the timeof enrolment, he still complained of gas and loose stoolincontinence, daily soiling, with necessity to wear pads.Endoanal ultrasound showed a 8–10-mm scar on the leftcircumference of internal and external sphincter muscle,where anal canal was ruptured during the accident, andsurgically repaired afterwards. Anorectal manometryshowed decreased both mean resting and maximum squeezepressure, with short high pressure zone length. Endoanal

From endometriosis to perineal trauma

From endometriosis to perineal trauma

Are obstetric anal sphincter ruptures preventable?– Large and consistent rupture rate variations between the Nordic countries and between delivery units in Norway

To study changes in the incidence of obstetric anal sphincter rupture (OASR) during recent years in Denmark, Finland, Sweden and Norway and hospital-based incidence in recent years in Norway. Retrospective birth register study. Unselected population of delivering women in four Nordic countries. All deliveries (574 175) registered in Denmark, Finland, Norway and Sweden, 2004-2010. Parity data, including maternal, obstetrical and fetal characteristics, were obtained. The incidence of OASR was calculated from vaginal deliveries. A chi-squared test was used to analyse differences between countries and time periods. Incidence of OASR. During the study period, the OASR incidence in Finland was notably lower (0.7-1.0%) than in the other three Nordic countries (4.2-2.3%). A significant and constant reduction in OASR incidence was observed in Norway only (from 4.1 to 2.3%, from 2004 to 2010, p < 0.001). This reduction occurred simultaneously with introduction of a national intervention program of improved delivery techniques that aimed to reduce the incidence of OASR. No major alterations in maternal or fetal risk factors for OASR or registration routines could explain this rapid reduction in the rate of OASR. Differences in the incidence of OASR between Norwegian delivery units were significant, with a threefold difference when comparing the units with lowest and highest incidences. Obstetric anal sphincter rupture seems to be preventable to a considerable extent, as indicated by the rapid and lasting reduction of OASR incidence after implementation of perineal protection programs in Norway. Improved delivery techniques should be implemented in all delivery units to prevent OASR as much as possible.