Cause Of Anal Incontinence Research Articles

GP's role in supporting women with anal incontinence after childbirth injury: a qualitative study.

Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women's lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs. To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries. A qualitative study investigating women's experiences with their GP, and GPs' perspectives about providing such care. This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries (n = 41); and second, focus groups with GPs (n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined. Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication. The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting.

Are we using best practice to guide laxative use in post-partum patients with obstetric anal sphincter injuries – A retrospective review

ObjectiveObstetric anal sphincter injury (OASI) is the leading cause of anal incontinence (AI) in young women. Laxatives are recommended to enhance recovery, however there are no consistent guidelines to guide best practice on the type, frequency, and dose of laxative should be used. This study aimed to evaluate the current use of laxatives following repair of OASIs, and to determine any association with AI.Study designA retrospective cohort study of 356 women who sustained OASIs between January 2016 and June 2020, at a single tertiary centre in Adelaide. Data regarding the type, dose and frequency of laxatives prescribed was extracted from each patient. The degree of OASIs was determined by clinical examination and endoanal ultrasound, and AI was measured by the St Marks incontinence score. ResultsMultiple combinations and classes of laxatives were prescribed including bulking agent (Metamucil and Fybogel), emollients (Coloxyl), and osmotic laxatives (lactulose and Movicol). Bulking agents were prescribed for 245 women (68.8%), which is contrary to the current recommendations based on two previous randomised controlled trials. AI reported by 51 (14.3%) women. There were no statistical differences between AI and laxative type, dose, or frequency. ConclusionConsiderable variation existed in laxatives prescription. Bulking agents was not associated with higher rates of AI. Further research is required to improve post-partum care in women following repair of OASIs.

A Retrospective Investigation on Electric Bidet Use as a Possible Cause of Anal Incontinence.

Objectives: The present study aimed to explore whether symptoms of anal incontinence (AI) in patients who used electric bidet toilets to clean the anus may improve after discontinuing bidet use. Methods: Fifty-three patients with AI who habitually used the bidets before or after defecation and were examined between June 2019 and September 2020 were included in this retrospective study. Questionnaires on Likert-scaled items that assessed bidet use were administered at baseline. The sum of all points was regarded as the “bidet use score”. The patients were instructed to discontinue bidets until subsequent examination. Incontinence severity was documented using the fecal incontinence severity index (FISI) score. Results: Follow-up data were available for 49 patients (92%). Of those, 43 had fecal incontinence and 6 had only mucus discharge at baseline. The median duration between the baseline and follow-up was 4 weeks. The median FISI score was significantly reduced at the follow-up [baseline vs. follow-up: 15 (range: 3-43) vs. 10 (range: 0-43); P < 0.0001]. The incidence of fecal incontinence was significantly lower at the follow-up than at the baseline (59% vs. 88%, P = 0.003). A higher maximum squeeze pressure and the absence of associated factors that may cause AI (such as rectoanal intussusception and/or rectocele, mucosal prolapse, and previous anorectal surgery) were significantly associated with a reduction of at least 50% in the FISI scores at follow-up; however, this was not observed for the bidet use score. Conclusions: Our findings suggest that electric bidet use is a possible cause of AI.

Welcome to ANZJOG 2021

Welcome to ANZJOG 2021

Management of obstetric anal sphincter injury: Colorectal surgeons' perspectives in Australia and New Zealand.

Obstetric anal sphincter injuries (OASIs) are a significant complication of vaginal delivery, and a leading cause of anal incontinence in women. The aims were to explore the management of OASIs in Australia and New Zealand (ANZ) by colorectal surgeons and how this compares with current recommendations and international experience, and to identify the deterrents to the provision of best-practice care among colorectal surgeons. Three hundred colorectal surgeons of the Colorectal Surgical Society of ANZ were mailed questionnaires. Areas of interest included: surgeon demographics; exposure to OASIs; understanding of current recommendations; and opinions regarding the importance of symptoms and assessment tools in OASIs. There were 94 completed questionnaires (response rate 31.3%). Fifty-seven surgeons (60.6%) reported low exposure to OASIs during their fellowship training. Greater than 90% believed patients with grade three tears and above should have anal sphincter assessment. Sixty-six (70.2%) reported that they routinely review women who have had OASIs. However, 56.4% were unaware if their obstetrics department followed a standard protocol for OASIs. Surgeons practising in metropolitan centres reported higher rates of their obstetrics department following a protocol (P=0.013), and greater access to investigative tools (P<0.001), when compared to rural-based surgeons. Most ANZ colorectal surgeons have had minimal training in OASI management. Colorectal surgeons are more commonly involved with OASI patients in the non-acute setting. Management protocols involving a multidisciplinary team of both colorectal surgeons and obstetricians should be clearly defined, and the gap between metropolitan and rural centres needs to be reviewed.

Is the older perineum a safer perineum? Risk factors for obstetric anal sphincter injury.

Obstetric anal sphincter injury (OASI) is the most common cause of anal incontinence. Identifying risk factors may facilitate change in labour and delivery practice, potentially reducing the risk. The objective of this study is to identify maternal, foetal and intrapartum risk factors for OASI in a regional hospital. We conducted a retrospective analysis of vaginal deliveries over a 10-year period (2008-2017). Anal sphincter injury was diagnosed by an experienced clinician and classified according to RCOG recommendations. A multiple logistic regression model was created using the presence of OASI as the dependent variable. Coefficients were adjusted for relevant maternal, foetal and intrapartum risk factors. During the study period, there were 23,887 vaginal deliveries. Of these births, 18,550 were spontaneous (77.66%), 3746 vacuum-assisted (15.68%), 1196 forceps (5.01%) and 395 sequential instrumental deliveries (1.65%). The overall rate of OASI was 1.76%, with an upward trend seen in nulliparous mothers. Significant factors that increased the risk of OASI were nulliparity, Asian ethnicity, delivery by forceps or sequential instruments, and shoulder dystocia. Vacuum delivery did not significantly increase risk. Maternal age ≥ 35years confers a protective effect after adjusting for parity, birth weight and mode of delivery. Given the context of an ageing reproductive population, additional research is required to investigate the impact of maternal age on anal sphincter injury.

Anatomical feasibility of a peripheral nerve transfer to reestablish the control of the external anal sphincter

BackgroundFaulty innervation from pudendal nerve branches is a common cause of anal incontinence, a condition that can severely impact quality of life. Current treatments include medication, rehabilitation, surgical repair of the sphincter and conversion to a definitive stoma. All these options have yielded unsatisfactory results to restore the function of the external anal sphincter, with success rates of approximately 50% (Thinn et al., 2013). Over the last 15 years, an increasing interest in exploring the possibilities of restoring rectum and bladder sphincteric function by means of nerve transfers has produced a number of experimental studies in animal models, indicating promising results (Bao et al., 2018).ObjectiveOur goal was to test the feasibility of dissecting a fascicle of the tibial component of the sciatic nerve to see if it would be long enough to serve as a “donor nerve” for coaptation with the pudendal nerve, in both gluteal and perineal regions.MethodsWe dissected the bilateral gluteal and posterior proximal third of the thigh region in 12 embalmed adult cadavers. We used micro‐surgical techniques to expose the pudendal nerve, the sciatic nerve inferiorly to the piriformis muscle, and the sciatic nerve branches in the long portion of the biceps femoris muscle. We measured the lengths of: (1) the donor nerve (DN) fascicle obtained from the tibial component of the sciatic nerve to the long portion of the biceps femoris muscle; (2) the length required for proximal coaptation (PC): from the cranial‐most point of the donor nerve at the inferior margin of the piriformis muscle to the pudendal nerve at the superior margin of the sacrotuberous ligament; and (3) the length required for distal coaptation (DC): from the cranial most point of the donor nerve at the inferior margin of the piriformis muscle to the pudendal nerve at entrance of the pudendal canal (Alcock's canal). We hypothesized that the ratios DN/PC and DN/DC would be higher than 1, meaning that the donor nerve would be long enough to allow for the development of a novel surgical technique to restore the control of the external anal sphincter in humans.ResultsThe DN length averaged 10.2cm (4.3cm to 14.8cm). The length required for PC averaged 3cm (2.0cm to 4.7cm). The length required for DC averaged 4.8cm (from 3.0 to 7.0cm). The ratio between the DN/PC averaged 3.6, ranging from 1.5 to 6.9, while the ratio between DN/DC averaged 2.3, ranging from 1.5 to 4.4.Conclusionsthe DN was consistently longer than the lengths required for PC and DC, since the ratios DN/PC and DN/DC were significantly greater than 1 across our 24 specimens and in each of our specimens assessed individually (p&lt;0.05). The described peripheral nerve transfer is anatomically feasible. Based on these findings, the next steps are to effectuate and study the surgical transfer in unembalmed cadavers.Support or Funding InformationIn conjunction with the Building Bridges initiativesThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Functional Outcome of Human Adipose Stem Cell Injections in Rat Anal Sphincter Acute Injury Model

Anal incontinence is a devastating condition that significantly reduces the quality of life. Our aim was to evaluate the effect of human adipose stem cell (hASC) injections in a rat model for anal sphincter injury, which is the main cause of anal incontinence in humans. Furthermore, we tested if the efficacy of hASCs could be improved by combining them with polyacrylamide hydrogel carrier, Bulkamid. Human ASCs derived from a female donor were culture expanded in DMEM/F12 supplemented with human platelet lysate. Female virgin Sprague‐Dawley rats were randomized into four groups (n = 14–15/group): hASCs in saline or Bulkamid (3 × 105/60 μl) and saline or Bulkamid without cells. Anorectal manometry (ARM) was performed before anal sphincter injury, at two (n = 58) and at four weeks after (n = 33). Additionally, the anal sphincter tissue was examined by micro‐computed tomography (μCT) and the histological parameters were compared between the groups. The median resting and peak pressure during spontaneous contraction measured by ARM were significantly higher in hASC treatment groups compared with the control groups without hASCs. There was no statistical difference in functional results between the hASC‐carrier groups (saline vs. Bulkamid). No difference was detected in the sphincter muscle continuation between the groups in the histology and μCT analysis. More inflammation was discovered in the group receiving saline with hASC. The hASC injection therapy with both saline and Bulkamid is a promising nonsurgical treatment for acute anal sphincter injury. Traditional histology combined with the 3D μCT image data lends greater confidence in assessing muscle healing and continuity. Stem Cells Translational Medicine 2018;7:295–304

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions

Obstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Modification of various risk factors and anatomical considerations have been reported to reduce the rate of OASI. A PubMed search (1989–2014) of studies and systematic reviews on risk factors for OASI. Perineal distension (stretching) of 170 % in the transverse direction and 40 % in the vertical direction occurs at crowning, leading to significant differences (15–30°) between episiotomy incision angles and suture angles. Episiotomies incised at 60° achieve suture angles of 43–50°; those incised at 40° result in a suture angle of 22°. Episiotomies with suture angles too acute ( 60°) are associated with an increased risk of OASI. Suture angles of 40–60° are in the safe zone. Clinicians are poor at correctly estimating episiotomy angles on paper and in patients. Sutured episiotomies originating 10 mm away from the midline are associated with a lower rate of OASIs. Compared to spontaneous tears, episiotomies appear to be associated with a reduction in OASI risk by 40–50 %, whereas shorter perineal lengths, perineal oedema and instrumental deliveries are associated with a higher risk. Instrumental deliveries with mediolateral episiotomies are associated with a significantly lower OASI risk. Other preventative measures include warm perineal compresses and controlled delivery of the head. Relieving pressure on the central posterior perineum by an episiotomy and/or controlled delivery of the head should be important considerations in reducing the risk of OASI. Episiotomies should be performed 60° from the midline. Prospective studies should evaluate elective episiotomies in women with a short perineal length and application of standardised digital perineal support.

Ultrasound Imaging of the Anal Sphincter Muscles: Comparison Between Endoanal and Transcutaneous Approaches

Introduction: Damage to the anal sphincter muscles is extremely common after vaginal birth and is a major cause of anal incontinence in women. Endoanal US imaging is currently the gold standard to diagnose occult injuries to the anal sphincter muscles. 3D-US imaging of the anal sphincters can also be performed using a transcutaneous (transperineal) approach. Our goal was to compare these two US techniques in assessing the internal anal sphincter (IAS), external anal sphincter (EAS) and puborectalis muscle (PRM). Methods: Studies were performed in 5 nulliparous women using the endoanal BK probe and Philips endo-vaginal probe. For the endoanal approach: the imaging was done using the standard 16 mm diameter anal US probe placed endo-luminally. Endo-vaginal images that provide views of the puborectalis muscle (PRM) were also obtained in each subject using the BK probe. For transcutaneous US imaging, the transducer was placed on the perineum; it was directed in the posterior direction to image the anal sphincters and in the cranial direction to image the PRM. Endoanal and transcutaneous US volumes were analyzed along the cranio-caudal length of the anal canal (every 2.5 mm) to visualize details of the IAS, EAS and PRM. Images were reviewed by DCK, RKM and an experienced US radiologist (DHP). Results:Figure 1 shows views of the IAS and EAS from the endoanal and transcutaneous approaches. Figure 2 shows the PRM and the pelvic floor hiatus from two approaches. Image analysis suggests the following pros and cons between the two US imaging methods. The pros of the transcutaneous approach are: 1) better global view of the IAS and EAS muscles. In addition to circular portions of the EAS, transverse perinea and perineal body, two important components of the EAS muscle complex are also visualized; 2) no deformation related to the US transducer probe in the anal/vaginal canal; 3) ability to record dynamic changes in the anorectal angle and pelvic floor hiatus with voluntary contraction. The limitation of the transcutaneous approach is that the images are not clear with regards to the outer margins of the EAS.Figure 1Figure 2Conclusion: Transcutaneous 3D-US imaging is a patient friendly (no probe insertion into the anus or vagina) technique to image the anal sphincters, puborectalis muscle and pelvic floor hiatus. The transcutaneous approach may provide better information on structures such as the perineal body and transverse perinea, which are commonly implicated in obstetrical injury and are the key components of the EAS.

Obstetric anal sphincter injuries: review of anatomical factors and modifiable second stage interventions.

Obstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Modification of various risk factors and anatomical considerations have been reported to reduce the rate of OASI. A PubMed search (1989-2014) of studies and systematic reviews on risk factors for OASI. Perineal distension (stretching) of 170% in the transverse direction and 40% in the vertical direction occurs at crowning, leading to significant differences (15-30°) between episiotomy incision angles and suture angles. Episiotomies incised at 60° achieve suture angles of 43-50°; those incised at 40° result in a suture angle of 22°. Episiotomies with suture angles too acute (<30°) and too lateral (>60°) are associated with an increased risk of OASI. Suture angles of 40-60° are in the safe zone. Clinicians are poor at correctly estimating episiotomy angles on paper and in patients. Sutured episiotomies originating 10mm away from the midline are associated with a lower rate of OASIs. Compared to spontaneous tears, episiotomies appear to be associated with a reduction in OASI risk by 40-50%, whereas shorter perineal lengths, perineal oedema and instrumental deliveries are associated with a higher risk. Instrumental deliveries with mediolateral episiotomies are associated with a significantly lower OASI risk. Other preventative measures include warm perineal compresses and controlled delivery of the head. Relieving pressure on the central posterior perineum by an episiotomy and/or controlled delivery of the head should be important considerations in reducing the risk of OASI. Episiotomies should be performed 60° from the midline. Prospective studies should evaluate elective episiotomies in women with a short perineal length and application of standardised digital perineal support.

Evaluation of the angled Episcissors-60(®) episiotomy scissors in spontaneous vaginal deliveries.

BackgroundObstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Episiotomies with a postdelivery suture angle of less than 30° to the midline are more likely to injure the anal sphincter directly, while those with a suture angle of more than 60° are associated with increased incidence of OASIs, as they do not relieve the pressure on the perineum. A safe zone of 40°–60° has been proposed. Recently, two new types of episiotomy scissors (Episcissors-60® Straight version and angled version) were introduced to ensure a standardized cutting angle of 60° to the midline. We audited our results with the angled Episcissors-60 in spontaneous vaginal deliveries.Materials and methodsConsecutive patients delivering in two private maternity hospitals in Thane, India undergoing clinically indicated episiotomies were included. Only patients delivering spontaneously were included. The scissors were introduced vaginally at crowning, and aligned to orient the guide limb vertically from the posterior fourchette to the anus. While a single cut was preferred, a stagger cut was needed for some women. Postdelivery angles were measured by placing a protractor transparency on the perineum after delivery and marking the angle with an indelible ink pen. Per rectal examination was performed prior to suturing to detect OASIs.ResultsA total of 25 women underwent clinically indicated episiotomies. Of these, 16 women were nulliparous, eight women were para 1, and one woman was a para 2. One woman had a vaginal breech delivery (para 2), and the rest were cephalic vertex deliveries. The average age was 27 (range 20–35) years. The median birth weight was 2,800 g (standard deviation 312 g, interquartile range 2,500–3,000 g). The median postdelivery suture angle of the episiotomy was 50° (standard deviation 3.5°, interquartile range 48°–54°, range 45°–55°). No cases of OASI were detected in this series.ConclusionThe Episcissors-60 angled version demonstrated a postdelivery suture angle of 50° in a cohort of Indian women undergoing spontaneous vaginal deliveries.

Purse-string morphology of external anal sphincter revealed by novel imaging techniques

The external anal sphincter (EAS) may be injured in 25-35% of women during the first and subsequent vaginal childbirths and is likely the most common cause of anal incontinence. Since its first description almost 300 years ago, the EAS was believed to be a circular or a "donut-shaped" structure. Using three-dimensional transperineal ultrasound imaging, MRI, diffusion tensor imaging, and muscle fiber tracking, we delineated various components of the EAS and their muscle fiber directions. These novel imaging techniques suggest "purse-string" morphology, with "EAS muscles" crossing contralaterally in the perineal body to the contralateral transverse perineal (TP) and bulbospongiosus (BS) muscles, thus attaching the EAS to the pubic rami. Spin-tag MRI demonstrated purse-string action of the EAS muscle. Electromyography of TP/BS and EAS muscles revealed their simultaneous contraction and relaxation. Lidocaine injection into the TP/BS muscle significantly reduced anal canal pressure. These studies support purse-string morphology of the EAS to constrict/close the anal canal opening. Our findings have implications for the effect of episiotomy on anal closure function and the currently used surgical technique (overlapping sphincteroplasty) for EAS reconstructive surgery to treat anal incontinence.

Womenʼs experience of anal incontinence following a history of obstetric anal sphincter injury: a literature review

Background Anal incontinence (AI) is the involuntary loss of a liquid or solid stool and flatus, resulting in a lifelong profound negative impact on a person's quality of life. One million Australians, half of whom are women, are affected by AI. The aetiology of AI is reported within research literature. Importantly obstetric anal sphincter injury following vaginal delivery is a predominant cause of AI. Factors cited as major risk factors of anal sphincter damage include instrumental delivery, macrosomia and primiparity. The incidence of AI increases with age and with further vaginal delivery. The impact lasts for life. Aim This study aims to identify women's experiences of AI following obstetric anal sphincter injury and their impact on quality of life. Method An extensive online literature search was undertaken within the medical and nursing databases including the Cumulative Index of Nursing and Allied Health Literature, Scopus, PubMed and Medline. Key search terms included AI, faecal incontinence, anal sphincter injuries, obstetric complications, trauma, obstetric, postnatal care, experiences, women's experience and quality of life. The literature search was further refined through fields that included English language only, literature published between 2000 and 2012 and full-text articles. Findings The review identified a significant amount of research literature that addressed the prevalence and cause of AI. While quality of life questionaries and symptom severity scores have been utilised to assess the impact of AI on a person's life, there are inherent weaknesses in providing the experience of AI on a person's life. Furthermore, there is limited in-depth research that addresses women's experiences of AI following a history of obstetric anal sphincter injury and the impact on their quality of life. Conclusion Research findings contribute to understanding the prevalence, physical, social and emotional impact of AI. While alterations in clinical practice can improve the identification and management of AI, further research that builds on the state of knowledge and seeks a deeper understanding of the issues for women with AI as a result of obstetric anal sphincter injury is required.

Obstetric anal sphincter injury audit at Borders general hospital (2004-2009)

IntroductionObstetric anal sphincter injury (OASI) is the most common cause of anal incontinence among women of childbearing age. OASI causes significant maternal morbidity in the postpartum period. Overall reported risk...

Third and fourth degree perineal tears hands-on repair course

Obstetric anal sphincter injuries are a major cause of anal incontinence and can have a devastating effect on a woman’s physical, social, and emotional wellbeing. When undiagnosed they are a frequent source of complaint and litigation. This one day hands-on course gave me the knowledge and practical skills to identify the risk factors and diagnose, classify, and manage obstetric anal sphincter injuries. I attended the course as a junior registrar in obstetrics and gynaecology because I wanted to understand the basic anatomy and physiology and, most importantly, how to identify obstetric anal sphincter injuries before being taught repair techniques. During postnatal ward rounds I realised how little is taught and known about the consequences of such injuries and how women should be managed in subsequent pregnancies. I chose this course …

Treatment of Experimental Injury of Anal Sphincters with Primary Surgical Repair and Injection of Bone Marrow-Derived Mesenchymal Stem Cells

Sphincter injury is a common cause of anal incontinence. Surgical repair remains the operation of choice; however, the outcome often is poor. We investigated the ability of injected bone marrow-derived mesenchymal stem cells to enhance sphincter healing after injury and primary repair in a preclinical model. Twenty-four inbred Wistar Furth rats were divided into three groups. As a control, Group A underwent sham operation. Group B had sphincterotomy and repair of both anal sphincters plus saline injections. The study group (Group C) underwent sphincterotomy and repair followed by intrasphincteric injections of syngenic bone marrow-derived mesenchymal stem cells. A further group (Group D) of outbred Wistar rats treated with mesenchymal stem cells and immunosuppressive therapy also was evaluated. At 30 days, histologic and morphometric analysis and in vitro contractility testing was performed. A significant decrease of muscle tissue was observed at the site of repair after sphincter injury. However, in Groups C and D, histologic examination demonstrated new muscle fibers and morphometric analysis revealed a significantly greater muscle area fraction than in Group B (P < 0.05). Moreover, mesenchymal stem cells injection improved contractility of sphincters strips compared with Group B (P < 0.05). No significant differences were found between Groups C and D. In our experimental model, bone marrow-derived mesenchymal stem cells injection improved muscle regeneration and increased contractile function of anal sphincters after injury and repair. Therefore, mesenchymal stem cells may represent an attractive tool for treating anal sphincter lesions in humans. Investigations into the biologic basis of this phenomenon should increase our knowledge on underlying mechanisms involved in sphincter repair.

Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county.

Anal sphincter tears during vaginal delivery are a major cause of anal incontinence. We wanted to assess the incidence in a Norwegian county where primary repairs are performed in four hospitals using similar per- and postoperative protocol for the treatment of such injuries. A postal questionnaire was distributed to all women who underwent primary repair of obstetric sphincter tears in the years 1999 and 2000 in the county of Möre and Romsdal. Symptoms of incontinence and fecal urgency were recorded. Incontinence was assessed using the Pescatori score system. Clinically detected sphincter tears occurred in 180 of 5123 vaginal deliveries (3.5%). The questionnaire was returned by 156 women (87%). Six women were excluded. Median follow-up was 25 months (range 4-39). Incontinence was reported by 88 women (59%), restricted to flatus incontinence in 53 cases (35%). Fecal urgency without incontinence was reported by 14 women (9%). Sixty-three women (42%) reported de novo moderate to severe symptoms. There was no difference in outcome whether the sphincter injury was partial or complete. Mean Pescatori score was 3.7 in women who felt disabled compared with 2.9 in women who did not feel disabled by their incontinence (P < 0.001). Of 29 women who felt disabled, only three had sought medical attention. Fifty-eight women (39%) had received no information about the sphincter tear before discharge. Anal incontinence is common after both partial and complete obstetric sphincter tears. Information before discharge is deficient, and women avoid seeking medical attention when incontinence develops.

Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county

Background. Anal sphincter tears during vaginal delivery are a major cause of anal incontinence. We wanted to assess the incidence in a Norwegian county where primary repairs are performed in four hospitals using similar per- and postoperative protocol for the treatment of such injuries. Methods. A postal questionnaire was distributed to all women who underwent primary repair of obstetric sphincter tears in the years 1999 and 2000 in the county of Möre and Romsdal. Symptoms of incontinence and fecal urgency were recorded. Incontinence was assessed using the Pescatori score system. Results. Clinically detected sphincter tears occurred in 180 of 5123 vaginal deliveries (3·5%). The questionnaire was returned by 156 women (87%). Six women were excluded. Median follow-up was 25 months (range 4–39). Incontinence was reported by 88 women (59%), restricted to flatus incontinence in 53 cases (35%). Fecal urgency without incontinence was reported by 14 women (9%). Sixty-three women (42%) reported de novo moderate to severe symptoms. There was no difference in outcome whether the sphincter injury was partial or complete. Mean Pescatori score was 3·7 in women who felt disabled compared with 2·9 in women who did not feel disabled by their incontinence (P < 0·001). Of 29 women who felt disabled, only three had sought medical attention. Fifty-eight women (39%) had received no information about the sphincter tear before discharge. Conclusion. Anal incontinence is common after both partial and complete obstetric sphincter tears. Information before discharge is deficient, and women avoid seeking medical attention when incontinence develops.

Diagnosis and conservative therapy of anal fecal incontinence

The main diagnostic tool for patients with anal incontinence is the anorectal physiology. The anorectal sphincter can be reliably tested. Due to the fact that an obstetric damage is the most common cause of anal incontinence, the transanal endosonography is the imaging method of choice for detecting a muscle defect. With high frequency ultrasound probes (preferable 10 Mhz) the pathomorphology of the sphincter can be studied in details. If conservative treatment is failing, the neurophysiology testing is helpful in deciding which surgical method (sphincter repair in case of an intact nervus pudendus, artificial sphincter or sacral stimulation in case of neuropathy). The conservative treatment includes increasing the internal sphincter muscle tonus by applying Phenylephrine locally or Loperamid per os. The biofeedback is basically a physical muscle training of the external sphincter with a visual or acoustic feedback of the muscle function to the patient. However, newer studies show that by this method the sensory function and the coordination of the anal sphincter are improving as well. With these conservative treatment options most of the patients suffering from anal incontinence can be treated satisfactorily.