Internal Anal Sphincter Defects Research Articles

The Use of Sphinkeeper® In Faecal Incontinence

Introduction: Faecal Incontinence is a condition that can affect up to 20% of population during their lifetime with female predominance. Sacral Nerve Stimulation (SNS) has been recently shown to have significant benefits in mainly urge incontinence but this has left a large group of patients with passive incontinence without effective management options. The SphinKeeper® (SK) allows treatment of more sizeable defects in the internal or external anal sphincter. Preliminary series have shown some benefit of the procedure in treatment of faecal incontinence. Methods: A single-centre retrospective observational study of SphinKeeper® prostheses was conducted at St Helens and Knowsley NHS trust and we believe this to be one of the largest series of SphinKeeper® in the UK. SphinKeeper® restores sphincter function by using placement of self-expanding prostheses into the inter-sphincteric space. The operation involves implantation of 10 self-expanding sterile prostheses between the internal and the external sphincter, thus creating a third ring around the circumference of the anal canal. Results: Most patients were ASA 2 (n=10). 43% (6/14) patients had previous colorectal surgery – THD and mucopexy (n=3), anorectal fistula surgery (n=1), anterior resection of rectum (n=1) and pelvic floor repair (n=1). EUS was carried out in 6 patients and in all 6 cases identified internal or external anal sphincter defect (IAS n=1, EAS n=3, IAS and EAS n=2). No patient sustained intraoperative complications. 2 patients reattended within 48 hours post op due to severe post-operative pain and were discharged with analgesia. Subjective results were evaluated using Vaizey and Wexner scores and showed significant improvement 4/14 patients, partial improvement in 7/14 patients and no improvement in 3/14 patients. Discussion: Our study evaluated the short-term outcomes of the procedure in 14 patients who had SphinKeeper® surgery between May 2017 and August 2020. Patients who took part in our study had previous treatment for faecal incontinence by a variety of methods (both medical and surgical) and suffered from different types of FI (passive, urge, mixed, associated urinary incontinence). It was promising to see there was a clinically significant improvement in continence indicated by a decrease in Vaizey and Wexner scores (p=0.00377 and p=0.00334 respectively (Wilcoxon test)) with 11 patients improving in scores. It is reasonable to consider Sphinkeeper™ as a safe and minimally invasive surgical intervention to achieve some degree of positive improvement for patients suffering from faecal incontinence.

Diagnostic capabilities of transperineal ultrasound (TPUS) to evaluate anal sphincter defect post obstetric anal sphincter injury (OASIS)? A systematic review

IntroductionEndoanal ultrasound (3D-EAUS) is the gold standard imaging investigation for evaluating the anal sphincter; unfortunately, it is not universally available in most obstetric units. This study aims to appraise the ability of transperineal ultrasound (TPUS) compared with 3D-EAUS as the gold standard to identify anal sphincter defects after primary repair of OASIS.MethodsA systematic search of major databases to identify diagnostic accuracy of 3D-TPUS in evaluating anal sphincter defects. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were designed for this systematic review. The risk of bias and applicability concerns were assessed using the QUADAS-2 tool. Our eligibility criteria are patients with a history of primary repair of anal sphincter injuries (OASIS). They were followed up after the primary repair to detect the anal sphincter defect using 3D-TPUS vs. 3D-EAUS as a gold standard.ResultsTwo eligible observational studies were included and assessed for risk of bias using the QUADAS-2 tool and showed a low risk of bias and a low risk of concerns. 3D-TPUS had various sensitivity to detect external anal sphincter defects in two studies; meanwhile, the specificity was around 67–70%. For detecting the internal anal sphincter defects, 3D-TPUS had low sensitivity but high specificity (93–94%).Conclusion3D-TPUS had various sensitivity to detect external anal sphincter defects and low sensitivity to detect internal anal sphincter defects. On the other hand, 3D-TPUS had low specificity for detecting external anal sphincter defects and high specificity for detecting internal anal sphincter defects.

Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound.

To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle. This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal(IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard. In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference. This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Administration of an Anal Bulking Agent With Polyacrylate-Polyalcohol Copolymer Particles Versus Endoanal Electrical Stimulation With Biofeedback for the Management of Mild and Moderate Anal Incontinence: A Randomized Prospective Study

There are few treatment options for mild-to-moderate anal incontinence with isolated internal anal sphincter defects or anal incontinence without muscle damage. Less-invasive techniques are generally favored. To compare the results between the use of an anal bulking agent with polyacrylate-polyalcohol copolymer particles and endoanal electrical stimulation with biofeedback in patients with mild or moderate anal incontinence. This was a prospective parallel-group, single-institution, randomized clinical trial. This study was conducted in an ambulatory setting at the Colorectal Physiology Service of the Hospital das Clinicas, Medical School, University of Sao Paulo. This study included patients who had anal incontinence for >6 months with isolated internal anal sphincter muscle damage or absence of anatomical defects in the anorectal sphincter complex. Anal bulking agent and endoanal electrical stimulation with biofeedback. The primary outcome measure was the Cleveland Clinic Florida Fecal Incontinence Score, and the secondary outcome measures included quality of life, recommended procedures, and anorectal manometry. There were no significant between-group differences in mean age, sex, BMI, stool consistency, and Cleveland Clinic Florida Fecal Incontinence Score (p = 0.20) at baseline. After 12 months, the Cleveland Clinic Florida Fecal Incontinence Score was found to be significantly improved in patients treated with the bulking agent compared to those treated with electrical stimulation (mean, 6.2 vs 9.2; p = 0.002), though the anorectal manometry parameters did not change significantly. The mean anal Cleveland Clinic Florida Fecal Incontinence Score declined by 4.2 points in the bulking agent group compared to a decline of 0.8 in the electrical stimulation group (mean difference in decline: 3.4 points; 95% CI, 1.2-5.5). Quality-of life evaluation showed similar results between groups comparing baseline parameters with 12-month follow-up. The short follow-up period of 1 year, atypical method of biofeedback, and unmatched baseline in some of the quality-of-life scales between the 2 groups limited this study. In patients with mild or moderate anal incontinence, the Cleveland Clinic Florida Fecal Incontinence Score significantly improved in the bulking agent with polyacrylate-polyalcohol copolymer group compared with the endoanal electrical stimulation with biofeedback group. See Video Abstract at http://links.lww.com/DCR/B938. ANTECEDENTES:Hasta la fecha, existen pocas opciones de tratamiento para la incontinencia anal de leve a moderada con defectos aislados del esfínter anal interno o la incontinencia anal sin daño muscular. Por lo general, se prefieren técnicas menos invasivas.OBJETIVO:El objetivo fue comparar los resultados entre el uso de un gel intra-anal con partículas de copolímero de poliacrilato-polialcohol y la estimulación eléctrica endoanal con ejercicios anales en pacientes con incontinencia anal leve o moderada.DISEÑO:Este fue un ensayo clínico aleatorio prospectivo de grupos paralelos, de una institución, realizado en cuatro etapas: base, procedimientos, postratamiento temprano y tardío.AJUSTE:Este estudio se realizó en el ambulatorio de Fisiología Colorrectal del Servicio de Coloproctología del Hospital das Clínicas, Facultad de Medicina, Universidad de São Paulo.PACIENTES:Paciente con incontinencia anal con más de 6 meses, con daño muscular aislado del esfínter anal interno o ausencia de defectos anatómicos en el esfínter anorrectal.INTERVENCIONES:Las intervenciones incluyeron la inyección del gel intra-anal y estimulación eléctrica endoanal con ejercicios anales.PRINCIPALES MEDIDAS DE RESULTADO:Indice de incontinencia fecal (Cleveland Clinic Florida), Indice de calidad de vida, los procedimientos recomendados y la manometría anorrectal.RESULTADOS:No hubo diferencias significativas entre los grupos en cuanto a la edad media, el sexo, el índice de masa corporal, la consistencia de las heces y la puntuación de incontinencia fecal (p = 0,20) al inicio del estudio. Después de 12 meses, la puntuación de incontinencia fecal mejoró significativamente en los pacientes tratados con el el gel intra-anal (media = 6,2) en comparación con los tratados con estimulación eléctrica (media = 9,2; p = 0,002), aunque los parámetros de manometría anorrectal no mejoraron significativamente. La puntuación anal media de incontinencia fecal disminuyó 4,2 puntos en el grupo del Gel intra-anal en comparación con 0,8 en el grupo de estimulación eléctrica (diferencia media en la disminución: 3,4 puntos; IC del 95%: 1,2 a 5,5). La evaluación de la calidad de vida mostró resultados similares entre los grupos que compararon los parámetros iniciales con un seguimiento de 12 meses.LIMITACIONES:Breve período de seguimiento de un año, métodos diferentes de ejercicios anales y línea de base sin igual en algunas de las escalas de calidad de vida entre los dos grupos.CONCLUSIONES:En pacientes con incontinencia anal leve y moderada, la puntuación de incontinencia fecal mejoró significativamente en el grupo de gel intra-anal con copolímero de poliacrilato-polialcohol en comparación con la estimulación eléctrica endoanal. Consulte Video Resumen en http://links.lww.com/DCR/B938. (Traducción- Dr Leonardo Alfonso Bustamante-Lopez).

A prospective trial of the THD SphinKeeper® for faecal incontinence.

THD SphinKeeper® is an emerging surgical technique for faecal incontinence (FI). The safety, indications and efficacy of the procedure are still being investigated. The aim of this study is to present the first experience of SphinKeeper® in Australia. This was a prospective single-centre observational study of patients undergoing SphinKeeper® implantation between February 2018 and September 2019. Baseline demographics, intraoperative and postoperative complications, Cleveland Clinic Faecal Incontinence Score, St Mark's Incontinence Score, Faecal Incontinence Quality of Life score (FIQOL), anorectal manometry and endo-anal ultrasound were assessed preoperatively and 3 and 12months after implantation. Thirteen patients (2 male, 11 female) underwent implantation during the study period. Anal sphincter defects were present in 13 (76.9%) patients [external anal sphincter (EAS) defect, 2 (15.4%); internal anal sphincter (IAS) defect 4 (30.8%); EAS+IAS defect, 4 (30.8%)]. Median follow-up was 32months (range 18-37months). There were four complications: one intraoperative (rectal perforation) and three postoperative (one implant extrusion, two implants that required removal due to malposition). At 12months, an average of 9/10 implants remained ideally placed in each patient. THD SphinKeeper® insertion was associated with an improvement in coping/behaviour as measured using FIQOL (p=0.047). However, the procedure did not improve FI scores or anorectal manometry parameters. In this study, SphinKeeper® marginally improved symptoms of FI but there was no significant impact on anorectal manometric measurements. Larger-scale studies are needed to determine the patient cohort most likely to benefit from this procedure.

Under-classified obstetric anal sphincter injuries

Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time. Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified. A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p< 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears. Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.

Pelvic floor architectural defects in female patients with urge fecal incontinence versus passive fecal leakage: a dynamic ultrasound study.

Fecal incontinence (FI) has two primary subtypes: urgency fecal incontinence (UFI) and passive fecal leakage (PFL). The pathophysiology underlying the subtypes is incompletely understood. To compare the bowel habits, physical examinations and pelvic floor anatomical defects in patients with UFI-dominant FI versus patients with PFL-dominant FI. This is a retrospective cross-sectional study of female patients who presented with fecal incontinence symptoms to our tertiary urogynecology center. All subjects underwent a comprehensive history, physical examination, 3D-static pelvic floor ultrasound, and 2D-dynamic ultrasound of the posterior compartment. Patients with UFI-dominant FI were compared to patients with PFL-dominant FI. One hundred forty-five patients were included in the analysis; 57 categorized as UFI-dominant FI, 69 PFL-dominant FI and 19 categorized as having "both" leakage patterns. In comparing bowel habits, patient with UFI-dominant FI had more frequent bowel movements (15.5 ± SD 13.0/week vs. 10.9 ± SD 7.6 /week, p = 0.022) and were more likely to have loose stools (48.2% vs. 26.1%, p = 0.01). No statistically significant differences were observed in the prevalence of external anal sphincter defect (11.3% vs. 17.2%, p = 0.38) or internal anal sphincter defect (11.3% vs. 19%, p = 0.26) between groups. Finally, patients with UFI-dominant FI had a higher incidence of rectal hypermobility (loss of rectal support on Valsalva) (58% vs. 36.9%, p = 0.025). Patients with urge-predominant FI have increased frequency of bowel movements, looser stools, and increased rectal folding diagnosed via dynamic ultrasound as compared to patients with passive-dominant FI.

Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature.

Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6months, early secondary repair of the anal sphincter can be completed within 14days. Our aims were to review the literature and to describe experiences in our unit. This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019. Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n= 10)], infection [5.2% (n= 5)] and fistula formation [8.2% (n= 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n= 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in thosewho also underwent secondary repair (Starck score 2.1 vs. 5.7, p= 0.01). Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.

Risk of obstetric anal sphincter injury with fundal pressure in second stage of labor: Transperineal ultrasound study.

Clinical management of the second stage of labor and effectiveness of preventive measures for severe perineal tears are controversial. The aim of this study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on obstetric anal sphincter injury (OASI), among primiparous women using three-dimensional (3D) transperineal ultrasonography. A total of 73 women who had their first vaginal birth were included in the study, the fundal pressure group included women where the fundal pressure maneuver was applied (n = 37); and the control group included women who delivered spontaneously without fundal pressure (n = 36). Tomographic ultrasound imaging with 3D transperineal assessment was performed within 48 h of delivery, internal anal sphincter (IAS) and external anal sphincter (EAS) defect were determined. Five (13.5%) women in the fundal pressure group, seven (20%) women in the control group had complete EAS defect (p = 0.4). Complete IAS defect was observed in one (2.7%) woman in the fundal pressure group and two (5.7%) women in the control group (p = 0.5).A Half-moon sign was observed in one woman in both groups (p = 0.9). The rate of other signs was similar in both groups. Multivariate regression models revealed that none of age, fetal birth weight, episiotomy, length of the second stage of labor, fundal pressure application status, and number were independent predictors of complete IAS or EAS defect. Fundal pressure with mediolateral episiotomy during the second stage of delivery does not increase the rate of OASI detected with ultrasonography.

Traumatic deficient perineum: surgical management and outcome from a single center.

Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair. Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS. There were 20 patients (median age 55.5years; range 29-81years) with a median duration of incontinence symptoms of 174 (range 1-540)months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322)months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients. Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery.

Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery. Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis. The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131. One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.

Patient's characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014-2016.

IntroductionObstetric Anal Sphincter Injuries (OASIS) is a common complication of vaginal delivery. The incidence was 4.53 % of total vaginal deliveries. OASIS is associated with an increased risk of fecal incontinence (FI), which affects one’s quality of life. The incidence of OASIS and FI varied from study to study. In this study, we described the characteristics of patients with OASIS at three Indonesian tertiary hospitals in 2014−2016 and FI outcome among those patients.MethodologyThis is a descriptive study on the characteristics of OASIS patients after primary repair in three tertiary hospitals: dr. Cipto Mangunkusumo National General Hospital, Persahabatan General Hospital and Fatmawati General Hospital from 2014 to 2016. From a total of 234 patients, only 58 patients could be contacted and interviewed using Revised Fecal Incontinence Score (RFIS) questionnaires. Out of the 58 patients, only 16 patients came for transperineal ultrasound. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.ResultsFrom a total of 234 patients, the mean age was 26.6 years old with a mean Body Mass Index (BMI) of 24.8 kg/m2. Most of the patients were nulliparous (67.5 %) and the median duration of second stage of labor was 45 min. Episiotomy was not performed on most patients (59.4 %) and most of them underwent spontaneous vaginal delivery (65.4 %) with mean baby’s birthweight of 3217 g. From 58 interviewed patients, three patients complained of FI (5.2 %). Sixteen patients came for transperineal ultrasound examination, and only one of them had FI. Anal sphincter defects were identified in five patients, comprising three external anal sphincter (EAS) and two internal anal sphincter (IAS) defects. All five patients did not experience FI. One patient who had FI had no anal sphincter defect.DiscussionThis is a pilot study for the incidence of FI among the OASIS population in Jakarta, Indonesia. The incidence of FI observed in this study was relatively low (3 out of 58 patients) compared to other studies. This could be due to differences in study population. The fact that the patient with FI had intact anal sphincter suggests that other factors may contribute to the development of FI in addition to the integrity of the anal sphincter. These factors may include pelvic floor muscle and innervation of the surrounding tissues.ConclusionThe outcomes of primary repair of OASIS varied between studies. Patients’ characteristics might play an important role in the development of OASIS as well as the outcome after repair. Further studies with larger sample size are needed.

Management of subsequent pregnancies following fourth-degree obstetric anal sphincter injuries (OASIS)

ObjectivesThe management of subsequent pregnancy in women who sustained OASIS remains an enigma. Nearly all studies include all grades of OASIS including fourth-degree tears. In addition, most protocols require endoanal ultrasound and anal manometric assessment to provide advice regarding mode of delivery. In reality, most women who sustain an OASI do not undergo these investigations. The aims of our study were firstly to evaluate outcomes of fourth-degree OASIS in terms of sphincter defects, anal manometry and anal incontinence symptoms. Secondly, we wished to review recommendations made regarding subsequent mode of delivery after fourth-degree OASIS according to different published protocols. Study designAn observational study of all women who had undergone a primary repair of a fourth-degree tear and seen in the perineal clinic of a tertiary urogynaecology unit between January 2006 and December 2017. Three-dimensional endoanal ultrasound and anal manometry were performed on all women, and symptoms assessed using the validated modified St Mark’s Score for anal incontinence. Diagnostic test accuracy analysis was performed for use of symptoms in predicting abnormal investigations. Results74 fourth-degree tears were identified (mean follow-up 5.9 months; SD 11.5). Endoanal scan showed an internal anal sphincter defect in 77 % and an external anal sphincter defect in 49 %. Only 18 % had no defect. The mean incremental pressure rise was 12.6 mmHg (SD 15.5). 61 % were asymptomatic with a mean St Mark’s Score of 3.8 (SD 5.4). The presence of symptoms alone had poor accuracy in predicting abnormal investigations. Based on Royal College of Obstetricians and Gynaecologists guidance, only 7% would not be offered a caesarean section as they are asymptomatic women with normal scan and manometry findings and would be counselled for a vaginal delivery. ConclusionsGiven that only a few units offer these specialist investigations to their OASI population, it would be reasonable to offer caesarean section to all women who have sustained a fourth-degree tear. However, in centres where endoanal ultrasound and anal manometry are available, individualised counselling can be offered.

What is a significant defect of the anal sphincter on translabial ultrasound?

The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two-thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound. This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed. There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single-slice defect angle on TUI was low, and areas under the receiver-operating-characteristics curves were too low to determine a distinct cut-off value for defect angle. Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single-slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut-off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Comparing the diagnostic accuracy of 3 ultrasound modalities for diagnosing obstetric anal sphincter injuries

The optimal imaging modality of obstetric anal sphincter injuries needs to take into consideration convenience, availability, and ability to assess the sphincter morphologic condition. Endoanal ultrasound imaging currently is regarded as the reference standard, but it is not widely available in obstetric units. Exoanal alternatives exist, such as 3-dimensional introital or transperineal ultrasound imaging, which are already readily available in most obstetrics and gynecology units. The primary objective was to evaluate the diagnostic accuracy of 3-dimensional introital and 3-dimensional transperineal ultrasound imaging compared with 3-dimensional endoanal ultrasound imaging as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate a diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort that is experienced for each imaging modality. A cross-sectional study was conducted of 250 women who sustained obstetric anal sphincter injuries, all of whom underwent 3-dimensional introital, transperineal, and endoanal ultrasound imaging. Introital and transperineal ultrasound imaging were assessed with tomographic ultrasound imaging. All of the women completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on receiver operating characteristic curves with endoanal ultrasound imaging as the reference standard. Diagnostic test characteristics of introital and transperineal ultrasound imaging were calculated with the use of these optimal cut-offs. Optimal cut-off for a significant external anal sphincter defect was ≥3 of 7 slices; sensitivity and specificity were 0.65 and 0.75 on introital imaging and 0.70 and 0.69 on transperineal ultrasound imaging. Optimal cut-off for a significant internal anal sphincter defect was ≥2 of 5 slices; sensitivity and specificity were 0.59 and 0.84 on introital imaging and 0.43 and 0.97 on transperineal ultrasound imaging. The area under the curve for the diagnosis of external and internal anal sphincter defects ranged from 0.70-0.74 (P<.001) for introital and transperineal imaging. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63, and negative predictive value ranged from 0.85-0.93 for introital and transperineal ultrasound imaging. Endoanal ultrasound imaging was the only modality for a defect to correlate with symptoms; mean modified St. Mark's score for a defect sphincter was 2.4 (standard deviation, 4.1) and for an intact sphincter was 0.9 (standard deviation, 2.7; P<.01). Introital and transperineal ultrasound imaging were associated with less discomfort than endoanal ultrasound imaging. Endoanal ultrasound imaging remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound imaging are not suitable for the identification of sphincter defects; however, high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardization of a significant defect. In women with a history of obstetric anal sphincter injuries, introital and transperineal ultrasound imagings are suitable to screen for an intact sphincter if endoanal ultrasound imaging is not available. When defects are found, women should then have endoanal ultrasound imaging to verify the diagnosis.

Medium- to Long-term Follow-up of Obstetric Anal Sphincter Injury.

Obstetric anal sphincter injury is the primary modifiable risk factor for anal incontinence in women. Currently, endoanal ultrasound is most commonly used to detect residual anal sphincter defects after childbirth. Translabial ultrasound has recently been introduced as a noninvasive alternative. This study aimed to determine medium- to long-term outcomes in women after obstetric anal sphincter injuries diagnosed and repaired at delivery. This is a cross-sectional study. This study was performed in a tertiary obstetric unit. Between 2005 and 2015, 707 women were diagnosed with obstetric anal sphincter injuries; 146 followed an invitation for follow-up. Clinical examination, anal manometry, and translabial ultrasound were performed. The primary outcomes measured were the St Mark incontinence score and the evidence of sphincter disruption on translabial ultrasound. Of 372 contactable patients, 146 attended at a mean follow-up of 6.6 years (1.7-11.9), of which 75 (51%) reported symptoms of anal incontinence with a median "bother score" of 6 (interquartile range, 3-8). Median St Mark score was 3 (interquartile range, 2-5). Twenty-four (16%) had a score of ≥5. Women who had been diagnosed with a 3c/4th degree tear had more symptoms (58% vs 44%), significantly lower mean maximal resting pressure (p < 0.001), maximal squeeze pressure (p < 0.001), and more residual external (p < 0.001) and internal (p = 0.012) sphincter defects in comparison with those who had a 3a/3b tear. Women with residual external sphincter defects had lower mean maximal squeeze pressure (p = 0.02). Residual internal sphincter defects (p = 0.001) and levator avulsion (p = 0.048) are independent risk factors for anal incontinence on multivariate modeling. This study was limited by the lack of predelivery data of bowel symptoms and BMI and incomplete intrapartum documentation of tear grade. Symptoms of anal incontinence were highly prevalent (51%), with a high bother score of 6. St Mark scores were associated with residual internal anal sphincter defects and levator avulsion. Women who had a higher tear grade showed a higher incidence of residual sphincter defects and lower manometry pressures. See Video Abstract at http://links.lww.com/DCR/A824.

Mode of delivery following an OASIS and caesarean section rates

ObjectivesWhile the rate of obstetric anal sphincter injury (OASIS) is increasing, there is a lack of evidence on how best to advise women on mode of delivery (MOD) afterwards. The objectives of this study were to assess the clinical value of bowel symptoms, endoanal ultrasound and anorectal manometry in the management of pregnancies after an OASIS and evaluate the performance of different algorithms. Study DesignThis was a retrospective analysis of prospectively collected data in a university hospital perineal clinic. Women with OASIS undergoing endoanal ultrasound scan (EAUS) and anorectal manometry (AM) were included in this study (all women with an OASIS, except the asymptomatic 3a tears). A number of published algorithms were theoretically applied in this cohort to define recommended MOD after an OASIS. ResultsOut of the 233 women included in the study, 51 (21.9%) were symptomatic, 141 (60.5%) had persistent sphincter defects on EAUS and 124 (53.2%) had abnormal AM. One asymptomatic and five symptomatic women were found to have isolated internal anal sphincter (IAS) defects without external anal sphincter (EAS) defects. There were no women with low resting pressure and normal incremental squeeze pressure.The application of the algorithm requiring only one abnormal investigation to be recommended caesarean would have led to an 81.5% caesarean rate. If women with symptoms of anal incontinence or abnormal investigations would be advised for caesarean the rate would be 85.0%. Using the local protocol where symptomatic women only needed one of the two investigations to be abnormal but asymptomatic women were required to have both investigations being abnormal, 94 were considered for caesarean (40.3%). ConclusionThere is a wide range in the number of patients recommended to have caesarean section after an OASIS, depending on the used criteria and management algorithms. There is minimal additional information gained from identifying internal anal sphincter defects and measuring low resting pressures at manometry.

Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study.

To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury

Introduction and hypothesisOur primary objective was to prospectively evaluate anorectal symptoms, anal manometry and endoanal ultrasound (EAUS) in women who followed the recommended mode of subsequent delivery following index obstetric anal sphincter injuries (OASIs) using our unit’s standardised protocol. Our secondary objectives were to evaluate the role of internal anal sphincter defects and also to compare outcomes in a subgroup of symptomatic women with normal anorectal physiology.MethodsThis is a prospective follow-up study of pregnant women with previous OASIs who were counselled regarding subsequent mode of delivery between January 2003 and December 2014. Assessment involved the St Mark’s Incontinence Score (SMIS), anal manometry and EAUS at both antepartum and 3-month postpartum visits. Data were analysed using Wilcoxon and Mann–Whitney U tests.ResultsThree hundred and fifty women attended the perineal clinic over the study period, of whom 122 met the inclusion criteria (99 vaginal delivery [VD], 23 caesarean section). No significant worsening of anorectal symptoms was observed following subsequent delivery in the VD group (p = 0.896), although a reduced squeeze pressure was observed at 3 months postpartum (p < 0.001). There were no new defects on EAUS in either group.ConclusionsThis study showed no significant worsening of bowel symptoms and sphincter integrity apart from lower squeeze pressures at 3 months postpartum in the VD group when our standardised protocol was used to recommend subsequent mode of delivery. In the absence of a randomised study, use of this protocol can aid clinicians in their decision-making.

Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal.

To determine the accuracy of clinical diagnosis of obstetric anal sphincter injuries (OASIS) using three-dimensional (3D) endoanal ultrasound (EA-US) and to compare symptoms and anal manometry measurements between women with anal sphincters adequately repaired and those with persistent anal sphincter defects. The EA-US images of women with clinically diagnosed and repaired OASIS, defined as third- or fourth-degree perineal tear, who attended the perineal clinic at Croydon University Hospital over a 10-year period (2003-2013) were reanalyzed by a single expert blind to symptoms and the results of clinical examination. St Mark's Incontinence Scores (SMIS) and anal manometry measurements were obtained and compared between women with an intact anal sphincter and those with an anal sphincter scar and between those with an intact anal sphincter and those with a defect. Anal manometry measurements were compared between women with an external anal sphincter (EAS) defect and those with an internal anal sphincter (IAS) defect. The images of 908 women were reanalyzed. No evidence of OASIS was found in 64 (7.0%) women, an EAS scar alone was detected in 520 (57.3%) and an anal sphincter defect in 324 (35.7%). Of the 324 women with a defect, 112 had an EAS defect, 90 had an IAS defect and 122 had a combined IAS and EAS defect. SMIS results were significantly higher in women with an anal sphincter defect compared with those with no evidence of OASIS (P = 0.018), but there was no significant difference in scores between women with an intact sphincter and those with an EAS scar only. Women with a defect had a significantly lower maximum resting pressure (median (range), 44 (8-106) vs 55 (29-86) mmHg; P < 0.001) and maximum squeeze pressure (median (range), 74 (23-180) vs 103 (44-185) mmHg; P < 0.001) compared with those in the intact group. Similar, but less marked, differences were observed in women with an EAS scar compared with those who had an intact anal sphincter. The anal length was significantly shorter in women with a defect compared with those in the intact group (median (range), 20 (10-40) vs 25 (10-40) mm; P = 0.003). Seven percent of women with a clinical diagnosis of OASIS were wrongly diagnosed. We believe that this rate may differ from that of other units but training methods and competency assessment tools for the diagnosis and repair of OASIS need urgent reappraisal. The role of EA-US in the immediate postpartum period needs further evaluation as the accurate interpretation of the images is dependent on the expertise of the staff involved. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.