Obstetric Sphincter Research Articles

Perineal massage and warm compresses–Implementation study of a complex intervention in health

ObjectivesTo determine the effect of using tailored and multifaceted strategies on the acceptability, appropriateness, feasibility and adoption of a perineal massage and warm compress intervention by midwives in a maternity ward of a tertiary hospital in Portugal. MethodsThe complex intervention in health was developed based on the Medical Research Council framework and guided by the Theory of Change. Tailored and multifaceted strategies, including dissemination, integration and implementing process strategies, were applied. A mixed-methods approach was adopted, with a combination of qualitative (semi-open interviews) and quantitative (surveys, audits and electronic health records) methods. Surveys were applied to assess the acceptability, appropriateness and feasibility of the intervention. In order to evaluate adoption of the intervention, data from interviews were introduced into NVivo Version 10 to perform thematic analysis, and each audit checklist criterion was analysed using McNemar's exact test to determine differences in paired proportion. ResultsThis study found high acceptability (mean±standard deviation 4.28±0.45), high appropriateness (4.32±0.47) and high feasibility (4.26±0.43) of the intervention by midwives. Differences were reported for most topics between interviews conducted before and after implementation of the intervention. Pre-intervention, the midwives reported that the main factor affecting the application of perineal protection techniques was the lack of continuous presence of the midwife. The birth position was the alternative birth position (hands and knees, side-lying, squatting and semi-sitting), avoiding the lithotomy position. Techniques used for perineal protection were warm compresses, hands-on techniques, hands-off techniques and spontaneous pushing; and the reasons given for performing an episiotomy were large (high-birthweight) baby, Kristeller manoeuvre, tense perineum and previous obstetric sphincter injury. Post-intervention, the midwives reported that the presence of a second person increases the safety of professionals and women and improves working relations. The technique used for perineal protection was autonomy to adapt the intervention with perineal massage and warm compresses. A comfortable birth position for woman was used, and the rate of episiotomy reduced (only performed in the case of fetal distress). Regarding audits, significant differences (p < 0.05) were found for all audit criteria (pre- and post-intervention), which means that midwives adopted the intervention into their clinical practice. ConclusionAcceptability, appropriateness, feasibility and adoption of the intervention by midwives were high. Thus, tailored and multifaceted strategies were effective to achieve the implementation outcomes.

Maternal obesity and the risk of postpartum infections according to mode of delivery

Objective The aim of the present study was to assess the impact of different maternal Body Mass Index (BMI) classes on the risk of postpartum endometritis, wound infection, and breast abscess after different modes of delivery. Secondly to estimate how the risk of postpartum infection varies with different maternal BMI groups after induction of labor and after obstetric anal sphincter injuries. Methods A population-based observational study including women who gave birth during eight years (N = 841,780). Data were collected from three Swedish Medical Health Registers, the Swedish Medical Birth Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. Outcomes were defined by ICD-10 codes given within eight weeks postpartum. The reference population was uninfected women. Odds ratios were determined using Mantel–Haenszel technique. Year of delivery, maternal age, parity and smoking in early pregnancy were considered as confounders. Results There was a dose-dependent relationship between an increasing maternal BMI and a higher risk for postpartum infections. Women in obesity class II and III had an increased risk for endometritis after normal vaginal delivery aOR 1.45 (95% CI: 1.29–1.63) and for wound infections after cesarean section aOR 3.83 (95% CI: 3.39–4.32). There was no difference in how maternal BMI affected the association between cesarean section and wound infection, regardless of whether it was planned or emergent. Women in obesity class II and III had a lower risk of breast abscess compared with normal-weight women, aOR 0.47 (95% CI: 0.38–0.58). The risk of endometritis after labor induction decreased with increasing maternal BMI. The risk of wound infection among women with an obstetrical sphincter injury decreased with increasing BMI. Conclusion This study provides new knowledge about the impact of maternal BMI on the risk of postpartum infections after different modes of delivery. There was no difference in how BMI affected the association between cesarean section and wound infections, regardless of whether it was a planned cesarean section or an emergency cesarean section.

Hubungan Antara Paritas dengan Kejadian Ruptur Perineum (Literature Review)

Perineal tears occurs either spontaneously with vaginal or instrument delivery, or as a result of an episiotomy. Severe perineal tears can involve damage to the anal sphincter and anal mucosa. Perineal tears is caused by several factors which are classified into three groups. Such as maternal factors, delivery procedures, and mothers where parity is a factor in perineal tears. This study used a literature review study design. Research article searches were sourced from the Pubmed, Google Scholar, SCOPUS, scientificdirect, and BMC electronic databases. Search articles using keywords, namely perineal tears, parity, obstetric sphincter anal injuries. The results of a review of nine journals that have been carried out show that parity with a small number can cause perineal tears with a high degree, and vice versa parity with a high number further reduces the degree of perineal tears. But it is also affected by physical activities such as gymnastics and sports which can help to reduce the risk of perineal tears regardless of existing parity. The data that we reviewed can be concluded that there is a relationship between parity and perineal tears.

Incidence and risk factors for secondary failure after acute obstetric sphincter injury repair - an audit of 239 women.

The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events. Prospective data were collected within a 2year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed. Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow-up of 23.4months postpartum. Patients with secondary repair failure had lower anal resting (p= 0.006) and maximum squeeze pressures compared with patients with intact repairs (p< 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p= 0.157). Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow-up periods is required to assess the validity of the findings.

Biofeedback therapy for anorectal functional disorder: Malaysian colorectal tertiary centre experience

BackgroundAnorectal functional disorder encompasses arrays of conditions including Obstructive Defecation Syndrome (ODS) and Fecal Incontinence (FI). Biofeedback Therapy (BFT) serves as first line therapy to re-train pelvic floor coordination, rectal sensation and strengthening pelvic floor muscle. The aim of this study is determining the efficacy of BFT in our centre. MethodsThis is a retrospective observational cohort study of patients attended biofeedback therapy session from January 2013 to December 2018. Descriptive statistic was used to analyse the data. ResultTotal 99 patients with mean age of 44.6 ± 18.1 with female 56% (n = 55) and male 44% (n = 44) attended BFT session. Overall, 77 had CC (77%) and 23 (23%) had FI. Mean number of sessions was 11.8. Overall improvement rate 42 (42%), no improvement 32 (32%) and defaulted 26 (26%). In patients with CC, 32 (41.6%) had improvement in symptoms, 23 (29.9%) had no improvements, 22 (28.6%) defaulted BFT.Patients with FI, 7 (30.4%) had Obstetric Sphincter Injury, 7 (30.4%) had traumatic anal injury, 3 (13.0%) has Low Anterior Resection Syndrome, 2 (8.7%) had sphincter injury following anal sepsis, 2 (13.0%) had rectocele repair and 1 (4.3%) were idiopathic. 9 patients (39.1%) had stoma created. Overall response rate was: 10 patients (43.5%) had improvement in symptoms, 9 patients (39.1%) had no improvement, 4 patients (17.4%) defaulted therapy. ConclusionOur outcome rate is lower compared to published due the limited access and logistic restrictions. This issue should be given great consideration such as broadening the service and training.

Busy day effect on intrapartum adverse maternal outcomes \u2013 a population\u2010based study of 601 247 singleton deliveries

BackgroundThis was a retrospective population-based study, utilizing the data of 601 247 singleton hospital deliveries collected from the Finnish Medical Birth Register (MBR) in 2006–2016. The aim of this study was to analyse the busy day effect on intrapartum adverse maternal outcomes.MethodsTo implement the study design, daily delivery frequencies and ranges (min-max) for each delivery unit (n = 26) were stratified to the daily delivery volume distributions by the delivery unit’s annual delivery volume and profile: Category (C)1 < 1000, C2 1000–1999, C3 2000–2999, C4 ≥ 3000 and C5 the profile of university hospitals. To study the busy day effect, the quiet, optimal and busy days were defined by calculating the number of days (%) with the lowest and highest daily delivery frequencies and summed to the nearest 10 % in each hospital category. Optimal days were determined by calculating approximately 80 % of deliveries occurring between the lowest 10 %, and highest 10 % in each hospital category. Crude and adjusted odd ratios (ORs) with 99 % confidence intervals (CIs) were used to analyze the busy day effect on adverse maternal outcomes, blood transfusions, manual removal of the placenta and obstetric anal sphincter injuries, separately in each hospital category.ResultsThe busy day effect was associated with the 28 % (99 % CI 8–52 %) and 25 % (99 % CI 11–40 %) increased need for blood transfusions in C2 and university hospitals (C5), respectively, whereas 22 % (99 % CI 10–31 %) less blood transfusions were needed at university hospitals during quiet days. In C3 hospitals, 83 % (99 % CI 65–92 %) less blood transfusions were needed during busy days. Obstetric and anal sphincter injury rates declined during quiet days by 22 % (99 % CI 3–38 %) only in university hospitals.ConclusionsThe findings of this study identify no specific pattern to the busy day effect for adverse maternal outcomes defined as manual removal of the placenta or obstetric and anal sphincter injuries. However, both quiet and busy days seem to be associated with increased or decreased need for blood transfusions in different sized delivery units. Findings also suggest that quiet days are associated with a decreased number of obstetric and anal sphincter injuries.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow‐up

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury. This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale. Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3[interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ±4.8 and the mean St. Mark's score was 11.7±5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner scoreof ≥9 had a significantly lower quality of life score in all domains than did women with a Wexner scoreof <9 (P<0.001). At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

The Role of Three-Dimensional Endoanal Ultrasound on Diagnosis and Classification of Sphincter Defects After Childbirth

BackgroundDiagnostic tests for fecal incontinence have been improved over time. This study aims to evaluate the role of Three-dimensional endoanal ultrasound (3D-EUS) and the Starck's score in the assessment and treatment of obstetric sphincter injuries. MethodsA prospective observational study was performed including primiparous women who were evaluated at 20 wk of pregnancy and 3 mo after childbirth. Sphincter defects were classified according to the Starck's and Obstetrical Anal Sphincter Injuries classifications. Patients also completed the Fecal Incontinence Quality of Life and the Wexner questionnaires before and after childbirth. ResultsSphincter defects were detected in 45% of the 56 women included, although 85% had an uneventful delivery. Most defects were found isolated to the external anal sphincter except for two cases, classified by a Starck’s score >8. Fecal Incontinence Quality of Life and Wexner questionnaires showed a rate of symptomatic patients of around 46%. We observed that 30% of patients with sphincter injuries remained asymptomatic. ConclusionsThe 3D-EUS is a useful test in assessing sphincter defects after childbirth. This method makes it possible to detect small sphincter defects that otherwise would have gone unnoticed, as 30% of patients with sphincter injuries were asymptomatic. In addition, both the 3D-EUS and the Starck's score were valuable in establishing an algorithm for the treatment of obstetric sphincter injuries.

Quality of life and 3D-EUS assessment for anal incontinence after childbirth.

the incidence of obstetric sphincter tears has risen to 15-30% and the prevalence of anal incontinence (AI) symptoms after childbirth may be as high as 40%. The present study evaluates the correlation between obstetric injuries detected by endoanal ultrasound (3D-EUS) and AI symptoms, as well as their impact on the quality of life (QOL) of women after childbirth. a prospective observational study was performed of pregnant women evaluated before (baseline) and three months after childbirth to ensure the integrity of the anal sphincters and to evaluate possible injuries. The Fecal Incontinence Quality of Life (FIQL) questionnaire and the Cleveland Clinic Score of Incontinence (Wexner) were completed before and after childbirth. The questionnaire results were correlated with an assessment of sphincter defects performed by 3D-EUS. a total of 56 females were included in the study. Overall, 48% developed symptoms of AI after childbirth, with a significant decrease in their FIQL compared to the initial evaluation, 3.9 (0.05) vs 3.4 (0.8), respectively (p = 0.000). In addition, 42% of the cohort presented with some kind of obstetric sphincter defect on the 3D-EUS. Instrumental assisted delivery and the sphincter defects were the only two significant factors identified via multivariate analysis that were associated with a decrease in QOL (0.4, 95% CI, 0.07-0.8). AI after childbirth was associated with a huge impact on QOL, especially in patients with sphincter injuries. A complete clinical evaluation, including 3D-EUS, is recommended to prevent, manage or treat AI in primiparous females.

Outcomes of treatment of faecal incontinence with sacral nerve stimulation – a Finnish multicentre study

The aim of this multicentre study is to report the results of sacral nerve stimulation (SNS) treatment for faecal incontinence (FI) in Finland and determine factors that could influence SNS treatment outcomes. This is a national multicentre study, involving all patients tested for SNS implantation in Finland from 1999 to 2017. Data were collected retrospectively from electronic patient archives and analysed for possible effects on treatment outcome. Of the 432 patients with FI tested for SNS, 365 were women. Three hundred and thirteen (72.5%) of the tested patients advanced to permanent implantation of a stimulator. A successful final treatment outcome, with subjective alleviation of FI, was reported by 59.3% of the patients at the end of follow-up (mean 2.4 years, range 8 days to 13.3 years). Patients with obstetric sphincter injury and idiopathic FI had more permanent stimulator implantations than patients with iatrogenic injury (P = 0.012). Male patients had significantly worse test phase outcomes than female patients (P < 0.001). Age did not influence treatment outcome (P = 0.446) CONCLUSION: Subjective final success of SNS treatment for FI was achieved in 59.3% of patients at a mean of 2.4 years. Gender and the aetiology of FI influenced the test phase and final treatment outcome of SNS treatment.

Efectos de la episiotomía sobre las lesiones obstétricas del esfínter anal. Una revisión bibliográfica

Obstetric sphincter injuries are a significant source of morbidity in the obstetrics population, as more than half of those affected report long-term anal incontinence. ObjectiveTo determine the effects of episiotomy on obstetric lesions of the anal sphincter. Material and methodsIn order to perform this review, a search made in April 2017 in the Medline and Scopus databases, using “episiotomy” as the Mesh descriptor, and the words, “obstetric anal sphincter injury”. ResultsA total of 23 and 91 results were obtained in Medline and Scopus, respectively, and after applying the inclusion and exclusion criteria, 3 Medline and 12 Scopus articles were selected. DiscussionThe results were analysed according to the type of study, sample size, type of episiotomy performed and the protocol used for it, whether liberal or restrictive. Inclusion and exclusion criteria applied in studies, and the obstetric, demographic and maternal characteristics, including type of delivery, gestational and maternal age, ethnicity, parity, epidural type, the duration of the second stage of labour, maternal and foetal size. ConclusionsEpisiotomy seems to be a protective factor for obstetric lesions of the anal sphincter.

Sacral neuromodulation for faecal incontinence following obstetric sphincter injury - outcome of percutaneous nerve evaluation.

The purpose of this study was to assess the efficacy of percutaneous nerve evaluation (PNE) in women with faecal incontinence (FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect. This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score. Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) (P<0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence (P=0.04), body mass index (BMI) (P=0.03) and pain during PNE (P=0.046) but not to the extent of the sphincter defect (P=0.1). Responders had a higher St Mark's score than nonresponders (P=0.046). The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect.

Reducing the incidence of Obstetric Sphincter Injuries using a hands-on technique: an interventional quality improvement project

A main concern for women giving birth is the risk of obstetric anal sphincter injuries. In our department the incidence of sphincter injuries was around 8 % among vaginally delivering...

An obstetric sphincter injury risk identification system (OSIRIS): is this a clinically useful tool?

Introduction and hypothesisTo establish the contribution of maternal, fetal and intrapartum factors to the risk of incidence of obstetric anal sphincter injuries (OASIS) and assess the feasibility of an OASIS risk prediction model based on variables available to clinicians prior to birth.MethodsThis was a population-based, retrospective cohort study using single-site data from the birth database of Aarhus University Hospital, Denmark. The participants were all women who had a singleton vaginal birth during the period 1989 to 2006. Univariate and multivariate logistic regression analyses were performed using multiple imputations for missing data and internally validated using bootstrap methods. The main outcome measures were the contributions of maternal, fetal and intrapartum events to the incidence of OASIS.ResultsA total of 71,469 women met the inclusion criteria, of whom 1,754 (2.45 %) sustained OASIS. In the multivariate analysis of variables known prior to birth, maternal age 20 – 30 years (OR 1.65, 95 % CI 1.44 – 1.89) and ≥30 years (OR 1.60, 95 % CI 1.39 – 1.85), occipitoposterior fetal position (OR 1.34, 95 % CI 1.06 – 1.70), induction/augmentation of labour (OR 1.46, 95 % CI 1.32 – 1.62), and suspected macrosomia (OR 2.20, 95 % CI 1.97 – 2.45) were independent significant predictors of OASIS, with increasing parity conferring a significant protective effect. The ‘prebirth variable’ model showed a 95 % sensitivity and a 24 % specificity in predicting OASIS with 1 % probability, and a 3 % sensitivity and a 99 % specificity in predicting OASIS with a 10 % probability.ConclusionsOur model identified several significant OASIS risk factors that are known prior to actual birth. The prognostic model shows potential for ruling out OASIS (high sensitivity with a low risk cut-off value), but is not useful for ruling in the event.

Is the risk of obstetric anal sphincter injuries increased in vaginal twin deliveries?

Objective: Vaginal twin deliveries have a higher rate of intrapartum interventions. We aimed to determine whether these characteristics are associated with an increased rate of obstetric anal sphincter injuries compared with singleton.Study design: Retrospective study of all twin pregnancies undergoing vaginal delivery trial was conducted from January 2000–September 2014. Sphincter injury rate compared with all concurrent singleton vaginal deliveries. Multivariable analysis was used to determine twin delivery association with sphincter injuries while adjusting for confounders.Results: About 717 eligible twin deliveries. Outcome was compared with 33 886 singleton deliveries. Twin pregnancies characterized by a higher rate of nulliparity (54.8% versus 49.5%, p = 0.005), labor induction (42.7% versus 29.1%, p < 0.001), and instrumental deliveries (27.5% versus 16.7%, p < 0.001), lower gestational (34.6 ± 3.3 versus 38.8 ± 2.3, p < 0.001), and lower birth weight. Total breech extraction was performed in 29.0% (208/717) of twin deliveries. Overall obstetric sphincter injury rate was significantly lower in the twins group (2.8% versus 4.4%, p = 0.03, OR = 0.6, 95% CI 0.4–0.9), due to lower rate of 3rd degree tears in twins versus singletons (2.2% versus 4.0%, p = 0.02), rate of 4th degree tears similar among the groups (0.6% versus 0.4%, p = 0.5). In multivariable analysis, sphincter injuries were associated with nulliparity (OR = 3.9, 95% CI 3.4–4.5), forceps (OR = 6.8, 95% CI 5.8–7.8), vacuum (OR = 2.9, 95% CI 2.5–3.3), earlier gestational age (OR = 0.2, 95% CI 0.1–0.3), episiotomy (OR = 0.8, 95% CI 0.7–0.9), and birth weight over 3500 g (OR = 1.8, 95% CI 1.6–2.0). However, the association between twins (versus singletons) deliveries and sphincter injuries was lost after adjustment for delivery gestational age (OR = 0.7, 95% CI 0.4–1.2).Conclusion: Despite a higher rate of intrapartum interventions, the rate of sphincter injuries is lower in twins versus singleton deliveries, mainly due to a lower gestational age at delivery.

Postpartum Incontinence. Narrative Review

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries; however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results.

Is the Outcome Indicator "3rd/4th Degree Perineal Tear in Spontaneous Singleton Births" a Reliable Quality Parameter in Obstetrics?

Obstetric sphincter damage is the most common cause of fecal incontinence in women. Between one-third and two-thirds of women who sustain a recognized third-degree tear during delivery subsequently suffer from fecal incontinence. We should therefore try to reduce the rate of high-grade tears as much as possible. But this rate can only be used as an outcome indicator for the quality of obstetric departments if the recognition and classification of sphincter injury is similar across departments in different hospitals.

Review of the diagnosis, management and treatment of fecal incontinence.

Fecal incontinence is a common problem affecting women but is underreported because of patients' reluctance to discuss their symptoms and an inconsistent use of screening tools by physicians. Obstetric injury from vaginal delivery is the principal cause of fecal incontinence among young women. Prevalence rates are highest in the elderly, especially those with declining cognitive function. There are multiple diagnostic tests including anal manometry, endosonography, defecography, and pudendal nerve latency testing to assist physicians in the workup of patients and aid in the selection of appropriate treatment options. After patient identification and workup, most patients can be offered conservative measures including dietary measures and biofeedback. Surgery is indicated for specific abnormalities such as rectal prolapse, fistula, and recent obstetrical sphincter injury repair. Management of refractory cases may include sacral nerve stimulation and percutaneous tibial nerve stimulation. Fecal diversion or an artificial bowel sphincter may be considered when all else has failed. Primary care physicians, gynecologists, and specialists in female pelvic medicine should screen women for fecal incontinence. Initial conservative therapy may be directed by the primary health provider, and those resistant to this approach should be referred to specialist care.

Incontinencia fecal posparto. Revisión de conjunto

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries, however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results.

Long‐term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury

More than 50% of women experience deteriorating continence over time following primary repair of obstetric anal sphincter injuries. The objectives of this study were to assess the function and morphology of the anal sphincters and pelvic floor in women with long-term faecal incontinence after sphincter repair (primary end-point) and to evaluate their correlation with severity of incontinence (secondary end-point). The participants in this prospective study were recruited from a cohort of all women who sustained third or fourth degree obstetric sphincter injury reconstruction (cases) from January 1976 to November 1991. The women who delivered immediately before and after each case, without sustaining obstetric damage, were included as controls. Cases and controls were stratified into three categories: (i) continent; (ii) minor incontinence; and (iii) severe incontinence. The function and morphology of the anal sphincters and pelvic floor were evaluated by MRI, three-dimensional endoanal ultrasonography and anorectal physiology tests. Fifty-nine women (29 cases/30 controls; mean age 51/53 years; mean follow-up 23.7/24.1 years, respectively) were assessed. Morphologically, cases had a significantly shorter anterior external anal sphincter length compared with controls when evaluated by three-dimensional endoanal ultrasonography (8.6 vs 10.2 mm; P = 0.03). Functionally, cases with severe incontinence had a significantly shorter anterior sphincter length compared with cases with minor incontinence (7.7 vs 10.4 mm; P = 0.04). No correlation could be found between anal pressures and severity of incontinence in the case group. Cases had a significantly shorter anterior external anal sphincter length. Functionally, anterior sphincter length correlated with increased severity of incontinence.