Repair Of Obstetric Sphincter Tears Research Articles

Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects

To determine if there is a correlation between the sonographic extent of anal sphincter defects revealed by three-dimensional endoanal sonography (EAUS) and the degree of anal incontinence following primary repair of obstetric sphincter tears. This was a follow-up study of women who had suffered anal sphincter tearing during vaginal delivery at Aalesund Hospital between January 2002 and July 2004. Incontinence was assessed by St Mark's score. The anal canal was assessed with three-dimensional endoanal sonography (EAUS). Sphincter defects were classified according to the Starck score and our new EAUS defect score. The EAUS images were interpreted by an observer blinded to other patient data. Sixty-one women were included in this study. Incontinence was reported by 32 (52%) women at a median of 21 (range, 9-35) months after delivery. Three-dimensional EAUS datasets were obtained in 55 women. There was a significant correlation between St Mark's score and our EAUS defect score (P = 0.034), and correlation approached but did not reach significance between St Mark's score and the Starck score (P = 0.053). There was a strong correlation between our EAUS defect score and the Starck score (P < 0.001). There is a positive correlation between the extent of sphincter defects and the degree of anal incontinence following primary repair of obstetric sphincter tears. Our findings highlight the importance of adequate reconstruction of the anal sphincters during primary repair.

The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence

To describe and classify endosonographic obstetric sphincter defects at 1 week, 3 months and 1 year after primary repair, and to relate the endosonographic results to anal sphincter pressure and to symptoms of anal incontinence over time. Forty-one women who had suffered a third- or fourth-degree perineal tear at delivery underwent anal endosonography and anal manometry 1 week, 3 months and 1 year after primary suture of the tear. The extent of the endosonographic defects was described using defect scores ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extent of the defect. The women answered a questionnaire with regard to bowel function 1 and 4 years after delivery, the degree of incontinence being expressed as a Wexner score. Some 90% (37/41) of the women had endosonographic defects at 1 week, 3 months and 1 year. The endosonographic defect scores increased significantly between the first and second examinations and then remained unchanged. At 1 year there was a negative correlation between endosonographic sphincter defect score and sphincter pressure. At 1 and 4 years, 54% (22/41) and 61% (25/41) of the women, respectively, had a Wexner score >/= 1. There was a positive correlation between the endosonographic sphincter defect score at 1 week, 3 months and 1 year and the Wexner incontinence score at 1 and 4 years. The endosonographic sphincter defect score at 1 week was the variable that was most predictive of the Wexner score at 4 years (r = 0.48, P = 0.002). The higher the endosonographic sphincter defect score after primary repair of an obstetric sphincter tear the lower the sphincter pressure and the higher the risk of anal incontinence.

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.

Obstetric sphincter tears and anal incontinence: an observational follow‐up study

Background. Persistent defects after primary sphincter repair and occult sphincter tears are common after vaginal deliveries. Anal incontinence may be associated with these morphological defects.Material and methods. Forty‐six primiparous women were evaluated with ultrasonography, manometry and electrophysiology. Twenty‐four women had undergone primary repair of obstetric sphincter tears (sphincter group), 16 women had no clinical sphincter tear but developed anal incontinence postpartum (symptom group), and six were delivered by elective cesarean section (cesarean group).Results. In the sphincter group, 50% had anal incontinence at follow‐up. At ultrasonography, 70% had injuries anteriorly in the midanal canal. At manometry, 4% had decreased resting pressure and 50% decreased squeeze pressure. At electrophysiology, 19% had pathologic pudendal latency and 25% pathologic fiber density.In the symptom group, 44% had injuries anteriorly in the midanal canal at ultrasonography. At manometry, all women had normal resting pressure and 19% had a decreased squeeze pressure. At electrophysiology, 46% had pathologic pudendal latency and 29% pathologic fiber density.In the cesarean group, 33% had mild anal incontinence at follow‐up. Ultrasonography and manometry were normal in all women. At electrophysiology, 33% had pathologic pudendal latency and 17% pathologic fiber density.Conclusion. Anal sphincter injuries at childbirth are often inadequately diagnosed and primary repair frequently results in persisting defects in the anal sphincter. Anatomic injuries to the anal sphincter play an important role in the development of anal incontinence after delivery, but a significant proportion of symptomatic women also demonstrate neurologic impairment at electrophysiologic testing.

Obstetric sphincter tears and anal incontinence: an observational follow-up study

Persistent defects after primary sphincter repair and occult sphincter tears are common after vaginal deliveries. Anal incontinence may be associated with these morphological defects. Forty-six primiparous women were evaluated with ultrasonography, manometry and electrophysiology. Twenty-four women had undergone primary repair of obstetric sphincter tears (sphincter group), 16 women had no clinical sphincter tear but developed anal incontinence postpartum (symptom group), and six were delivered by elective cesarean section (cesarean group). In the sphincter group, 50% had anal incontinence at follow-up. At ultrasonography, 70% had injuries anteriorly in the midanal canal. At manometry, 4% had decreased resting pressure and 50% decreased squeeze pressure. At electrophysiology, 19% had pathologic pudendal latency and 25% pathologic fiber density. In the symptom group, 44% had injuries anteriorly in the midanal canal at ultrasonography. At manometry, all women had normal resting pressure and 19% had a decreased squeeze pressure. At electrophysiology, 46% had pathologic pudendal latency and 29% pathologic fiber density. In the cesarean group, 33% had mild anal incontinence at follow-up. Ultrasonography and manometry were normal in all women. At electrophysiology, 33% had pathologic pudendal latency and 17% pathologic fiber density. Anal sphincter injuries at childbirth are often inadequately diagnosed and primary repair frequently results in persisting defects in the anal sphincter. Anatomic injuries to the anal sphincter play an important role in the development of anal incontinence after delivery, but a significant proportion of symptomatic women also demonstrate neurologic impairment at electrophysiologic testing.

OC178: Endosonographic anal sphincter defect classification after primary repair of obstetric sphincter tears: relation to sphincter pressure and anal incontinence

Objective: To classify endosonographic obstetric sphincter defects and relate the endosonographic results to anal sphincter pressure and symptoms of anal incontinence. Methods: Forty-one women who had undergone primary repair of third or fourth degree perineal tear at delivery underwent anal endosonography and anal manometry at 1 week, 3 months and 1 year after the tear. The extension of the endosonographic defects were classified using scores (1–16; the higher the score the larger the defect). The women answered a questionnaire with regard to bowel function at 1 and 4 years after delivery. Wexner incontinence score (1–20) was used for classification of anal incontinence. Results: 90% of the women had endosonographic defects at 1 week, 3 months and 1 year. The endosonographic defect scores increased significantly between the first and the second examination, then remained unchanged. At 1 and 4 years 54% and 61% of the women, respectively, reported anal incontinence. At 1 year there was a negative correlation between endosonographic sphincter defect score and sphincter pressure (resting pressure: r2 = 0.39, p < 0.0001; squeeze pressure: r2 = 0.16, p = 0.01; resting pressure area: r2 = 0.29, p = 0.0003). There was a positive correlation between endosonographic sphincter defect score at 1 year and incontinence score at 1 year (r2 = 0.13, p = 0.02) and 4 years (r2 = 0.22, p = 0.002). Multiple linear regression analysis showed resting pressure to be the only variable to independently predict Wexner score at 1 year and endosonographic defect score to be the only variable to independently predict Wexner score at 4 years. Conclusion: Endosonographic sphincter defects are common after primary suture of obstetric sphincter tears. The more damaged the sphincter appears to be at endosonography, i.e. the higher the endosonographic defect score, the lower is the sphincter pressure and the higher is the incontinence score.