Sphincter Rupture Research Articles

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

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

Sacral neuromodulation for bowel dysfunction

Bowel dysfunction generally refers to a variety of clinical conditions including fecal incontinence, constipation, and chronic pelvic pain. Fecal incontinence is the uncontrolled loss of stool, either liquid or solid. Its true prevalence in the adult population is unknown, but might be as high as 5 % if based on a Cleveland Clinic score above 5/20 [1]. The resulting handicap is responsible for social isolation and reduced quality of life. First treatment should be dietary measures, medication, and biofeedback physiotherapy. Surgery is indicated when conservative treatment fails. Direct sphincter repair is suggested in the case of limited total sphincter rupture, but results deteriorate over time, with only around 50 % of patients still continent at long-term follow-up. Sphincter substitution is indicated in patients with large sphincter defects or a severely disrupted sphincter and in the case of failure of other surgical treatment. Non-stimulated graciloplasty (the so-called Pickrell’s procedure) has been abandoned because of the fatigability of the transposed muscle [2]. Dynamic graciloplasty is nowadays very rarely proposed in the treatment of fecal incontinence because the technique is complex, expensive and has a high morbidity rate [3]. Despite a certain level of expertise, our results with the artificial bowel sphincter, like other authors have recently shown, are less promising than those previously published in the literature [4]. Sacral nerve modulation, first developed for the treatment of urinary dysfunction, is another option that has proved to be effective in the treatment of fecal incontinence in patients with an intact or nearly intact sphincter complex [5]. Some authors have demonstrated that sacral neuromodulation could also be beneficial in patients with sphincter defects, in patients presenting with fecal incontinence following anterior resection and chemoradiation for rectal cancer, and in patients suffering from systemic sclerosis or Crohn’s disease. After implantation, 41–75 % of patients achieve complete fecal continence and 75–100 % experience improvement in episodes of incontinence [5]. A few studies have also reported efficacy of sacral neuromodulation in patients suffering from double incontinence, the urinary incontinence being due to either urge incontinence (involuntary urine leakage following urgency), stress incontinence (involuntary urine leakage during efforts), or mixed (associating both urge and stress incontinence) [6, 7]. These functional results are obtained with a reasonable, moderate level of complications [8, 9]. We published the number and causes of reoperation from a series of 87 consecutive patients operated on in a single institution. Among these patients, 36 had surgical revision of the device for the following reasons: device-related failure due to infection in 4 (successful reimplant in 4), electrode displacement in 2, electrode breakage in 2 (reimplantation of electrode in 4), and dysfunction owing to impedance increase in the system in 4; adverse stimulation with pain in 7 (stimulator repositioning in 4 and explantation in 3); battery depletion either spontaneously (n = 6) or owing to an MRI examination (n = 2); total or partial loss of clinical efficacy in 9 (removal of the generator and electrode). In total, nearly 40 % of patients needed a revision of their stimulator, but some of the reoperations were due to the learning curve, the patients in question having been the very first patients being included in the study. A position statement, based on a collective experience of French J.-L. Faucheron (&) G. Martin Colorectal Unit, Department of Surgery, University Hospital, CS 10217, B.P. 217, 38043 Grenoble Cedex, France e-mail: JLFaucheron@chu-grenoble.fr

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

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

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

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

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

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

Midwives' experiences of sphincter tears

Perineal tears are very difficult to prevent, thus one of the midwife’s responsibilities during childbirth is to minimise trauma to the perineum. This study examines the experiences of eight midwives who attended births that resulted in a sphincter rupture. Midwives from two maternity clinics in northern Sweden were interviewed using semi-structured questionnaires. Data were analysed using qualitative content analysis and four themes were identified: feeling guilt, shame and failure; working through feelings; needing support from colleagues, and feeling confident with their skills. The category ‘striving to be good at her job’ was found to be common to all four themes. A midwife may feel guilty and unprofessional when he/she is singled out and criticised. Therefore, in order to reduce these feelings and to further develop professional skills, midwives should be offered mentoring throughout their career.

From endometriosis to perineal trauma

From endometriosis to perineal trauma

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

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

Symptoms after obstetric sphincter injuries have little effect on quality of life

To compare the prevalence of anal incontinence and dyspareunia in women with or without obstetric sphincter injury after standardizing the suture technique. Retrospective case-control study. Regional hospital, Sweden. 305 women with an obstetric sphincter injury and 297 women with spontaneous vaginal delivery. In order to standardize and improve the repairing skills of sphincter injuries, collaboration between obstetricians and colorectal surgeons was begun in 2000. Inner and external sphincters were repaired in two layers with continuous monofilament polidioxane sutures. The participating women received a questionnaire with validated questions on anal incontinence, dyspareunia and quality of life. The follow-up time was 15 months to 8 years. Anal incontinence, dyspareunia and quality of life. Of the sphincter group, 72% returned the questionnaire, as did 67% in the control group. Significantly more women in the sphincter group suffered from incontinence of flatus and loose stool compared to controls (p < 0.05). There was no significant difference of incontinence of solid stool, soiling, or fecal urgency between the groups. The quality of life questions showed no significant difference between the groups. In the sphincter group, there was significantly more superficial coital pain compared to controls (p= 0.02). Significantly more women with complete sphincter injury reported anal incontinence than women with a partial sphincter injury. In spite of increased rate of anal incontinence and dyspareunia after anal sphincter rupture, there was no statistically significant reduction in the women's quality of life.

Risk factors of recurrent anal sphincter ruptures: a population‐based cohort study

To determine the incidence and risk factors of recurrent anal sphincter rupture (ASR). Population-based retrospective cohort study. Data were taken from the National Medical Birth Registry, Denmark. Patients with a first and a second vaginal delivery in the time period 1997-2010. Univariate analysis and multivariate logistic regression were used to determine risk factors of recurrent ASR. The incidence of recurrent ASR and odds ratios for possible risk factors of recurrent ASR: age, body mass index, grade of ASR, birthweight, head circumference, gestational age, presentation, induction of labour, oxytocin augmentation, epidural, episiotomy, vacuum extraction, forceps, shoulder dystocia, delivery interval and year of second delivery. Out of 159 446 women, 7336 (4.6%) experienced an ASR at first delivery, and 521 (7.1%) had a recurrent ASR (OR 5.91). The risk factors of recurrent ASR in the multivariate analysis were: birthweight (adjusted OR, aOR, 2.94 per increasing kg, 95% CI 2.31-3.75); vacuum extraction (aOR 2.96, 95% CI 2.03-4.31); shoulder dystocia (aOR 1.98, 95% CI 1.11-3.54); delivery interval (aOR 1.08 by year, 95% CI 1.02-1.15); year of second delivery (aOR 1.06, 95% CI 1.03-1.09); and prior fourth-degree ASR (aOR 1.72, 95% CI 1.28-2.29). Head circumference was a protective factor (aOR 0.91 per increasing cm, 95% CI 0.85-0.98). The incidence of recurrent ASR was 7.1%. Risk factors of recurrent ASR were excessive birthweight, vacuum extraction, shoulder dystocia, delivery interval, year of second delivery and prior fourth-degree ASR. A larger head circumference reduced the risk of recurrent ASR.

Evaluation of the Role of the Puborectal Part of the Levator Ani Muscle in Anal Incontinence: A Prospective Study of 78 Female Patients With Anal Incontinence

Anal incontinence is most often linked with sphincter rupture and/or stretching the pudendal nerves. The aim of our study was to investigate the involvement of the puborectal part of the levator ani muscle in anal incontinence. Seventy-eight female patients were studied by anorectal manometry, 3-dimensional ultrasound examination, and concentric needle electromyography of the external anal sphincter, puborectal muscle, and bulbocavernous muscles, completing with the evaluation of the pudendal nerve terminal motor latencies. Damage to the puborectal muscle was defined by an abnormal ultrasound and/or abnormal electromyography. Rupture of the anal sphincter apparatus and puborectal muscle was found in 23% and 3.8%. The EMG showed damage to the puborectal part in 39 cases: this was isolated in 4 cases and combined with external anal sphincter damage in 35 patients. Unilateral or bilateral increase in the terminal motor latencies of the pudendal nerves was found in 36% (28/78) of the patients. The frequency of peripheral neurogenic lesions varied from 36% to 90% according to the electromyographic tests used. There was no correlation between puborectal part damage and resting pressure, perception threshold, and maximum tolerable rectal volume. The mean Wexner index score was not increased by the existence of a defect involving the puborectal part found by echography or by damage to the puborectal part shown by the EMG. Investigating puborectal muscle lesions reduced the percentage of idiopathic anal incontinence to 2.5%. Our study confirms the feasibility and usefulness of combined electromyography and 3-dimensional ultrasound examination of the puborectal muscle in anal incontinence.

Experiences of expert midwives in a training program aimed at decreasing perineal tears

This descriptive study explored the roles and responsibilities of expert midwives involved in teaching staff from midwifery students to senior consultants/physicians. We have earlier conducted an intervention project, aimed at decreasing the number of anal sphincter tears. During this intervention a local core team of expert midwives was established. These experts continued the training of colleagues after the midwife instructor had fulfilled the active training period. Eighteen expert midwives from the four Norwegian hospitals which took part in this training program were recruited. To explore the views and experiences of these expert midwives, a questionnaire was completed, and the results were analyzed qualitatively. Before starting the program 24% of the midwives, working at the delivery ward were negative towards the supervision and project, while 46% were positive. One year after the program’s start 92% were positive.Negative feedback at the beginning of the intervention came mostly from the media and professional midwifery organizations. The expert midwives felt that doctors were the most challenging to teach. The response from pregnant women was ultimately positive.Eighteen well motivated midwives became highly appreciated experts after an intensive training program and deemed themselves better and more successful professionals than before. Key words: Delivery, anal sphincter rupture, prevention, qualitative research, interdisciplinary education.

Morbidité périnéale des extractions instrumentales par spatules et ventouses : qu’en est-il réellement ?

To evaluate the perineal morbidity of operative vaginal delivery using spatulas and vacuum. From December 2008 to May 2010, 419 single pregnancies after 37 weeks of gestation in cephalic position were prospectively included: 226 spontaneous vaginal deliveries and 193 operative vaginal deliveries (126 spatulas and 67 vacuum). Each patient had rigorous clinical examination of the perineum. Perineal tears were classified in four different degrees depending on their severity: injury to skin only or episiotomy, injury to the perineum involving perineal muscles, anal sphincter rupture without and with anal epithelium tear, respectively. The rate of second degree or more perineal tear among patients who had spontaneous vaginal delivery, operative vaginal delivery using spatulas and vacuum was: 5.9%, 27% and 28.6%, respectively (p<0.001). If no significant difference was observed between the rate of perineal damages after spatulas and vacuum, compared to spontaneous vaginal delivery, only spatulas were significantly associated to the risk of third degree or more perineal damage: 2 (0.9%) vs. 6 (5.2%), respectively (p=0.022). Only operative vaginal delivery was identified as an independent risk factor for second degree or more perineal tear (AOR: 4.589; 95%CI: 2.012-10.467; p<0.001). Episiotomy had no independent significant impact on that risk (AOR: 0.690; 95%CI: 0.350-1.359; p=0.283). Operative vaginal delivery using spatulas and vacuum does significantly increase perineal morbidity. This risk appears to be independent of the practice of episiotomy.

High episiotomy rate protects from obstetric anal sphincter ruptures: A birth register-study on delivery intervention policies in Finland

To assess the impact of hospital episiotomy policy on obstetric and anal sphincter rupture (OASR, n = 2448) rates and risks among singleton vaginal deliveries in Finland between 1997 and 2007. An observational, retrospective, population-based register study. All 424,297 women in hospitals with more than 1000 deliveries annually, were divided into three groups based on the episiotomy rate quartiles for 11 years and separated on the basis of whether the women were primiparous or multiparous. The lowest and the highest quartiles were compared against the hospitals with intermediate episiotomy rates, comprising the two quartiles around the median. Stepwise logistic regression analysis was used to adjust significant risk factors. The annual range of episiotomy varied from 11 to 94% in primiparous women, and from 1 to 46% in multiparous women. After adjustment the risk of OASR appears to be 39% lower (OR 0.61, 95% CI 0.52-0.90) in primiparous and 45% lower (OR 0.55, 95% CI 0.42-0.72) in multiparous women delivered in the highest quartile hospitals. At an individual level, episiotomy was a protective factor (OR 0.82, 95% CI 0.75-0.91) in primiparous women, but increased the risk by 2.36-fold in multiparous women (OR 2.36, 95% CI 1.86-2.84). The results suggest that high episiotomy rate provided protection from OASR among both groups of women. Among the multiparous women, the 2.4-fold risk of OASR related to episiotomy at an individual level might be explained by confounding by indication, since episiotomy was performed more often to women at a high risk of OASR.

Prevalence and risk factors for anal incontinence after obstetric anal sphincter rupture

To study prevalence and risk factors for anal incontinence (AI) after obstetric anal sphincter rupture. This was a retrospective clinical observational study. Among 14 959 vaginal deliveries, 591 women were diagnosed with obstetric anal sphincter ruptures (3.9%) at one Norwegian University Hospital in 2003-2005. Patients were examined and interviewed approximately 10 months after delivery. Anal continence was classified with St. Mark's incontinence score (0, complete anal continence; ≥3, anal incontinence), and defects in anal sphincter muscles were diagnosed by endoanal ultrasound. Prevalence of anal incontinence was assessed in relation to obstetrical and maternal characteristics as well as the correlation between anal incontinence and ultrasound-detectable defects of sphincter muscle. Anal incontinence with a St. Mark's score of ≥3 was reported by 21% of women with obstetric anal sphincter rupture, with inability to control gas as the most prevalent symptom. Women with AI were more likely to report urinary incontinence compared with women having no AI. In a multiple regression analysis of maternal and obstetrical risk factors, fourth degree sphincter tear was the only significant risk factor for AI. Anal incontinence was more frequent in patients diagnosed with than without ultrasound-identified anal sphincter muscle defects at 10 months postpartum follow-up. Anal as well as urinary incontinence after delivery with obstetric anal sphincter rupture is common, and prenatal obstetric and maternal variables could not predict anal incontinence. Fourth degree perineal tear and a persistent ultrasound-detected defect in the anal sphincter muscles are associated with AI.

Improvement of Recto-anal Function after Successful Two-tage Surgery for External Injury-related Anal Sphincter Rupture: A Case Report

症例は24歳女性でジェットスキーから転落し，外傷性ショックの状態で他院救急搬送となった．直腸膀胱腟壁損傷と診断され，損傷部の可及的な縫合閉鎖，ドレナージおよびS状結腸人工肛門造設術が施行された．膀胱機能は改善したものの括約筋断裂によって肛門機能は廃絶状態となり，受傷から3カ月後に当院紹介となった．排便造影で安静時に粘性造影剤の直腸内保持は不可能で完全便失禁であった．しかし恥骨直腸筋のわずかな動きと筋電図で断裂した括約筋の一部に収縮波を認めたため括約筋訓練を行った．2カ月後に最大随意圧の上昇を確認，また造影剤の直腸内保持が短時間ではあるが可能であり，恥骨直腸筋の収縮と超音波で断裂部の瘢痕組織への置換が確認された．受傷から6カ月後に瘢痕組織を用いた括約筋前方形成術，9カ月後に括約筋後方形成術と括約筋人工靭帯形成術を実施した．受傷から17カ月後に人工肛門を閉鎖し，便失禁もみられず経過は順調である．

The overlap technique versus end‐to‐end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study

To compare the outcome of end-to-end approximation versus the overlap technique for primary repair of obstetric anal sphincter rupture (OASR) at 12 month follow-up. Prospective, randomized controlled study. University hospital. Sample. One hundred and twenty-eight patients with grade 3b, 3c or 4 OASR were randomized; 119 (end-to-end 60, overlap 59) received the allocated treatment. We obtained information concerning fecal incontinence from 101 (85%) patients. The obstetric team on call performed the repairs. Wexner score, endoanal ultrasound (EAUS), and manometry were used to evaluate anal sphincter function at 12 months post-surgery. Primary outcome was incidence of solid stool leakage at least once a week. Secondary outcomes were flatus incontinence, Wexner score, external anal muscle defect examined by EAUS, and anal manometry results. One patient in the end-to-end group and none in the overlap group reported leakage of solid stool once a week or more. Fourteen patients in the end-to-end group and 10 in the overlap group reported flatus incontinence (p = 0.48). Mean Wexner score was similar in both groups, 2.4 versus 2.2. One patient in the end-to-end group and none in the overlap group had a Wexner score >10 (severe anal incontinence) (NS). External sphincter defect was found in 2/46 in the end-to-end group compared to 0/41 in the overlap group (NS). Anal manometry findings were similar in both groups. The overlap repair was not superior to the approximation technique with regard to fecal incontinence at 12 months.

Anorectal Functional Results After Transanal Endoscopic Microsurgery in Benign and Early Malignant Tumors

Transanal endoscopic microsurgery (TEM) has been suggested as a minimally invasive procedure of low morbidity for rectal villous adenomas and early anorectal adenocarcinomas. It has been used clinically in many areas outside of China for more than 20 years, but it began in mainland China only about 2 years ago. Some articles have reported excellent results with regard to morbidity and relapse rate with TEM, but there are no studies addressing its functional results in China until now. The aim of the present study was to analyze the effect of TEM on the manometric results. Thirty-seven patients (16 females, 21 males) underwent TEM and were followed for more than 6 months. Anorectal manometry and an incontinence questionnaire were administered 1 week preoperatively, 2 weeks postoperatively, 3 and 6 months postoperatively. Of the 37 patients, 24 had villous adenomas and 13 had adenocarcinomas (11 uT1 and 2 uT2). Anorectal manometric values showed the mean anal resting pressure (ARP) decrease from 45 +/- 6 mmHg to 29 +/- 4 mmHg (p < 0.05) and the maximum tolerable volume (MTV) decrease from 175 +/- 21 ml to 90 +/- 15 ml (p < 0.05) at the third month after TEM. Maximal squeeze pressure (MSP) decreased from 181 +/- 20 mmHg to 92 +/- 14 mmHg (p < 0.05) at second week after operation and returned to normal value by the third postoperative month. The ARP and MTV were 45 +/- 5 mmHg and 177 +/- 21 ml, respectively, at 6 months after TEM, near the normal value (p > 0.05). Rectoanal inhibitory reflex (RAIR) was absent preoperatively in two patients; it was also absent in 10 patients 3 months postoperatively and in three patients 6 months postoperatively. Endosonography demonstrated internal anal sphincter (IAS) rupture in five patients, and full integrity of the external anal sphincter (EAS) in all patients. Of the five patients with IAS rupture, four had temporary incontinence to flatus normalized up to three postoperative months. Most patients had more times of stools per day and relative higher Wexner scores in a short period after TEM. All these patients were followed for 6-20 months with no incidence of relapse. Anorectal function was preserved well after TEM, although some anorectal manometric parameters changed over time. Thus TEM is safe, in terms of anorectal function, for the cure of benign and early malignant tumors of the rectum.

On a cold winter's day

Winter is here, it is cold outside. From my windows I can see that the Sound between Denmark and Sweden is covered with ice – like in the cold winter of 1658 when the Swedes used the frozen waterways to transport military troops. We were defeated and lost one third of Denmark to the Swedes. Like in those days, we did not expect a cold winter this year. Leading up to the Climate Summit in Copenhagen last December we had all expected a warm winter. Based on observational studies and extrapolations – admittedly poor evidence not higher than level 5 – we believed that the carbon dioxide we produced in recent years had changed the climate. And we thought that we would be able to control the weather by a slight change in behaviour. Did we insult the weather gods? Did we get too close to their jurisdiction? Was it Hybris to even suggest and discuss a plan for how to avoid climate changes? The answer is blowing in the cold wind. In times of uncertainty and even despair, it is nice to know that we have ACTA – the journal that publishes only scientific papers. Even if this issue of ACTA does not provide evidence that changes the World, it may give you some thoughts and ideas to come closer to an understanding of the nature of women, and the results of our care and interventions. In this issue of ACTA you will find an invitation to come to the European (EBCOG) and Nordic (NFOG) meetings this late spring. The chairman of EBCOG, Peter Hornnes, appraises the state of the current level of collaboration and harmonisation within Europe: It is too soon to have common European guidelines – they are simply unattainable. However, EBCOG wants to develop common standards – not to regulate the actual medical treatment – but to set up a framework to point out which issues we need to address and how. Examples of such standards are found in the guest comment. A European project on serious rare complications at delivery has been initiated by Marian Knight and Peter Brocklehurst from NPEU, Oxford. The project is based on reportings from delivery units in UK, who does not collect background data like the Nordic countries. In this issue of ACTA, colleagues from Italy (Stivanello et al.) report on peripartum hysterectomy and how far you can get with routine registration, without prospective collection of data in a specific project. The Nordic countries have started to collect case based data on peripartum hystertectomy, uterine rupture, placenta accreta and excessive postpartum bleeding using identical specific questionnaires – the NOSS project (www.noss.nu) – and will in this way update our knowledge on risk factors and current treatment modalities in these serious complications. We already have information on the background population and medical history and follow up in cases and controls in our medical birth registries and patient registers, which will enable us to get a more complete picture of the consequences of different attitudes towards cesarean delivery in obstetrics. In a commentary three UK researchers convey a dream that serum biomarkers may be used for a diagnosis of ectopic pregnancies in the future. Admittedly, we will need a lot of research before we have a kit – and we still need to select the women to test. Bols et al. have written an outstanding and very detailed systematic review of longitudinal studies on fecal incontinence after delivery – one of the subjects raised when we discuss mode of delivery and when we repair sphincter ruptures. They found that a third or fourth degree tear was the only factor that was associated with subsequent fecal incontinence. Now we only need good studies on how to prevent the ruptures – it seems that good Norwegian studies are on their way. Tyldum et al. in a well-defined cohort could not find any protective effect of pre-pregnancy physical activity on preeclampsia risk. This is an important message to convey to the prepregnant women who are on endorphins. The study is a good example of

A systematic review of etiological factors for postpartum fecal incontinence

Conflicting results are reported about the contribution of maternal, obstetric and fetal characteristics to postpartum fecal incontinence (FI), which is hampering prevention and management of FI. To perform a systematic review identifying delivery-related etiological factors for postpartum FI. Search strategy. Literature searches of PubMed, EMBASE, CINAHL, DocOnline and reference lists from 1980 up to 2009 were conducted. Selection criteria. Prospective cohort studies evaluating maternal, obstetric or fetal risk factors for postpartum FI, with a follow-up period of at least three months, were assessed. We reviewed full reports in English, German or Dutch, with anal incontinence (AI), FI, flatus incontinence, soiling, urgency and FI severity scores as reported outcomes. Data collection and analysis. Data on study characteristics, methodological quality and outcome were extracted from 31 studies according to a standardized protocol. Clinical and methodological sources of heterogeneity permitted only a qualitative analysis. A third- or fourth-degree sphincter rupture was the only etiological factor strongly (AI) or moderately (flatus incontinence) associated with postpartum FI. No association with other postulated risk factors was found, for example, birth weight or instrumental delivery. The potential co-existence of different risk factors impedes the interpretation of the influence of a single delivery-related risk factor. This systematic review, including only longitudinal studies and recognizing the importance of separating results for different outcomes, identifies that a third- or fourth-degree sphincter rupture is the only factor that is strongly (AI) or moderately (flatus incontinence) associated with postpartum FI.