Sphincter Tears Research Articles

Quels sont les facteurs de risque de l’incontinence anale du post-partum ?

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head ; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.

Operative vaginal delivery and the use of episiotomy—A survey of practice in the United Kingdom and Ireland

Objective To establish the views and current practice of obstetricians with regard to operative vaginal delivery and the use of episiotomy. Study design A national survey of consultant obstetricians and specialist registrars practising in the United Kingdom and Ireland registered with the Royal College of Obstetricians and Gynaecologists (RCOG), London. A postal questionnaire was sent to all obstetricians with two subsequent reminders to non-responders. The choice of procedure for specific circumstances, instrument preference, use of episiotomy and views on the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery were explored. Results The response rate was 80.4%. Instrument preference varied according to the fetal position and station and the grade of operator. Vacuum and forceps were both used for mid-cavity non-rotational deliveries (64% and 56% reported frequent use respectively). Rotational vacuum was preferred for a mid-cavity mal-position (69%) followed by equal numbers using rotational forceps or manual rotation and forceps (34% and 36%, respectively). Inexperienced operators were more likely to proceed directly to caesarean section (35%). A restrictive approach to use of episiotomy was preferred for vacuum delivery (72%) and a routine approach for forceps (73%). Obstetricians varied greatly in their perception of the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery. Conclusion There is wide variation in the use of episiotomy at operative vaginal delivery with uncertainty about its role in preventing anal sphincter tears. A randomised controlled trial would address this important aspect of obstetric care.

A validation of the diagnosis of obstetric sphincter tears in two Norwegian databases, the Medical Birth Registry and the Patient Administration System

The purpose of the present study was to validate the registration of obstetric sphincter tears in 2 registers, the Medical Birth Registry of Norway [MBRN] and Patient Administration System [PAS]. A retrospective cohort study of all obstetric sphincter tears that occurred in our department in 1990-1992 and 2000-2002 was performed. The case records of all patients registered either in MBRN, PAS or the birth logs were compared with the information in the medical records, which constituted the 'golden standard'. The incidence of obstetric sphincter tears in 1990-1992 was 5.8% (774/13381), 5.6% (745/13381) had a perineal tear of third degree and 0.2% (29/13381) of fourth degree. In 2000-2002, the total incidence was 6.6% (813/12380), 5.9% (731/12380) was a third degree perineal tear and 0.7% (82/12380) fourth degree, respectively. The sensitivity and specificity of the MBRN database to detect obstetric sphincter tears was 85.3 and 99.5% in 1990-1992, and 91.8 and 99.7% in 2000-2002, respectively. The positive and negative predictive values of a MBRN-registered diagnosis of obstetric sphincter tears in 1990-1992 were 91.4 and 99.1%, while the corresponding percentages in 2000-2002 were 95.4 and 99.4%, respectively. The sensitivity and specificity of the PAS database was correspondingly 52.1 and 99.0% in 1990-1992, and 84.6 and 98.5% in 2000-2002. The positive and negative predictive values of a PAS-diagnosis of obstetric sphincter tears were 75.8 and 97.1% in 1990-1992. In 2000-2002, they were 92.7 and 98.9%, respectively. The validity of a diagnosis of obstetric sphincter tears, based on the MBRN, is sufficiently high to justify future large-scale epidemiologic studies based on this database, while the validity of a PAS diagnosis is lower, but improves.

Postpartum evaluation of the anal sphincter by transperineal three‐dimensional ultrasound in primiparous women after vaginal delivery and following surgical repair of third‐degree tears by the overlapping technique

Intrapartum damage to the anal sphincter is an important factor in fecal incontinence. Recognized lacerations occur in 0.36-8.4% of vaginal deliveries, and occult sphincter damage in up to 35% of primiparous women. We examined the role of three-dimensional transperineal ultrasound (3DTUS) in the evaluation of the anal sphincter in primiparous women after vaginal delivery and after surgical repair of third-degree intrapartum tears by the overlapping technique. During 2004-2005 139 primiparous women without clinically recognized third- to fourth-degree anal sphincter tears were prospectively studied 24-72 h postpartum (Group 1) and 13 primiparous women were examined 48 h to 4 months following surgical repair of third-degree tears with the overlapping technique (Group 2). A 3D 5-9-MHz transvaginal probe was placed in the area of the fourchette and perineal body in transverse and sagittal planes and 2-4 volumes were stored. The parameters studied were: examination duration; continuity of the internal and external sphincters; occult sphincter damage; internal sphincter and external sphincter width-measured 1.5 cm from the distal margin of the anus-at the '12, 3, 6 and 9 o'clock positions'; length of the posterior internal sphincter. Scanning was possible in all women and the stored volumes were adequate in 127/139 (91.4%) cases. Mean examination time was 3.5 min. In Group 1, occult sphincter defect was suspected in 10/127 women (7.9%). These patients were excluded from measurement calculations, leaving 117 cases for analysis. The internal sphincter was consistently visualized in all the remaining patients (n = 117), while the external sphincter was fully visualized in 99/117 women (84.6%), and partially visualized in the remainder. Mean internal sphincter thickness was 2.60, 2.55, 2.60 and 2.72 mm at the 12, 3, 6 and 9 o'clock positions, respectively, and mean internal sphincter length was 3.34 cm. Mean external sphincter thickness was 4.15, 4.20, 4.21 and 4.20 mm at the 12, 3, 6 and 9 o'clock measurement points. In Group 2, 3DTUS confirmed anatomic abnormalities in all the women in the area surrounding the 12 o'clock position. Evaluation of sphincter tears and their position and length was possible using the longitudinal view. Thinning of the internal sphincter in the area of damage and thickening on the opposite side, the 'half moon sign', sphincter discontinuity, thickening of the external sphincter in the area of repair and abnormality of mucous folds, seemed to be common signs of third-degree intrapartum sphincter tears, even after repair. 3DTUS is an accessible and promising method for postpartum sphincter evaluation, that is apparently well tolerated by patients. Reference data for sphincter anatomy representative of findings at transperineal ultrasound in primiparous women in the postpartum period have been established.

Risk Factors for Anal Sphincter Tear During Vaginal Delivery

To identify risk factors associated with anal sphincter tear during vaginal delivery and to identify opportunities for preventing this cause of fecal incontinence in young women. We used baseline data from two groups of women who participated in the Childbirth and Pelvic Symptoms (CAPS) study: those women who delivered vaginally, either those with or those without a recognized anal sphincter tear. Univariable analyses of demographic and obstetric information identified factors associated with anal sphincter tear. We calculated odds ratios (ORs) for these factors alone and in combination, adjusted for maternal age, race, and gestational age. We included data from 797 primaparous women: 407 with a recognized anal sphincter tear and 390 without. Based on univariable analysis, a woman with a sphincter tear was more likely to be older, to be white, to have longer gestation or prolonged second stage of labor, to have a larger infant (birth weight/head circumference), or an infant who was in occiput posterior position, or to have an episiotomy or operative delivery. Logistic regression found forceps delivery (OR 13.6, 95% confidence interval [CI] 7.9-23.2) and episiotomy (OR 5.3, 95% CI 3.8-7.6) were strongly associated with a sphincter tear. The combination of forceps and episiotomy was markedly associated with sphincter tear (OR 25.3, 95% CI 10.2-62.6). The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4). Our results highlight the existence of modifiable obstetric interventions that increase the risk of anal sphincter tear during vaginal delivery. Our results may be used by clinicians and women to help inform their decisions regarding obstetric interventions. II.

Research Summaries for Normal Birth

In this column, the author summarizes four research studies that further support the benefits of normal birth. The topics of the studies include the optimality of midwifery care for pregnant women at moderate risk; obstetric care practices associated with anal sphincter tears in vaginal births; the effect of acupuncture treatment on women with prelabor rupture of membranes at term; and women's ability to adapt to early labor.

Endoanal Ultrasound Findings and Fecal Incontinence Symptoms in Women With and Without Recognized Anal Sphincter Tears

To estimate whether endoanal ultrasound findings are more prevalent in primiparous women with a history of anal sphincter tear than in women without this history and whether the findings are associated with fecal incontinence symptoms. A total of 251 primiparous women at seven clinical sites underwent standardized ultrasound assessment of the internal and external anal sphincter 6-12 months after delivery. Participants were women in the three cohorts of the Childbirth and Pelvic Symptoms Study: 1) women with clinically evident third- or fourth-degree tear at vaginal delivery (n=106); 2) no tear at vaginal delivery (n=106); and 3) cesarean delivery without labor (n=39). Women completed the Fecal Incontinence Severity Index to assess fecal incontinence symptoms. Thirty-five percent of the sphincter tear group exhibited internal sphincter gaps compared with 3% of vaginal controls (odds ratio [OR] 18.4, 95% confidence interval [CI] 5.5-62.1) and 10% of cesarean controls. External sphincter gaps were identified in 51% of the tear group compared with 31% of vaginal controls (OR 2.3, 95% CI 1.3-4.0) and 28% of cesarean controls. In the tear group, fecal incontinence severity was greater in those with internal sphincter gaps compared with those with no internal sphincter gaps (Fecal Incontinence Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well as in those with external sphincter gaps (6.1+/-8.4 compared with 2.7+/-5.0, P=.01), and greatest in those with both internal and external sphincter gaps compared with at least one gap not present (7.2+/-8.1 compared with 3.4+/-6.4, P=.003). Anal sphincter gaps detected by ultrasonography are prevalent in postpartum primiparous women with a history of sphincter tear and are associated with fecal incontinence severity. II-2.

Sekundär beschleunigte Fremdkörper als Gefahrenquelle bei Airbagauslösung

The use of airbag systems in motor vehicle construction has led to a significant reduction in both the frequency and intensity of injuries during traffic accidents. However, recent reports have shown numerous cases in which it is assumed that the airbag was the major cause of serious injury. In a collision with a wild boar, both airbags in the automobile deployed. The driver suffered facial abrasion and belt contusion to the left shoulder. The passenger held a glass bottle in her hands during the impact that, secondarily accelerated through the airbag, hit both eyes and the bridge of her nose. On clinical admission, the patient showed fractures of the nasal bridge, of both medial orbital walls on both sides and a massive periocular haematoma which required direct examination under narcosis. Both eyes showed an orbital contusion, a large area of corneal abrasion, traumatic mydriasis with sphincter tears such as bilateral 90% hyphema. During surveillance, a progressive reduction in visual acuity occurred. After posterior chamber vitrectomy with epiretinal peeling and posterior chamber lens implantation in the left eye, visual acuity was 0.05 in the left eye and 0.01 in the right. A considerable danger emanates from objects which are situated between head and airbag in the moment of airbag deployment. This requires public education and, in addition, airbag systems which are adapted to the drivers height and weight, as well as to objects in its immediate vicinity.

Risk factors for sonographic internal anal sphincter gaps 6 to 12 months after delivery complicated by anal sphincter tear

Risk factors for sonographic internal anal sphincter gaps 6 to 12 months after delivery complicated by anal sphincter tear

Imaging of the pelvic floor

Disorders of the pelvic floor are complicated and abnormalities rarely exist in isolation. Evacuation proctography combined with dynamic MRI allows a comprehensive imaging assessment. Patients are categorized into treatment-defined groups on the basis of imaging, physiological testing, history and physical examination. Endo-anal ultrasound or MRI is the most sensitive method for examining for sphincter tears in patients with faecal incontinence. Disorders of the pelvic floor are common, particularly among women, and may manifest themselves as either constipation, faecal incontinence or a variety of other symptoms. Imaging plays an increasingly important role in the investigation of these disorders. Defecography provides both structural and functional information about rectal evacuation and prolapse. Dynamic MRI may be a valuable alternative, as this technique also allows the pelvic floor muscles to be visualized in detail. The treatment of constipation and prolapse is partly empirical, but imaging has a key role in categorizing the structural and functional causes of constipation and incontinence. In this article, common imaging modalities for investigating the pelvic floor are described, and pictorial illustrations of abnormal findings are presented.

Fecal and Urinary Incontinence in Primiparous Women

To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence. The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site. Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8-4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2-3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence. Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders. II-3.

Mechanism of Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs

Mechanism of Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs

The clinical significance of postpartum transperineal ultrasound of the anal sphincter

Background and objective To evaluate the clinical significance of postpartum anal sphincter damage by transperineal ultrasonography (TPUS) performed on the day of delivery. Methods Continence questionnaires were handed out and TPUS was performed on 154 consecutive primiparous women 6–24 h after vaginal delivery. At 2 and 6 months later, complaints and sphincteric sonographic appearance were reassessed. The puerperal women's clinical status and sonographic findings in the immediate and late postpartum period were evaluated. Results Thirty-five (23%) women complained of anal incontinence on the first postpartum day and anal sphincter damage was demonstrated by TPUS in 31 (89%) of them. Four women with anorectal complaints had an intact anal sphincter by TPUS. Follow-up questionnaires, 2 months later, revealed 30 symptomatic women: all of them had sonographically recognized tears on the initial TPUS and 27 of them had positive findings on the TPUS performed 2 months after birth. Six months after delivery, 27 women reported symptoms and all of them had sphincteric disruption evidenced on TPUS performed on the day of delivery. All the women with intact sphincter on the initial TPUS were asymptomatic 6 months later. Conclusion TPUS findings on the day of delivery are related to long-term anorectal complaints, supporting a potential role for TPUS as a screening aid for anal sphincter tears.

Which factors determine the sexual function 1 year after childbirth?

To evaluate which factors determine sexual activity and satisfaction with the sexual relationship 1 year after the first delivery. Prospective longitudinal cohort study. Ten midwifery practices. Three hundred and seventy-seven nulliparous women were included. The Maudsley Marital Questionnaire is a standardised and validated questionnaire with 15 items relating to marital and sexual adjustment, with a nine-point (0-8) scale appended to each question. Scores on the sexual scale (MMQ-S) range from 0 to 40. Higher scores are indicative of greater dissatisfaction. Sexual intercourse was dichotomised into having sexual intercourse or not having sexual intercourse. Several obstetric and maternal factors were analysed. Sexual intercourse at 1 year postpartum and dissatisfaction with the sexual relationship as assessed by the MMQ-S scale. In multiple logistic regression analysis, the main predictive factor for no sexual intercourse 1 year postpartum was no sexual intercourse at 12 weeks of gestation (beta 11.0 [4.01-30.4]). Women were five times less likely to be sexually active after a third/fourth degree anal sphincter tear as compared with women with an intact perineum (beta 0.2 [0.04-0.93]). Dissatisfaction with the sexual relationship 1 year after childbirth, assessed with the MMQ-S scale, is associated with not being sexually active at 12 weeks of gestation (beta- 0.208, P= 0.004) and with an older maternal age at delivery (beta 0.405, P= 0.032). An important prognostic factor for dissatisfaction with the sexual relationship 1 year postpartum was not being sexually active in early pregnancy. Satisfaction with the sexual relationship seems not to depend on pregnancy- and parturition-associated factors.

Mechanism of Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs

Mechanism of Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs: PDF Only

The role of mediolateral episiotomy during labour. Analysis of risk factors for obstetric anal sphincter tears

To determine risk factors for third-degree and complete third- or fourth-degree anal sphincter tears in vaginal delivery. This is a retrospective comparative study. Fifty-three women who had sustained an anal sphincter tear were compared with 9,178 women without such a complication between August 1997 and October 2001. Obstetric data was collected from an electronic database. The main outcome measures were odds ratios. In the whole study population, odds ratios (ORs) for third-degree tears were: primiparity, 8.34 (95% confidence interval [CI] 3.98-17.48); vacuum extraction, 5.22 (95% CI 2.69-10.13); parietal presentation, 3.97 (95% CI 1.16-13.64); and birth weight >4,000 g, 3.77 (95% CI 2.11-6.68); and for complete third- or fourth-degree tears odds ratios were 5.42, 2.98, 5.64, and 3.01, respectively. In multivariate analysis, mediolateral episiotomy appeared to be protective as regards third-degree tears (OR 0.37 [95% CI 0.2020-0.70]). Vacuum-assisted vaginal delivery bears an increased risk of third-degree anal sphincter tears in a maternity unit where forceps are not used. Restricted use of mediolateral episiotomy may have a protective effect on the perineum.

Risk Factors for Anal Sphincter Tear in Multiparas

To assess maternal, newborn, and obstetric risk factors associated with anal sphincter tear in multiparous women. This case-control study identified 18,779 multiparous vaginal deliveries from 1992 to 2004 from an obstetric automated record database at the University of Alabama at Birmingham. Two hundred eighty-four patients were selected, 145 cases and 139 controls. Variables from the index pregnancy and prior pregnancies were analyzed, and multivariable logistic regression models were constructed to determine significant predictor variables for anal sphincter tear in multiparous women. One hundred forty-five multiparous women with no history of cesarean delivery sustained a sphincter tear. Multivariable logistic regression showed a significant association with episiotomy (odds ratio [OR] 16.3, 95% confidence interval [CI] 7.7-34.4), shoulder dystocia (OR 7.9, CI 1.6-38), forceps delivery (OR 4.7, CI 2.0-11.2), and being married (OR 2.2, CI 1.1-4.6). A second exploratory model that included variables from previous pregnancies, showed that in addition to episiotomy (OR 34.6, CI 8.8-136), shoulder dystocia (OR 11.1, CI 1.3-95.2), forceps delivery (OR 6.1, CI 1.6-23.5), previous sphincter tear (OR 7.7, CI 1.2-48.7), and second stage of labor greater than 1 hour (OR 6.7, CI 1.1-42.5) were associated with tear. The strongest clinical risk factors for anal sphincter tear in multiparous women are episiotomy, shoulder dystocia, previous sphincter tear, prolonged second stage of labor, and forceps delivery. II-2.

Facoemulsificação e utilização de lentes intra-oculares em portadores de hanseníase: estudo caso-controle

To check the complications of cataract surgery with intraocular lens implantation in leprosy patients by the phacoemulsification technique, and to compare these results, with a control group. The used method was a case control study, where 31 eyes from leprosy patients were submitted to cataract surgery, from June 1999 to January 2003, called Case Group. On the other hand, 31 eyes of healthy patients were selected for the Control Group. The comparison between the groups was performed using Fisher's exact test. The used program was EPI INFO 6.04. Sphincter tear was the only postoperative complication higher in the leprosy group (p=0.024). The other alterations did not show statistic differences (p>0.05). Visual acuity improvement was the same in both groups. This study showed that the visual acuity and complications after cataract surgery with intraocular lens are the same in leprosy patients and healthy ones.

How to Repair an Anal Sphincter Injury After Vaginal Delivery: Results of a Randomized Controlled Trial

Anal sphincter injuries have been reported to complicate up to 20% of vaginal deliveries. Fecal urgency and incontinence as well as dyspareunia and perineal pain are among the sequelae of these injuries. Traditionally, they have been repaired at the time of injury by trainee obstetricians who perform end-to-end approximation of the torn sphincter. There is some evidence that the overlap technique may yield better outcomes. In addition, monofilament sutures may be preferable to braided sutures because of a longer life but may themselves cause discomfort or stitch abscess. Among 10,266 women who delivered vaginally were 150 (1.5%) who sustained a third- or fourth-degree anal sphincter tear. Three fourths of them were randomized to have overlap pair with braided polyglactin (Vicryl) sutures, end-to-end repair with the same sutures, or either type of repair using polydioxanone (PDS) sutures. All repairs were carried out as primary procedures under full aseptic conditions by staff trained in both methods. Patients received either regional or general anesthesia. No significant differences in suture-related morbidity—the primary outcome—were evident after 6 weeks. A substantial majority of patients (70%) were totally asymptomatic at this time. Bowel symptoms were infrequent as was an adverse change in quality of life. The 4 treatment groups did not differ in these respects. All but 2% of women were sexually active 12 months postoperatively. The most common symptoms were vaginal dryness and loss of libido. Fewer than 10% of women reported fecal incontinence. No differences in outcome were found between women having a complete third- or fourth-degree tear and those with a partial third-degree tear. When properly trained individuals repair postvaginal delivery anal sphincter tears, long-term morbidity is infrequent and does not depend on the method of repair or the suture material used. All medical staff assigned to labor wards should be trained to accurately diagnose these injuries.

Effect of vaginal delivery on endosonographic anal sphincter morphology

Objective To describe the effect of vaginal delivery with no clinically recognized sphincter tear on endosonographic anal sphincter morphology and sphincter pressure and to relate endosonographic results to anal sphincter pressure and anal incontinence score. Study design Thirty-two nullipara underwent anal endosonography and anal manometry in the third trimester of pregnancy, 2 weeks and 6 months post-partum. The sphincter defect scores (1–16) and the thickness and length of the sphincters were measured by endosonography, and sphincter pressures and manometric sphincter lengths were determined. The Wexner incontinence score (1–20) was used to classify anal incontinence 6 months post-partum. Results Five (16%) women had small endosonographic anal sphincter defects (score 3–4) before delivery. Eight women (25%; confidence interval 11–43%) had new defects detected post-partum, five small, one moderate (score 7), and two large (score 10–11). Six (75%) of eight women with new defects post-partum had undergone episiotomy versus five (21%) of 24 women with no new defects ( p = 0.02). Six months after delivery 16 (50%) women reported anal incontinence, and there was a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score. The sphincter was significantly longer during pregnancy than 6 months post-partum. Conclusion New sphincter defects may arise after vaginal delivery without any clinically recognizable sphincter tear. There is a positive correlation between the endosonographic defect score 6 months post-partum and the Wexner incontinence score.