Starck Score Research Articles

Retrospective analysis of 3a obstetric anal sphincter injury repairs in a teaching hospital: Subjective and objective outcomes

IntroductionThe Royal College of Obstetricians and Gynaecologists (RCOG) recommends offering elective caesarean sections (CS) to patients with anorectal dysfunction, or abnormal endoanal ultrasonography (EAUSS) or anal manometry following obstetric anal sphincter injury (OASI) for subsequent deliveries. (1) Asymptomatic OASI patients however, are not always offered these investigations due to limited access to diagnostic resources across the United Kingdom, particularly those with 3a tears. This paper reviews subjective and objective outcomes in women with 3a tears and aims to add to the body of literature supporting good practice and management of these patients. ObjectivesIdentify the incidence of defects in patients with 3a tears following a primary repair and compare the rate and extent of defects found on EAUSS between symptomatic and asymptomatic women. Study DesignWe performed a retrospective study of 69 women following primary repair of 3a OASI tears in a tertiary referral perineal clinic between January 2020 and December 2022. Symptoms were evaluated using the St Mark’s Score for anal incontinence (SMI) and Starck score for defects on EAUSS. Findings were analyzed using R Foundation Statistical Software (version 4.2.2, 2022). ResultsOut of the total, 42 % (29/69) had defects on EAUSS and 30 % (21/69) of women were symptomatic. Thirty eight percent (18/48) of asymptomatic women were noted to have defects compared with 52 % (11/21) of symptomatic patients. Majority of defects were situated in the upper and mid anal canal (69 %) either as <1 hr or >3 hr hypoechoic areas. There was no significant difference in Starck score (2.23 v 1.53, p = 0.46) between the two groups but those delivered by forceps (p = 0.004) and Asian ethnicity (p = 0.01) were more likely to be symptomatic. ConclusionEAUSS should be offered to all patients following an OASI as symptoms alone are not predictive of anorectal compromise in structure and/or function. Asymptomatic patients with 3a tears should be informed that there is up to a 40% chance of finding a defect on EAUSS.

Under-classified obstetric anal sphincter injuries

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

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

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

Can ultrasound 10 days after obstetric anal sphincter injury predict anal incontinence at long-term follow-up?

The objective was to investigate whether endoanal ultrasound (EAUS) performed 10days after a primary repaired obstetric anal sphincter injury (OASIS) can predict the severity of anal incontinence (AI) in the long term. This prospective cohort study included women with a primary repaired 3b-degree tear, 3c-degree tear or fourth-degree tear at Aarhus University Hospital, Denmark, from 1 September 2010 to 31 May 2011. Clinical assessment and EAUS were performed on day 2, day 10, and day 20 after delivery. Functional outcomes were assessed using a questionnaire at the time of all clinical visits and at the long-term follow-up, 7years after delivery. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score. Ninety-six out of 99 women consented to participate. Five women had a secondary sphincter repair and were subsequently excluded from follow-up. Fifty-seven women underwent both EAUS 10days after delivery and answered the long-term follow-up questionnaire. Median follow-up time was 7.7years (IQR 7.4-7.8). Mean Wexner score was 4.4 ± 4.8 10days after delivery and 2.5 ± 2.8 at follow-up; thus, the Wexner score improved over time (p = 0.01). Ultrasound sphincter defects were found in 82.6% of the women. Mean Starck score was 3.0 ± 1.8. The risk of AI was 0% (95% CI 0.0-30.8) if the Starck score was 0. No correlation was found between the Starck score and the Wexner score at follow-up. We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.

Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS)\u2014a nested case-controlled study

Introduction and hypothesisObstetric anal sphincter injury (OASI) is a significant risk factor for developing anal incontinence. It can therefore be hypothesised that recurrent OASI in a subsequent delivery may predispose women to further anal sphincter dysfunction.MethodsA nested case-controlled study based on data collected prospectively between 2006 and 2019. Women matched for age and ethnicity, with a history of one OASI and no sphincter damage in a subsequent delivery (control) were compared to women sustaining a second OASI. Assessment was carried out using the St Mark’s score (SMIS), anorectal manometry and endoanal ultrasound scan (findings quantified using the modified Starck score).ResultsEighty-four women were included and equally distributed between the two groups, who were followed up 12 weeks postnatally. No difference in SMIS scores was found. Maximum resting pressure (MRP, mmHg) and maximum squeeze pressure (MSP, mmHg) were significantly reduced in the study group. Median (IQR) MRP in the study group was 40.0 (31.3–54.0) versus 46.0 (39.3–61.5) in the control group (p = 0.030). Median (IQR) MSP was 73.0 (58.3–93.5) in the study group versus 92.5 (70.5–110.8) (p = 0.006) in the control group. A significant difference (p = 0.002) was found in the modified Starck score between the study group (median 0.0 [IQR 0.0–6.0]) and control group (median 0.0 [IQR 0.0–0.0]).ConclusionsWe have demonstrated that women with recurrent OASI do not have significant anorectal symptoms compared to those with one OASI 12 weeks after delivery, but worse anal sphincter function and integrity. Therefore, on long-term follow-up, symptoms may possibly develop. This information will be useful when counselling women in a subsequent pregnancy.

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.

Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury.

To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, withan average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.

The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury.

Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.

Sphincter lesions observed on ultrasound after transanal endoscopic surgery.

To assess the morphological impact of transanal endoscopic surgery on the sphincter apparatus using the modified Starck classification. A prospective, observational study of 118 consecutive patients undergoing Transanal Endoscopic Operation/Transanal Endoscopic Microsurgery (TEO/TEM) from March 2013 to May 2014 was performed. All the patients underwent an endoanal ultrasound prior to surgery and one and four months postoperatively in order to measure sphincter width, identify sphincter defects and to quantify them in terms of the level, depth and size of the affected anal canal. To assess the lesions, we used the "modified" Starck classification, which incorporates the variable "sphincter fragmentation". The results were correlated with the Wexner incontinence questionnaire. Of the 118 patients, twelve (sphincter lesions) were excluded. The results of the 106 patients were as follows after one month: 31 (29.2%) lesions found on ultrasound after one month, median overall Starck score of 4 (range 3-6); 10 (9.4%) defects in the internal anal sphincter (IAS) and 3 (2.8%) in the external anal sphincter (EAS); 17 patients (16%) had fragmentation of the sphincter apparatus with both sphincters affected in one case. At four months: 7 (6.6%) defects, all in the IAS, overall median Starck score of 4 (range 3-6). Mean IAS widths were 3.5 mm (SD 1.14) preoperatively, 4.38 mm (SD 2.1) one month postoperatively and 4.03 mm (SD 1.46) four months postoperatively. The only statistically significant difference in sphincter width in the IAS measurements was between preoperatively and one month postoperatively. No incontinence was reported, even in cases of ultrasound abnormalities. TEO/TEM may produce ultrasound abnormalities but this is not accompanied by clinical changes in continence. The modified Starck classification is useful for describing and managing these disorders.

Evaluation of sphincter damage degree with anal endosonography for children with fecal incontinence

To evaluate the application of anal endosonography in the morphology of internal anal sphincter (IAS), external anal sphincter (EAS) and puborectalis (PR) in order to provide necessary information for analysis of the etiology of fecal incontinence and formulation of the therapeutic schedule. From December 2010 to November 2012, 18 children of anorectal malformation (n=14) or Hirschsprung's disease(n=4) with fecal incontinence received anal endosonography. The morphology of IAS, EAS and PR was observed. The damage of anal sphincter was classified according to Starck criteria. Anorectal mamometry and anal clinical score were measured simultaneously. Spearman analysis was performed to examine the correlation of anal sphincter damage with anorectal mamometric score and anal clinical score. According to Starck criteria, anal sphincter damage was small in 11 children, moderate in 6, and severe in 1. PR damage was found in 4 cases. Starck score was positively correlated with manometric score(P<0.05), while not correlated with anal clinical score(P>0.05). Anal endosonography can clearly display the morphology of IAS, EAS and PR, and their integrity and damage degree. It is a very valuable technique to evaluate the anal sphincter of the children with fecal incontinence, which however can not reflect the function of anal sphincter and anal continence thoroughly.

Defects on endoanal ultrasound and anal incontinence after primary repair of fourth‐degree anal sphincter rupture: a study of the anal sphincter complex and puborectal muscle

To perform three-dimensional endoanal ultrasound (EAUS) after primary repair of fourth-degree anal sphincter rupture (ASR) and correlate the sonographic defects with anal incontinence (AI); to measure the axial and sagittal thickness and angle of the puborectal muscle (PRM) as well as the length of the anal canal, and then correlate these measures with AI; and to assess the interobserver measurement agreement between an inexperienced and an experienced sonologist. EAUS was offered to 84 consecutive women, who were asked to answer a validated questionnaire after fourth-degree ASR. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score. Sixty-one women (73%) answered the questionnaire. The median (range) follow-up time was 5.1 (1.3-8.7) years. Thirty-three (54%) of these women underwent EAUS and were included in the study. There was no difference in the incontinence scores between women who underwent EAUS and those who did not. Eleven of the women who underwent EAUS (33%) were continent, 22 women (67%) had flatus incontinence at least once a month, of whom 12 also had incontinence for liquid stool and two had incontinence for solid stool. The median Wexner score was 2 (range, 0-12). Five of the patients (15%) had no ultrasound defects. All of the patients with Wexner scores > or = 4 had a Starck score of > or = 10. No association between ultrasound defects and AI was demonstrated, however, the angle of the PRM and parity were associated with Starck score. No clear association between the measurements of the PRM and AI was shown. The experienced observer detected more of the small defects than did the inexperienced observer. In a 1-9-year follow-up period after primary suture of fourth-degree ASR, the frequency of AI was high, at 67%. No clear association was seen between AI and sphincter defects detected on ultrasonography. There was an association between the angle of the PRM and the extent of ultrasound defects.

Descripción de los hallazgos de la ecografía endoanal en pacientes con incontinencia fecal mediante un sistema de puntuación

Introduction The main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence. Material and method Data were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed. Results A total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender ( P=0.172), although it did correlate with younger ages ( P=0.028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender ( P=0.327) or to the age ( P=0.350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure ( P=0.008) or anorectal squeeze pressure ( P=0.011). Conclusions The presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.

Three‐dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classification of anal sphincter defects

To determine the degree of intraobserver and interobserver agreement for an experienced and an inexperienced sonologist using two scoring systems for ultrasonographic assessment of anal sphincter defects. The study sample comprised the datasets of all women aged between 20 and 40 years who had attended our outpatient clinic and undergone a complete three-dimensional (3D) endoanal ultrasound (EAUS) examination in the period from January 2003 to December 2005. The EAUS datasets were assessed twice independently by two sonologists: one with experience of > 400 3D EAUS assessments and one inexperienced sonologist who had performed approximately 50 assessments before the study. Cases with intraobserver disagreement were resolved by a third (final) assessment. The final assessment from each observer was used to determine the degree of interobserver agreement. Sphincter defects were classified according to our EAUS defect score and the Starck score. EAUS datasets of 55 women were included. Based on first vs. second assessments, intraobserver agreement for the experienced sonologist was good for our EAUS defect score (weighted kappa, 0.75) and the Starck score (weighted kappa, 0.73). Intraobserver agreement for the inexperienced sonologist was moderate for our EAUS defect score (weighted kappa, 0.58) and good for the Starck score (weighted kappa, 0.62). Interobserver agreement was good for both our EAUS defect score (weighted kappa, 0.65) and the Starck score (weighted kappa, 0.74). Intraobserver and interobserver agreement was acceptable for both scoring systems. The experienced sonologist obtained a higher degree of intraobserver agreement than did the inexperienced sonologist.

Endoanal ultrasound findings in patients with faecal incontinence using a scoring system

IntroductionThe main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence. Material and methodData were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed. ResultsA total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender (P=.172), although it did correlate with younger ages (P=.028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender (P=.327) or to the age (P=.350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure (P=.008) or anorectal squeeze pressure (P=.011). ConclusionsThe presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.

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.

OP23.06: Defects and anal incontinence after primary repair of 4th degree sphincter rupture: an endo‐anal study of the sphincter complex and the m. puborectalis

Objectives: The aim of this study was to look for a possible correlation between anal incontinence (AI) and 3D ultrasonic defects after primary repair of 4th-degree anal sphincter ruptures (ASR). Furthermore, the aim was to measure the thickness/length of the m. puborectalis and the length of the anal canal to investigate if any of these parameters correlated with AI. Methods: A validated, symptom specific questionnaire on AI including the St Marks and the Wexner score was sent to 84 consecutive women, who were registered with a 4th-degree anal sphincter rupture (ASR) at our institution between 1 January 2000 and 31 December 2005 (follow up time 12–72 months). Sixty-five women returned the questionnaire (77%) and 36 (43%) gave written informed consent to have ultrasound performed (EAUS). A 3D B-K Medical pro focus machine with a 2050 13-MHz probe was used. Images were analyzed using Starck score (0–16). Results: There was no difference in incontinence score in women with and women without EAUS examination. The distribution of symptoms among the 36 women participating in the EAUS examination: Eleven women were continent (31%), fifteen (42%) had flatus incontinence, seven (19%) had incontinence for liquid stool and flatus and three (8%) were incontinent for hard stool, liquid stool and flatus. Eighteen (50%) had urgency. Clear images of the anal sphincter anatomy was obtained in all 36 women. A weak correlation between the St Marks and sphincter defects scores was demonstrated. All women with a St Marks score > 8 had sphincter defects on ultrasound > 13. The length of the m. puborectalis was independent of the length of the anal canal. A weak correlation between the thickness of the m. puborectalis and the Starck defect score was found. However, no correlation between AI and thickness of the m. puborectalis could be demonstrated. Conclusions: A weak correlation in a 6-year follow-up period was seen between St Marks score and ultrasound sphincter defect score. All patients with St Marks score > 8 had ultrasound defects > 13.