Obstetric anal sphincter injury ten years after: subjective and objective long term effects

Abstract

Objective To establish the long term effects of obstetric anal sphincter rupture.Design Prospective observational study.Setting University hospital in Sweden.Population Eighty-two women from a prospective study from 1990 to compare anorectal function after third degree tear. Methods Women completed a structured questionnaire, underwent a clinical examination and anorectal manometry, endoanal ultrasound (EAUSG) with perineal body measurement. Main outcome measures Symptoms of anal incontinence, sexual symptoms, anal manometry scores and evidence of sphincter damage on EAUSG. Results Five women had undergone secondary repair and three were lost to follow up. Fifty-one women (80%) completed the questionnaire. Twenty-six out of 46 (57%) of the original study group and 6/28 (20%) of the original controls were examined. Incontinence to flatus and liquid stool was more severe in the study group than in controls. Flatus incontinence was significantly more pronounced among women with subsequent vaginal deliveries. Mean maximal anal squeeze pressures were 69 mmHg in the partial rupture group and 42 mmHg in the complete rupture group (P ¼ 0.04). Study group women with signs of internal sphincter injury reported more pronounced faecal incontinence and had lower anal resting pressures (24 mmHg) than those with intact internal sphincters (40 mmHg) (P ¼ 0.01). Perineal body thickness of less than 10 mm was associated with incontinence for flatus and liquid stools, less lubrication during sex and lower anal squeeze pressures (58 mmHg vs 89 mmHg, P ¼ 0.04). Conclusions Subjective and objective anal function after anal sphincter injury deteriorates further over time and with subsequent vaginal deliveries. Thin perineal body and internal sphincter injury seem to be important for continence and anal pressure.

Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery

“…The results of this study suggested that women with anal sphincter disruption had a slightly increased risk of fecal incontinence with no impact on urinary or sexual symptoms and mental or physical health [11]. In contrast, other authors reported a higher incidence of urinary symptoms [12,13] and sexual dysfunction [5,7,14,15] after anal sphincter tear.…”

“…The limitation of the present study was the overall response rate of 36%, which may appear low in comparison to other studies [5,7,[9][10][11]. However, we did not contact women by phone before sending the questionnaires [10,11] nor ask them to participate in the study in the direct postpartum period [6], or considered a group of women that had already participated in a previous study [5,7,9], which might all induce a selection bias. Similar response rates (32-33%) were obtained by others who mailed a brief questionnaire about pelvic floor symptoms in an unselected group of women after vaginal birth [13].…”

“…Tears in the connective and muscular tissue as well as compression of the vascular supply and nerve bundles represent direct and indirect trauma responsible for defects in pelvic organ support and functional alterations of surrounding organs. A thirddegree tear increases the risk of fecal incontinence [4][5][6], although long-term results are conflicting [7,8]. Nygard et al found a large number of fecal incontinence in middleaged women, without statistical differences between the episiotomy, anal sphincter tear, or Caesarean groups [8].…”

“…Nygard et al found a large number of fecal incontinence in middleaged women, without statistical differences between the episiotomy, anal sphincter tear, or Caesarean groups [8]. Deterioration of anal continence over time and with subsequent deliveries has been described [6,7], but other authors failed to confirm such results after obstetrical anal sphincter tear [9].…”

Myoarchitectural and functional alterations in rabbit external anal sphincter muscle following experimental surgical trauma

“…Second is the trauma related to instrumentation, and third is surgical episiotomy. Women who sustain thirddegree obstetrical tear develop FI soon after delivery if muscles are not properly repaired (13). However, in the significant majority of women, injury to the anal sphincter and other pelvic floor muscle is occult.…”