Obstetric anal sphincter injury: How to avoid, how to repair: A literature review

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Applied Evidence

Obstetric anal sphincter injury: How to avoid, how to repair: A literature review

J Fam Pract. 2006 March;55(3):193-200

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References

1. Mellgren A, Jensen LL, Zetterstrom JP, Wong WD, Hofmeister JH, Lowry AC. Long-term cost of fecal incontinence secondary to obstetric injuries. Dis Colon Rectum 1999;42:857-865.

2. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905-1911.

3. Royal College of Obstetricians and Gynaecologists. Methods and Materials used in Perineal Repair. Guideline No. 23. London: RCOG Press; 2004.

4. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol 2000;183:1220-1224.

5. Simhan HN, Krohn MA, Heine RP. Obstetric rectal injury: risk factors and the role of physician experience. J Matern Fetal Neonatal Med 2004;16:271-274.

6. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98:225-230.

7. Oberwalder M, Connor J, Wexner SD. Meta-analysis to determine the incidence of obstetric anal sphincter damage. Br J Surg 2003;90:1333-1337.

8. Oberwalder M, Dinnewitzer A, Baig MK, et al. The association between late-onset fecal incontinence and obstetric anal sphincter defects. Arch Surg 2004;139:429-432.

9. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries-myth or reality? BJOG 2006;113:195-200.

10. Sultan AH, Nugent K. Pathophysiology and nonsurgical treatment of anal incontinence. BJOG 2004;111 (Suppl 1):84-90.

11. Schafer A, Enck P, Furst G, et al. Anatomy of the anal sphincters. Dis Colon Rectum 1994;37:777-781.

12. Mahony R, Daly L, Behan M, Kirwan C, O’Herlihy C, O’Connell R. Internal Anal Sphincter injury predicts continence outcome following obstetric sphincter trauma. AJOG 2004;191:6s1-s89.

13. Bartram CL, Frudringer A. Handbook of Anal Endosonography. Petersfield, UK: Wrightson Biomedical Publishing; 1997.

14. Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labor: prospective study before and after childbirth. BJOG 1994;101:22-28.

15. Snooks SJ, Henry MM, Swash M. Fecal incontinence due to external anal sphincter division in childbirth is associated with damage to the innervation of the pelvic floor musculature: a double pathology. BJOG 1985;92:824-828.

16. Donnelly V, Fynes M, Campbell D, Johnson H, O’Connell PR, O’Herlihy C. Obstetric events leading to anal sphincter damage. Obstet Gynecol 1998;92:955-961.

17. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. Randomized clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery. BJOG 2003;110:424-429.

18. Deering SH, Carlson N, Stitely M, Allaire AD, Satin AJ. Perineal body length and lacerations at delivery. J Reproductive Medicine 2004;49:306-310.

19. Goldberg J, Hyslop T, Tolosa JE, Sultana C. Racial Differences in severe Perineal lacerations after vaginal delivery. Am J Obstet Gynecol 2003;188:1063-1067.

20. Robinson JN, Norwitz ER, Cohen AP, McElrath TF, Lieberman ES. Epidural analgesia and third- or fourth-degree lacerations in nulliparas. Obstet Gynecol 1999;94:259-262.

21. Carroll TG, Engelken M, Mosier MC, Nazir N. Epidural analgesia and severe perineal laceration in a community-based obstetric practice. J Am Board Fam Prac 2003;16:1-6.

22. Riskin-Mashiah S, O’Brian Smith E, Wilkins IA. Risk factors for severe perineal tear: can we do better? Am J Perinatol 2002;19:225-234.

23. Bodner-Adler B, Bodner K, Kaider A, et al. Risk factors for third-degree perineal tears in vaginal deliveries with an analysis of episiotomy types. J Reprod Med 2001;46:752-756.

24. Eason E, Labrecque M, Marcoux S, Mondor M. Anal incontinence after childbirth. CMAJ 2002;166:326-330.

25. Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000;95:464-471.

26. Cargill YM, MacKinnon CJ, Arsensault MY, et al. Clinical Practice Obstetrics Committee. Guidelines for operative vaginal birth. J Obstet Gynaecol Can 2004;26:747-761.

27. Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database System Rev 1999;(3):CD000081.-

28. Schlomer G, Gross M, Meyer G. Effectiveness of liberal vs. conservative episiotomy in vaginal delivery with reference to preventing urinary and fecal incontinence: a systematic review [in German]. Wien Med Wochenschr 2003;153:269-275.

29. Klein MC, Gauthier RJ, Jorgensen SH, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online J Curr Clin Trials 1992;Doc No 10.

30. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: retrospective cohort study. BMJ 2000;320:86-90.

31. Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990;75:765-770.

32. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. BJOG 1980;87:408-412.

33. Poen AC, Felt-Bersma RJ, Dekker GA, Deville W, Cuesta MA, Meuwissen SG. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 1997;104:563-566.

34. Eogan M, O’Connell R, O’Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006;113:190-194.

35. Cook TA, Keane D, Mortensen NJ. Is there a role for the colorectal team in the management of acute severe third-degree vaginal tears? Colorectal Dis 1999;1:263-266.

36. Leeman L, Spearman M, Rogers R. Repair of obstetric perineal lacerations. Am Fam Physician 2003;68:1585-1590.

37. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: a systematic review & national practice survey. BMC Health Serv Res 2002;2:9.-

38. Sultan AH, Kamm MA, Hudson CN. Obstetric perineal trauma: an audit of training. J Obstet Gynaecol 1995;15:19-23.

39. Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. BJOG 1999;106:318-23.

40. Royal College of Obstetricians and Gynaecologists. Management of third- and fourth-degree perineal tears following vaginal delivery. Guideline No. 29. London: RCOG Press; 2001.

41. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. A randomised clinical trial comparing primary overlap with approximation repair of third degree tears. Am J Obstet Gynecol 2000;183:1220-1224.

42. Kairaluoma MV, Raivio P, Aarnio MT, Kellokumpo IH. Immediate repair of obstetric anal sphincter rupture: medium-term outcome of the overlap technique. Dis Colon Rectum 2004;47:1358-1363.

43. Mahony R, Behan M, O’Herlihy C, O’Connell PR. Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear. Dis Colon Rectum 2004;47:12-17.

44. Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam M. Antibiotic prophylaxis for operative vaginal delivery (Cochrane review). In: The Cochrane Library, Issue 2, 2004.

45. Fitzpatrick M, O’Herlihy C. Postpartum anal sphincter dysfunction. Current Obstet Gynaecol 1999;9:210-215.

46. Mahony R, O’Brien C, O’Herlihy C. Evaluation of obstetric anal sphincter injury. Reviews in Gynaecological Practice 2001;1:114-121.

47. Jorge M, Wexner S. Etiology and management of fecal incontinence. Dis Colon Rectum 1993;36:77-97.

48. Fynes M, Donnelly V, Behan M, O’Connell PR, O’Herlihy C. Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study. Lancet 1999;354:983-986.

49. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal deliver: is recurrence predictable? Eur J Obstet Gynaecol 2003;109:149-152.

50. Fitzpatrick M, O’Herlihy C. The effects of labour and delivery on the pelvic floor. Best Pract Res Clin Obstet Gynaecol 2001;15:63-79.

51. Wood J, Amos L, Rieger N. Third degree anal sphincter tears: risk factors and outcome. Aust N Z J Obstet Gynaecol 1998;38:414-417.

Long-term management

Ask patients about incontinence

Given that some women are too embarrassed to seek assistance, ask those with obstetric anal sphincter injury specific questions about any symptoms of anal incontinence at a follow-up visit, such as the 6-week postpartum visit (SOR: C).^37,40 In some practices, all women who have sustained a third- or fourth-degree laceration are routinely scheduled for a 3-month follow-up visit to a dedicated clinic, irrespective of symptoms. Given the prevalence of occult obstetric anal sphincter injury for primigravid women, you may find it best to survey all women postnatally concerning any changes in anal continence. TABLE 3 demonstrates a validated, modified patient survey of anal incontinence.^37,40 A score of 6 is often used as a cutoff.

TABLE 3
Fecal Continence Scoring scale

SYMPTOM
1. Passage of any flatus when socially undesirable
2. Any incontinence of liquid stool
3. Any need to wear a pad because of anal symptoms
4. Any incontinence of solid stool
5. Any fecal urgency (inability to defer defecation for more than 5 minutes)
SCALE
0 Never
1 Rarely (<1/month)
2 Sometimes (1/week–1/month
3 Usually (1/day–1/week)
4 Always (>1/day)
A score of 0 implies complete continence and a score of 20 complete incontinence.
A score of 6 has been suggested as a cut-off to determine need for evaluation.
Source: Mahony et al, 2001;⁴³ modified from Jorge and Wexner, 1993.⁴⁴

When additional evaluation is needed

Patients who have symptoms of altered continence at 3 months (or who score above 6 on the Wexner scale) should be seen at a dedicated gynecologic or colorectal surgery clinic,⁴⁶ where they can receive a more detailed clinical evaluation and undergo anal manometry (during resting and forced squeezing) or endoanal ultrasonography. Some patients respond well to physical therapy, though a few patients ultimately require reconstructive colorectal surgery and temporary colostomy.

Management in a subsequent pregnancy

FAST TRACK

Given primagravid women’s rate of anal sphincter injury, you might find it best to survey all postnatally concerning changes in continence

Women who have had an obstetric anal sphincter injury are at increased risk for repeat injury in a future pregnancy.⁴⁸ At some units, all such women are routinely offered a prenatal visit at the end of the second trimester to review their symptoms and to evaluate the anal sphincter with manometry or ultrasound. A large prospective study, however, found that recurrence of obstetric anal sphincter injury could not be predicted and that 95% of women with prior injury did not sustain further overt sphincter damage during a subsequent vaginal delivery.⁴⁹

However, for some women, a repeat anal sphincter laceration could prove devastating. For these women—eg, those with previous severe symptoms that required secondary surgical repair—initiate an in-depth discussion concerning the risks and benefits of elective cesarean delivery versus vaginal delivery.^37,40

New definitions and prevalence of incontinence

Historically, fecal incontinence was defined as “the involuntary or inappropriate passage of feces.”¹⁰ However, a preferred definition now refers instead to anal incontinence, which is “any involuntary loss of feces or flatus, or urge incontinence, that is adversely affecting a woman’s quality of life.”⁴⁰ This definition includes urgency of defecation and incontinence of flatus, both of which are much more common symptoms than fecal incontinence.⁵⁰

Data are lacking on the community prevalence of incontinence, although it is known that women of age 45 experience 8 times the incidence of incontinence as men of the same age and that it increases in prevalence with age.¹⁰ A Canadian survey of almost 1000 women at 3 months postpartum revealed that 3.1% admitted to incontinence of feces while 25% admitted to involuntary escape of flatus. The subgroup of women who suffered clinical anal sphincter injury (that is, third- or fourth-degree lacerations) had considerably increased rates of incontinence of feces (7.8%) and of flatus (48%).²⁴ It has been reported that approximately half of women who sustained anal sphincter tears in labor complained of anal, urinary, or perineal symptoms at a mean follow-up of 2.6 years after the injury.⁵¹ Most studies agree that many women are embarrassed about symptoms of anal incontinence and are reluctant to self-report them.⁵⁰

CORRESPONDENCE
David Power, MD, MPH, Department of Family Medicine and Community Health, University of Minnesota, Mayo Mail Code 381, 516 Delaware St SE, Minneapolis, MN 55455. E-mail: power007@umn.edu