http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(3): 288–292 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.916264
ORIGINAL ARTICLE
Anal incontinence in women with recurrent obstetric anal sphincter rupture: a case control study Renee` A. Bøgeskov1, Carsten N. A. Nickelsen1, and Niels J. Secher2 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
1
Department of Obstetrics and Gynaecology, University Hospital of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark and 2The Research Unit Women’s and Children’s Health, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark Abstract
Keywords
Objectives: To determine the risk of recurrent anal sphincter rupture (ASR), and compare the risk of anal incontinence (AI) after recurrent ASR, with that seen in women with previous ASR who deliver by caesarean section or vaginally without sustaining a recurrent ASR. Methods: Women with recurrent ASR between January 2000 and June 2011 were identified at two delivery wards in Copenhagen. The women answered a questionnaire with a validated scoring system for AI (St. Mark‘s score), and the results were compared with those obtained in two control groups: women with subsequent uncomplicated vaginal delivery or caesarean section. Results: There were 93 437 vaginal deliveries. ASR occurred in 5.5% (n ¼ 2851) of the nulliparous and 1.5% (n ¼ 608) of the multiparous women. Recurrent ASR occurred in 8% (n ¼ 49) of whom 50% reported symptoms of AI. We found no difference in the occurrence of AI between women with recurrent ASR, and those who delivered vaginally without repeat ASR (p ¼ 0.37; OR ¼ 2.0) or by caesarean section (p ¼ 0.77; OR ¼ 1.3). Conclusion: Women with a past history of ASR have an 8% risk of recurrence. AI affects half of the women with recurrent ASR. Larger studies are required to confirm our findings.
Anal incontinence, anal sphincter, subsequent delivery
Introduction Anal sphincter rupture (ASR) is a serious complication to vaginal delivery, occurring in 6.9% of Danish nulliparous women [1]. Obstetric ASR is a known risk factor for the development of anal incontinence (AI), and there is a significant increase in the risk of AI after a grade 3 or 4 obstetric anal sphincter rupture [2]. Up to half of the women who sustain an ASR will experience some degree of AI [3,6] with potentially devastating effects on their quality of life [7]. The risk of AI and/or recurrent ASR in deliveries subsequent to a delivery complicated by an ASR has been studied previously, but results are conflicting, and no clear picture has emerged [8–11]. This could be because some studies have included women who had AI before the second vaginal delivery. The aim of our study was to investigate the risk of recurrent ASR in subsequent vaginal deliveries, and the risk of AI in previously asymptomatic women who suffer a recurrent ASR, in comparison with women who undergo
Address for correspondence: Renee` Anita Bøgeskov, Department of Obstetrics and Gynaecology, University Hospital of Copenhagen, Hvidovre Hospital, Kettegaard Alle 30, 2650 Hvidovre, Denmark. Tel: +4531418284. E-mail: [email protected]
History Received 13 September 2013 Accepted 15 April 2014 Published online 22 May 2014
uncomplicated vaginal delivery and delivery by caesarean section after a previous ASR. We also report the women’s subjective experiences regarding mode of delivery following the second delivery.
Materials and methods Women with recurrent 3 or 4 degree ASR between 1 January 2000 and 1 June 2011 were identified from the obstetric databases at Hvidovre Hospital (HH) and Rigshospitalet (RH). This is possible because the discharging doctor register the proper diagnostic codes for all obstetrical patients upon discharge from the hospital. We searched our obstetric database using the SKS code (Danish national healthcare classification system) DO 70.2, corresponding to the ICD-10 codes (international classification of diseases) O 70.2 and O 70.3. 3. degree ASR is defined as a partial or complete tear of the anal sphincter complex, while a 4. degree tear also includes injury to the anal mucosa. The term AI is used for both flatus and faecal incontinence, defined as involuntary leakage of flatus, liquid or solid stools. Medical records were reviewed to confirm the diagnosis, as well as to determine any symptoms of AI following the index delivery. As the focus of our study was to determine the risk of AI after recurrent ASR in previously asymptomatic women, we chose to categorize the women as either continent or incontinent at six months following the index
Anal incontinence after recurrent ASR
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
DOI: 10.3109/14767058.2014.916264
delivery. This was possible because all women who suffer an ASR in our hospital are routinely offered six months of medical follow-up and intensive physiotherapy to strengthen the pelvic floor muscles in an attempt to prevent AI. At six months, the women are seen by an obstetrician for final evaluation of any AI following their ASR. Also, women with a history of ASR are seen by a senior obstetrician at week 20 in their subsequent pregnancy, to decide on the optimal mode of delivery. Only if there are no symptoms of AI, then the woman be advised to deliver vaginally. Patients from HH were used to form two control groups, with 50 patients in each group. The criterion for selection was the absence of persistent symptoms of AI previous to the second delivery, based on an information in the medical records. Group 1 consisted of women who delivered vaginally after previous ASR, without sustaining a recurrent ASR. Group 2 consisted of women with a history of ASR who were delivered by elective caesarean section on maternal request. That is, women who were recommended vaginal delivery but preferred caesarean section, thus were comparable with the women who chose a vaginal route of delivery. The women were contacted with a letter informing them about the study, as well as a self-administered questionnaire. The women were asked about the presence of persisting symptoms of AI after their second ASR (yes/no), and then asked to grade their symptoms using a validated scoring system for AI (St. Mark’s score) [12,13]. St. Mark’s score is a measure of faecal incontinence based on the type and frequency of AI (gas, fluid, solid) and the impact on daily life (subjective), the need to wear a pad/plug, the use of constipating drugs and the ability to withhold defecation for 15 min, thereby, assessing both quantitative and qualitative aspects of AI. To detect any misunderstandings in regards to grading their symptoms in a St. Mark’s questionnaire form, we added additional yes/no questions regarding subjective symptoms of AI. If the woman gave conflicting answers, she was contacted by phone to clarify, and St. Mark’s score was re-evaluated accordingly. We also asked the women if they regretted the mode of delivery in the subsequent pregnancy (yes/no), and if they in retrospect would have preferred a different mode of delivery. After two months, a reminder letter was sent to the women who had not responded initially. Some women were contacted by phone to clarify incomplete or missing answers in the questionnaire. Women with chronic inflammatory bowel disease or perineal fistula were excluded from the study. We also excluded six women in control group 2 because a caesarean section had been recommended due to other medical circumstances. We also excluded women who were unable to communicate in Danish. All data were entered into a computer database for storage and analysis. Categorical data were analysed for significance with Fisher’s exact test. A Mann–Whitney U-test was performed to compare St. Mark’s score between the three groups. We chose a standard 95% CI for our statistical analysis. The study was approved by The Danish Data Protection Agency.
289
93.437 vaginal deliveries
52.167 Nullipara
41.270 Multipara
2.851 ASR (5,5%)
608 ASR (1,5%)
3.459 ASR (3,5%)
609 subsequent deliveries
49 recurrent ASR (8%)
32 patients included in study. 12 patients excluded due to missing medical records. 3 patients excluded due to AI after index delivery. 1 patient excluded due to caesarean section in between the two deliveries of interrest. 1 patient excluded due to emigration.
Figure 1. How the patients were included, and excluded, in this study.
Results There were 93 437 registered vaginal deliveries at HH and RH in the period of interest, of which 52 167 were nulliparous. The occurrence of ASR (grade 3 or 4) was 5.5% among nullipara (n ¼ 2851) and 1.5% among multipara (n ¼ 608), the overall risk was 3.7%. Six hundred and nine of the women with an ASR at their first delivery had at least one subsequent vaginal delivery, and 49 (8%) of these sustained a recurrent ASR (Figure 1). The response rate to the questionnaire was 69% among the women with recurrent ASR versus 55% in women with subsequent uncomplicated delivery and 68% among the women who delivered by caesarean section. All three groups were similar in regard to mean age at the time of delivery, time passed between the two investigated deliveries, and time passed between the last delivery and answering the questionnaire. Results are shown in Tables 1 and 2. Fifty percent of the women suffering repeat ASR reported persistent symptoms of AI versus 33.3% in the group with uncomplicated vaginal delivery, and 42.3% in the group who delivered by caesarean section. In all three groups of women, AI was predominantly flatus and liquid stool. Transient symptoms of AI following the initial ASR occurred more frequently among the cases, than in the two control groups. There was no significant difference in St. Mark’s score between the cases versus control group 1 and 2 (p ¼ 0.34 versus p ¼ 0.63, respectively). Regardless of the mode of delivery, the occurrence of AI after subsequent delivery was significant (p50.005),
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R. A. Bøgeskov et al.
J Matern Fetal Neonatal Med, 2015; 28(3): 288–292
Table 1. Prevalence of AI among cases and controls. Control group 1
Cases
N ¼ 20 % n ¼ 27
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
Incontinence for solid stool Incontinence for liquid stool Incontinence for gas Alteration in lifestyle Need to wear a pad or plug Use of constipating drugs Inability to defer defecation for 15 min AI in any degree Regrets on mode of delivery
Control group 2
%
n ¼ 26
%
0 4 10 1 1 0 0
0 20 50 5 5 0 0
3 1 8 2 1 0 1
11.1 3.7 29.6 7.4 3.7 0 3.7
0 0 9 2 0 1 2
0 0 34.6 7.7 0 3.9 7.7
10 6
50 30
9 5
33.3 18.5
11 3
42.3 11.5
Table 2. Reported complaints and symptoms of AI.
Occurence of anal incontinence Cases versus Control group 1 Cases versus Control group 2 Control group 1 versus Control group 2
p value
OR (95% CI)
0.3680 0.7664 0.5772
2.0 (0.6–6.6) 1.3 (0.4–4.4) 0.7 (0.2–2.1)
Transient symptoms after first delivery and risk of AI Cases 1.0000 Control group 1 1.0000 Control group 2 1.0000
1.5 (0.3–8.8) 1.4 (0.2–10.6) 0.7 (0.1–8.2)
Regrets on mode of delivery Cases versus Control group 1 Cases versus Control group 2
1.9 (0.5–7.4) 3.3 (0.7–15.3)
0.4895 0.1487
but there was no significant difference in the occurrence of AI in women with recurrent ASR versus women with uncomplicated vaginal delivery or caesarean section after a previous ASR. Nor was there a significant difference in the occurrence of AI between the two control groups. There were no significant differences in mean St. Mark’s score. We found a higher occurrence of women who had a regretted mode of delivery among the cases than among women who had an uncomplicated vaginal delivery or a caesarean section; this difference was, however, not significant.
Comments ASR is a serious complication to vaginal delivery that results in varying degrees of AI in up to half of the women affected [2–6]. Even though our study is small, it is based on a large number of deliveries, over a period of 10 years, giving an accurate estimation of the risk of obstetric ASR. Our finding of a 5.5% occurrence rate of ASR among nulliparous women is slightly lower than the national prevalence reported by The Danish Health and Medicines Authority (2010) [1]. Whereas, Edwards et al. [11] reported that prior ASR did not increase the risk of recurrent laceration, we found the risk of recurrent ASR in subsequent deliveries to be 8%, which is slightly higher than the risk of ASR in nulliparous Danish women. This is supported by the findings reported by Scheer et al. [9] and Dandolu et al. [14] who found the recurrence rate to be 7% and 6%, respectively, but not as high
as Elfaghi et al. [15] who suggested a five- to seven-fold increase in the risk of ASR in subsequent deliveries. Soerensen et al. [16] found that complete obstetric anal sphincter tear increases the long-term risk of faecal incontinence two-fold. Several other studies have shown that about half of the women with an ASR will develop some degree of AI [2–6]. In our material, we found a 50% risk of AI in previously asymptomatic women after recurrent ASR. Thus, it might seem that a second ASR represents the same risk of AI as the initial injury. However, we also found that about onethird of the women with subsequent uncomplicated vaginal deliveries, as well as the women who delivered by caesarean section, suffered persistent symptoms of AI. The findings in our study are supported by Scheer et al. [9], who also found no preventive effect of elective caesarean section compared with vaginal delivery in women with a history of ASR. Lal et al. [17] also reported that caesarean section was not always protective against AI, and that symptoms of AI could be severe. This indicates that pregnancy in itself represents a substantial risk factor for AI in women with previous ASR. In accordance with this assumption, it is plausible that a disruption of the anal sphincter may not be the primary cause of AI in women with recurrent ASR. AI after childbirth is the result of not only a direct disruption of the sphincter complex, but also of the stretching of the pudendal nerve and pelvic floor muscles [8,16]. Choosing caesarean section for mode of delivery does, however, avoid the risk of a recurrent ASR, thereby indirectly preventing a higher incidence of AI in these women. Somewhat surprisingly, we found no evidence of a connection between transient symptoms of AI after the initial ASR and persistent symptoms of AI after the recurrent ASR. This is not in agreement with a previous study, which concluded that symptoms of AI following the initial injury were an important predictor of AI following subsequent deliveries [8]. At Hvidovre hospital, women suffering from an ASR are routinely offered 6 months of medical follow-up and intensive physiotherapy to strengthen the pelvic floor muscles in an attempt to prevent AI. This might affect the outcome/ rate of persistent AI in a positive way, thereby making it difficult to compare our findings with previous studies in which women were not offered such intervention. Regretting mode of delivery was more common among the women suffering a repeat ASR, with 30% reporting that they in retrospect would have preferred to deliver by caesarean section. Considering the negative effects on quality of life that is associated with an ASR [7], it was not surprising to find a higher occurrence of women regretting the mode of delivery among the cases, compared to the control groups. It does, however, show the importance of thorough information about the risk and potential consequences of recurrent ASR, as well as always taking the woman’s personal preferences into consideration when recommending the mode of delivery to a patient with a history of ASR. An important strength of our study is the large patient cohort of women from two delivery wards in Copenhagen, resulting in generalizable rates of ASR in primi- and multiparas that are in keeping with findings from previous studies on this subject. We consider the sensitivity of the study to be high, because all women had their injury
Anal incontinence after recurrent ASR
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
DOI: 10.3109/14767058.2014.916264
diagnosed and operated on by highly experienced specialists, or under supervision from such. There are unfortunately some weaknesses in our study. The most important problem being that even though based on a large number of deliveries, the number of available cases with recurrent ASR in our material was small, making it difficult to achieve a desired level of statistical power, even if more control subjects had been included. Hence the risk of a type II statistical error is present, and the results should therefore be considered with caution. Also, due to the low number of available cases, we chose to include women regardless of parity. Thus, women might have delivered vaginally between the two deliveries investigated; and therefore, a natural progression of AI with successive pregnancies and deliveries cannot be ruled out. Several studies have been performed to determine the cumulative effect of multiple pregnancies and deliveries on AI, and the results have been conflicting. The RCOG 2007 reported an estimated risk for faecal incontinence or worsening of symptoms with successive deliveries varying from 17 to 24% in four different studies [18]. In contrast, Faltin et al. [19] performed a large retrospective cohort study of 4569 women with 19 years follow-up and reported that no association was found between long-term AI and subsequent deliveries, regardless of sphincter reconstruction. Thus, the effect of multiple vaginal deliveries on faecal incontinence is ambiguous, and studies on this topic may be difficult to compare due to different follow-up periods or different methodological approaches. However, as all three groups of women in our study are similar and comparable, we do expect that any potential bias regarding possible deterioration of AI due to parity, would be distributed equally among all three groups of women. Determination of symptoms following the index delivery was also complicated. Even though medical notes might not always be the most reliable source of information when collecting data; it does, however, eliminate the recall bias that would be associated with the use of a retrospectively collected questionnaire. It would have been optimal if St. Mark’s score had been available for all women at the end of the 6-month follow-up; however, this was not the case, and we therefore had to assume that the women were asymptomatic if nothing else was specified in the medical records and vaginal delivery was recommended for future pregnancies. As it is highly unlikely that any woman suffering AI following an ASR would be recommended vaginal delivery in our facilities, we feel confident that this was a safe assumption to make. To determine symptoms of AI following the second delivery investigated, we used a self-administered questionnaire, meaning that present symptoms were reported by the women directly in the questionnaire using St. Mark’s score. Hence, the score was not determined by a doctor, as is more common, and to our knowledge St. Mark’s score has only been validated when performed by a doctor [13].
Conclusion Regardless of the mode of delivery, there is a significant risk of persistent AI after subsequent delivery in women with a previous ASR. In our small study of asymptomatic women
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with a history of ASR, caesarean section did not offer a significant preventive effect on AI compared with uncomplicated vaginal delivery. Caesarean section does, however, eliminate the risk of recurrent ASR, thereby indirectly preventing a higher incidence of AI compared with vaginal delivery. This study is too small to draw any safe conclusions; larger studies are needed on this subject before any clear recommendations can be made.
Acknowledgements We thank Mr. Sten Ladelund for his contribution to the statisticial analysis and Dr Edwin Stanton Spencer for English proofreading.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. RAB conducted the study, performed the analysis and was in-charge of the writing of the article. CN and NJS contributed to the study design, helped with statistical methods and helped to interpret the results as well as supervise the study. All authors assisted in critical revision of the manuscript and have read and approved the final version of the article.
Details of ethics approval The study was approved by The Danish Data Protection Agency, and was carried out in compliance with the Helsinki Guidelines for Ethical Research. The National Committee on Health Research Ethics defined our project as a questionnaire based study, and not a health research project. Questionnaire based studies can be commenced without receiving permission from the Scientific Ethics Committees in the Capital Region of Denmark.
References 1. SST: Quality indicators – DSOG standard population of low risk nullipara, 2010. [Internet]. Available from: http://www.sst.dk/ /media/Indberetning%20og%20statistik/Sundhedsstyrelsens%20 registre/Foedsler%20Kvalitetsindikatorer%202010/Kvalitetsindikat orer%20Lavrisiko/1330_Hvidovre_standardpopulation_frstegangsf dende_2010.ashx [last accessed 8 Sep 2012]. 2. Bols EMJ, Hendriks EJM, Berghmans BCM, et al. A systematic review of etiological factors for postpartum fecal incontinence. Acta Obstet Gynecol Scand 2010;89:302–14. 3. Wegnelius G, Hammarstro¨m M. Complete rupture of anal sphincter in primiparas: long-term effects and subsequent delivery. Acta Obstet Gynecol Scand 2011;90:258–63. 4. Laine K, Skjeldestad FE, Sanda B, et al. Prevalence and risk factors for anal incontinence after obstetric anal sphincter rupture. Acta Obstet Gynecol Scand 2011;90:319–24. 5. Samaraseka DN, Bekhit MT, Wright Y, et al. Long-term anal incontinence and quality of life following postpartum anal sphincter injury. Colorectal Dis 2008;10:793–9. 6. Nordenstam J, Altman D, Brismar S, Zetterstro¨m J. Natural progression of anal incontinence after childbirth. Int Urogynecol J 2009;20:1029–35. 7. Williams A, Lavender T, Richmond D, Tincello DG. Women’s experiences after a third degree obstetric anal sphincter tear: a qualitative study. Birth 2005;32:129–36. 8. Faltin DL, Sangalli MR, Roche B, et al. Does a second delivery increase the risk of anal incontinence? Br J Obstet Gynaecol 2001; 108:684–8.
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9. Scheer I, Thakar R, Sultan AH. Mode of delivery after previous obstetric anal sphincter injuries (OASIS) – a reappraisal? Int Urogynecol J 2009;20:1095–101. 10. Sze EHM. Anal incontinence among women with one versus two complete third-degree perineal lacerations. Int J Gynaecol Obstet 2005;90:213–17. 11. Edwards H, Grotegut C, Harmanli OH, et al. Is severe perineal damage increased in women with prior anal sphincter injury? J Matern Fetal Neonatal Med 2006;19:723–7. 12. Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut 1999;44: 77–80. 13. Roos AM, Sultan AH, Thakar R. St. Mark’s incontinence score for assessment of anal incontinence following obstetric anal sphincter injuries (OASIS). Int Urogynecol J 2009;20:407–10. 14. Dandolu V, Gaughan JP, Chatwani AJ, et al. Risk of recurrence of anal sphincter lacerations. Obstet Gynecol 2005;105:831–5.
J Matern Fetal Neonatal Med, 2015; 28(3): 288–292
15. Elfaghi I, Johansson-Ernste B, Rydhstroem H. Rupture of the sphincter ani: the recurrence rate in second delivery. Br J Obstet Gynaecol 2004;111:1361–4. 16. Soerensen MM, Buntzen S, Bek KM, Laurberg S. Complete obstetric anal sphincter tear and risk of long term fecal incontinence: a cohort study. Dis Colon Rectum 2013;56: 992–1001. 17. Lal M, Mann CH, Callender R, Radley S. Does cesarean delivery prevent anal incontinence? Obstet Gynecol 2003;101: 305–12. 18. Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree perineal tears. Green-top Guideline No. 29; 2007. Available from: http://www.rcog.org.uk/ files/rcog-corp/GTG2911022011.pdf [last accessed 21 Nov 2013]. 19. Faltin DL, Otero M, Petignat P, et al. Women’s health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. Am J Obstet Gynecol 2006;194:1255–9.
ORIGINAL ARTICLE
Anal incontinence in women with recurrent obstetric anal sphincter rupture: a case control study Renee` A. Bøgeskov1, Carsten N. A. Nickelsen1, and Niels J. Secher2 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
1
Department of Obstetrics and Gynaecology, University Hospital of Copenhagen, Hvidovre Hospital, Copenhagen, Denmark and 2The Research Unit Women’s and Children’s Health, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark Abstract
Keywords
Objectives: To determine the risk of recurrent anal sphincter rupture (ASR), and compare the risk of anal incontinence (AI) after recurrent ASR, with that seen in women with previous ASR who deliver by caesarean section or vaginally without sustaining a recurrent ASR. Methods: Women with recurrent ASR between January 2000 and June 2011 were identified at two delivery wards in Copenhagen. The women answered a questionnaire with a validated scoring system for AI (St. Mark‘s score), and the results were compared with those obtained in two control groups: women with subsequent uncomplicated vaginal delivery or caesarean section. Results: There were 93 437 vaginal deliveries. ASR occurred in 5.5% (n ¼ 2851) of the nulliparous and 1.5% (n ¼ 608) of the multiparous women. Recurrent ASR occurred in 8% (n ¼ 49) of whom 50% reported symptoms of AI. We found no difference in the occurrence of AI between women with recurrent ASR, and those who delivered vaginally without repeat ASR (p ¼ 0.37; OR ¼ 2.0) or by caesarean section (p ¼ 0.77; OR ¼ 1.3). Conclusion: Women with a past history of ASR have an 8% risk of recurrence. AI affects half of the women with recurrent ASR. Larger studies are required to confirm our findings.
Anal incontinence, anal sphincter, subsequent delivery
Introduction Anal sphincter rupture (ASR) is a serious complication to vaginal delivery, occurring in 6.9% of Danish nulliparous women [1]. Obstetric ASR is a known risk factor for the development of anal incontinence (AI), and there is a significant increase in the risk of AI after a grade 3 or 4 obstetric anal sphincter rupture [2]. Up to half of the women who sustain an ASR will experience some degree of AI [3,6] with potentially devastating effects on their quality of life [7]. The risk of AI and/or recurrent ASR in deliveries subsequent to a delivery complicated by an ASR has been studied previously, but results are conflicting, and no clear picture has emerged [8–11]. This could be because some studies have included women who had AI before the second vaginal delivery. The aim of our study was to investigate the risk of recurrent ASR in subsequent vaginal deliveries, and the risk of AI in previously asymptomatic women who suffer a recurrent ASR, in comparison with women who undergo
Address for correspondence: Renee` Anita Bøgeskov, Department of Obstetrics and Gynaecology, University Hospital of Copenhagen, Hvidovre Hospital, Kettegaard Alle 30, 2650 Hvidovre, Denmark. Tel: +4531418284. E-mail: [email protected]
History Received 13 September 2013 Accepted 15 April 2014 Published online 22 May 2014
uncomplicated vaginal delivery and delivery by caesarean section after a previous ASR. We also report the women’s subjective experiences regarding mode of delivery following the second delivery.
Materials and methods Women with recurrent 3 or 4 degree ASR between 1 January 2000 and 1 June 2011 were identified from the obstetric databases at Hvidovre Hospital (HH) and Rigshospitalet (RH). This is possible because the discharging doctor register the proper diagnostic codes for all obstetrical patients upon discharge from the hospital. We searched our obstetric database using the SKS code (Danish national healthcare classification system) DO 70.2, corresponding to the ICD-10 codes (international classification of diseases) O 70.2 and O 70.3. 3. degree ASR is defined as a partial or complete tear of the anal sphincter complex, while a 4. degree tear also includes injury to the anal mucosa. The term AI is used for both flatus and faecal incontinence, defined as involuntary leakage of flatus, liquid or solid stools. Medical records were reviewed to confirm the diagnosis, as well as to determine any symptoms of AI following the index delivery. As the focus of our study was to determine the risk of AI after recurrent ASR in previously asymptomatic women, we chose to categorize the women as either continent or incontinent at six months following the index
Anal incontinence after recurrent ASR
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/09/15 For personal use only.
DOI: 10.3109/14767058.2014.916264
delivery. This was possible because all women who suffer an ASR in our hospital are routinely offered six months of medical follow-up and intensive physiotherapy to strengthen the pelvic floor muscles in an attempt to prevent AI. At six months, the women are seen by an obstetrician for final evaluation of any AI following their ASR. Also, women with a history of ASR are seen by a senior obstetrician at week 20 in their subsequent pregnancy, to decide on the optimal mode of delivery. Only if there are no symptoms of AI, then the woman be advised to deliver vaginally. Patients from HH were used to form two control groups, with 50 patients in each group. The criterion for selection was the absence of persistent symptoms of AI previous to the second delivery, based on an information in the medical records. Group 1 consisted of women who delivered vaginally after previous ASR, without sustaining a recurrent ASR. Group 2 consisted of women with a history of ASR who were delivered by elective caesarean section on maternal request. That is, women who were recommended vaginal delivery but preferred caesarean section, thus were comparable with the women who chose a vaginal route of delivery. The women were contacted with a letter informing them about the study, as well as a self-administered questionnaire. The women were asked about the presence of persisting symptoms of AI after their second ASR (yes/no), and then asked to grade their symptoms using a validated scoring system for AI (St. Mark’s score) [12,13]. St. Mark’s score is a measure of faecal incontinence based on the type and frequency of AI (gas, fluid, solid) and the impact on daily life (subjective), the need to wear a pad/plug, the use of constipating drugs and the ability to withhold defecation for 15 min, thereby, assessing both quantitative and qualitative aspects of AI. To detect any misunderstandings in regards to grading their symptoms in a St. Mark’s questionnaire form, we added additional yes/no questions regarding subjective symptoms of AI. If the woman gave conflicting answers, she was contacted by phone to clarify, and St. Mark’s score was re-evaluated accordingly. We also asked the women if they regretted the mode of delivery in the subsequent pregnancy (yes/no), and if they in retrospect would have preferred a different mode of delivery. After two months, a reminder letter was sent to the women who had not responded initially. Some women were contacted by phone to clarify incomplete or missing answers in the questionnaire. Women with chronic inflammatory bowel disease or perineal fistula were excluded from the study. We also excluded six women in control group 2 because a caesarean section had been recommended due to other medical circumstances. We also excluded women who were unable to communicate in Danish. All data were entered into a computer database for storage and analysis. Categorical data were analysed for significance with Fisher’s exact test. A Mann–Whitney U-test was performed to compare St. Mark’s score between the three groups. We chose a standard 95% CI for our statistical analysis. The study was approved by The Danish Data Protection Agency.
289
93.437 vaginal deliveries
52.167 Nullipara
41.270 Multipara
2.851 ASR (5,5%)
608 ASR (1,5%)
3.459 ASR (3,5%)
609 subsequent deliveries
49 recurrent ASR (8%)
32 patients included in study. 12 patients excluded due to missing medical records. 3 patients excluded due to AI after index delivery. 1 patient excluded due to caesarean section in between the two deliveries of interrest. 1 patient excluded due to emigration.
Figure 1. How the patients were included, and excluded, in this study.
Results There were 93 437 registered vaginal deliveries at HH and RH in the period of interest, of which 52 167 were nulliparous. The occurrence of ASR (grade 3 or 4) was 5.5% among nullipara (n ¼ 2851) and 1.5% among multipara (n ¼ 608), the overall risk was 3.7%. Six hundred and nine of the women with an ASR at their first delivery had at least one subsequent vaginal delivery, and 49 (8%) of these sustained a recurrent ASR (Figure 1). The response rate to the questionnaire was 69% among the women with recurrent ASR versus 55% in women with subsequent uncomplicated delivery and 68% among the women who delivered by caesarean section. All three groups were similar in regard to mean age at the time of delivery, time passed between the two investigated deliveries, and time passed between the last delivery and answering the questionnaire. Results are shown in Tables 1 and 2. Fifty percent of the women suffering repeat ASR reported persistent symptoms of AI versus 33.3% in the group with uncomplicated vaginal delivery, and 42.3% in the group who delivered by caesarean section. In all three groups of women, AI was predominantly flatus and liquid stool. Transient symptoms of AI following the initial ASR occurred more frequently among the cases, than in the two control groups. There was no significant difference in St. Mark’s score between the cases versus control group 1 and 2 (p ¼ 0.34 versus p ¼ 0.63, respectively). Regardless of the mode of delivery, the occurrence of AI after subsequent delivery was significant (p50.005),
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Table 1. Prevalence of AI among cases and controls. Control group 1
Cases
N ¼ 20 % n ¼ 27
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Incontinence for solid stool Incontinence for liquid stool Incontinence for gas Alteration in lifestyle Need to wear a pad or plug Use of constipating drugs Inability to defer defecation for 15 min AI in any degree Regrets on mode of delivery
Control group 2
%
n ¼ 26
%
0 4 10 1 1 0 0
0 20 50 5 5 0 0
3 1 8 2 1 0 1
11.1 3.7 29.6 7.4 3.7 0 3.7
0 0 9 2 0 1 2
0 0 34.6 7.7 0 3.9 7.7
10 6
50 30
9 5
33.3 18.5
11 3
42.3 11.5
Table 2. Reported complaints and symptoms of AI.
Occurence of anal incontinence Cases versus Control group 1 Cases versus Control group 2 Control group 1 versus Control group 2
p value
OR (95% CI)
0.3680 0.7664 0.5772
2.0 (0.6–6.6) 1.3 (0.4–4.4) 0.7 (0.2–2.1)
Transient symptoms after first delivery and risk of AI Cases 1.0000 Control group 1 1.0000 Control group 2 1.0000
1.5 (0.3–8.8) 1.4 (0.2–10.6) 0.7 (0.1–8.2)
Regrets on mode of delivery Cases versus Control group 1 Cases versus Control group 2
1.9 (0.5–7.4) 3.3 (0.7–15.3)
0.4895 0.1487
but there was no significant difference in the occurrence of AI in women with recurrent ASR versus women with uncomplicated vaginal delivery or caesarean section after a previous ASR. Nor was there a significant difference in the occurrence of AI between the two control groups. There were no significant differences in mean St. Mark’s score. We found a higher occurrence of women who had a regretted mode of delivery among the cases than among women who had an uncomplicated vaginal delivery or a caesarean section; this difference was, however, not significant.
Comments ASR is a serious complication to vaginal delivery that results in varying degrees of AI in up to half of the women affected [2–6]. Even though our study is small, it is based on a large number of deliveries, over a period of 10 years, giving an accurate estimation of the risk of obstetric ASR. Our finding of a 5.5% occurrence rate of ASR among nulliparous women is slightly lower than the national prevalence reported by The Danish Health and Medicines Authority (2010) [1]. Whereas, Edwards et al. [11] reported that prior ASR did not increase the risk of recurrent laceration, we found the risk of recurrent ASR in subsequent deliveries to be 8%, which is slightly higher than the risk of ASR in nulliparous Danish women. This is supported by the findings reported by Scheer et al. [9] and Dandolu et al. [14] who found the recurrence rate to be 7% and 6%, respectively, but not as high
as Elfaghi et al. [15] who suggested a five- to seven-fold increase in the risk of ASR in subsequent deliveries. Soerensen et al. [16] found that complete obstetric anal sphincter tear increases the long-term risk of faecal incontinence two-fold. Several other studies have shown that about half of the women with an ASR will develop some degree of AI [2–6]. In our material, we found a 50% risk of AI in previously asymptomatic women after recurrent ASR. Thus, it might seem that a second ASR represents the same risk of AI as the initial injury. However, we also found that about onethird of the women with subsequent uncomplicated vaginal deliveries, as well as the women who delivered by caesarean section, suffered persistent symptoms of AI. The findings in our study are supported by Scheer et al. [9], who also found no preventive effect of elective caesarean section compared with vaginal delivery in women with a history of ASR. Lal et al. [17] also reported that caesarean section was not always protective against AI, and that symptoms of AI could be severe. This indicates that pregnancy in itself represents a substantial risk factor for AI in women with previous ASR. In accordance with this assumption, it is plausible that a disruption of the anal sphincter may not be the primary cause of AI in women with recurrent ASR. AI after childbirth is the result of not only a direct disruption of the sphincter complex, but also of the stretching of the pudendal nerve and pelvic floor muscles [8,16]. Choosing caesarean section for mode of delivery does, however, avoid the risk of a recurrent ASR, thereby indirectly preventing a higher incidence of AI in these women. Somewhat surprisingly, we found no evidence of a connection between transient symptoms of AI after the initial ASR and persistent symptoms of AI after the recurrent ASR. This is not in agreement with a previous study, which concluded that symptoms of AI following the initial injury were an important predictor of AI following subsequent deliveries [8]. At Hvidovre hospital, women suffering from an ASR are routinely offered 6 months of medical follow-up and intensive physiotherapy to strengthen the pelvic floor muscles in an attempt to prevent AI. This might affect the outcome/ rate of persistent AI in a positive way, thereby making it difficult to compare our findings with previous studies in which women were not offered such intervention. Regretting mode of delivery was more common among the women suffering a repeat ASR, with 30% reporting that they in retrospect would have preferred to deliver by caesarean section. Considering the negative effects on quality of life that is associated with an ASR [7], it was not surprising to find a higher occurrence of women regretting the mode of delivery among the cases, compared to the control groups. It does, however, show the importance of thorough information about the risk and potential consequences of recurrent ASR, as well as always taking the woman’s personal preferences into consideration when recommending the mode of delivery to a patient with a history of ASR. An important strength of our study is the large patient cohort of women from two delivery wards in Copenhagen, resulting in generalizable rates of ASR in primi- and multiparas that are in keeping with findings from previous studies on this subject. We consider the sensitivity of the study to be high, because all women had their injury
Anal incontinence after recurrent ASR
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DOI: 10.3109/14767058.2014.916264
diagnosed and operated on by highly experienced specialists, or under supervision from such. There are unfortunately some weaknesses in our study. The most important problem being that even though based on a large number of deliveries, the number of available cases with recurrent ASR in our material was small, making it difficult to achieve a desired level of statistical power, even if more control subjects had been included. Hence the risk of a type II statistical error is present, and the results should therefore be considered with caution. Also, due to the low number of available cases, we chose to include women regardless of parity. Thus, women might have delivered vaginally between the two deliveries investigated; and therefore, a natural progression of AI with successive pregnancies and deliveries cannot be ruled out. Several studies have been performed to determine the cumulative effect of multiple pregnancies and deliveries on AI, and the results have been conflicting. The RCOG 2007 reported an estimated risk for faecal incontinence or worsening of symptoms with successive deliveries varying from 17 to 24% in four different studies [18]. In contrast, Faltin et al. [19] performed a large retrospective cohort study of 4569 women with 19 years follow-up and reported that no association was found between long-term AI and subsequent deliveries, regardless of sphincter reconstruction. Thus, the effect of multiple vaginal deliveries on faecal incontinence is ambiguous, and studies on this topic may be difficult to compare due to different follow-up periods or different methodological approaches. However, as all three groups of women in our study are similar and comparable, we do expect that any potential bias regarding possible deterioration of AI due to parity, would be distributed equally among all three groups of women. Determination of symptoms following the index delivery was also complicated. Even though medical notes might not always be the most reliable source of information when collecting data; it does, however, eliminate the recall bias that would be associated with the use of a retrospectively collected questionnaire. It would have been optimal if St. Mark’s score had been available for all women at the end of the 6-month follow-up; however, this was not the case, and we therefore had to assume that the women were asymptomatic if nothing else was specified in the medical records and vaginal delivery was recommended for future pregnancies. As it is highly unlikely that any woman suffering AI following an ASR would be recommended vaginal delivery in our facilities, we feel confident that this was a safe assumption to make. To determine symptoms of AI following the second delivery investigated, we used a self-administered questionnaire, meaning that present symptoms were reported by the women directly in the questionnaire using St. Mark’s score. Hence, the score was not determined by a doctor, as is more common, and to our knowledge St. Mark’s score has only been validated when performed by a doctor [13].
Conclusion Regardless of the mode of delivery, there is a significant risk of persistent AI after subsequent delivery in women with a previous ASR. In our small study of asymptomatic women
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with a history of ASR, caesarean section did not offer a significant preventive effect on AI compared with uncomplicated vaginal delivery. Caesarean section does, however, eliminate the risk of recurrent ASR, thereby indirectly preventing a higher incidence of AI compared with vaginal delivery. This study is too small to draw any safe conclusions; larger studies are needed on this subject before any clear recommendations can be made.
Acknowledgements We thank Mr. Sten Ladelund for his contribution to the statisticial analysis and Dr Edwin Stanton Spencer for English proofreading.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. RAB conducted the study, performed the analysis and was in-charge of the writing of the article. CN and NJS contributed to the study design, helped with statistical methods and helped to interpret the results as well as supervise the study. All authors assisted in critical revision of the manuscript and have read and approved the final version of the article.
Details of ethics approval The study was approved by The Danish Data Protection Agency, and was carried out in compliance with the Helsinki Guidelines for Ethical Research. The National Committee on Health Research Ethics defined our project as a questionnaire based study, and not a health research project. Questionnaire based studies can be commenced without receiving permission from the Scientific Ethics Committees in the Capital Region of Denmark.
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