The Eurasian

Eurasian J Med 2013; 45:176-80

Journal of Medicine

Original Artide

Episiotomy and the Development of Postpartum Dyspareunia and Anal Incontinence in Nulliparous Females Epizyotomi, Nullipar Kodmlorda Postpartum Disparoni ve Anal Inkontinansa SebepOlabilirMi? Saadet Unsal Boran\ Huseyin Cengiz^ Ozlenn Erman^ Salim Erkaya^ 'Yakacik Maternity and Children Hospital, istanbul, Turkey ^Bakirköy Dr.Sadi KonukTeaching and Research Hospital, Istanbul,Turkey ^Etlik ZCJbeyde Hamm Maternity and Women's Health Education and Research Hospital, Ankara, Turkey

Abstract

Ozet

Objective: The impacts of an episiotonny on a woman's sex life and ability to relax the pelvic musculature remain largely unknown. The aim of the present study was to assess the impact of an episiotomy on the development of postpartum dyspareunia and anal incontinence.

Amaç: Epizyotominin kadinlarin seks hayatina ve petvik relaksasyon üzerine etkisi büyük ölcüde bilinmemektedir. Bu çalijmanin amaci, epziyotominin postpartum disparoni ve anal inkontinans üzerine oían etkisini degerlendirmektir.

Materials and Methods: A total of 200 patients participated in the present study.The patients were grouped as follows: vaginal delivery with episiotomy (Group 1, N=100) and Caesarian section {Group 2, N=l 00). An interview, which asked about the presence of dyspareunia or anal incontinence, was conducted with the participants at 12 weeks postpartum.

Gereç ve YÖntem: Bu prospektif çali^ma Ankara Etiik Dogumevi ve Egitim-Arajtirma Hastanesinde (Türkiye) yürütülmüjtür.Toplam 200 hasta çaliçmaya dahil edilmiçtir. Hastalar epizyotomili vajinal dogum (Grup 1, N=l 00) ve Sezaryen Dogum (Grup 2, N=l 00) çekiinde iki gruba aynlmi^tir. Katilimcilarla, postpartum 12. haftada disparoni ve anal inkontinans varligi açisindan görücme yapilmiçtir.

Results:The mean age (years) of Group 1 was 22.6±4.4, and the mean age of Group 2 was 24.1 ±4.6. Anal incontinence was detected in 4 patients (4%) in Group 1 and 2 patients (2%) in Group 2. Dyspareunia was present in 21 patients (21%) in Group 1 and 8 patients (8%) in Group 2. No significant differences were detected in the severity of anal incontinence between the two groups. The amount of time to the first coitus following delivery and the total amount of intercourse was compared between the two groups.

Bulgular: Grup l'de ortalama ya$ 22.6±4.4; Grup 2 'nin ortalama yaçi ise 24.1 ±4.6 idi. Grup l'de 4 (%4) hastada, Grup 2'de (%2) ise 2 hastada anal inkontinans tespit edildi. Grup Vde disparoni 21 (%21) hastada, Grup 2'de ise 8 (%8) hastada disparoni saptandi. Her iki grup arasinda anal inkontinans çiddeti açisindan anlamli fark saptanmadi. Her iki grup; dogumu takiben ilk cinsel ilijki süresi ve total cinsel iliçki sikligi açisindan karçila^tinldi.

Conclusion: It appears that episiotomies do not lead to anal incontinence. However, episiotomies may cause dyspareunia, a condition that may negatively affect a women's sex life. Therefore, routine episiotomies are not suggested. Key Words: Anal incontinence, delivery, dyspareunia, episiotomy, perineal laceration

Introduction

Sonuç: Epizyotomiler anal inkontinansa yol açmamaktadir, ancak epizyotomiler disparoniye sebep olabilir ve disparoni kadinlarin cinsel yajamianni olumsuz yönde etkileyebilir. Bu sebeple rutin epizyotomi uygulamasi önerilmemektedir. Anahtar Kelimeler: Anal inkontinans, dogum, disparoni, epizyotomi, perineal laserasyon

or edematous perineum; and complications during previous episiotomies. However, data concerning the indications for

Episiotomies are one of the most common surgical procedures conducted among females [1 ]. Although not evidencebased, one of the most common clinical indications for episiotomy is increased risk of anal sphincter trauma, e.g., short perineal body length; a long perineum; a rigid, firm, inelastic.

episiotomy are not included in register-based studies are not available in register-based studies [2]. Indeed, whether episiotomies reduce the risk of obstetric anal sphincter injuries remains controversial [3]. The use of episiotomy varies greatly worldwide. A study from Iran reported an episiotomy

Received: January 10, 2013 / Accepted: June 25, 2013 Correspondence to: Huseyin Cengiz,Tevfik Saglam Street. No: 11, Zuhuratbaba, Istanbul, Turkey Phone: +90 212 414 7372 e-mail: [email protected] doi:10.5152/eajm.2013.36

Eurasian J Med 2013; 45:176-80

rate of approximately 39% in primiparous women [4], while data from Turkey on this topic are quite limited. In one Turkish report, nearly 90% of primigravid women underwent an episiotomy, while a reduction in the incidence of episiotomy was noted with increased parity [5]. The impacts of an episiotomy on a female's sex life and pelvic relaxation are largely unknown. One report suggested that women who underwent an episiotomy during delivery displayed delayed sexual activity and had more severe dyspareunia at 3 months postpartum [6]. The aim of the present study was to assess the impacts of episiotomy on the development of postpartum dyspareunia and anal incontinence.

Materials and Methods The medical records of patients who gave birth at Etiik Zübeyde Hamm Maternity and Women's Health Education and Research Hospital, Department of Obstetrics and Gynecology, from March 2008 to September 2008 were evaluated. A total of 200 patients participated in the present study. Participants were divided into groups based on the type of delivery (i.e., Caesarian section or vaginal delivery with episiotomy). The patients were grouped as follows: vaginal delivery with episiotomy (Group 1, N=100) and Caesarian section (Group 2, N = 100). Women who experienced 3'" or 4"" grade lacerations during vaginal delivery were excluded from the study. Age, gravidity, labor duration, type of induction, and birth weight were recorded. In addition to episiotomy, V and 2""' degree lacerations were recorded. Women who suffered from dyspareunia or incontinence prior to pregnancy, patients with a previous history of surgery in the anal region, and patients with colorectal disorders or neurological disorders were excluded from the present study. Moreover, patients who did not provide written informed consent were excluded. This prospective study was conducted at EtIik Zubeyde Hanim Maternity and Women's Health Education and Research Hospital (Ankara, Turkey). This study was approved by the ethics board át our hospital. In the present study, an episiotomy was defined as a 3-4 cm incision over the medial lateral line of the perineum from the introitus, which included the skin, subcutaneous cellular tissue, superficial fascia, and perineal muscle, and a 4-cm incision of the vaginal mucosa. This procedure was conducted under local anesthesia using lidocaine. An interview concerning the presence of dyspareunia or anal incontinence was conducted with all participants at 12 weeks postpartum. The questionnaire was used to evaluate the degree and severity of anal incontinence and dyspareunia. The Pescatori scoring system was used to evaluate anal incontinence [7]. Anal incontinence was categorized in the

Boran et al. Episiotomy in Nulliparous Females

177

following manner: A, flat/mucus; B, liquid feces; and C, solid feces incontinence. A total of 1 point was given for A, 2 points for B, and 3 points for C. The frequency of incontinence was scored as follows: less than once a week, 1 point; at least once a week, 2 points; and daily, 3 points.The incontinence state and frequency values were combined and recorded as an incontinence score. To determine the severity of dyspareunia, a Visual Analog Scale (VAS), which rates pain from nonexistent to very severe, was used on the follow-up form. On the follow-up form, participants were also asked to assess the severity, timing, type, and impact of dyspareunia on their sex drive. Statistical Analysis The Statistical Package for the Social Sciences, version 13.0, was used to evaluate the collected data (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was used to determine whether the distribution of the quantitative data was normally distributed. Those data that were normally distributed were expressed as the arithmetic mean±standard deviation and compared using Student's t-test. Those data that were not normally distributed were expressed as median values (minimum-maximum) and compared using the MannWhitney U test. To compare categorical data, Pearson's chisquare and Fisher's exact chi-square tests were conducted. An assessment of the relationship between different variables was completed using Pearson's simple correlation coefficient and Spearman's correlation coefficient. P