IJG-07940; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms Eefje J. Oude Lohuis a,b, Ellen Everhardt a,⁎ a b
Department of Obstetrics and Gynecology, Medisch Spectrum Twente Hospital Group, Enschede, Netherlands Department of Obstetrics and Gynecology, Deventer Hospital, Deventer, Netherlands
a r t i c l e
i n f o
Article history: Received 1 September 2013 Received in revised form 31 December 2013 Accepted 27 March 2014 Keywords: Anal incontinence Defecatory symptoms Endoanal ultrasound Obstetric anal sphincter injury
a b s t r a c t Objective: To determine the prevalence of persisting endoanal ultrasonographic defects among women with obstetric anal sphincter injuries (OASIS), and the incidence of defecatory symptoms. Methods: In a prospective study in Enschede, Netherlands, women with OASIS were enrolled between 2007 and 2012. Three months after surgical repair, all women had an endoanal ultrasound, and data were collected on gas and fecal incontinence, soiling, and fecal urgency. Results: Overall, 99 women were included. At follow-up, 35 (35.4%) women had a persisting defect of the external anal sphincter on ultrasound, and 5 women (5.1%) also had a persisting defect of the internal anal sphincter. Overall, 35 (35.4%) women had one or more defecatory complaints—predominantly involuntary loss of gas and fecal urgency. Overall, 22 of 35 (63.0%) women with and 13 of 64 (20.3%) women without a persisting defect on ultrasound had defecatory complaints. The number of defecatory symptoms showed a positive correlation with severity of injury. Women with a persisting defect had a threefold higher risk of defecatory complaints as compared with women who had a successful repair (odds ratio, 6.6; 95% confidence interval, 2.6–16.6). Conclusion: The results emphasize the importance of adequate repair of OASIS and demonstrate that repair can be difficult or underestimated. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Obstetric anal sphincter injuries (OASIS) affect approximately 2.9% (0.7%–9.0%) of primiparous women who deliver vaginally, and an additional 0.8% of multiparous women [1–4]. Both third- and fourth-degree perineal tears include injury of the anal sphincter. A third-degree perineal tear is defined as partial or complete disruption of the anal sphincter muscles, which might involve the external anal sphincter (EAS) alone or both the EAS and the internal anal sphincter (IAS). A fourthdegree tear is defined as disruption of both the EAS and the IAS in addition to a defect of the rectal mucosa [3,5]. Box 1 gives an overview of the classification of the degrees of anal sphincter rupture [3,6]. A median episiotomy, prolonged second stage of labor (N2 hours), vaginal birth after cesarean, use of epidural, birth weight of more than 4 kg, instrumental delivery, and shoulder dystocia are known risk factors for OASIS and anal incontinence [3,7]. OASIS occurs more frequently than has been previously reported: many sphincter injuries remain
undiagnosed and are subsequently classified as occult when subsequently identified on anal endosonography [8]. Anal incontinence is characterized by an involuntary loss of gas, or liquid or solid stools, and is a distressing condition that has a profound psychological impact [3]. The reported incidence of anal incontinence after OASIS ranges from 0% to 68.2% [2,9,10]. A recent study reported a prevalence of 7.7%, 19.7%, and 38.2% for incontinence of formed stools, loose stools, and gas, respectively [11]. One study showed that 5 years after the primary repair of OASIS, 40% of patients had anal incontinence [12]; however, the influence of persisting sphincter defects was not reported. Another study did investigate the persistence of sphincter defects, reporting that, after the primary repair of third-degree tears, the endosonographic pattern of the anal sphincter correlated with continence status at the short-term follow-up [13]. The primary objective of the present study was to determine the prevalence of persisting endoanal ultrasonographic defects among postpartum women after OASIS. A secondary aim was to specify the prevalence of defecatory symptoms among these women. 2. Materials and methods
⁎ Corresponding author at: Medisch Spectrum Twente, Gynecologie en Obstetrie, VKC, Haaksbergerstraat 55, 7513 ER Enschede, Netherlands. Tel.: +31 534872330; fax: +31 534339571. E-mail address: [email protected] (E. Everhardt).
The present prospective cohort study enrolled women with a thirdor fourth-degree perineal tear who underwent primary repair at a large teaching hospital in Enschede, Netherlands, between January 1, 2007, and January 31, 2012. The ethical board of the hospital approved the
http://dx.doi.org/10.1016/j.ijgo.2014.01.018 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
2
E.J. Oude Lohuis, E. Everhardt / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Box 1 Classification of anal sphincter injury. First degree: Injury to perineal skin only Second degree: Injury to perineum that affects the muscles but not the anal sphincter Third degree: Injury to perineum that affects the anal sphincter complex as follows: 3a: Less than 50% of external anal sphincter torn 3b: More than 50% of external anal sphincter torn 3c: Both external and internal anal sphincter torn Fourth degree: Injury to perineum involving the anal sphincter complex and anal epithelium
collection of data from this group of patients. All patients gave consent for the standard protocol treatment. The study enrolled all patients needing surgical repair of OASIS, which included both women who had delivered at the hospital and those who delivered at home under midwifery care. All of the tears were classified and repaired by the consultant gynecologist, who was specialized in OASIS, according to the study unit’s protocol. Surgery was performed by either end-to-end (approximation) repair or overlap repair. In the end-to-end method, the torn ends of the external anal sphincter are approximated together and sutured without any overlap of the muscle. In the overlap method, the torn ends of the external anal sphincter are brought together and sutured by overlapping one end of the muscle over the other in a double-breasted fashion, as described by Sultan et al. [6,14]. Before surgery, all patients received prophylactic antibiotic therapy (single-dose co-amoxiclav, 1200 mg intravenously). Overall, 87 out of 103 repairs were performed in the theater under general or spinal anesthesia. Sixteen were repaired in the delivery room under adequate analgesia. Patients were given laxatives (chewable magnesium oxide tablets) after surgery and were instructed how to clean their wound. At 2 weeks after surgery, all patients were reviewed at the outpatient clinic by the same consultant gynecologist both to evaluate the healing process and to be provided with additional instructions if necessary. The women were re-assessed 6 weeks after surgery by the same gynecologist, and both vaginal and rectal examinations were performed. At this time, pelvic floor muscle training was commenced by a specialized physiotherapist. Several tests were conducted to identify the current state of dysfunction of the EAS including anal function tests for strength, coordination, and condition of the EAS. In addition, myofeedback tests for ground-level tension of the sphincter were performed. Depending on the results of these tests, a specific training program to optimize sphincter condition was designed individually for each patient, which took up to 6 months. All patients had an endoanal ultrasonography performed by an independent experienced gastroenterologist, who was blind to the continence status, 3 months after delivery in order to detect persisting sphincter defects. This was performed in the left lateral position using a 7.5–10.0-MHz transrectal mechanical radial scanner (ALOKA ASU67, Hitachi Aloka Medical, Tokyo, Japan), which is a two-dimensional 360° radial rectal transducer. A rigid probe was inserted into the anal canal, and ultrasonographic imaging was performed proximally to distally to identify the circumference and consistency of the IAS and EAS. An EAS defect was defined as a gap or a region of lower echogenicity in the external sphincter. An IAS defect was defined as loss of continuity in the internal sphincter. Both defects were documented as a percentage of the total sphincter circumference. The last follow-up appointment at the outpatient clinic took place after the endoanal ultrasonography. Persisting defecatory complaints
(anal incontinence, soiling, and fecal urgency), and the results of both pelvic floor training and the endoanal ultrasound were recorded. Information was also collected from patient records, including type of delivery, birth weight, and whether or not an episiotomy was performed. Statistical analysis was carried out with SPSS version 18.0 (IBM, Armonk, NY, USA). Pearson χ2 and Fisher exact tests were used to examine the presence of anal incontinence within various factors, including use of forceps or ventouse, episiotomy, and birth weight. These tests were also used to identify significant differences in the presence of ultrasonographic defects among women with different degrees of tears. The confidence interval (95% CI) was calculated for key outcomes, and a P value of 0.05 was considered to indicate statistical significance. 3. Results In total, 103 women were enrolled in the study. Four women were subsequently excluded from analysis: two had a rectal mucosal tear without injury of the anal sphincter; one woman had a tear that was repaired in theater, but both sphincters were found to be intact at the time; and one woman could not undergo an endoanal ultrasonographic examination because she had an ileostomy and, therefore, atrophy of the anal canal. The mean ± SD age was 29.6 ± 4.0 years. The demographic and obstetric characteristics of the study patients and details of the annual deliveries of the study unit are shown in Table 1. There were 89 (90.0%) patients with a third-degree tear, and 10 (10.0%) patients with a fourth-degree tear. Furthermore, there were 25 (25.3%) 3a tears, 45 (45.5%) 3b tears and 19 (19.2%) 3c tears. Of the fourth-degree tears, 5 were repaired via the overlap technique and 5 via the end-to-end method. Of the 19 3c degree ruptures, 6 were repaired via the overlap technique and 12 were repaired via the endto-end method; for one patient, the type of method was not documented. All 3a and 3b degree tears were repaired via the end-to-end method. There was a significant difference in the presence of an episiotomy among women with different degrees of tear. Significantly fewer episiotomies had been performed in the group with 3a tears (difference, 0.3; 95% CI, 0.0–0.6; P = 0.046). There was also a significant difference in birth weight among the groups. Neonates were significantly heavier in the fourth-degree tear group than in the 3c tear group (difference, 532 g; 95% CI, 74–989 g; P = 0.015). A least significant difference post-hoc test was used for these calculations. There was also a significant difference in the degree of tear in the assisted versus spontaneous delivery groups. The assisted delivery group showed significantly more 3c ruptures, whereas the spontaneous delivery group had more 3a tears (difference, 0.3; 95% CI, 0.0–0.6; P = 0.04). Three months postoperatively, persisting defects of the anal sphincter were visible on endoanal ultrasound among women with each Table 1 Demographic and obstetric variables.a Variable Patient characteristics (n = 99) Age, y Spontaneous Delivery by midwife Ventouse Forceps Episiotomy Birth weight N4 kg Breast feeding Shoulder dystocia Occipito-posterior position Delivery unit characteristics (n = 2511) Mean annual incidence of OASIS Mean annual no. of cesarean deliveries Mean annual no. of instrumental deliveries
Data (n = 99) 29.6 ± 4.0 59 (59.6) 18 (18.2) 14 (14.1) 8 (8.0) 33 (33.3) 21 (21.2) 36 (36.4) 10 (10.1) 10 (10.1) 19.8 (0.8) 391 (15.6) 262 (10.4)
Abbreviation: OASIS, obstetric anal sphincter injuries. a Values are given as mean ± SD or number (percentage).
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
E.J. Oude Lohuis, E. Everhardt / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
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Table 2 Prevalence of defects on endoanal ultrasonography at 3 months postpartum.a Defect
EAS defect IAS defect a b
P valueb
Degree of anal sphincter injury 3a (n = 25)
3b (n = 45)
3c (n = 19)
4 (n = 10)
Total (n = 99)
6 (24.0) 0 (0)
15 (33.3) 2 (4.4)
8 (42.1) 1 (5.3)
6 (60.0) 2 (20.0)
35 (35.4) 5 (5.1)
0.22 0.10
Values are given as number (percentage) unless stated otherwise. By Fisher exact test.
4. Discussion
degree of tear (Table 2). In total, 64 women (64.6%) had no persistent defect of the IAS or EAS. Of the 35 (35.4%) women with a persisting defect of the EAS, 5 (5.1%) also had a persisting defect of the IAS. An increase in the degree of tear did not lead to a significant increase in persisting EAS or IAS defects (P = 0.22 and P = 0.10, respectively). The mean defect (as a percentage of sphincter circumference) of the EAS was 18.3%, 20.8%, 21.4%, and 26.0% in the 3a, 3b, 3c, and fourthdegree tear groups, respectively. Analysis of variance did not show a significant increase in circumference defect with growing degree of rupture (P = 0.27). After 3 months, 64 women (64.6%) were asymptomatic and 35 (35.4%) women had one or more defecatory symptoms. The distribution of patients with each degree of tear and their symptoms at follow-up are summarized in Table 3. Fecal urgency occurred significantly more among women with a fourth-degree tear as compared with women with a third-degree tear (P = 0.03). There were no significant differences in the presence of fecal incontinence, gas incontinence, and fecal soiling among the degrees of tear (P = 0.35, P = 0.43 and P = 0.19, respectively). The number of defecatory symptoms showed a positive correlation with the severity of injury (P = 0.02). There were no significant differences in defecatory complaints among breastfeeding women versus nonbreastfeeding women. The number of women with defecatory complaints and that of women with ultrasonographic defects seemed to be associated (Tables 4 and 5). Among the 35 women with a persisting defect on ultrasound, 22 (62.9%) had defecatory symptoms; by contrast, among the 64 women without a persisting defect, 13 (20.3%) had complaints (odds ratio, 6.6; 95% CI, 2.6–16.6; P = 0.001). In the group without a persisting defect, the number of defecatory complaints increased significantly as the degree of tear increased (P = 0.038). No significant difference in these numbers was found in the group with a persisting defect.
In the present study group, 35 (35.4%) women had a persisting EAS defect 3 months after delivery and 5 (5.1%) women also had a persisting IAS defect on ultrasound. Other studies have reported values ranging from 7.8% to 91%, but the definitions of the significance of an ultrasonographic defect vary [12,13,15,16]. One study accepted only tears of the EAS if they exceeded 30 degrees of the total sphincter circumference [16]. Other studies included only ultrasonographic results from women with anal incontinence complaints [12,13]. One study of women with fourth-degree tears showed that only 15% of the patients had no persisting ultrasound defect [17]. In the present study, 3 months after primary repair of OASIS, 35 (35.4%) women had one or more defecatory complaints, which were predominantly involuntary loss of gas and fecal urgency. This proportion is low as compared with literature values [9–11]. Except for fecal urgency, which presented among significantly more women in the fourth-degree tear group, the incidence of other individual defecatory symptoms did not differ significantly among the OASIS groups. However, there was a significantly higher number of defecatory complaints in the more severe rupture groups (P = 0.02). This emphasizes the need for an adequate repair technique that also includes the higher degrees of OASIS, which are more often accompanied by episiotomies and are therefore even more difficult to mend. One study with a follow-up period of 9 weeks has shown that women with a major (3c and 4 degree) tear have a significantly worse outcome in terms of the development of defecatory symptoms [18]. Twenty-two (62.9%) of the 35 women with and 13 of the 64 (20.3%) without a persisting defect on ultrasound had defecatory complaints. No other comparable data are available on the association between defecatory complaints among women with and without sphincter defects. Although one study reported the number of women with
Table 3 Prevalence of defecatory symptoms at 3 months postpartum.a Symptom
Gas incontinence Fecal soiling Fecal incontinence Fecal urgency Two of the above Three of the above All of the above a b
P valueb
Degree of anal sphincter injury 3a (n = 25)
3b (n = 45)
3c (n = 19)
4 (n = 10)
Total (n = 99)
3 (14.3) 1 (4.0) 0 (0) 6 (24.0) 1 (4.0) 0 (0) 0 (0)
9 (20.0) 2 (4.4) 1 (2.2) 10 (22.2) 4 (8.9) 3 (6.7) 0 (0)
6 (31.6) 3 (15.8) 2 (10.5) 6 (31.6) 3 (15.8) 2 (10.5) 1 (5.3)
3 (30.0) 2 (20.0) 1 (10.0) 6 (60.0) 1 (10.0) 2 (20.0) 0 (0)
21 (21.2) 8 (8.1) 4 (4.0) 28 (28.3) 9 (9.1) 7 (7.1) 1 (1.0)
0.43 0.19 0.35 0.03 0.23 0.42 –
Values are given as number (percentage) unless stated otherwise. By Fisher exact test.
Table 4 Distribution of women with a persisting defect and defecatory symptoms by degree of tear.a Degree of anal sphincter injury
Persisting defect with defecatory symptoms a
3a (n = 6)
3b (n = 15)
3c (n = 8)
4 (n = 6)
Total (n = 35)
4 (66.6)
8 (54.4)
6 (75.0)
4 (66.6)
22 (62.9)
Values are given as number (percentage).
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
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E.J. Oude Lohuis, E. Everhardt / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Table 5 Distribution of women without a persisting defect but with defecatory symptoms by degree of tear.a Degree of anal sphincter injury
No persisting defect but defecatory symptoms a
3a (n = 19)
3b (n = 30)
3c (n = 11)
4 (n = 4)
Total (n = 64)
5 (26.3)
4 (13.3)
1 (9.1)
3 (75.0)
13 (20.3)
Values are given as number (percentage).
complaints, not all of the cohort had an ultrasound examination in that study [12]. In another, retrospective study, only half of the women with OASIS had an ultrasound investigation and a clear association between anal incontinence and sphincter defects was not found [17]. A correct diagnosis is crucial to enable adequate repair. In the present study, two women (4.4%) with a 3b tear had an IAS defect on ultrasound and six women (24.0%) with a 3a tear had a persisting EAS defect. The risk of underestimating the degree of the tear at primary repair was highest in the 3a group. However, we do not have information on the numbers of overestimation. A strength of the present study is that 98.0% patients were seen by the same gynecologist at follow-up, and 92.9% of the ultrasound examinations were performed by the same gastroenterologist. A limitation was the relatively short follow-up period. There may have been an overestimation of defecatory complaints because the questionnaires were completed at 3 months; at this point, some patients had not finished all of their physiotherapy sessions, although the follow-up period was good for the patients’ pelvic floor awareness. The women were advised to train their pelvic muscles daily from then on to reduce the risk of anal incontinence symptoms developing after menopause. In fact, the occurrence of anal incontinence complaints in postmenopausal women was the reason behind the present research. It would be interesting to investigate this cohort of women for anal incontinence complaints again after the menopause, because an anal sphincter injury that seems like a relatively minor incident at delivery might cause severe problems later in life. In the study hospital, consultant gynecologists perform an average of two OASIS repairs a year. This low number would not be accepted as satisfactory to maintain a surgeon’s skills for any type of major surgery. The high number of persisting defects not only highlights the need for further training, but also might form an argument for restricting this repair to specialists. Although a successful anatomic repair without persisting defects is not a guarantee of a life without defecatory symptoms, one can imagine that the prospect is at least better. The present results point in this direction, because women with a persisting defect on ultrasound were found to have a threefold higher risk of defecatory complaints. In summary, the present study shows that sphincter defects persist in approximately one-third of women who undergo primary repair of OASIS. A persisting defect increases the risk of defecatory symptoms threefold. Women will benefit from adequate diagnosis and optimal repair of OASIS. The present results once again emphasize the need for further and more adequate training regarding OASIS repair. Defining more risk factors for OASIS and a subsequent strategy for preventing OASIS present a challenge for the near future.
Conflict of interest The authors have no conflicts of interest.
References [1] Harkin R, Fitzpatrick M, O'Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol 2003;109(2):149–52. [2] Abbott D, Atere-Roberts N, Williams A, Oteng-Ntim E, Chappell LC. Obstetric anal sphincter injury. BMJ 2010;341:c3414. [3] Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears. Green-top Guideline No. 29. http://www.rcog.org. uk/files/rcog-corp/GTG2911022011.pdf. Published March 2007. [4] Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 2008;247(2):224–37. [5] Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329(26):1905–11. [6] Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev 2006(3):CD002866. [7] Faltin DL, Sangalli MR, Roche B, Floris L, Boulvain M, Weil A. Does a second delivery increase the risk of anal incontinence? BJOG 2001;108(7):684–8. [8] Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries–myth or reality? BJOG 2006;113(2):195–200. [9] Oberwalder M, Connor J, Wexner SD. Meta-analysis to determine the incidence of obstetric anal sphincter damage. Br J Surg 2003;90(11):1333–7. [10] Bagade P, Mackenzie S. Outcomes from medium term follow-up of patients with third and fourth degree perineal tears. J Obstet Gynaecol 2010;30(6):609–12. [11] Tin RY, Schulz J, Gunn B, Flood C, Rosychuk RJ. The prevalence of anal incontinence in post-partum women following obstetrical anal sphincter injury. Int Urogynecol J 2010;21(8):927–32. [12] Poen AC, Felt-Bersma RJ, Strijers RL, Dekker GA, Cuesta MA, Meuwissen SG. Thirddegree obstetric perineal tear: long-term clinical and functional results after primary repair. Br J Surg 1998;85(10):1433–8. [13] Savoye-Collet C, Savoye G, Koning E, Sassi A, Leroi AM, Dacher JN. Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear. Scand J Gastroenterol 2003;38(11):1149–53. [14] Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol 1999;106(4):318–23. [15] Kołodziejczak M, Sudoł-Szopińska I, Stefański R, Panorska AK, Gardyszewska A, Krasnodębski I. Anal endosonographic findings in women after vaginal delivery. Eur J Radiol 2011;78(1):157–9. [16] de Vogel J, van der Leeuw-van Beek A, Gietelink D, Vujkovic M, de Leeuw JW, van Bavel J, et al. The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J Obstet Gynecol 2012;206(5):404.e1–5. [17] Sakse A, Secher NJ, Ottesen M, Starck M. 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. Ultrasound Obstet Gynecol 2009;34(6):693–8. [18] Roos AM, Thakar R, Sultan AH. Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter? Ultrasound Obstet Gynecol 2010;36 (3):368–74.
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms Eefje J. Oude Lohuis a,b, Ellen Everhardt a,⁎ a b
Department of Obstetrics and Gynecology, Medisch Spectrum Twente Hospital Group, Enschede, Netherlands Department of Obstetrics and Gynecology, Deventer Hospital, Deventer, Netherlands
a r t i c l e
i n f o
Article history: Received 1 September 2013 Received in revised form 31 December 2013 Accepted 27 March 2014 Keywords: Anal incontinence Defecatory symptoms Endoanal ultrasound Obstetric anal sphincter injury
a b s t r a c t Objective: To determine the prevalence of persisting endoanal ultrasonographic defects among women with obstetric anal sphincter injuries (OASIS), and the incidence of defecatory symptoms. Methods: In a prospective study in Enschede, Netherlands, women with OASIS were enrolled between 2007 and 2012. Three months after surgical repair, all women had an endoanal ultrasound, and data were collected on gas and fecal incontinence, soiling, and fecal urgency. Results: Overall, 99 women were included. At follow-up, 35 (35.4%) women had a persisting defect of the external anal sphincter on ultrasound, and 5 women (5.1%) also had a persisting defect of the internal anal sphincter. Overall, 35 (35.4%) women had one or more defecatory complaints—predominantly involuntary loss of gas and fecal urgency. Overall, 22 of 35 (63.0%) women with and 13 of 64 (20.3%) women without a persisting defect on ultrasound had defecatory complaints. The number of defecatory symptoms showed a positive correlation with severity of injury. Women with a persisting defect had a threefold higher risk of defecatory complaints as compared with women who had a successful repair (odds ratio, 6.6; 95% confidence interval, 2.6–16.6). Conclusion: The results emphasize the importance of adequate repair of OASIS and demonstrate that repair can be difficult or underestimated. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Obstetric anal sphincter injuries (OASIS) affect approximately 2.9% (0.7%–9.0%) of primiparous women who deliver vaginally, and an additional 0.8% of multiparous women [1–4]. Both third- and fourth-degree perineal tears include injury of the anal sphincter. A third-degree perineal tear is defined as partial or complete disruption of the anal sphincter muscles, which might involve the external anal sphincter (EAS) alone or both the EAS and the internal anal sphincter (IAS). A fourthdegree tear is defined as disruption of both the EAS and the IAS in addition to a defect of the rectal mucosa [3,5]. Box 1 gives an overview of the classification of the degrees of anal sphincter rupture [3,6]. A median episiotomy, prolonged second stage of labor (N2 hours), vaginal birth after cesarean, use of epidural, birth weight of more than 4 kg, instrumental delivery, and shoulder dystocia are known risk factors for OASIS and anal incontinence [3,7]. OASIS occurs more frequently than has been previously reported: many sphincter injuries remain
undiagnosed and are subsequently classified as occult when subsequently identified on anal endosonography [8]. Anal incontinence is characterized by an involuntary loss of gas, or liquid or solid stools, and is a distressing condition that has a profound psychological impact [3]. The reported incidence of anal incontinence after OASIS ranges from 0% to 68.2% [2,9,10]. A recent study reported a prevalence of 7.7%, 19.7%, and 38.2% for incontinence of formed stools, loose stools, and gas, respectively [11]. One study showed that 5 years after the primary repair of OASIS, 40% of patients had anal incontinence [12]; however, the influence of persisting sphincter defects was not reported. Another study did investigate the persistence of sphincter defects, reporting that, after the primary repair of third-degree tears, the endosonographic pattern of the anal sphincter correlated with continence status at the short-term follow-up [13]. The primary objective of the present study was to determine the prevalence of persisting endoanal ultrasonographic defects among postpartum women after OASIS. A secondary aim was to specify the prevalence of defecatory symptoms among these women. 2. Materials and methods
⁎ Corresponding author at: Medisch Spectrum Twente, Gynecologie en Obstetrie, VKC, Haaksbergerstraat 55, 7513 ER Enschede, Netherlands. Tel.: +31 534872330; fax: +31 534339571. E-mail address: [email protected] (E. Everhardt).
The present prospective cohort study enrolled women with a thirdor fourth-degree perineal tear who underwent primary repair at a large teaching hospital in Enschede, Netherlands, between January 1, 2007, and January 31, 2012. The ethical board of the hospital approved the
http://dx.doi.org/10.1016/j.ijgo.2014.01.018 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
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E.J. Oude Lohuis, E. Everhardt / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Box 1 Classification of anal sphincter injury. First degree: Injury to perineal skin only Second degree: Injury to perineum that affects the muscles but not the anal sphincter Third degree: Injury to perineum that affects the anal sphincter complex as follows: 3a: Less than 50% of external anal sphincter torn 3b: More than 50% of external anal sphincter torn 3c: Both external and internal anal sphincter torn Fourth degree: Injury to perineum involving the anal sphincter complex and anal epithelium
collection of data from this group of patients. All patients gave consent for the standard protocol treatment. The study enrolled all patients needing surgical repair of OASIS, which included both women who had delivered at the hospital and those who delivered at home under midwifery care. All of the tears were classified and repaired by the consultant gynecologist, who was specialized in OASIS, according to the study unit’s protocol. Surgery was performed by either end-to-end (approximation) repair or overlap repair. In the end-to-end method, the torn ends of the external anal sphincter are approximated together and sutured without any overlap of the muscle. In the overlap method, the torn ends of the external anal sphincter are brought together and sutured by overlapping one end of the muscle over the other in a double-breasted fashion, as described by Sultan et al. [6,14]. Before surgery, all patients received prophylactic antibiotic therapy (single-dose co-amoxiclav, 1200 mg intravenously). Overall, 87 out of 103 repairs were performed in the theater under general or spinal anesthesia. Sixteen were repaired in the delivery room under adequate analgesia. Patients were given laxatives (chewable magnesium oxide tablets) after surgery and were instructed how to clean their wound. At 2 weeks after surgery, all patients were reviewed at the outpatient clinic by the same consultant gynecologist both to evaluate the healing process and to be provided with additional instructions if necessary. The women were re-assessed 6 weeks after surgery by the same gynecologist, and both vaginal and rectal examinations were performed. At this time, pelvic floor muscle training was commenced by a specialized physiotherapist. Several tests were conducted to identify the current state of dysfunction of the EAS including anal function tests for strength, coordination, and condition of the EAS. In addition, myofeedback tests for ground-level tension of the sphincter were performed. Depending on the results of these tests, a specific training program to optimize sphincter condition was designed individually for each patient, which took up to 6 months. All patients had an endoanal ultrasonography performed by an independent experienced gastroenterologist, who was blind to the continence status, 3 months after delivery in order to detect persisting sphincter defects. This was performed in the left lateral position using a 7.5–10.0-MHz transrectal mechanical radial scanner (ALOKA ASU67, Hitachi Aloka Medical, Tokyo, Japan), which is a two-dimensional 360° radial rectal transducer. A rigid probe was inserted into the anal canal, and ultrasonographic imaging was performed proximally to distally to identify the circumference and consistency of the IAS and EAS. An EAS defect was defined as a gap or a region of lower echogenicity in the external sphincter. An IAS defect was defined as loss of continuity in the internal sphincter. Both defects were documented as a percentage of the total sphincter circumference. The last follow-up appointment at the outpatient clinic took place after the endoanal ultrasonography. Persisting defecatory complaints
(anal incontinence, soiling, and fecal urgency), and the results of both pelvic floor training and the endoanal ultrasound were recorded. Information was also collected from patient records, including type of delivery, birth weight, and whether or not an episiotomy was performed. Statistical analysis was carried out with SPSS version 18.0 (IBM, Armonk, NY, USA). Pearson χ2 and Fisher exact tests were used to examine the presence of anal incontinence within various factors, including use of forceps or ventouse, episiotomy, and birth weight. These tests were also used to identify significant differences in the presence of ultrasonographic defects among women with different degrees of tears. The confidence interval (95% CI) was calculated for key outcomes, and a P value of 0.05 was considered to indicate statistical significance. 3. Results In total, 103 women were enrolled in the study. Four women were subsequently excluded from analysis: two had a rectal mucosal tear without injury of the anal sphincter; one woman had a tear that was repaired in theater, but both sphincters were found to be intact at the time; and one woman could not undergo an endoanal ultrasonographic examination because she had an ileostomy and, therefore, atrophy of the anal canal. The mean ± SD age was 29.6 ± 4.0 years. The demographic and obstetric characteristics of the study patients and details of the annual deliveries of the study unit are shown in Table 1. There were 89 (90.0%) patients with a third-degree tear, and 10 (10.0%) patients with a fourth-degree tear. Furthermore, there were 25 (25.3%) 3a tears, 45 (45.5%) 3b tears and 19 (19.2%) 3c tears. Of the fourth-degree tears, 5 were repaired via the overlap technique and 5 via the end-to-end method. Of the 19 3c degree ruptures, 6 were repaired via the overlap technique and 12 were repaired via the endto-end method; for one patient, the type of method was not documented. All 3a and 3b degree tears were repaired via the end-to-end method. There was a significant difference in the presence of an episiotomy among women with different degrees of tear. Significantly fewer episiotomies had been performed in the group with 3a tears (difference, 0.3; 95% CI, 0.0–0.6; P = 0.046). There was also a significant difference in birth weight among the groups. Neonates were significantly heavier in the fourth-degree tear group than in the 3c tear group (difference, 532 g; 95% CI, 74–989 g; P = 0.015). A least significant difference post-hoc test was used for these calculations. There was also a significant difference in the degree of tear in the assisted versus spontaneous delivery groups. The assisted delivery group showed significantly more 3c ruptures, whereas the spontaneous delivery group had more 3a tears (difference, 0.3; 95% CI, 0.0–0.6; P = 0.04). Three months postoperatively, persisting defects of the anal sphincter were visible on endoanal ultrasound among women with each Table 1 Demographic and obstetric variables.a Variable Patient characteristics (n = 99) Age, y Spontaneous Delivery by midwife Ventouse Forceps Episiotomy Birth weight N4 kg Breast feeding Shoulder dystocia Occipito-posterior position Delivery unit characteristics (n = 2511) Mean annual incidence of OASIS Mean annual no. of cesarean deliveries Mean annual no. of instrumental deliveries
Data (n = 99) 29.6 ± 4.0 59 (59.6) 18 (18.2) 14 (14.1) 8 (8.0) 33 (33.3) 21 (21.2) 36 (36.4) 10 (10.1) 10 (10.1) 19.8 (0.8) 391 (15.6) 262 (10.4)
Abbreviation: OASIS, obstetric anal sphincter injuries. a Values are given as mean ± SD or number (percentage).
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
E.J. Oude Lohuis, E. Everhardt / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
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Table 2 Prevalence of defects on endoanal ultrasonography at 3 months postpartum.a Defect
EAS defect IAS defect a b
P valueb
Degree of anal sphincter injury 3a (n = 25)
3b (n = 45)
3c (n = 19)
4 (n = 10)
Total (n = 99)
6 (24.0) 0 (0)
15 (33.3) 2 (4.4)
8 (42.1) 1 (5.3)
6 (60.0) 2 (20.0)
35 (35.4) 5 (5.1)
0.22 0.10
Values are given as number (percentage) unless stated otherwise. By Fisher exact test.
4. Discussion
degree of tear (Table 2). In total, 64 women (64.6%) had no persistent defect of the IAS or EAS. Of the 35 (35.4%) women with a persisting defect of the EAS, 5 (5.1%) also had a persisting defect of the IAS. An increase in the degree of tear did not lead to a significant increase in persisting EAS or IAS defects (P = 0.22 and P = 0.10, respectively). The mean defect (as a percentage of sphincter circumference) of the EAS was 18.3%, 20.8%, 21.4%, and 26.0% in the 3a, 3b, 3c, and fourthdegree tear groups, respectively. Analysis of variance did not show a significant increase in circumference defect with growing degree of rupture (P = 0.27). After 3 months, 64 women (64.6%) were asymptomatic and 35 (35.4%) women had one or more defecatory symptoms. The distribution of patients with each degree of tear and their symptoms at follow-up are summarized in Table 3. Fecal urgency occurred significantly more among women with a fourth-degree tear as compared with women with a third-degree tear (P = 0.03). There were no significant differences in the presence of fecal incontinence, gas incontinence, and fecal soiling among the degrees of tear (P = 0.35, P = 0.43 and P = 0.19, respectively). The number of defecatory symptoms showed a positive correlation with the severity of injury (P = 0.02). There were no significant differences in defecatory complaints among breastfeeding women versus nonbreastfeeding women. The number of women with defecatory complaints and that of women with ultrasonographic defects seemed to be associated (Tables 4 and 5). Among the 35 women with a persisting defect on ultrasound, 22 (62.9%) had defecatory symptoms; by contrast, among the 64 women without a persisting defect, 13 (20.3%) had complaints (odds ratio, 6.6; 95% CI, 2.6–16.6; P = 0.001). In the group without a persisting defect, the number of defecatory complaints increased significantly as the degree of tear increased (P = 0.038). No significant difference in these numbers was found in the group with a persisting defect.
In the present study group, 35 (35.4%) women had a persisting EAS defect 3 months after delivery and 5 (5.1%) women also had a persisting IAS defect on ultrasound. Other studies have reported values ranging from 7.8% to 91%, but the definitions of the significance of an ultrasonographic defect vary [12,13,15,16]. One study accepted only tears of the EAS if they exceeded 30 degrees of the total sphincter circumference [16]. Other studies included only ultrasonographic results from women with anal incontinence complaints [12,13]. One study of women with fourth-degree tears showed that only 15% of the patients had no persisting ultrasound defect [17]. In the present study, 3 months after primary repair of OASIS, 35 (35.4%) women had one or more defecatory complaints, which were predominantly involuntary loss of gas and fecal urgency. This proportion is low as compared with literature values [9–11]. Except for fecal urgency, which presented among significantly more women in the fourth-degree tear group, the incidence of other individual defecatory symptoms did not differ significantly among the OASIS groups. However, there was a significantly higher number of defecatory complaints in the more severe rupture groups (P = 0.02). This emphasizes the need for an adequate repair technique that also includes the higher degrees of OASIS, which are more often accompanied by episiotomies and are therefore even more difficult to mend. One study with a follow-up period of 9 weeks has shown that women with a major (3c and 4 degree) tear have a significantly worse outcome in terms of the development of defecatory symptoms [18]. Twenty-two (62.9%) of the 35 women with and 13 of the 64 (20.3%) without a persisting defect on ultrasound had defecatory complaints. No other comparable data are available on the association between defecatory complaints among women with and without sphincter defects. Although one study reported the number of women with
Table 3 Prevalence of defecatory symptoms at 3 months postpartum.a Symptom
Gas incontinence Fecal soiling Fecal incontinence Fecal urgency Two of the above Three of the above All of the above a b
P valueb
Degree of anal sphincter injury 3a (n = 25)
3b (n = 45)
3c (n = 19)
4 (n = 10)
Total (n = 99)
3 (14.3) 1 (4.0) 0 (0) 6 (24.0) 1 (4.0) 0 (0) 0 (0)
9 (20.0) 2 (4.4) 1 (2.2) 10 (22.2) 4 (8.9) 3 (6.7) 0 (0)
6 (31.6) 3 (15.8) 2 (10.5) 6 (31.6) 3 (15.8) 2 (10.5) 1 (5.3)
3 (30.0) 2 (20.0) 1 (10.0) 6 (60.0) 1 (10.0) 2 (20.0) 0 (0)
21 (21.2) 8 (8.1) 4 (4.0) 28 (28.3) 9 (9.1) 7 (7.1) 1 (1.0)
0.43 0.19 0.35 0.03 0.23 0.42 –
Values are given as number (percentage) unless stated otherwise. By Fisher exact test.
Table 4 Distribution of women with a persisting defect and defecatory symptoms by degree of tear.a Degree of anal sphincter injury
Persisting defect with defecatory symptoms a
3a (n = 6)
3b (n = 15)
3c (n = 8)
4 (n = 6)
Total (n = 35)
4 (66.6)
8 (54.4)
6 (75.0)
4 (66.6)
22 (62.9)
Values are given as number (percentage).
Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
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E.J. Oude Lohuis, E. Everhardt / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Table 5 Distribution of women without a persisting defect but with defecatory symptoms by degree of tear.a Degree of anal sphincter injury
No persisting defect but defecatory symptoms a
3a (n = 19)
3b (n = 30)
3c (n = 11)
4 (n = 4)
Total (n = 64)
5 (26.3)
4 (13.3)
1 (9.1)
3 (75.0)
13 (20.3)
Values are given as number (percentage).
complaints, not all of the cohort had an ultrasound examination in that study [12]. In another, retrospective study, only half of the women with OASIS had an ultrasound investigation and a clear association between anal incontinence and sphincter defects was not found [17]. A correct diagnosis is crucial to enable adequate repair. In the present study, two women (4.4%) with a 3b tear had an IAS defect on ultrasound and six women (24.0%) with a 3a tear had a persisting EAS defect. The risk of underestimating the degree of the tear at primary repair was highest in the 3a group. However, we do not have information on the numbers of overestimation. A strength of the present study is that 98.0% patients were seen by the same gynecologist at follow-up, and 92.9% of the ultrasound examinations were performed by the same gastroenterologist. A limitation was the relatively short follow-up period. There may have been an overestimation of defecatory complaints because the questionnaires were completed at 3 months; at this point, some patients had not finished all of their physiotherapy sessions, although the follow-up period was good for the patients’ pelvic floor awareness. The women were advised to train their pelvic muscles daily from then on to reduce the risk of anal incontinence symptoms developing after menopause. In fact, the occurrence of anal incontinence complaints in postmenopausal women was the reason behind the present research. It would be interesting to investigate this cohort of women for anal incontinence complaints again after the menopause, because an anal sphincter injury that seems like a relatively minor incident at delivery might cause severe problems later in life. In the study hospital, consultant gynecologists perform an average of two OASIS repairs a year. This low number would not be accepted as satisfactory to maintain a surgeon’s skills for any type of major surgery. The high number of persisting defects not only highlights the need for further training, but also might form an argument for restricting this repair to specialists. Although a successful anatomic repair without persisting defects is not a guarantee of a life without defecatory symptoms, one can imagine that the prospect is at least better. The present results point in this direction, because women with a persisting defect on ultrasound were found to have a threefold higher risk of defecatory complaints. In summary, the present study shows that sphincter defects persist in approximately one-third of women who undergo primary repair of OASIS. A persisting defect increases the risk of defecatory symptoms threefold. Women will benefit from adequate diagnosis and optimal repair of OASIS. The present results once again emphasize the need for further and more adequate training regarding OASIS repair. Defining more risk factors for OASIS and a subsequent strategy for preventing OASIS present a challenge for the near future.
Conflict of interest The authors have no conflicts of interest.
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Please cite this article as: Oude Lohuis EJ, Everhardt E, Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.018
