Introduction and hypothesis
Pregnancy and childbirth are considered risk factors for pelvic floor dysfunction, including anorectal dysfunction. We aimed to assess the effect of obstetric events on anal incontinence and constipation after delivery.
We systematically reviewed the literature by searching MEDLINE, Embase and CENTRAL. We included studies in women after childbirth examining the association between obstetric events and anorectal dysfunction assessed through validated questionnaires. We selected eligible studies and clustered the data according to the type of dysfunction, obstetric event and interval from delivery. We assessed risk of bias using the Newcastle Ottawa Scale and we performed a random-effects meta-analysis and reported the results as odds ratios (ORs) with their 95% confidence intervals. Heterogeneity across studies was assessed using I2 statistics.
Anal sphincter injury (OR: 2.44 [1.92–3.09]) and operative delivery were risk factors for anal incontinence (forceps—OR :1.35 [1.12–1.63]; vacuum—OR: 1.17 [1.04–1.31]). Spontaneous vaginal delivery increased the risk of anal incontinence compared with caesarean section (OR: 1.27 [1.07–1.50]). Maternal obesity (OR:1.48 [1.28–1.72]) and advanced maternal age (OR: 1.56 [1.30–1.88]) were risk factors for anal incontinence. The evidence on incontinence is of low certainty owing to the observational nature of the studies. No evidence was retrieved regarding constipation after delivery because of a lack of standardised validated assessment tools.
Besides anal sphincter injury, forceps delivery, maternal obesity and advanced age were associated with higher odds of anal incontinence, whereas caesarean section is protective. We could not identify obstetric risk factors for postpartum constipation, as few prospective studies addressed this question and none used a standardised validated questionnaire.
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Sultan A, Monga A, Lee J, Emmanuel A, Norton C, Santoro G, et al. An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female anorectal dysfunction. Int Urogynecol J. 2017;28(1):5–31.
Sultan AH. Editorial: obstetrical perineal injury and anal incontinence. J Patient Saf Risk Manag. 1999;5(6):193–6.
Drusany Staric K, Norcic G. Obstetric risk factors for early-onset anal incontinence. Int J Colorectal Dis. 2019;34(1):177–80.
Chandler P, Buek D. Rectovaginal septal defects after vaginal delivery. Obstet Gynecol. 2001;97(4, Suppl 1):S50.
Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777–84.
Morrison A, Polisena J, Husereau D, Moulton K, Clark M, Fiander M, et al. The effect of English-language restriction on systematic review-based meta-analyses: a systematic review of empirical studies. Int J Technol Assess Health Care. 2012;28(2):138–44.
Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14:579.
Lampinen R, Vehviläinen-Julkunen K, Kankkunen P. A review of pregnancy in women over 35 years of age. Open Nurs J. 2009;3:33–8.
Wells GA SB, O'Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. 2000. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm.
Tähtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y, Cárdenas JL, et al. Long-term impact of mode of delivery on stress urinary incontinence and urgency urinary incontinence: a systematic review and meta-analysis. Eur Urol. 2016;70(1):148–58.
Wilson D, Dornan J, Milsom I, Freeman R. UR-CHOICE: can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? Int Urogynecol J. 2014;25(11):1449–52.
Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: systematic review and meta-analysis. PLoS Med. 2018;15(1):e1002494.
Tähtinen RM, Cartwright R, Vernooij RWM, Rortveit G, Hunskaar S, Guyatt GH, et al. Long-term risks of stress and urgency urinary incontinence after different vaginal delivery modes. Am J Obstet Gynecol. 2019;220(2):181.e1–8.
Friedman T, Eslick GD, Dietz HP. Delivery mode and the risk of levator muscle avulsion: a meta-analysis. Int Urogynecol J. 2019;30(6):901–7.
Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A. Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012;119(2):233–9.
Fitzpatrick M, Behan M, O'Connell PR, O'Herlihy C. Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery. BJOG. 2003;110(4):424–9.
Dietz HP. Obstetric forceps: a species on the brink of extinction and forceps, simulation, and social media and simulation training for forceps-assisted vaginal delivery and rates of maternal perineal trauma. Obstet Gynecol. 2016;128(6):1447–8.
Dietz HP. Forceps: towards obsolescence or revival? Acta Obstet Gynecol Scand. 2015;94(4):347–51.
Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen K. Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16–24 years after first delivery. Ultrasound Obstet Gynecol. 2015;46(4):487–95.
Krofta L, Otcenásek M, Kasíková E, Feyereisl J. Pubococcygeus-puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(10):1175–81.
O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev. 2010;(11):CD005455.
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.
Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev. 2013;(12):Cd002866.
Nordenstam J, Mellgren A, Altman D, López A, Johansson C, Anzén B, et al. Immediate or delayed repair of obstetric anal sphincter tears—a randomised controlled trial. BJOG. 2008;115(7):857–65.
Abramov Y, Feiner B, Rosen T, Bardichev M, Gutterman E, Lissak A, et al. Primary repair of advanced obstetric anal sphincter tears: should it be performed by the overlapping sphincteroplasty technique? Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(8):1071–4.
Peirce C, Murphy C, Fitzpatrick M, Cassidy M, Daly L, O'Connell PR, et al. Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third-degree tears (EBAPT trial). BJOG. 2013;120(10):1240–7; discussion 6.
Kwok SP, Wan OY, Cheung RY, Lee LL, Chung JP, Chan SS. Prevalence of obstetric anal sphincter injury following vaginal delivery in primiparous women: a retrospective analysis. Hong Kong Med J. 2019;25(4):271–8.
Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG. 2008;115(13):1695–702; discussion 702–3.
Lund NS, Persson LK, Jangö H, Gommesen D, Westergaard HB. Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;207:193–9.
De Leeuw J, De Wit C, Kuijken J, Bruinse H. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG. 2008;115(1):104–8.
Murphy DJ, Strachan BK, Bahl R. Assisted vaginal birth green-top guideline no. 26. BJOG. 2020;127(9):E70–E112.
Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004;103(1):31–40.
Krofta L, Havelková L, Urbánková I, Krčmář M, Hynčík L, Feyereisl J. Finite element model focused on stress distribution in the levator ani muscle during vaginal delivery. Int Urogynecol J. 2017;28(2):275–84.
Youssef A, Salsi G, Cataneo I, Pacella G, Azzarone C, Paganotto MC, et al. Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion. Ultrasound Obstet Gynecol. 2019;53(1):95–100.
Guerby P, Parant O, Chantalat E, Vayssiere C, Vidal F. Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function. Arch Gynecol Obstet. 2018;298(1):111–20.
Fitzgerald MP, Weber AM, Howden N, Cundiff GW, Brown MB. Risk factors for anal sphincter tear during vaginal delivery. Obstet Gynecol. 2007;109(1):29–34.
Glazener C, Elders A, MacArthur C, Lancashire RJ, Herbison P, Hagen S, et al. Childbirth and prolapse: long-term associations with the symptoms and objective measurement of pelvic organ prolapse. BJOG. 2013;120(2):161–8.
Gyhagen M, Bullarbo M, Nielsen T, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013;120(2):152–60.
Glazener CM, Herbison GP, MacArthur C, Lancashire R, McGee MA, Grant AM, et al. New postnatal urinary incontinence: obstetric and other risk factors in primiparae. BJOG. 2006;113(2):208–17.
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013;120(2):144–51.
Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008;115(8):979–84.
Rahmanou P, Caudwell-Hall J, Kamisan Atan I, Dietz HP. The association between maternal age at first delivery and risk of obstetric trauma. Am J Obstet Gynecol. 2016;215(4):451.e1–7.
Callewaert G, Da Cunha MMCM, Sindhwani N, Sampaolesi M, Albersen M, Deprest J. Cell-based secondary prevention of childbirth-induced pelvic floor trauma. Nat Rev Urol 2017;14(6):373–85.
Sherratt M. Tissue elasticity and the ageing elastic fibre. Age (Dordr). 2009;31(4):305–25.
Giri A, Hartmann KE, Hellwege JN, Velez Edwards DR, Edwards TL. Obesity and pelvic organ prolapse: a systematic review and meta-analysis of observational studies. Am J Obstet Gynecol. 2017;217(1):11–26.e3.
Pomian A, Lisik W, Kosieradzki M, Barcz E. Obesity and pelvic floor disorders: a review of the literature. Med Sci Monit. 2016;22:1880–6.
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Faecal incontinence 20 years after one birth: a comparison between vaginal delivery and caesarean section. Int Urogynecol J. 2014;25(10):1411–8.
Marchi J, Berg M, Dencker A, Olander EK, Begley C. Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev. 2015;16(8):621–38.
Esposito K, Chiodini P, Colao A, Lenzi A, Giugliano D. Metabolic syndrome and risk of cancer: a systematic review and meta-analysis. Diabetes Care. 2012;35(11):2402–11.
Mottillo S, Filion KB, Genest J, Joseph L, Pilote L, Poirier P, et al. The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis. J Am Coll Cardiol. 2010;56(14):1113–32.
Markland AD, Richter HE, Burgio KL, Myers DL, Hernandez AL, Subak LL. Weight loss improves fecal incontinence severity in overweight and obese women with urinary incontinence. Int Urogynecol J. 2011;22(9):1151–7.
Marquis P, De La Loge C, Dubois D, McDermott A, Chassany O. Development and validation of the patient assessment of constipation quality of life questionnaire. Scand J Gastroenterol 2005;40(5):540–51.
Frank L, Kleinman L, Farup C, Taylor L, Miner P Jr. Psychometric validation of a constipation symptom assessment questionnaire. Scand J Gastroenterol. 1999;34(9):870–7.
Marshall K, Thompson KA, Walsh DM, Baxter GD. Incidence of urinary incontinence and constipation during pregnancy and postpartum: survey of current findings at the rotunda lying-in hospital. Br J Obstet Gynaecol. 1998;105(4):400–2.
Murad-Regadas S, Peterson TV, Pinto RA, Regadas FS, Sands DR, Wexner SD. Defecographic pelvic floor abnormalities in constipated patients: does mode of delivery matter? Tech Coloproctol. 2009;13(4):279–83.
Derbyshire EJ, Davies J, Detmar P. Changes in bowel function: pregnancy and the puerperium. Dig Dis Sci. 2007;52(2):324–8.
Ferdinande K, Dorreman Y, Roelens K, Ceelen W, De Looze D. Anorectal symptoms during pregnancy and postpartum: a prospective cohort study. Colorectal Dis 2018;20(12):1109–1116.
Van Brummen H, Bruinse H, van de Pol G, Heintz A, van der Vaart C. Defecatory symptoms during and after the first pregnancy: prevalences and associated factors. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(3):224–30.
Glazener CMA, MacArthur C, Hagen S, Elders A, Lancashire R, Herbison GP, et al. Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial. BJOG. 2014;121(1):112–9.
Macarthur C, Glazener C, Lancashire R, Herbison P, Wilson D. Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG. 2011;118(8):1001–7.
Andrews V, Shelmeridine S, Sultan AH, Thakar R. Anal and urinary incontinence 4 years after a vaginal delivery. Int Urogynecol J. 2013;24(1):55–60
Bollard RC, Gardiner A, Duthie GS, Lindow SW. Anal sphincter injury, faecal and urinary incontinence: a 34-year follow-up after forceps delivery. Dis Colon Rectum. 2003;46(8):1083–8
Casey BM, Schaffer JI, Bloom SL, Heartwell SF, McIntire DD, Leveno KJ. Obstetric antecedents for postpartum pelvic floor dysfunction. Am J Obstet Gynecol. 2005;192(5):1655–62
Damon H, Bretones S, Henry L, Mellier G, Mion F. Long-term consequences of first vaginal delivery-induced anal sphincter defect. Dis Colon Rectum. 2005;48(9):1772–6
Dolan LM, Hilton P. Obstetric risk factors and pelvic floor dysfunction 20 years after first delivery. Int Urogynecol J. 2010;21(5):535–44
Donnelly V, Fynes M, Campbell D, Johnson H, O’Connell PR, O’Herlihy C. Obstetric events leading to anal sphincter damage. Obstet Gynecol. 1998;926:955–61
Ducarme G, Hamel JF, Brun S, Madar H, Merlot B, Sentilhes L. Pelvic floor disorders 6 months after attempted operative vaginal delivery according to the fetal head station: a prospective cohort study. PLOS One. 2016;11(12):e0168591
Evers EC, Blomquist JL, McDermott KC, Handa VL. Obstetrical anal sphincter laceration and anal incontinence 5–10 years after childbirth. Am J Obstet Gynecol. 2012;207(5):425.e1–6
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
Gommesen D, Nohr EA, Qvist N, Rasch V. Obstetric perineal ruptures—risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study. Am J Obstet Gynecol. 2019;222(2):165.e1–11
Guise JM, Boyles SH, Osterweil P, Li H, Eden KB, Mori M. Does caesarean protect against faecal incontinence in primiparous women? Int Urogynecol J. 2009;20(1):61–7
Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Munoz A. Pelvic floor disorders 5–10 years after vaginal or caesarean childbirth. Obstet Gynecol. 2011;118(4):777–84
Huser M, Janku P, Hudecek R, Zbozinkova Z, Bursa M, Unzeitig V, et al. Pelvic floor dysfunction after vaginal and caesarean delivery among singleton primiparas. Int J Gynaecol Obstet. 2017;137(2):170–3
Johannessen HH, Wibe A, Stordahl A, Sandvik L, Mørkved S. Anal incontinence among first time mothers—what happens in pregnancy and the first year after delivery? Acta Obstet Gynecol Scand. 2015;94(9):1005–13
Johannessen HH, Stafne SN, Falk RS, Stordahl A, Wibe A, Mørkved S. Prevalence and predictors of anal incontinence 6 years after first delivery. Neurourol Urodyn. 2019;38(1):310–9
Lal M, Mann CH, Callender R, Radley S. Does caesarean delivery prevent anal incontinence? Obstet Gynecol. 2003;101(2):305–12
Nordenstam J, Altman D, Brismar S, Zetterstrom J. Natural progression of anal incontinence after childbirth. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(9):1029–35
Parant O, Simon-Toulza C, Cristini C, Vayssiere C, Arnaud C, Reme JM. Faecal incontinence after first instrumental vaginal delivery using Thierry’s spatulas. Int Urogynecol J. 2010;21(10):1195–203
Pinta TM, Kylänpää ML, Salmi TK, Teramo KAW, Luukkonen PS. Primary sphincter repair: are the results of the operation good enough? Dis Colon Rectum. 2004;47(1):18–23
Pinta TM, Kylänpää ML, Teramo KAW, Luukkonen PS. Sphincter rupture and anal incontinence after first vaginal delivery. Acta Obstet Gynecol Scand. 2004;83(10):917–22
Pollack J, Nordenstam J, Brismar S, Lopez A, Altman D, Zetterstrom J. Anal incontinence after vaginal delivery: a five-year prospective cohort study. Obstet Gynecol. 2004;104(6):1397–402
Rogers RG, Leeman LM, Borders N, Qualls C, Fullilove AM, Teaf D, et al. Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women. BJOG. 2014;121(9):1145–53
Solans-Domènech M, Sánchez E, Espuña-Pons M. Urinary and anal incontinence during pregnancy and postpartum: incidence, severity, and risk factors. Obstet Gynaecol. 2010;115(3):618–28
Stedenfeldt M, Pirhonen J, Blix E, Wilsgaard T, Vonen B, Øian P. Anal incontinence, urinary incontinence and sexual problems in primiparous women. BMC Womens Health. 2014;14:157
Torrisi G, Minini G, Bernasconi F, Perrone A, Trezza G, Guardabasso V et al. A prospective study of pelvic floor dysfunctions related to delivery. Eur J Obstet Gynecol Reprod Biol. 2012;160(1):110–5
Yang X, Zhang HX, Yu HY, Gao XL, Yang HX, Dong Y. The prevalence of faecal incontinence and urinary incontinence in primiparous postpartum Chinese women. Eur J Obstet Gynecol Reprod Biol. 2010;152(2):214–7
Altman D, Ekström Å, Forsgren C, Nordenstam J, Zetterström J. Symptoms of anal and urinary incontinence following caesarean section or spontaneous vaginal delivery. Am J Obstet Gynecol. 2007;197(5):512.e1–7
Badiou W, Bousquet PJ, Prat-Pradal D, Monrozies X, Mares P, de Tayrac R. Short vs long second stage of labour: is there a difference in terms of postpartum anal incontinence? Eur J Obstet Gynecol Reprod Biol. 2010;152(2):168–71
Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, et al. Faecal and urinary incontinence in primiparous women. Obstet Gynecol. 2006;108(4):863–72
Burgio KL, Borello-France D, Richter HE, Fitzgerald MP, Whitehead W, Handa VL, et al. Risk factors for faecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastroenterol. 2007;102(9):1998–2004
Chan SSC, Cheung RYK, Yiu KW, Lee LL, Chung TKH. Prevalence of urinary and faecal incontinence in Chinese women during and after their first pregnancy. Int Urogynecol J Pelvic Floor Dysfunct. 2013;24(9):1473–9
Chiarelli P, Murphy B, Cockburn J. Faecal incontinence after high-risk delivery. Obstet Gynecol. 2003;102(6):1299–305
De Leeuw JW, Vierhout ME, Struijk PC, Hop WCJ, Wallenburg HCS. Anal sphincter damage after vaginal delivery: functional outcome and risk factors for faecal incontinence. Acta Obstet Gynecol Scand. 2001;80(9):830–4
Gartland D, MacArthur C, Woolhouse H, McDonald E, Brown SJ. Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG. 2016;123(7):1203–11
Halle TK, Salvesen KA, Volloyhaug I. Obstetric anal sphincter injury and incontinence 15–23 years after vaginal delivery. Acta Obstet Gynecol Scand. 2016;95(8):941–7
Ng K, Cheung RYK, Lee LL, Chung TKH, Chan SSC. An observational follow-up study on pelvic floor disorders to 3–5 years after delivery. Int Urogynecol J. 2017;28(9):1393–9
Nilsson I, Akervall S, Milsom I, Gyhagen M. Long-term effects of vacuum extraction on pelvic floor function: a cohort study in primipara. Int Urogynecol J. 2016;27(7):1051–6
Palm A, Israelsson L, Bolin M, Danielsson I. Symptoms after obstetric sphincter injuries have little effect on quality of life. Acta Obstet Gynecol Scand. 2013;92(1):109–15
Volloyhaug I, Morkved S, Salvesen O, Salvesen K. Pelvic organ prolapse and incontinence 15–23 years after first delivery: a cross-sectional study. BJOG. 2015;122(7):964–71
Baud D, Meyer S, Vial Y, Hohlfeld P, Achtari C. Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery. Int Urogynecol J. 2011;22(9):1127–34
Svare JA, Hansen BB, Lose G. Prevalence of anal incontinence during pregnancy and 1 year after delivery in a cohort of primiparous women and a control group of nulliparous women. Acta Obstet Gynecol Scand. 2016;95(8):920–5
Wagenius J, Laurin J. Clinical symptoms after anal sphincter rupture: a retrospective study. Acta Obstet Gynecol Scand. 2003;82(3):246–50
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Cattani, L., Neefs, L., Verbakel, J.Y. et al. Obstetric risk factors for anorectal dysfunction after delivery: a systematic review and meta-analysis. Int Urogynecol J 32, 2325–2336 (2021). https://doi.org/10.1007/s00192-021-04723-z
- Anal incontinence
- Faecal incontinence
- Obstructive defecation