Introduction and hypothesis
The objective was to investigate whether endoanal ultrasound (EAUS) performed 10 days after a primary repaired obstetric anal sphincter injury (OASIS) can predict the severity of anal incontinence (AI) in the long term.
This prospective cohort study included women with a primary repaired 3b-degree tear, 3c-degree tear or fourth-degree tear at Aarhus University Hospital, Denmark, from 1 September 2010 to 31 May 2011. Clinical assessment and EAUS were performed on day 2, day 10, and day 20 after delivery. Functional outcomes were assessed using a questionnaire at the time of all clinical visits and at the long-term follow-up, 7 years after delivery. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score.
Ninety-six out of 99 women consented to participate. Five women had a secondary sphincter repair and were subsequently excluded from follow-up. Fifty-seven women underwent both EAUS 10 days after delivery and answered the long-term follow-up questionnaire. Median follow-up time was 7.7 years (IQR 7.4–7.8). Mean Wexner score was 4.4 ± 4.8 10 days after delivery and 2.5 ± 2.8 at follow-up; thus, the Wexner score improved over time (p = 0.01). Ultrasound sphincter defects were found in 82.6% of the women. Mean Starck score was 3.0 ± 1.8. The risk of AI was 0% (95% CI 0.0–30.8) if the Starck score was 0. No correlation was found between the Starck score and the Wexner score at follow-up.
We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.
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Pirhonen JP, Grenman SE, Haadem K, Gudmundsson S, Lindqvist P, Siihola S, et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland—result of difference in manual help to the baby's head. Acta Obstet Gynecol Scand. 1998;77(10):974–7.
Norderval S, Nsubuga D, Bjelke C, Frasunek J, Myklebust I, Vonen B. Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county. Acta Obstet Gynecol Scand. 2004;83(10):989–94. https://doi.org/10.1111/j.0001-6349.2004.00647.x.
Nordenstam J, Mellgren A, Altman D, Lopez A, Johansson C, Anzen B, et al. Immediate or delayed repair of obstetric anal sphincter tears—a randomised controlled trial. BJOG. 2008;115(7):857–65. https://doi.org/10.1111/j.1471-0528.2008.01726.x.
Bek KM, Laurberg S. Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear. Br J Obstet Gynaecol. 1992;99(9):724–6.
Pinta TM, Kylanpaa ML, Salmi TK, Teramo KA, Luukkonen PS. Primary sphincter repair: are the results of the operation good enough? Dis Colon Rectum. 2004;47(1):18–23. https://doi.org/10.1007/s10350-003-0006-9.
Smith TM, Menees SB, Xu X, Saad RJ, Chey WD, Fenner DE. Factors associated with quality of life among women with fecal incontinence. Int Urogynecol J. 2013;24(3):493–9. https://doi.org/10.1007/s00192-012-1889-6.
Heymen S. Psychological and cognitive variables affecting treatment outcomes for urinary and fecal incontinence. Gastroenterology. 2004;126(1 Suppl 1):S146–51.
Rothbarth J, Bemelman WA, Meijerink WJ, Stiggelbout AM, Zwinderman AH, Buyze-Westerweel ME, et al. What is the impact of fecal incontinence on quality of life? Dis Colon Rectum. 2001;44(1):67–71.
Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, et al. Obstetrical anal sphincter injuries (OASIS): prevention, recognition, and repair. J Obstet Gynaecol Can. 2015;37(12):1131–48.
Walsh KA, Grivell RM. Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. Cochrane Database Syst Rev. 2015;10:CD010826. https://doi.org/10.1002/14651858.CD010826.pub2.
Soerensen MM, Bek KM, Buntzen S, Hojberg KE, Laurberg S. Long-term outcome of delayed primary or early secondary reconstruction of the anal sphincter after obstetrical injury. Dis Colon Rectum. 2008;51(3):312–7. https://doi.org/10.1007/s10350-007-9084-4.
Barbosa M, Glavind-Kristensen M, Christensen P. Early secondary repair of obstetric anal sphincter injury: postoperative complications, long-term functional outcomes, and impact on quality of life. Tech Coloproctol. 2020;24(3):221–9. https://doi.org/10.1007/s10151-019-02146-z.
Starck M, Bohe M, Valentin L. Results of endosonographic imaging of the anal sphincter 2–7 days after primary repair of third- or fourth-degree obstetric sphincter tears. Ultrasound Obstet Gynecol. 2003;22(6):609–15. https://doi.org/10.1002/uog.920.
Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36(1):77–97.
Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut. 1999;44(1):77–80.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. https://doi.org/10.1016/j.jbi.2008.08.010.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.
Bland JM, Altman DG. Applying the right statistics: analyses of measurement studies. Ultrasound Obstet Gynecol. 2003;22(1):85–93. https://doi.org/10.1002/uog.122.
Carstensen B. Measures of association and agreement. In: Comparing clinical measurement methods. New York: Wiley. 2010. p. 115–26. https://doi.org/10.1002/9780470683019.ch10.
Kuismanen K, Nieminen K, Karjalainen K, Lehto K, Uotila J. Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment. Tech Coloproctol. 2018;22(3):209–14. https://doi.org/10.1007/s10151-018-1770-9.
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. https://doi.org/10.1002/uog.7478.
Luciano L, Bouvier M, Baumstarck K, Vitton V. Is the extent of obstetric anal sphincter injury correlated with the severity of fecal incontinence in the long term? Tech Coloproctol. 2020;24(1):49–55. https://doi.org/10.1007/s10151-019-02128-1.
Starck M, Bohe M, Valentin L. The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence. Ultrasound Obstet Gynecol. 2006;27(2):188–97. https://doi.org/10.1002/uog.2630.
Shin GH, Toto EL, Schey R. Pregnancy and postpartum bowel changes: constipation and fecal incontinence. Am J Gastroenterol. 2015;110(4):521–9; quiz 530. https://doi.org/10.1038/ajg.2015.76.
Soerensen MM, Pedersen BG, Santoro GA, Buntzen S, Bek K, Laurberg S. Long-term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury. Colorectal Dis. 2014;16(10):O347–55. https://doi.org/10.1111/codi.12579.
Norderval S, Markskog A, Rossaak K, Vonen B. Correlation between anal sphincter defects and anal incontinence following obstetric sphincter tears: assessment using scoring systems for sonographic classification of defects. Ultrasound Obstet Gynecol. 2008;31(1):78–84. https://doi.org/10.1002/uog.5155.
Egekvist AG, Forman A, Seyer-Hansen M. Transvaginal ultrasonography of rectosigmoid endometriosis: interobserver variation of lesion size. Acta Obstet Gynecol Scand. 2012;91(2):264–8. https://doi.org/10.1111/j.1600-0412.2011.01308.x.
Morgan DM, Umek W, Stein T, Hsu Y, Guire K, DeLancey JO. Interrater reliability of assessing levator ani muscle defects with magnetic resonance images. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(7):773–8. https://doi.org/10.1007/s00192-006-0224-5.
Huebner M, Margulies RU, Fenner DE, Ashton-Miller JA, Bitar KN, DeLancey JO. Age effects on internal anal sphincter thickness and diameter in nulliparous females. Dis Colon Rectum. 2007;50(9):1405–11. https://doi.org/10.1007/s10350-006-0877-7.
Norderval S, Dehli T, Vonen B. Three-dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classification of anal sphincter defects. Ultrasound Obstet Gynecol. 2009;33(3):337–43. https://doi.org/10.1002/uog.6295.
Dunn KM, Jordan K, Lacey RJ, Shapley M, Jinks C. Patterns of consent in epidemiologic research: evidence from over 25,000 responders. Am J Epidemiol. 2004;159(11):1087–94. https://doi.org/10.1093/aje/kwh141.
Ramalingam K, Monga AK. Outcomes and follow-up after obstetric anal sphincter injuries. Int Urogynecol J. 2013;24(9):1495–500. https://doi.org/10.1007/s00192-013-2051-9.
Turawa EB, Musekiwa A, Rohwer AC. Interventions for preventing postpartum constipation. Cochrane Database Syst Rev. 2015;2015(9):Cd011625. https://doi.org/10.1002/14651858.CD011625.pub2.
Derbyshire EJ, Davies J, Detmar P. Changes in bowel function: pregnancy and the puerperium. Dig Dis Sci. 2007;52(2):324–8. https://doi.org/10.1007/s10620-006-9538-x.
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Barbosa, M., Christensen, P., Møller-Bek, K. et al. Can ultrasound 10 days after obstetric anal sphincter injury predict anal incontinence at long-term follow-up?. Int Urogynecol J 32, 2511–2520 (2021). https://doi.org/10.1007/s00192-021-04733-x
- Obstetric sphincter injury
- Anal sphincter
- Anal incontinence
- Anal ultrasound