A Systematic Review of the Efficacy of Cesarean Section in the Preservation of Anal Continence

Abstract

PURPOSE: Elective primary cesarean section is performed largely to avoid maternal pelvic trauma that may result in anal incontinence, although its efficacy in this regard has not been thoroughly assessed. We perform a systematic review of published reports that compare anal incontinence risk by mode of delivery. METHODS: PubMed was searched from 1966 through August 2005. Authors were contacted for missing data or analyses. Both randomized and nonrandomized reports were included. Eligible studies included females having vaginal delivery or cesarean section, fecal and/or flatal incontinence was reported as an outcome, and risk was calculable from the reported data. Crude data were extracted from the reports, as well as reported odds ratios and confidence intervals. In the nonrandomized studies, adjusted odds ratios also were extracted and additional data obtained from authors to adjust risks for age and parity if not originally done. Sensitivity analyses were performed using quality indicators: age and parity adjustment, time to continence assessment, and mode of previous delivery. RESULTS: Fifteen studies were found eligible, encompassing 3,010 cesarean sections and 11,440 vaginal deliveries. The summary relative risk for fecal incontinence was 0.91 (95 percent confidence interval, 0.74-1.14). For flatus the relative risk was 0.98 (range, 0.86-1.13). The number needed to treat by cesarean section was 167 to prevent a single case of fecal incontinence. Five studies were judged to be of high quality. In these studies, the summary relative risk was 0.94 (range, 0.72-1.22) and number needed to treat was 198. CONCLUSIONS: The best evidence to assess the efficacy of cesarean section in the prevention of anal incontinence would be in randomized trials of averagerisk pregnancies with few crossovers. In the absence of such trials and based on this review, cesarean section does not prevent anal incontinence. This implies that incontinence associated with delivery may be more likely incontinence caused by pregnancy. [

Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians

“…42 However, notwithstanding the catastrophic consequences of such a complication, the incidence is extremely low and the evidence for caesarean section preventing anal incontinence is weak. 43 Nelson found that 198 caesarean sections would need to be performed to prevent one case of anal incontinence and that such incontinence is more likely to be caused by pregnancy than by mode of delivery.…”

“…15 Instrumental VD, vacuum extraction and forceps-assisted delivery, and emergency caesarean section are all potential consequences from an attempted VD but are often omitted from studies evaluating VD outcomes. 16 Various studies have canvassed a range of obstetricians' opinions regarding their personal choice of mode of delivery and their willingness to perform caesarean section at patient request in the absence of an obstetric indication. 14,[17][18][19][20] Seventeen percent of London obstetricians (31% of female obstetricians) said that they would have an elective caesarean section in the absence of obstetric indications; their main concern was the risk of pelvic floor injuries.…”

Anal Incontinence after Childbirth: Incidence in the Korean Population

“…The present study did not find that cesarean delivery protected against anal incontinence, with 4 of 9 fecal incontinence and 23 of 59 flatal incontinence women delivering via cesarean section. These findings add to the growing evidence that cesarean delivery does not completely protect against anal incontinence [29,30] . However, we did find that women who entered second-stage labor and then underwent a cesarean section were more likely to have anal incontinence compared to women who underwent a cesarean section without entering labor.…”

“…The key lies in whether the cesarean section is performed before labor. Incontinence associated with delivery may actually be caused by pregnancy [29] . The present study did not find that cesarean delivery protected against anal incontinence, with 4 of 9 fecal incontinence and 23 of 59 flatal incontinence women delivering via cesarean section.…”

Kontinenzstörungen nach Analeingriffen – ein relevantes Problem?

“…Im Langzeitverlauf stellen Sphinkterdefekte einen wichtigen Risikofaktor für eine Kontinenzstörung dar [21]. Andererseits wird von Gynäkologen keine generelle Sectio-Empfehlung zur Prävention gefordert, da neben den grundsätzlichen Problemen einer Sectio bereits die Schwangerschaft an sich zu einer Beeinträchti-gung der Kontinenz führt und somit durch eine Sectio Kontinenzstörungen nicht grundsätzlich verhindert werden können [67].…”