Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound

Okeahialam, Nicola Adanna; Thakar, Ranee; Sultan, Abdul H.

doi:10.1002/uog.24957

Cited by 7 publications

(17 citation statements)

References 30 publications

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“…Moreover, we found that, in comparison to TPUS, EAUS has the strongest association with anal incontinence symptoms up to 2 years following OASI 7 . The take‐home message of our study 1 is that the defect angle measurement obtained on EAUS is not equivalent to that of TPUS for the same reason acknowledged by Dietz and Shek, namely, that EAUS distends the anal canal.…”

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confidence: 51%

“…We appreciate Prof. Dietz and Dr Shek's interest in our publication 1 . We agree that transperineal ultrasound (TPUS) is less intrusive than endoanal ultrasound (EAUS), but in our practice we perform both examinations, as can be seen in a number of our publications.…”

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confidence: 72%

“…individualized recommendations on mode of delivery are made in a number of maternity units in the UK in which EAUS is available, accounting for anal incontinence severity, EAUS findings, anal manometry and patient wishes 5 . As we have shown that an anal sphincter defect of 30° on EAUS is not equivalent to that on TPUS, our study suggests that the use of this diagnostic cut‐off for significant defect on TPUS could be erroneous when making mode of delivery recommendations in a subsequent pregnancy 1 . If an improper recommendation of vaginal birth is made, this could potentially compromise anal sphincter function in a future delivery.…”

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confidence: 86%

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Okeahialam

Thakar

Sultan

2022

Ultrasound in Obstet & Gyne

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We appreciate Prof. Dietz and Dr Shek's interest in our publication 1 . We agree that transperineal ultrasound (TPUS) is less intrusive than endoanal ultrasound (EAUS), but in our practice we perform both examinations, as can be seen in a number of our publications. EAUS is the only modality that has been validated using histology as the reference and therefore remains the gold standard for anal sphincter evaluation. The International Urogynecological Association and International Continence Society recommend EAUS as the gold standard imaging modality for the diagnosis of maternal birth trauma and the investigation of fecal incontinence 2 . Unlike TPUS, EAUS has been shown to be useful in recommendations regarding the mode of delivery in a subsequent birth following obstetric anal sphincter injury (OASI) 3 . Therefore, the Royal College of Obstetricians and Gynaecologists advise that EAUS

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confidence: 72%

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confidence: 86%

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Okeahialam

Thakar

Sultan

2022

Ultrasound in Obstet & Gyne

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“…We used a well‐validated imaging modality 7 , 9 to assess any sphincter defects and a validated symptom scoring system 12 . While endoanal ultrasound is a recommended form of imaging, the appearance of a ‘normal’ IAS has not been examined as thoroughly as that of a ‘normal’ EAS.…”

Section: Discussionmentioning

confidence: 99%

“…There is growing interest in multiple imaging modalities, such as translabial or introital ultrasound, for the diagnosis of obstetric anal sphincter injury (OASI), especially for use in a ‘rule‐out’ capacity 6 . Endoanal 7 and translabial 8 ultrasound have been found to be in good agreement for the diagnosis of sphincter trauma 9,10 , though validation of both for the IAS is limited 11 . Despite these advances in imaging technology, the diagnosis of OASI immediately following delivery is based on clinical suspicion and the accoucheur's clinical acumen.…”

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confidence: 99%

Underdiagnosis of internal anal sphincter trauma following vaginal delivery

OʼLeary

Kelly

Fitzpatrick

et al. 2023

Ultrasound in Obstet & Gyne

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Objective Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade‐3a or ‐3b obstetric anal sphincter injury (OASI) in a tertiary‐referral perineal clinic. Methods This was a retrospective observational study of all women referred to a tertiary‐referral perineal clinic after primary repair of OASI (Grade 3a–c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30–90° or > 90°) on endoanal imaging in the axial plane. Results In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade‐3a/3b injury. In women referred with a Grade‐3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade‐3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26–15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25–6.45); P < 0.001). Conclusions One in 11 women diagnosed with a Grade‐3a or ‐3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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Assessing Obstetric Anal Sphincter Injuries

Zhao

Tang³

et al. 2023

J of Ultrasound Medicine

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ObjectivesTo explore the differences in assessing obstetric anal sphincter injuries (OASI) between transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS) and test relationships between ultrasound findings and anal incontinence (AI) symptoms.MethodsA group of 196 women with a history of vaginal delivery was recruited. OASI was detected in a set of 5 slices by EAUS and 8 slices by TPUS. OASI grading was performed on TPUS rules and EAUS rules. A “significant sphincter defect” was diagnosed by TPUS and EAUS using “2/3 rules.” Symptoms of AI were determined using the St Mark's Incontinence Score (SMIS). Ultrasound findings were compared between the two methods and correlated with symptoms.ResultsOf 196 women, 29 (14.8%) suffered from AI with a mean SMIS of 12.1 ± 4.5, and 70 (35.7%) women with a mean age of 57 years had suspected OASI on imaging. Twenty‐one (10.7%) “significant defects” were diagnosed by TPUS and 24 (12.2%) by EAUS. OASI Grades on TPUS had good agreement with EAUS rules (k = 0.70, P < .001). Logistic regression analysis showed that OASI Grade on imaging and “significant sphincter defects” seen on both forms of imaging were associated with AI symptoms. The odds ratio was 46 and 38 for “significant defects” on TPUS and EAUS, and 14 and 7 for OASI 3b+ on TPUS and EAUS in predicting AI, respectively.Conclusions“Significant defects” diagnosed by EAUS or TPUS and OASI Grade 3b+ predict AI symptoms. The diagnostic performance of endoanal and exoanal ultrasound (EAUS and TPUS) appear to be very similar.

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Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound

Cited by 7 publications

References 30 publications

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Underdiagnosis of internal anal sphincter trauma following vaginal delivery

Assessing Obstetric Anal Sphincter Injuries

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