Parturition mode recommendation and symptoms of pelvic floor disorders after obstetric anal sphincter injuries

Abstract

Introduction and hypothesis Our primary objective was to evaluate parturition mode (PM) recommendations following obstetric anal sphincter injuries (OASIs) and adherence to these recommendations and to evaluate recurrence of OASIs in women who had a subsequent vaginal delivery (VD). The hypothesis was that adherence to the PM recommendations leads to a reasonable OASI recurrence rate. Methods This was a retrospective observational cohort study of patients with previous OASIs between 2010 and 2016. After an outpatient visit including 3D transperineal ultrasound to screen for pelvic floor and anal sphincter injuries, all patients received recommendations for a subsequent PM. Patients were invited to complete validated questionnaires 2 to 5 years post-OASIs. Results The majority of invited patients (265/320) attended follow-up, with 264 receiving a recommendation for PM. Only 5.6% did not adhere to the received recommendation. One hundred sixty-one patients delivered again, 58% had a VD, and 42% had a cesarean section (CS). Recurrence of OASIs was observed in 4.3% of the patients that had a VD. Fecal incontinence occurred in 4.9%, however any form of anal incontinence in 48% of patients. While dyspareunia was common in patients with residual external anal sphincter (EAS) injuries and levator ani muscle (LAM) avulsions, anal pain occurred more frequently in EAS injuries and fecal incontinence in LAM avulsions. Conclusions This study showed that the vast majority of patients followed PM recommendations, and this resulted in a low recurrence of OASIs with a high CS rate. Fecal incontinence after OASIs was correlated with the degree of OASIs.

Diagnostic capabilities of transperineal ultrasound (TPUS) to evaluate anal sphincter defect post obstetric anal sphincter injury (OASIS)? A systematic review

“…However, a follow-up examination focuses more on evaluating the symptoms, sequelae, and decisions regarding future deliveries. RCOG and ACOG recommend that if resources and facilities are available, women with OASIS should undergo endoanal ultrasonography and anal manometry to decide on future deliveries [13,14]. Unfortunately, endoanal ultrasonography and anal manometry are not convenient for postpartum women and it is usually conducted by colorectal surgeon, not a gynecologist.…”

“…Unfortunately, endoanal ultrasonography and anal manometry are not convenient for postpartum women and it is usually conducted by colorectal surgeon, not a gynecologist. A woman with the symptom of incontinence, severe anatomical defect on anal sphincter or levator ani avulsion, and low pressure of anal manometry is recommended to have an elective cesarean delivery [ 13 , 15 ]. Thus, emphasizing the importance of imaging examination on post-repair OASIS women.…”

“…Endoanal ultrasound as a gold standard instrument to examine the anal sphincter is very expensive and requires subsequent years of training. Lately, TPUS is widely more available and has started to be routinely used to examine the anal sphincter [ 15 , 16 ]. The advantages of using TPUS are higher patient applicability with its non-intrusive method, less distortion of the anal canal by the transducer, more affordable, and more straightforward interpretation.…”

Sonographic postpartum anal sphincter defects and the association with pelvic floor pain and dyspareunia

“…13 Several studies have shown that the extent of endosonographic anal sphincter defects is related to anal incontinence, [14][15][16] and one study aimed at evaluating parturition mode recommendations following obstetric anal sphincter injuries found that dyspareunia was more common in patients with residual external anal sphincter (EAS) defects. 17 This study aimed to determine the prevalence of postpartum anal sphincter defects using three-dimensional endoanal ultrasonography (3D-EAUS). The primary outcome was association of postpartum sonographic sphincter defects with symptoms of pelvic floor pain and dyspareunia.…”

“…Three dimensional endoanal ultrasound (3D‐EAUS) is a documented, well‐tolerated, and inexpensive method of evaluating damage to the anal sphincter and is considered the gold standard 13 . Several studies have shown that the extent of endosonographic anal sphincter defects is related to anal incontinence, 14–16 and one study aimed at evaluating parturition mode recommendations following obstetric anal sphincter injuries found that dyspareunia was more common in patients with residual external anal sphincter (EAS) defects 17 …”