Anal sphincter function and integrity after primary repair of third-degree tear: uncontrolled prospective analysis

Background: The purpose of the present paper was to determine the anatomical integrity and functional effect of a tear to the anal sphincter in women after vaginal delivery. Methods: A prospective review of third‐ and fourth‐degree vaginal tears over a 3 year period at Lyell McEwin and Queen Elizabeth Hospitals, Adelaide. Obstetric details were obtained from the records. All were counselled by a continence advisor and offered consultation with a colorectal surgeon. The integrity of the anal sphincter was assessed by endoanal ultrasound. Results: During the study period there were 6875 vaginal deliveries. There were 89 women (1.3%) who had a third‐ or fourth‐degree tear. Fifty‐one (57%) agreed to participate. Primiparity (67%), episiotomy (49%), forceps delivery (29%) and instrumental delivery were common in women sustaining a tear. Symptoms of anal incontinence (mild) or faecal urgency were described in 23 women (45%). Except for three women with an anovaginal fistula none required surgery for the management of faecal incontinence. A sphincter defect was seen in 27 women (53%) on endoanal ultrasound. The presence or absence of a sphincter defect was not significantly associated with symptoms but a trend was suggested (χ² = 3.21; P = 0.07). Conclusions: Third‐degree tear after vaginal delivery was a significant intrapartum event, yet associated only with minimal symptoms (excluding patients with anovaginal fistula) even in the presence of a sphincter defect on anal ultrasound.     

Predictive factors for faecal incontinence after third or fourth degree obstetric tears: a clinico-physiologic study

Objective  This is a prospective study to review the natural history of anorectal dysfunction after primary repair for third or fourth degree obstetric tear and to identify the predictive factors for significant faecal incontinence.
Method  From January 2003 to December 2005, 121 consecutive women (mean age 29.9 ± 4.7) who sustained third or fourth degree obstetric tears were assessed. All had primary repair by obstetricians. They were assessed using anorectal physiology testing and endoanal ultrasound. Short-term (3-month postpartum) and medium-term (mean 18.8 ± 7.7 months) Wexner's continence scores were obtained.
Results  Among the 121 women, seven were excluded because of incomplete follow-up. At short-term assessment, 25 out of 114 women were incontinent. One of them underwent another sphincter repair for significant faecal incontinence. Twenty-one and three patients respectively, had mild (Wexner's score 1–4) and moderate (Wexner's score 5–8) symptoms. At medium-term assessment, 24 patients remained incontinent; of these, 20 had mild symptoms (Wexner's score 1–4) and four had moderate incontinence (Wexner's score 5–8). The parity ( P  =   0.04), degree of obstetric tear ( P  =   0.036) and short-term Wexner's scores at 3 months postpartum ( P  <   0.0001) were significantly related to the change in Wexner's scores at medium-term assessment. However, the short-term Wexner's score was the only identifiable predictive factor for significant faecal incontinence.
Conclusion  Most women suffering from third or fourth degree obstetric tear were continent or mildly incontinent. Poor Wexner's score at short-term assessment at 3 months postpartum was predictive of faecal incontinence in the medium-term.     

Delayed sphincter repair for obstetric ruptures: Analysis of failure

Objective The aim of this study was to examine the clinical results after anterior anal sphincter repair in patients with obstetric trauma and to evaluate possible risk factors for poor outcome. Patients and methods In years 1990–99 anterior anal sphincter repair for anal incontinence due to obstetric trauma was performed in 39 patients at Helsinki University Central Hospital. Clinical examination with Parks' classification and patients' questionnaire with endoanal ultrasound (EAUS) were done before and after surgery. Pudendal nerve terminal motor latency (PNTML) was measured postoperatively. The median follow‐up time after the operation was 22 months (range 2–99). Results The follow‐up results of the patients' questionnaire for 12 patients (31%) were good, for 15 patients (38%) acceptable and for 12 patients (31%) poor. Postoperative EAUS showed sphincter overlap in 28 (72%) patients but a defect was still found in 11 (28%) patients. A defect found on postoperative EAUS correlated with poor clinical result according to Parks' (R = 0.8, P < 0.01) and patients' questionnaire results (R = 0.7, P < 0.01). Patients with poor clinical results (Parks III/IV) were statistically significantly older (median 63 years, range 26–73) than those with favourable results (Parks I/II) (median 45 years, range 27–79) (P < 0.05). Further, the duration of incontinence symptoms correlated with poor functional results (R = 0.4, P < 0.05). Conclusion After obstetric trauma anterior anal repair gives acceptable short‐term clinical results. EAUS investigation is easy and harmless to perform and should be used pre‐ and post‐operatively. Advanced age, pre‐operative signs of perineal descent, long‐lasting severe incontinence symptoms and a persistent defect on postoperative EAUS seem to be related to poor clinical result.     

Anal sphincter defects and anal incontinence symptoms after repair of obstetric anal sphincter lacerations in primiparous women

A study was carried out to identify (1) incidence of anal incontinence symptoms, (2) incidence and size of both external anal sphincter (EAS) and internal anal sphincter (IAS) defects, and (3) relationship between anal incontinence symptoms and IAS or EAS defect size after repair of an obstetric anal sphincter laceration. Forty-seven vaginally primiparous women underwent obstetric anal sphincter laceration repair. At 8–12 weeks postpartum, anal incontinence symptoms were assessed, and endoanal ultrasound was performed. At 1–2 years postpartum, symptoms were reassesseds. The incidence of anal incontinence symptoms at 8–12 weeks was 43%. The incidence of IAS and EAS defects were 32% and 77%, respectively. IAS defects ≥45 degrees were predictive of symptoms (p = 0.02). After 18 months mean follow-up, 11% reported chronic symptoms. After anal sphincter laceration repair, anal incontinence symptoms occur in 43% of women and remain chronic in 11%. Anal incontinence symptoms are associated with increasing IAS defect size. Poster presentation at the American Urogynecologic Society Annual Meeting, Hollywood, Florida, USA, 27–29 September 2007.     

Three‐dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry

Aim Anal sphincter anatomy on two‐dimensional endoanal ‐ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three‐dimensional (3D) measurements yield a better correlation. Method The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2‐year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF‐FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. Results Sixty‐one patients of median age 53 years (range 15–82) were evaluated. Thirty‐two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF‐FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact‐sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF‐FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. Conclusion Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.     

Effect of rectal distension on voluntary external anal sphincter function in healthy subjects

Aim Quantification of the anorectal reflex function is critical for explaining the physiological control of continence. Reflex external anal sphincter activity increases with rectal distension in a dynamic response. We hypothesized that rectal distension would similarly augment voluntary external anal sphincter function, quantified by measuring the anal maximum squeeze pressure. Method Fifty‐seven subjects (32 men, 25 women; median age 62 years), with normal anal canal manometry and endoanal ultrasound results, underwent a rectal barostat study with simultaneous anal manometry. Stepwise isovolumetric 50‐ml distensions (n = 35) or isobaric 4‐mmHg distensions (n = 22) above the minimum distending pressure were performed (up to 200 ml or 16 mmHg respectively), whilst anal resting pressure and maximum squeeze pressure were recorded and compared with the baseline pressure. Results The distension‐induced squeeze increment was calculated as the maximum percentage increase in maximum squeeze pressure with progressive rectal distension. This was observed in 53 of the 57 subjects as a mean ± standard deviation (range) increase of 32.8 ± 24.1 (?5.5 to 97.7)%. The mean ± standard deviation (range) distension‐induced squeeze increment in male subjects was 36.1 ± 25.7 (?5.5 to 97.7)% and in female subjects was 28.1 ± 20.1 (?3.8 to 70.2)%. There was no significant difference between the sexes (P = 0.194). Conclusion Rectal distension augments external anal sphincter function, confirming the existence of a dynamic rectoanal response. This may represent a quantifiable and important part of the continence mechanism.     

Imbrication of the external anal sphincter may yield similar functional results as overlapping repair in selected patients

Objective Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates. Method Patients who had external anal sphincter repair and follow up of at least 3 months were studied. Fecal incontinence was measured using the validated Wexner fecal Incontinence Scoring system (0 = perfect continence, 20 = complete incontinence); postoperative scores 0–10 were interpreted as successful, and scores of 11–20 as failures. Results A total of 131 females who had anal sphincter repair between 1988 and 2000 were analysed. One hundred and twenty‐one patients had overlapping external anal sphincter repair (group I), and 10 had external anal sphincter imbrication (group II). Indications for external anal sphincter imbrication were attenuation of the external anal sphincter without overt defect (n = 5), partial disruption of external anal sphincter with muscle fibres bridging the scar (n = 2), thick bulk of scar between the muscle edges (n = 2), and wide lateral retraction of the muscle edges (n = 1). There were no statistically significant differences between the groups relative to preoperative incontinence score (16.5 vs 16.5, P = 0.99), pudendal nerve terminal motor latency assessment (left 9.6%vs 0.0%, P = 0.19; right 13.4%vs 11.1%, P = 0.84), and extent of electromyography pathology (61%vs 47%, P = 0.30). The patients in group I were younger than those in group II (mean age 50.8 years vs. 61.7 years, respectively; P = 0.052) and the length of follow‐up was significantly longer (32.3 months vs 14.3 months, respectively; P < 0.0001). Both procedures had similar success rates (59.5%vs 60%; P = 0.98). Conclusion Imbrication of the external anal sphincter may yield similar results as overlapping external anal sphincter repair in patients with incomplete external anal sphincter disruptions, external anal sphincter attenuation, and in patients presenting with wide lateral retraction of the muscle edges.     

Primary repair of advanced obstetric anal sphincter tears: should it be performed by the overlapping sphincteroplasty technique?

Advanced obstetric anal sphincter tears are often associated with a high incidence of fecal and flatus incontinence. We aimed to assess the clinical outcome of these repairs when done by the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. Between August 2005 and December 2006, all grades 3 and 4 obstetric anal sphincter tears in our department were repaired by a reconstructive pelvic surgeon, primarily using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. All women were followed every 6 months using the Colorectal Anal Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, a physical examination of the anal sphincter, anal manometry, and transperineal anal sonography. There were 3,478 deliveries of which 22 (0.63%) anal sphincter tears were repaired in women aged 22-41 years. Two women were diagnosed with Royal College of Obstetricians and Gynecologists grade 3a, eight with grade 3b, nine with grade 3c, and three with grade 4 anal sphincter tears. Postoperatively, 21 patients attended the outpatient clinic, with an average follow-up time of 9.2+/-1.4 months. Only two women (9.5%) complained of flatus incontinence and fecal urgency and had mildly decreased anal sphincter squeeze pressure and a small sonographic anal sphincter defect. None of the women complained of fecal incontinence. Two women (9.5%) reported on transient perineal pain and one (4.8%) on transient dyspareunia. All other women were asymptomatic and had normal anal manometry and sonographic evaluation. Repair of obstetric anal sphincter tears using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum seems to carry favorable clinical outcome and reduced risk for anal incontinence, perineal pain, and sexual dysfunction.     

Structured hands-on training in repair of obstetric anal sphincter injuries (OASIS): an audit of clinical practice

We conducted an audit to evaluate how effective a structured course in the management of obstetric anal sphincter injuries (OASIS) was at imparting knowledge. Training was undertaken using models and cadaveric pig’s anal sphincters. An anonymous questionnaire was completed prior to and 8 weeks after the course. Four hundred and ninety seven completed the questionnaire before and 63% returned it after the course. Prior to the course, participants performed on average 14 OASIS repairs independently. Only 13% were satisfied with their level of experience prior to performing their first unsupervised repair. After the course, participants classified OASIS more accurately and changed to evidence-based practice. Particularly, there was a change in identifying (60% vs. 90%; P < 0.0001) and repairing the internal sphincter (60% vs. 90%; P < 0.0001). This audit demonstrated that training in the management of OASIS is suboptimal. Structured training may be effective in changing clinical practice and should be an adjunct to surgical training. An erratum to this article can be found at