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Lilleberg HS, Siafarikas F, Starck M, Bø K, Rotstein E, Ellström Engh M. Association Between Sonographic Deviations in the Perineum and Symptoms of a Deficient Perineum in Primiparous Women One Year After Birth: A Prospective Cohort Study. BJOG 2025. [PMID: 40091528 DOI: 10.1111/1471-0528.18135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 01/31/2025] [Accepted: 02/28/2025] [Indexed: 03/19/2025]
Abstract
OBJECTIVES This study aimed to investigate whether primiparous women with sonographic deviations in the muscles fusing into the perineal body reported more symptoms of deficient perineum than women without deviations 1 year after birth. DESIGN Non-consecutive prospective cohort study. SETTING Akershus University Hospital, Norway. POPULATION Three hundred and eighty-eight primiparas. METHODS Women were examined 1 year after birth using three-dimensional endovaginal and endoanal ultrasound with a high-resolution probe. In the blinded analysis, the transverse perineal, the puboperinealis and the puboanalis muscles were identified where they fuse into the perineal body and assessed for deviations. Symptoms of deficient perineum were evaluated using the 'Karolinska Symptoms After Perineal Teras Inventory' (KAPTAIN). MAIN OUTCOME MEASURES Symptoms of a deficient perineum, assessed using two outcomes: the median total score of KAPTAIN and a KAPTAIN score ≥ 8 1 year postpartum. RESULTS Sonographic deviations in one or more of the muscles fusing into the perineal body 1 year after birth were observed in 168 participants (43.3%). Of these, 54 (32.1%) reported a KAPTAIN score ≥ 8. The median KAPTAIN score was 6.0 (IQR 3.0-9.0) in the group with sonographic deviations and 4.0 (IQR 2.0-6.0) in women with a sonographically intact perineum (p > 0.001). The unadjusted and adjusted odds ratio (OR) for reporting a KAPTAIN score ≥ 8 was 2.9 (95% CI 1.7-4.7) and 2.3 (95% CI 1.2-4.2), respectively, when comparing women with sonographic deviations to those with no sonographic deviations. CONCLUSION Our results indicate that sonographic deviations of the perineal body are associated with symptoms of a deficient perineum in primiparous women 1 year after birth.
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Affiliation(s)
- Hanne S Lilleberg
- Department of Gynecology and Obstetrics, Akershus University Hospital, Norbyhagen, Norway
- Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Franziska Siafarikas
- Department of Gynecology and Obstetrics, Akershus University Hospital, Norbyhagen, Norway
- Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marianne Starck
- Pelvic Floor Center, Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Kari Bø
- Department of Gynecology and Obstetrics, Akershus University Hospital, Norbyhagen, Norway
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
| | - Emilia Rotstein
- Department of Clinical Science, Intervention and Technology (CLINTEC), institution of Obstetrics and Gynecology, Karolinska Institute, Huddinge, Sweden
- Karolinska Pelvic Floor Centre, Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Ellström Engh
- Department of Gynecology and Obstetrics, Akershus University Hospital, Norbyhagen, Norway
- Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
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Borycka K, Młyńczak M, Rosoł M, Korzeniewski K, Iwanowski P, Heřman H, Janku P, Uchman-Musielak M, Dosedla E, Diaz EG, Sudoł-Szopińska I, Mik M, Ratto C, Spinelli A. Detection of obstetric anal sphincter injuries using machine learning-assisted impedance spectroscopy: a prospective, comparative, multicentre clinical study. Sci Rep 2025; 15:7522. [PMID: 40033085 PMCID: PMC11876446 DOI: 10.1038/s41598-025-92392-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Accepted: 02/27/2025] [Indexed: 03/05/2025] Open
Abstract
To evaluate the clinical performance and safety of the ONIRY system for obstetric anal sphincter injuries (OASI) detection versus three-dimensional endoanal ultrasound (EAUS). A prospective, comparative, multicentre, international study. Poland, Czechia, Slovakia, and Spain. 152 women between the first moments up to 8 weeks after vaginal delivery. Participants underwent EAUS and were allocated to groups based on OASIS classification: A (no perineal tear), B (1st or 2nd degree tear), or C (3rd or 4th degree, anal sphincters affected). Electric impedance was measured in the anal canal using the ONIRY system. The primary endpoint was the diagnostic outcome of impedance spectroscopy versus EAUS. Adverse events were collected. Part II involved in silico modelling and 10-time 10-fold cross-validation for automated analysis. Accuracy, sensitivity, and specificity. 30 women were allocated to group A, 61 to group B, and 61 to group C. The diagnostic outcome was determined for 147 participants. The accuracy, sensitivity, and specificity of the ML-assisted impedance spectroscopy were 87.0 ± 0.5%, 90.6 ± 2.0%, and 84.6 ± 1.9%, respectively, compared with EAUS. After data cleaning, the performance metrics of the proposed final ML model for ONIRY were: 90.0 ± 0.4%, 90.0 ± 1.2%, and 90.0 ± 0.7%, respectively. No adverse device effects or deficiencies were observed. By enabling early identification of sphincter injuries, ML-assisted impedance spectroscopy facilitates timely diagnosis and intervention, potentially reducing long-term complications such as faecal incontinence. Its rapid, bedside application in obstetric settings supports immediate postpartum care, complementing digital rectal examination and optimizing clinical decision-making.
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Affiliation(s)
- Katarzyna Borycka
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland.
- Department of General Surgery, Faculty of Medicine, Lazarski University, Warsaw, Poland.
| | - Marcel Młyńczak
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
- Faculty of Mechatronics, Institute of Metrology and Biomedical Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Maciej Rosoł
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
- Faculty of Mechatronics, Institute of Metrology and Biomedical Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Kacper Korzeniewski
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
- Faculty of Mechatronics, Institute of Metrology and Biomedical Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Piotr Iwanowski
- OASIS Diagnostics, R&D of Medical Technology, Warsaw, Poland
| | - Hynek Heřman
- Institute for the Care of Mother and Child, Prague, Czech Republic
- 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Petr Janku
- Department of Obstetrics and Gynaecology, University Hospital Brno and Medical Faculty, Masaryk University, Brno, Czech Republic
- Department of Health Sciences, Medical Faculty, Masaryk University, Brno, Czech Republic
| | | | - Erik Dosedla
- Department of Gynaecology and Obstetrics, Faculty of Medicine, Univerzita Pavla Jozefa Šafárika, Košice, Slovakia
| | - Enrique Gonzalez Diaz
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de Leon, León, Spain
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Ultrasound Department, Warsaw Medical University, Warsaw, Poland
| | - Michał Mik
- Department of General and Colorectal Surgery, Medical University of Lodz, Lodz, Poland
| | - Carlo Ratto
- Proctology and Pelvic Floor Surgery Unit, Isola Tiberina Hospital, Gemelli Isola, Catholic University, Rome, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089, Rozzano, Milan, Italy
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Cattani L, Packet B, Samešova A, Williams H, Van Schoubroeck D, Deprest J. Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1673-1681. [PMID: 38867553 DOI: 10.1002/jum.16490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/22/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVES To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. METHODS Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings. RESULTS Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. CONCLUSION TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.
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Affiliation(s)
- Laura Cattani
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Bram Packet
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Adela Samešova
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Third Faculty of Medicine, Institute for the Care of Mother and Child, Charles University, Prague, Czech Republic
| | - Helena Williams
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Dominique Van Schoubroeck
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
- Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, London, UK
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Schmidt PC, Fenner DE. Repair of episiotomy and obstetrical perineal lacerations (first-fourth). Am J Obstet Gynecol 2024; 230:S1005-S1013. [PMID: 37427859 DOI: 10.1016/j.ajog.2022.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 07/11/2023]
Abstract
Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal trauma is associated with both short- and long-term morbidity, including persistent pain, dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new mother's ability to care for her newborn. The morbidity experienced after perineal injury is dependent on the type of laceration incurred, the technique and materials used for repair, and the skill and knowledge of the birth attendant. After all vaginal deliveries, a systematic evaluation including visual inspection and vaginal, perineal, and rectal exams is recommended to accurately diagnose perineal lacerations. Optimal management of perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique and materials used for repair, providers experienced in perineal laceration repair, and close follow-up. In this article, we review the prevalence, classification, diagnosis, and evidence supporting different closure methods for first- through fourth-degree perineal lacerations and episiotomies. Recommended surgical techniques and materials for different perineal laceration repairs are provided. Finally, best practices for perioperative and postoperative care after advanced perineal trauma are reviewed.
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Affiliation(s)
- Payton C Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Dee E Fenner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Frigerio M, D'Alessandro G, Re I, Cola A, Vergani P, Barba M. Clinical, ultrasonographic, and functional outcomes after obstetric anal sphincter injury primary repair: A single-center experience. Int J Gynaecol Obstet 2023; 163:234-242. [PMID: 37128949 DOI: 10.1002/ijgo.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/14/2022] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To present clinical and instrumental sequelae after obstetric anal sphincter injuries (OASIS), evaluating correlations between intrapartum severity of lesions, postpartum symptoms, and sonographic and manometric findings; outcomes during subsequent deliveries were also evaluated. METHODS This retrospective study evaluated all consecutive women who sustained an OASIS between 2015 and 2020. Postpartum symptoms, anorectal manometry (ARM), and three-dimensional endoanal ultrasonography (3D-EAUS) were analyzed. RESULTS A total of 107 women underwent OASIS primary repair; 84 (78.5%) of them were asymptomatic after 1 month. The presence and severity of symptoms showed a great correlation with instrumental outcomes in terms of maximum resting pressure, squeeze pressure increment (SPI), circumferential extension of defect for both external anal sphincter (EAS) and internal anal sphincter (IAS), and EAS, IAS and total Starck scores. There was a significant correlation between ARM and 3D-EAUS findings, with the exception of SPI, for which the abnormalities were not predictable based on EAUS results. CONCLUSION Both ARM and EAUS findings after OASIS are directly related to each other, and associated with symptoms. These instrumental tools may be useful for OASIS assessment and counseling.
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Affiliation(s)
| | | | - Ilaria Re
- University of Milano-Bicocca, Monza, Italy
| | - Alice Cola
- ASST Monza, Ospedale San Gerardo, Monza, Italy
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Okeahialam NA, Thakar R, Sultan AH. Postpartum perineal wound infection and its effect on anal sphincter integrity: Results of a prospective observational study. Acta Obstet Gynecol Scand 2023; 102:473-479. [PMID: 36707852 PMCID: PMC10008287 DOI: 10.1111/aogs.14515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Perineal wound infection can affect tissues at superficial, deep, and organ space levels. Women with obstetric anal sphincter injuries (OASIS) are at risk of infection; however, no study to date has investigated if infection can extend to affect the anal sphincter integrity. The aim of this study was to evaluate the clinical progression of perineal wound infection and its effect on the anal sphincter in women with or without OASIS using three-dimensional endoanal ultrasound (3D-EAUS). MATERIAL AND METHODS Women were recruited into the Prospective Observational Study Evaluating the Sonographic Appearance of the Anal Sphincter in Women With Perineal Wound Infection Following Vaginal Delivery (PERINEAL Study) between August 2020 and August 2021 (NCT04480684). 3D-EAUS was performed weekly until complete wound healing. Significant bacterial colonization was diagnosed using the MolecuLight i:X camera. The primary study outcome was a change in a sphincter defect angle from baseline (wound infection) until wound healing. A robust Poisson regression model was used to analyze the effect of significant bacterial loads on the anal sphincter. RESULTS Seventy-three women were included. A median of two ultrasound scans were performed in each patient (range 1-16). Five women (6.8%) had an OASI clinically diagnosed at delivery. In total, 250 EAUS were performed. An external anal sphincter defect was found on EAUS in 55 (22.0%) scans (n = 10 women). An external anal sphincter and internal anal sphincter defect was found in 26 scans (10.4%) (n = 3 women). During the course of the wound healing process, there was no significant change in defect size in wounds with or without significant bacterial colonization. In cases of an intact anal sphincter, wound infection did not disrupt its integrity. CONCLUSIONS We found that perineal wound infection does not disrupt an intact anal sphincter or OASIS. This new information can provide important information for clinicians and patients. As there are myths frequently encountered in cases of litigation when disruption of sphincter integrity is attributed to perineal infection, the findings of this study should be tested in larger studies in the future.
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Affiliation(s)
| | - Ranee Thakar
- Croydon University Hospital, Croydon, UK.,St George's University of London, London, UK
| | - Abdul H Sultan
- Croydon University Hospital, Croydon, UK.,St George's University of London, London, UK
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Marcellier G, Dupont A, Bourgeois-Moine A, Le Tohic A, De Carne-Carnavalet C, Poujade O, Girard G, Benbara A, Mandelbrot L, Abramowitz L. Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study. J Clin Med 2023; 12:jcm12041531. [PMID: 36836068 PMCID: PMC9967240 DOI: 10.3390/jcm12041531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22-21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.
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Affiliation(s)
- Gabriel Marcellier
- Proctology and Gastroenterology Department, APHP-Bichat Hospital, 75018 Paris, France
- Correspondence: ; Tel.: +33-6-68-97-79-05
| | - Axelle Dupont
- Biostatistics and Medical IT Department, APHP-Bichat Hospital, 75018 Paris, France
| | | | - Arnaud Le Tohic
- Department of Obstetrics and Gynecology, Versailles Hospital, 78157 Le Chesnay, France
| | | | - Olivier Poujade
- Department of Obstetrics and Gynecology, APHP-Beaujon Hospital, 92110 Clichy, France
| | - Guillaume Girard
- Department of Obstetrics and Gynecology, APHP-Armand Trousseau Hospital, 75012 Paris, France
| | - Amélie Benbara
- Department of Obstetrics and Gynecology, APHP-Jean Verdier Hospital, 93140 Bondy, France
| | - Laurent Mandelbrot
- Department of Obstetrics and Gynecology, APHP-Louis Mourier Hospital, 92700 Colombes, France
| | - Laurent Abramowitz
- Proctology and Gastroenterology Department, APHP-Bichat Hospital, 75018 Paris, France
- Proctology and Gastroenterology Department, Blomet Clinic (Ramsay GDS Group), 75015 Paris, France
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O'Leary BD, Kelly L, Fitzpatrick M, Keane DP. Underdiagnosis of internal anal sphincter trauma following vaginal delivery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:251-256. [PMID: 36722430 PMCID: PMC10108077 DOI: 10.1002/uog.26049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 05/27/2023]
Abstract
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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Affiliation(s)
- B. D. O'Leary
- Perineal ClinicNational Maternity HospitalDublinIreland
- UCD Perinatal Research CentreNational Maternity HospitalDublinIreland
| | - L. Kelly
- Perineal ClinicNational Maternity HospitalDublinIreland
| | | | - D. P. Keane
- UCD Perinatal Research CentreNational Maternity HospitalDublinIreland
- Royal College of Surgeons IrelandNational Maternity HospitalDublinIreland
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Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study. Int Urogynecol J 2022; 33:3391-3399. [PMID: 35467140 DOI: 10.1007/s00192-022-05188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury. METHODS A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6-12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion. RESULTS Twelve (20.7%, 95% CI 10.9-32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02). CONCLUSIONS There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.
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Okeahialam NA, Thakar R, Sultan AH. Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:793-799. [PMID: 35638253 PMCID: PMC10100122 DOI: 10.1002/uog.24957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle. METHODS This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal (IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard. RESULTS In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and ± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and ± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference. CONCLUSIONS This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 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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Affiliation(s)
- N. A. Okeahialam
- Urogynaecology and Pelvic Floor Reconstruction UnitCroydon University HospitalCroydonUK
| | - R. Thakar
- Urogynaecology and Pelvic Floor Reconstruction UnitCroydon University HospitalCroydonUK
- St George's University of LondonLondonUK
| | - A. H. Sultan
- Urogynaecology and Pelvic Floor Reconstruction UnitCroydon University HospitalCroydonUK
- St George's University of LondonLondonUK
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Kayapınar AK, Çetin DA, Paköz ZB, Karakolcu K, Ertaş İE, Kamer KE. Short and long term results of anatomical reconstruction of perineal body and sphincter complex in obstetric anal sphincter injuries. Turk J Surg 2022; 38:159-168. [PMID: 36483166 PMCID: PMC9714649 DOI: 10.47717/turkjsurg.2022.5528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 04/13/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The effective way to reduce the risk of fecal incontinence (FI) in primary repaired obstetric anal sphincter injuries (OASIS) patients is to accurately detect the injury and provide complete anatomical reconstruction. The aim of the study was to evaluate the short-term and long-term results of OASIS cases that were diagnosed by an experienced surgical team and whose perineal body and anal sphincters were reconstructed separately. MATERIAL AND METHODS Sixteen patients that required consultations due to anal sphincter damage during vaginal delivery and underwent anatomical reconstruction due to Grade 3c and Grade 4 sphincter damage between 2007 and 2019 were included in the study. These cases were divided into three groups [Group 1 (≤12 months), Group 2 (12-60 months), Group 3 (≥60 months)] according to the time elapsed until anal manometry, and incontinence questionnaires were conducted in the postoperative period. Recto-anal inhibitory reflex (RAIR), mean resting (IB) and squeezing (SB) pressures were measured by anal manometry. Anal incontinence (AI) and FI rates were determined by questionnaires. Anal sphincter damage repair techniques (overlapping, end-to-end) were determined. These parameters were compared between the three groups. RESULTS Mean age of the patients was 27.5 (16-35) years. Six (37.5%) patients had Grade 3c, while 10 (62.5%) had Grade 4 injury. The overall mean RP and SP were 35 (26-56) mmHg and 67 (31-100) mmHg, respectively. Mean RP and SP were 46/67 mmHg, 33.5/75.5 mmHg, and 37.5/70.5 mmHg in Groups 1, 2, and 3 respectively. There was no difference between the three groups in terms of mean RP and SP (p= 0.691, p= 0.673). The rate of AI and FI in all patients were 18.75% and 12.5%, respectively while the rate of severe AI incontinence was 6%. Severe AI was observed in 1 (16.7%) case in Group 1, mild AI was observed in 1 (25%) case in group 2, and in 1 (16.7%) case in Group 3. RAIR was positive in all patients. In Group 1, 5 (83.3%) patients underwent overlapping repair, and in Group 3, 6 (100%) patients underwent end-to-end repair. This difference was statistically significant (p= 0.011). CONCLUSION In vaginal births, evaluation of anal sphincter damage, determination of perineal body structures and anal sphincters separately and performing anatomical reconstruction when needed significantly reduce the rate of FI in the short and long term.
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Affiliation(s)
- Ali Kemal Kayapınar
- Clinic of General Surgery, Tepecik Training and Research Hospital, University of Health Sciences, İzmir, Türkiye
| | - Durmuş Ali Çetin
- Clinic of General Surgery, Tepecik Training and Research Hospital, University of Health Sciences, İzmir, Türkiye
| | - Zehra Betül Paköz
- Clinic of Gastroenterology, Atatürk Training and Research Hospital, Katip Çelebi University Faculty of Medicine, İzmir, Türkiye
| | - Kübra Karakolcu
- Clinic of Obstetrics and Gynecology, Tepecik Training and Research Hospital, University of Health Sciences, İzmir, Türkiye
| | - İbrahim Egemen Ertaş
- Clinic of Obstetrics and Gynecology, Tepecik Training and Research Hospital, University of Health Sciences, İzmir, Türkiye
| | - Kemal Erdinç Kamer
- Clinic of General Surgery, Tepecik Training and Research Hospital, University of Health Sciences, İzmir, Türkiye
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Roper JC, Thakar R, Sultan AH. Under-classified obstetric anal sphincter injuries. Int Urogynecol J 2022; 33:1473-1479. [PMID: 35150290 DOI: 10.1007/s00192-021-05051-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOSTHESIS Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time. METHODS Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified. RESULTS A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears. CONCLUSION Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.
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Affiliation(s)
- Joanna C Roper
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK.,Honorary Senior Lecturer, St George's University of London, London, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK. .,Honorary Reader, St George's University of London, London, UK.
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13
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Critical appraisal of international guidelines for the management of fecal incontinence in adults: is it possible to define what to do in different clinical scenarios? Tech Coloproctol 2021; 26:1-17. [PMID: 34767095 PMCID: PMC8587500 DOI: 10.1007/s10151-021-02544-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 10/28/2021] [Indexed: 11/10/2022]
Abstract
Fecal incontinence (FI) is a complex often multifactorial functional disorder which is associated with a significant impact on patients’ quality of life. There is a broad spectrum of symptoms, and degrees of severity and diverse patient backgrounds. Several treatment algorithms from different professional societies and experts are available in the literature. However, no consensus has been reached on several aspects of FI management. We performed a critical review of the most recently published guidelines on FI, emphasising the lack of consensus, highlighting specific topics mentioned in each of the guidelines that are not covered in the others and defining the treatment proposed in different clinical scenarios.
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Young R, Nippita TAC. Training in obstetric anal sphincter injuries in Australia and New Zealand: A survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees. Aust N Z J Obstet Gynaecol 2021; 62:250-254. [PMID: 34585741 DOI: 10.1111/ajo.13437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/08/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Training in obstetric anal sphincter injuries (OASIS) in Australia and New Zealand relies upon consultant teaching and has not previously been assessed. AIMS The aims of this study are to establish if training in OASIS is consistent and optimal in Australia and New Zealand and to evaluate trainee perspectives on supervision and teaching, along with confidence in repairing OASIS. MATERIALS AND METHODS A descriptive cross-sectional study was performed. Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees were sent a 21-question survey. The survey was distributed to 725 trainees, and 132 trainees provided complete responses (18.2%). The main outcome measures were (i) comparison of confidence in performing a caesarean section versus OASIS repair and (ii) descriptive analysis of views towards training and suggestions for improvement. RESULTS Trainees were significantly more confident in performing a caesarean section independently compared to OASIS repair (P < 0.05). This was the case for all year groups. Confidence increased with each year of training. Only 62% reported credentialing at their site. Whereas 50% reported training at the time of first unsupervised repair as good or excellent, 22.7% felt it was suboptimal and 2.3% unsatisfactory; 75.8% had attended a workshop; 38.6% requested mandatory workshops. Requests included that workshops be yearly, include video training and be required at consultant level. Trainees asked for supervision despite credentialing and for separate credentialing for 3A/B- and 3C/4th-degree tears. CONCLUSIONS Trainees have increasing confidence in their ability to independently perform OASIS repairs throughout training. They requested that improvements be made to training and that there be an increase in structured teaching.
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Affiliation(s)
- Rebecca Young
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia.,Department of Urogynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Tanya A C Nippita
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia.,Department of Urogynaecology, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine and Health, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Women and Babies Research, Kolling Institute, Royal North Shore Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia
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15
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Okeahialam NA, Thakar R, Sultan AH. Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature. Int Urogynecol J 2021; 32:1611-1622. [PMID: 33991222 DOI: 10.1007/s00192-021-04822-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/18/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6 months, early secondary repair of the anal sphincter can be completed within 14 days. Our aims were to review the literature and to describe experiences in our unit. METHODS This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019. RESULTS Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n = 10)], infection [5.2% (n = 5)] and fistula formation [8.2% (n = 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n = 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in those who also underwent secondary repair (Starck score 2.1 vs. 5.7, p = 0.01). CONCLUSION Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.
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Affiliation(s)
| | - Ranee Thakar
- Croydon University Hospital, Thornton Heath, CR7 7YE, UK
- St George's University of London, London, UK
| | - Abdul H Sultan
- Croydon University Hospital, Thornton Heath, CR7 7YE, UK.
- St George's University of London, London, UK.
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Barbosa M, Christensen P, Møller-Bek K, Brogaard L, Glavind-Kristensen M. Can ultrasound 10 days after obstetric anal sphincter injury predict anal incontinence at long-term follow-up? Int Urogynecol J 2021; 32:2511-2520. [PMID: 33730232 DOI: 10.1007/s00192-021-04733-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/09/2021] [Indexed: 12/13/2022]
Abstract
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. METHODS 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. RESULTS 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. CONCLUSIONS We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.
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Affiliation(s)
- Malou Barbosa
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Peter Christensen
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Karl Møller-Bek
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Lise Brogaard
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marianne Glavind-Kristensen
- Pelvic Floor Unit, Department of Gynecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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17
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de la Portilla F, Guerrero JL, Maestre MV, Leyva L, Mera S, García-Olmo D, Rodríguez A, Mata R, Lora F. Treatment of faecal incontinence with autologous expanded mesenchymal stem cells: results of a pilot study. Colorectal Dis 2021; 23:698-709. [PMID: 32986295 DOI: 10.1111/codi.15382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023]
Abstract
AIM Management of faecal incontinence (FI) remains challenging because no definitive optimal treatment for this condition has yet been determined. Regenerative medicine could be an attractive therapeutic alternative for treating FI. Here, we aimed to determine the safety and feasibility of autologous expanded mesenchymal stem cells derived from adipose tissue (AdMSCs) in the treatment of patients diagnosed with structural FI. METHOD This was a randomized, multicentre, triple-blinded, placebo-controlled pilot study conducted at four sites in Spain with 16 adults with FI and a sphincter defect. Autologous AdMSCs were obtained from patients from surgically excised adipose tissue. These patients were intralesionally infused with a single dose of 4 × 107 AdMSCs or a placebo while under anaesthesia. We assessed the safety and feasibility of the treatment as the cumulative incidence of adverse events and the treatment efficacy using the Cleveland Clinic Faecal Incontinence Score, Faecal Incontinence Quality of Life score and Starck criteria to classify sphincter defects and anorectal physiology outcomes. RESULTS Adipose tissue extraction, cell isolation and intralesional infusion procedures were successful in all the patients. There was only one adverse event connected to adipose tissue extraction (a haematoma), and none was associated with the injection procedure. There were no significant differences in any of the assessed clinical, manometric or ultrasonographic parameters. CONCLUSION This study indicates that this infusion procedure in the anal sphincter is feasible and safe. However, it failed to demonstrate efficacy to treat patients with structural FI.
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Affiliation(s)
- Fernando de la Portilla
- Coloproctology Clinical Management Unit, General and Gastrointestinal Surgery Division, Biomedical Research Institute (IBIS), Hospital Universitario Virgen del Rocio/CSIC University of Seville, Seville, Spain
| | - José Luis Guerrero
- Coloproctology Clinical Management Unit, General and Gastrointestinal Surgery Division, Biomedical Research Institute (IBIS), Hospital Universitario Virgen del Rocio/CSIC University of Seville, Seville, Spain
| | - Maria Victoria Maestre
- Coloproctology Clinical Management Unit, General and Gastrointestinal Surgery Division, Biomedical Research Institute (IBIS), Hospital Universitario Virgen del Rocio/CSIC University of Seville, Seville, Spain
| | - Laura Leyva
- GMP Cell Manufacturing Unit, Biomedical Research Institute of Malaga (IBIMA), Hospital Regional Universitario de Malaga, Málaga, Spain
| | - Santiago Mera
- Coloproctology Unit Clinical Management, Unit of General Surgery Division, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Damián García-Olmo
- Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Antonio Rodríguez
- GMP Cell Manufacturing Unit, Biomedical Research Institute of Malaga (IBIMA), Hospital Regional Universitario de Malaga, Málaga, Spain
| | - Rosario Mata
- Andalusian Network for Design and Translation of Advanced Therapies, Seville, Spain
| | - Fabiola Lora
- Andalusian Network for Design and Translation of Advanced Therapies, Seville, Spain
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18
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Ong K, Bordeianou L, Brunner M, Buntzen S, Collie MHS, Hanly A, Hunt CW, Matzel KE, O'Connell PR, Rydningen M, Savitt L, Totaro A, Vaizey CJ, Maeda Y. Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres. Colorectal Dis 2021; 23:710-715. [PMID: 32894636 DOI: 10.1111/codi.15349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/26/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013. METHOD This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded. RESULTS A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05). CONCLUSION The paradigm of surgical intervention for FI has changed with increasing use of SNM.
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Affiliation(s)
- K Ong
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - L Bordeianou
- Colorectal Surgery Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Brunner
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - S Buntzen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - M H S Collie
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - A Hanly
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - C W Hunt
- Colorectal Surgery Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - K E Matzel
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - P R O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - M Rydningen
- Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsoe, Norway
| | - L Savitt
- Colorectal Surgery Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - A Totaro
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
| | - C J Vaizey
- Sir Alan Parks Physiology Unit, St Mark's Hospital, Harrow, UK
| | - Y Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
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19
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Martinez Franco E, Ros C, Santoro GA, Cassadó Garriga J, Amat Tardiu L, Cuadras D, Espuña M. Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique? Eur J Obstet Gynecol Reprod Biol 2020; 257:70-75. [PMID: 33360872 DOI: 10.1016/j.ejogrb.2020.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/22/2020] [Accepted: 12/08/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES "Significant" obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. METHODS Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck's and the Norderval's systems. Intraobserver and inter-techniques correlations were calculated. RESULTS From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, "button hole" tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck's Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval's classification. CONCLUSIONS OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.
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Affiliation(s)
- Eva Martinez Franco
- Obstetrics and Gynecology. Parc Sanitari Sant Joan de Déu, Sant Boi del Llobregat, Barcelona, Spain.
| | - Cristina Ros
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - Jordi Cassadó Garriga
- Obstetrics and Gynecology. University Hospital Mutua Terrassa, Terrassa, Barcelona, Spain
| | - Lluís Amat Tardiu
- Obstetrics and Gynecology, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Daniel Cuadras
- Statistical Advising Service, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Montserrat Espuña
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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20
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Okeahialam NA, Thakar R, Sultan AH. Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI). Int Urogynecol J 2020; 32:1719-1726. [PMID: 33263781 PMCID: PMC8295136 DOI: 10.1007/s00192-020-04607-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/10/2020] [Indexed: 12/28/2022]
Abstract
Introduction and hypothesis Endoanal ultrasound (EAUS) and anal manometry are used in the assessment women with a history of obstetric anal sphincter injury (OASI), both postpartum and in a subsequent pregnancy, to aid counselling regarding mode of delivery (MOD). Methods A prospective observational study between 2012 to 2020 was completed. Women were reviewed 3 months postpartum following OASI and in the second half of a subsequent pregnancy. Anorectal symptoms were measured using the validated St Mark’s Incontinence Score (SMIS: asymptomatic to mild symptoms = ≤ 4). Anal manometry (incremental maximum squeeze pressure [iMSP: normal = > 20 mmHg]) and EAUS (abnormal = sphincter defect > 1 h in size) were performed. Results One hundred forty-six women were identified and 67.8% had an anal sphincter defect ≤ 1 h in size postnatally. In those with a defect ≤ 1 h, postpartum mean iMSP and SMIS significantly improved in a subsequent pregnancy (p = 0.04 and p = 0.01, respectively). In women with a defect > 1 h, there was no significant difference between the mean iMSP or SMIS score postnatally compared to a subsequent pregnancy. At both time points, significantly more women had an anal sphincter defect ≤ 1 h and SMIS of ≤ 4 (p = 0.001 and p < 0.001 respectively) compared to those with a defect < 1 h. In addition, significantly more women had an anal sphincter defect ≤ 1 h and iMSP ≥ 20 mmHg (p < 0.001). Overall, out of the 146 women included in this study, 76 (52.1%) with a defect ≤ 1 h also had an iMSP ≥ 20 mmHg and SMIS ≤ 4 at 3 months postpartum. Conclusions Women who remain asymptomatic with normal anal manometry and no abnormal sphincter defects on EAUS postnatally do not need to have these investigations repeated in a subsequent pregnancy and can be recommended to have a vaginal delivery. If our protocol was modified, over half of the women in this study could have had their MOD recommendation made in the postnatal period alone.
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Affiliation(s)
- Nicola Adanna Okeahialam
- Croydon Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Thornton Heath, UK
| | - Ranee Thakar
- Croydon Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Thornton Heath, UK.,St George's, University of London, London, UK
| | - Abdul H Sultan
- Croydon Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Thornton Heath, UK. .,St George's, University of London, London, UK.
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21
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Grossi U, Brusciano L, Tolone S, Del Genio G, Di Tanna GL, Gambardella C, Docimo L. Implantable Agents for Fecal Incontinence: An Age-Matched Retrospective Cohort Analysis of GateKeeper versus SphinKeeper. Surg Innov 2020; 27:608-613. [PMID: 32543984 DOI: 10.1177/1553350620934932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background. We aim to evaluate morphofunctional changes of the sphincter complex after GateKeeper (GK) and SphinKeeper (SK) procedures and correlate these with symptom improvement. Methods. Ten consecutive females undergoing SK implant were age-matched with a cohort of 10 females who previously underwent the GK procedure. Patients in the SK and GK groups underwent implantation of 10 and 6 prostheses, respectively. Muscle tension (Tm), expressed in millinewtons per centimetre squared, mN (cm2)-1, was calculated using the equation Tm = P(ri)(tm)-1, where P is the average maximum squeeze pressure and ri and tm the inner radius and thickness of the external anal sphincter, respectively. The pre- and postimplant changes in Tm and Cleveland Clinic Fecal Incontinence Score (CCFIS) were tested by linear and Poisson regression models, respectively. Results. The CCFIS significantly improved in both groups at 12-month postimplantation. Although not reaching statistical significance, symptom improvement after SK was 33% above that observed after GK (P = .088). Compared to the baseline, a significant increase in Tm was observed in both groups at 12 months (GK, 508.1 [478.8-568.0] vs 864.4 [827.0-885.8] mN (cm2)-1; SK, 528.0 [472.7-564.0] vs 858.6 [828.0-919.6] mN (cm2)-1, P = .005). Compared to the GK group, Tm was significantly higher in patients after SK implant (158.3 mN (cm2)-1 [95% confidence interval, 109.6-207.0]; P < .001), after controlling for baseline values, at 12-month postimplantation. Conclusions. GK and SK are safe and effective treatments for FI with good short-term clinical outcomes. Comparative analysis showed superiority of SK over GK in terms of gain in Tm, with borderline significantly better improvement in symptoms. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Ugo Grossi
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy.,Colorectal and Pelvic Floor Unit, Regional Hospital Treviso, University of Padua, Italy
| | - Luigi Brusciano
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Salvatore Tolone
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Gianmattia Del Genio
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Gian Luca Di Tanna
- Statistics Division, 58453The George Institute for Global Health, Australia
| | - Claudio Gambardella
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
| | - Ludovico Docimo
- General, Mini-invasive and Obesity Surgery Unit, Department of Advanced Medical and Surgical Sciences, 18994University of Campania "Luigi Vanvitelli" Naples, Italy
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22
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Okeahialam NA, Thakar R, Naidu M, Sultan AH. Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS)-a nested case-controlled study. Int Urogynecol J 2020; 31:2405-2410. [PMID: 32556846 PMCID: PMC7561534 DOI: 10.1007/s00192-020-04377-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/28/2020] [Indexed: 11/24/2022]
Abstract
Introduction and hypothesis Obstetric anal sphincter injury (OASI) is a significant risk factor for developing anal incontinence. It can therefore be hypothesised that recurrent OASI in a subsequent delivery may predispose women to further anal sphincter dysfunction. Methods A nested case-controlled study based on data collected prospectively between 2006 and 2019. Women matched for age and ethnicity, with a history of one OASI and no sphincter damage in a subsequent delivery (control) were compared to women sustaining a second OASI. Assessment was carried out using the St Mark’s score (SMIS), anorectal manometry and endoanal ultrasound scan (findings quantified using the modified Starck score). Results Eighty-four women were included and equally distributed between the two groups, who were followed up 12 weeks postnatally. No difference in SMIS scores was found. Maximum resting pressure (MRP, mmHg) and maximum squeeze pressure (MSP, mmHg) were significantly reduced in the study group. Median (IQR) MRP in the study group was 40.0 (31.3–54.0) versus 46.0 (39.3–61.5) in the control group (p = 0.030). Median (IQR) MSP was 73.0 (58.3–93.5) in the study group versus 92.5 (70.5–110.8) (p = 0.006) in the control group. A significant difference (p = 0.002) was found in the modified Starck score between the study group (median 0.0 [IQR 0.0–6.0]) and control group (median 0.0 [IQR 0.0–0.0]). Conclusions We have demonstrated that women with recurrent OASI do not have significant anorectal symptoms compared to those with one OASI 12 weeks after delivery, but worse anal sphincter function and integrity. Therefore, on long-term follow-up, symptoms may possibly develop. This information will be useful when counselling women in a subsequent pregnancy.
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Affiliation(s)
| | - Ranee Thakar
- Croydon University Hospital, 530 London Rd, Thornton Heath, CR7 7YE, UK
| | | | - Abdul H Sultan
- Croydon University Hospital, 530 London Rd, Thornton Heath, CR7 7YE, UK. .,Honorary Reader at St George's University of London, London, UK.
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Capanna F, Haslinger C, Wisser J. Accuracy of clinical diagnosis of anal sphincter defect: clinical evaluation versus 3D-transperineal ultrasound. MINERVA GINECOLOGICA 2020; 72:187-194. [PMID: 32403913 DOI: 10.23736/s0026-4784.20.04562-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are common and an important factor in the etiology of anal incontinence. The objective of this study was to evaluate, classify and compare the agreement of clinically diagnosed third-degree sphincter tears with 3D-transperineal ultrasound (3D-TPUS) realized within 3-7 days post-delivery. METHODS This is a retrospective observational study were 119 patients with third-degree obstetric anal sphincter tears were diagnosed and treated, 85 of those underwent a 3D-TPUS examination 3-7 days postpartum. We compared the proportion of third-degree perineal tears, classified with the clinical examination as grade 3a+b and grade 3c, with the 3D-TPUS. RESULTS In 16 patients with clinically diagnosed third-degree perineal tears grade a and b, the ultrasound examination confirmed the lesion of the external anal sphincter (EAS) muscle, but in nine patients (56% of the cases) we found a lesion of the internal anal sphincter (IAS) muscle, missed by clinical examination. In the remaining 69 patients with the third-degree perineal tears grade c, the ultrasound examination confirmed both lesions (EAS and IAS muscles) in 56 women, but in 13 patients (19% of the cases) defects of the IAS muscle could not be confirmed by the ultrasound. CONCLUSIONS There was moderate agreement regarding diagnosis of grade 3a+b and grade c perineal tears between ultrasound and clinical examination, so a combined use of clinical and ultrasound knowledge can improve the possibility to find a gold standard in the diagnosis of OASIS.
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Affiliation(s)
- Federica Capanna
- Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland - .,Department of Obstetrics, Geneva University Hospitals, Geneva, Switzerland -
| | | | - Josef Wisser
- Department of Obstetrics, Zurich University Hospital, Zurich, Switzerland
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24
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25
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Bellussi F, Montaguti E, Youssef A, Salsi G, Ghi T, Pilu G. Dynamic 2-dimensional transperineal ultrasound evaluation in labor room as a screening tool for anal sphincter injuries and anal incontinence in primiparous women. Am J Obstet Gynecol MFM 2019; 1:100037. [DOI: 10.1016/j.ajogmf.2019.100037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 07/27/2019] [Accepted: 08/07/2019] [Indexed: 11/27/2022]
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Taithongchai A, Veiga SI, Sultan AH, Thakar R. The consequences of undiagnosed obstetric anal sphincter injuries (OASIS) following vaginal delivery. Int Urogynecol J 2019; 31:635-641. [PMID: 31338522 DOI: 10.1007/s00192-019-04033-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/17/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to compare anal and urinary incontinence symptoms and anal manometry between women with undiagnosed obstetric anal sphincter injuries (OASIS) and women who had OASIS diagnosed and repaired. METHODS This was a matched retrospective cohort study. Each missed OASI was matched with a diagnosed OASI for severity [minor (3a/b) or major (3c)], parity and length of follow-up. Women completed the modified St Mark's Incontinence Score and International Consultation on Incontinence Questionnaire. Women with OASIS or those without OASIS but with anal incontinence symptoms were seen in perineal clinic for perineal examinations, anorectal manometry and three-dimensional endoanal ultrasound 8-12 weeks postnatally or in a subsequent pregnancy. RESULTS Forty missed OASIS were matched with 40 recognised OASIS (16 3a/b; 24 3c). The median modified St Mark's scores were higher for missed tears [11 (4, 15) vs. 1 (0, 4), p < 0.001] as well as the urinary incontinence scores [4 (0, 6) vs. 0 (0, 2), p = 0.01] than for the control group. Missed OASIS patients had a shorter perineal body [1.6 ± 1.3 vs. 2.4 ± 0.8, p = 0.009]. All missed OASIS had larger defects on endoanal ultrasound. One in four missed OASIS required further surgery [aOR 4.1 (95% CI 1.0-16.3), p = 0.04] and almost all needed colorectal input [aOR 24.1 (95% CI 7.3-80.0), p < 0.0001]. There were no differences in anal manometry. CONCLUSIONS Women with symptomatic missed OASIS are compromised in terms of anal and urinary incontinence symptoms, sphincter defect size and perineal body size requiring additional colorectal input. This highlights the importance of preventing OASIS and perseverance with training to diagnose OASIS.
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Affiliation(s)
| | - Susana I Veiga
- Croydon University Hospital, 530 London Road, London, CR7 7YE, UK
| | - Abdul H Sultan
- Croydon University Hospital, 530 London Road, London, CR7 7YE, UK
| | - Ranee Thakar
- Croydon University Hospital, 530 London Road, London, CR7 7YE, UK.
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27
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Tejedor P, Plaza J, Bodega-Quiroga I, Ortega-López M, García-Olmo D, Pastor C. The Role of Three-Dimensional Endoanal Ultrasound on Diagnosis and Classification of Sphincter Defects After Childbirth. J Surg Res 2019; 244:382-388. [PMID: 31325659 DOI: 10.1016/j.jss.2019.06.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 05/21/2019] [Accepted: 06/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Diagnostic tests for fecal incontinence have been improved over time. This study aims to evaluate the role of Three-dimensional endoanal ultrasound (3D-EUS) and the Starck's score in the assessment and treatment of obstetric sphincter injuries. METHODS A prospective observational study was performed including primiparous women who were evaluated at 20 wk of pregnancy and 3 mo after childbirth. Sphincter defects were classified according to the Starck's and Obstetrical Anal Sphincter Injuries classifications. Patients also completed the Fecal Incontinence Quality of Life and the Wexner questionnaires before and after childbirth. RESULTS Sphincter defects were detected in 45% of the 56 women included, although 85% had an uneventful delivery. Most defects were found isolated to the external anal sphincter except for two cases, classified by a Starck's score >8. Fecal Incontinence Quality of Life and Wexner questionnaires showed a rate of symptomatic patients of around 46%. We observed that 30% of patients with sphincter injuries remained asymptomatic. CONCLUSIONS The 3D-EUS is a useful test in assessing sphincter defects after childbirth. This method makes it possible to detect small sphincter defects that otherwise would have gone unnoticed, as 30% of patients with sphincter injuries were asymptomatic. In addition, both the 3D-EUS and the Starck's score were valuable in establishing an algorithm for the treatment of obstetric sphincter injuries.
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Affiliation(s)
- Patricia Tejedor
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain.
| | - Javier Plaza
- Department of Gynaecology and Obstetrics, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | | | - Mario Ortega-López
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Damián García-Olmo
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
| | - Carlos Pastor
- Division of Colorectal Surgery, Department of General Surgery, University Hospital Fundacion Jimenez Diaz, Madrid, Spain
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Cole J, Bulchandani S. Predictors of patient preference for mode of delivery following an obstetric anal sphincter injury. Eur J Obstet Gynecol Reprod Biol 2019; 239:35-38. [PMID: 31163355 DOI: 10.1016/j.ejogrb.2019.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Patients who sustain an Obstetric Anal Sphincter Injury (OASI) have the opportunity to select an elective caesarean section over a vaginal delivery in subsequent pregnancies. It remains unclear whether there are identifiable factors which predict expectant mothers' choices. The primary aim of our study was to explore this issue further in a consecutive group of patients who had suffered OASI. STUDY DESIGN Data were retrospectively collected for patients attending a specialist OASIS clinic between July 2016 and February 2018. Information routinely collected in clinical practice was considered including mode of previous delivery, severity of OASI, combined with anal incontinence symptoms and endoanal ultrasound results. Logistic regression analysis was used to explore the relationship between these variables and the preferred mode of delivery. RESULTS A total of 188 patients were identified of whom 153 had complete data for analysis. Approximately 30% (n = 45) of patients preferred to have a caesarean section in their subsequent pregnancy. Bivariate analysis revealed significant associations between choosing a caesarean section in subsequent pregnancy and individuals with major tears (p = 0.001), high anal incontinence scores (p = 0.001) and defects on endoanal ultrasound (p < 0.001). Logistic regression analysis showed statistically significant associations between Caucasian ethnicity (Odds ratio (OR) 12.6, 95% CI 2.4-69.9) and endoanal ultrasound results (OR 2.3, 95% CI 1.7-3.2) with preference for caesarean section. CONCLUSION Our data suggests that emphasis is placed by patients on endoanal ultrasound results when making their decision about mode of delivery in a subsequent pregnancy, suggesting a useful application of this tool. Ethnicity is a strong predictor of choice of delivery after OASI and may be potentially useful in forecasting maternity unit services.
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Affiliation(s)
- Jennifer Cole
- University Hospital Coventry, Clifford Bridge Road, Coventry, UK.
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Risk factors and outcome of repair of obstetric anal sphincter injuries as followed up in a dedicated perineal clinic. Int Urogynecol J 2019; 30:1649-1655. [DOI: 10.1007/s00192-019-03960-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/17/2019] [Indexed: 12/17/2022]
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30
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Patton V, Kumar S, Parkin K, Karantanis E, Dinning P. The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury. Neurourol Urodyn 2018; 38:193-199. [PMID: 30387531 DOI: 10.1002/nau.23826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/31/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. METHODS Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. MAIN OUTCOME MEASURES Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. RESULTS 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. CONCLUSION The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.
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Affiliation(s)
- Vicki Patton
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Swetha Kumar
- Nepean Hospital Sydney, Department of Women and Children's Health, Sydney, New South Wales, Australia
| | - Katrina Parkin
- Department of Women and Children's Health St George Public Hospital, University of NSW St George Clinical School, Kogarah, New South Wales, Australia
| | - Emmanuel Karantanis
- Department of Women and Children's Health St George Public Hospital, University of NSW St George Clinical School, Kogarah, New South Wales, Australia
| | - Phil Dinning
- College of Medicine and Public Health and Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia.,Department of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Dietz HP. Exoanal Imaging of the Anal Sphincters. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:263-280. [PMID: 28543281 DOI: 10.1002/jum.14246] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/21/2017] [Indexed: 06/07/2023]
Abstract
Since its introduction in the early 1990s, endoanal sonography has become the mainstay of morphologic assessment of the anal canal and sphincter, especially for obstetric anal sphincter trauma. Lack of availability of suitable systems and the invasive nature of the method have limited uptake and clinical utility. More recently, exoanal or transperineal/translabial tomographic imaging has been developed as a noninvasive alternative. This pictorial overview aims to introduce the reader to this new diagnostic modality and to demonstrate common findings in asymptomatic and symptomatic women.
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Affiliation(s)
- Hans Peter Dietz
- Department of Obstetrics and Gynecology, Sydney Medical School Nepean, Penrith, New South Wales, Australia
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32
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Liu W, Sturiale A, Fabiani B, Giani I, Menconi C, Naldini G. Internal Delorme's Procedure for Treating ODS Associated With Impaired Anal Continence. Surg Innov 2017; 24:566-573. [PMID: 28778136 DOI: 10.1177/1553350617723771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the medium-term outcomes of internal Delorme's procedure for treating obstructed defecation syndrome (ODS) patients with impaired anal continence. PATIENTS AND METHODS In a retrospective study, 41 ODS patients who underwent internal Delorme's procedure between 2011 and 2015 were divided into 3 subgroups according to their associated symptoms of impaired continence, as urgency, passive fecal incontinence and both, before study. Then the patients' preoperative statuses, perioperative complications, and postoperative outcomes were investigated and collected from standardized questionnaires, including Altomare ODS score, Fecal Incontinence Severity Index (FISI), Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QoL), and Fecal Incontinence Quality of Life Scale (FIQLS). All results with a 2-tailed P < .05 were considered statistically significant. RESULTS At an average 2.8 years of follow-up, there were significant improvements ( P < .01) in Altomare ODS score, FISI, PAC-QoL, and FIQLS in all patients when comparing scores from before the operation with those at the final follow-up. Similar results were also observed in both the urgency subgroup and passive fecal incontinence subgroup, but there were no statistically significant improvements ( P > .05) in Altomare ODS score, FISI, PAC-QoL, or FIQLS in the urgency and passive fecal incontinence subgroups. Anorectal manometry showed the mean value of anal resting pressure increased 20%. Additionally, no major complications occurred. CONCLUSION Internal Delorme's procedure is effective without major morbidity for treating ODS associated with urgency or passive fecal incontinence, but it may be less effective for treating ODS associated with both urgency and passive fecal incontinence.
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Affiliation(s)
- Weicheng Liu
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
| | | | | | - Iacopo Giani
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
| | - Claudia Menconi
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
| | - Gabriele Naldini
- 1 Cisanello Hospital of Pisa, University Hospital of Pisa, Pisa, Italy
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Ros C, Martínez-Franco E, Wozniak MM, Cassado J, Santoro GA, Elías N, López M, Palacio M, Wieczorek AP, Espuña-Pons M. Postpartum two- and three-dimensional ultrasound evaluation of anal sphincter complex in women with obstetric anal sphincter injury. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:508-514. [PMID: 27087312 DOI: 10.1002/uog.15924] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 02/22/2016] [Accepted: 03/16/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS). METHODS External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated. RESULTS Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (κ = 0.01), fair for 2D-TPUS (κ = 0.30) and good for 3D-TPUS (κ = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (κ = 0.41) and 2D-TPUS (κ = 0.52) and good for 3D-TPUS (κ = 0.66). Good intraobserver (3D-EAUS, κ = 0.73; 3D-TPUS, κ = 0.78) and interobserver (3D-EAUS, κ = 0.68; 3D-TPUS, κ = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04). CONCLUSIONS 2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Ros
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - E Martínez-Franco
- Department of Obstetrics and Gynecology, Parc Sanitari Sant Joan de Déu, Sant Boi del Llobregat, Barcelona, Spain
| | - M M Wozniak
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - J Cassado
- Department of Obstetrics and Gynecology, Hospital Universitari Mutua de Terrassa, Terrassa, Barcelona, Spain
| | - G A Santoro
- Pelvic Floor Unit, First Department of Surgery, Treviso Regional Hospital, Treviso, Italy
| | - N Elías
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - M López
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - M Palacio
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - A P Wieczorek
- Department of Pediatric Radiology, Medical University of Lublin, Lublin, Poland
| | - M Espuña-Pons
- Pelvic Floor Unit, ICGON, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Khafagy WW, El-Said MM, Thabet WM, Aref SES, Omar W, Emile SH, Elfeki H, El-Ghonemy MS, El-Shobaky MT. Evaluation of anatomical and functional results of overlapping anal sphincter repair with or without the injection of bone marrow aspirate concentrate: a case-control study. Colorectal Dis 2017; 19:O66-O74. [PMID: 27943520 DOI: 10.1111/codi.13579] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 10/20/2016] [Indexed: 12/11/2022]
Abstract
AIM Overlapping anal sphincter repair (OASR) is used for treatment of faecal incontinence due to an external anal sphincter (EAS) defect; however, it is not the optimal treatment as its functional results tend to deteriorate significantly with time. The present study aimed to evaluate the effect of local injection of bone marrow aspirate concentrate (BMAC) on the outcome of OASR. METHOD We compared a prospective group of 20 patients with EAS defect who were managed with OASR and BMAC injection (group I) with a historical control group of an equal number of patients managed with OASR alone (group II). Patients were assessed preoperatively and during follow-up by the Wexner continence score and endoanal ultrasound. The primary end-points were the improvement of the continence level measured by the Wexner score and the residual EAS defect size measured by endoanal ultrasound. RESULTS At the end of follow-up, group I had significantly lower mean postoperative Wexner score (5.4 ± 7.6 vs 10.6 ± 7.4; P = 0.03) and smaller EAS defect percentage (12.2 ± 17.5 vs 18.3 ± 18.9). These findings were statistically significant in patients with a small preoperative EAS defect equal to or less than one-third of the anal circumference. Patients with larger preoperative EAS did not show a significant improvement of the continence level after repair in either group. CONCLUSION Augmenting OASR with local injection of BMAC in patients with faecal incontinence caused by an EAS defect, particularly a smaller defect, can improve both functional and anatomical outcomes of OASR.
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Affiliation(s)
- W W Khafagy
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - M M El-Said
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - W M Thabet
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - S E-S Aref
- Clinical Pathology Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - W Omar
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - S H Emile
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - H Elfeki
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - M S El-Ghonemy
- Clinical Pathology Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
| | - M T El-Shobaky
- General Surgery Department, Mansoura Faculty of Medicine, Mansoura University, Mansoura City, Dakahlia Providence, Egypt
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García-Mejido JA, Gutiérrez Palomino L, Fernández Palacín A, Sainz-Bueno JA. [Applicability of 3/4D transperineal ultrasound for the diagnosis of anal sphincter injury during the immediate pospartum]. CIR CIR 2016; 85:80-86. [PMID: 26769527 DOI: 10.1016/j.circir.2015.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/04/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND The most common cause of anal sphincter injuries in women is vaginal birth. Endo-anal ultrasound is currently used for the diagnosis of anal sphincter defect. However, due to the inconvenience caused, it is not an applicable technique during the immediate post-partum. The aim of this study was to determine whether transperineal ultrasound in 3/4D is a useful diagnostic method for the assessment of anal sphincter during the immediate post-partum. MATERIAL AND METHODS A prospective study was conducted on the vaginal deliveries performed between September 2012 and June 2013 in the Valme University Hospital (Seville). Obstetric and foetal parameters that could influence the onset of perineal tears were studied. The patients underwent a transperineal 3/4D ultrasound and a multislice study (48hours after birth). RESULTS The study included 146 puerperal women. The sphincter complex was assessed in all of them during the immediate post-partum. External anal injuries were observed in 10.3% of the cases. In 8.2% of cases, the primary suture of the external anal sphincter was detected during ultrasound examination, and 2.1% of asymptomatic lesions were diagnosed only with post-partum ultrasound. None of the patients reported discomfort or pain. CONCLUSIONS The 3-dimensional transperineal ultrasound is helpful in determining the primary repair of the anal sphincter during the immediate post-partum, with no discomfort for patients, as well as for establishing those early sphincter injuries that go unnoticed during vaginal delivery.
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Krissi H, Aviram A, Hiersch L, Ashwal E, Eitan R, Peled Y. Structured hands-on workshop decreases the over-detection rate of obstetrical anal sphincter injuries. Int J Colorectal Dis 2016; 31:45-50. [PMID: 26293790 DOI: 10.1007/s00384-015-2365-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to assess the effect of a structured hands-on workshop on the detection rate of obstetric anal sphincter injuries. METHODS All physicians attending the delivery ward in our institution participated in a structured obstetric anal sphincter injury hands-on workshop developed by Dr. Ranee Thakar and Dr. Abdul Sultan which demonstrated proper identification and techniques for obstetric anal sphincter injury detection and repair. We retrospectively reviewed the electronic records of all singleton-pregnancy women who delivered vaginally (vertex presentation) during the 2 years prior to and 1 year following the workshop to assess the workshop's effect on the rate of detection of obstetric anal sphincter injuries. RESULTS Overall, 20,484 women met the inclusion criteria during the study period and were eligible for final analysis. There were no significant differences in patient's characteristics between the groups. Women in the pre-workshop group had a higher rate of obstetric anal sphincter injuries than the post-workshop group (0.4 vs. 0.2 %, p = 0.005). On multivariate analysis, factors independently associated with a decreased risk for obstetric anal sphincter injuries were deliveries in the post-workshop period (odds ratio 0.43, 95 % confidence interval 0.24-0.79, p = 0.006), parity (odds ratio 0.37, 95 % confidence interval 0.25-0.54, p < 0.001), and spontaneous vaginal delivery (odds ratio 0.43, 95 % confidence interval 0.26-0.71, p = 0.001). CONCLUSIONS A proper detection of obstetric anal sphincter injuries may depend on the experience of the assessor. A structured hands-on workshop is important to avoid over diagnosis third-degree perineal tears.
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Affiliation(s)
- Haim Krissi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel.
| | - Amir Aviram
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Ram Eitan
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
| | - Yoav Peled
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, 49100, Tel Aviv, Israel
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Mora López L, Serra-Aracil X, Navarro Soto S. Sphincter lesions observed on ultrasound after transanal endoscopic surgery. World J Gastroenterol 2015; 21:13160-13165. [PMID: 26674666 PMCID: PMC4674735 DOI: 10.3748/wjg.v21.i46.13160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the morphological impact of transanal endoscopic surgery on the sphincter apparatus using the modified Starck classification.
METHODS: A prospective, observational study of 118 consecutive patients undergoing Transanal Endoscopic Operation/Transanal Endoscopic Microsurgery (TEO/TEM) from March 2013 to May 2014 was performed. All the patients underwent an endoanal ultrasound prior to surgery and one and four months postoperatively in order to measure sphincter width, identify sphincter defects and to quantify them in terms of the level, depth and size of the affected anal canal. To assess the lesions, we used the “modified” Starck classification, which incorporates the variable “sphincter fragmentation”. The results were correlated with the Wexner incontinence questionnaire.
RESULTS: Of the 118 patients, twelve (sphincter lesions) were excluded. The results of the 106 patients were as follows after one month: 31 (29.2%) lesions found on ultrasound after one month, median overall Starck score of 4 (range 3-6); 10 (9.4%) defects in the internal anal sphincter (IAS) and 3 (2.8%) in the external anal sphincter (EAS); 17 patients (16%) had fragmentation of the sphincter apparatus with both sphincters affected in one case. At four months: 7 (6.6%) defects, all in the IAS, overall median Starck score of 4 (range 3-6). Mean IAS widths were 3.5 mm (SD 1.14) preoperatively, 4.38 mm (SD 2.1) one month postoperatively and 4.03 mm (SD 1.46) four months postoperatively. The only statistically significant difference in sphincter width in the IAS measurements was between preoperatively and one month postoperatively. No incontinence was reported, even in cases of ultrasound abnormalities.
CONCLUSION: TEO/TEM may produce ultrasound abnormalities but this is not accompanied by clinical changes in continence. The modified Starck classification is useful for describing and managing these disorders.
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Rodríguez R, Alós R, Carceller MS, Solana A, Frangi A, Ruiz MD, Lozoya R. Incontinencia fecal posparto. Revisión de conjunto. Cir Esp 2015; 93:359-67. [DOI: 10.1016/j.ciresp.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 09/05/2014] [Accepted: 10/05/2014] [Indexed: 12/01/2022]
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Ozyurt S, Aksoy H, Gedikbasi A, Yildirim G, Aksoy U, Acmaz G, Ark C. Screening occult anal sphincter injuries in primigravid women after vaginal delivery with transperineal use of vaginal probe: a prospective, randomized controlled trial. Arch Gynecol Obstet 2015; 292:853-9. [DOI: 10.1007/s00404-015-3708-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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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:O347-55. [PMID: 24502361 DOI: 10.1111/codi.12579] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 10/29/2013] [Indexed: 12/24/2022]
Abstract
AIM More than 50% of women experience deteriorating continence over time following primary repair of obstetric anal sphincter injuries. The objectives of this study were to assess the function and morphology of the anal sphincters and pelvic floor in women with long-term faecal incontinence after sphincter repair (primary end-point) and to evaluate their correlation with severity of incontinence (secondary end-point). METHOD The participants in this prospective study were recruited from a cohort of all women who sustained third or fourth degree obstetric sphincter injury reconstruction (cases) from January 1976 to November 1991. The women who delivered immediately before and after each case, without sustaining obstetric damage, were included as controls. Cases and controls were stratified into three categories: (i) continent; (ii) minor incontinence; and (iii) severe incontinence. The function and morphology of the anal sphincters and pelvic floor were evaluated by MRI, three-dimensional endoanal ultrasonography and anorectal physiology tests. RESULTS Fifty-nine women (29 cases/30 controls; mean age 51/53 years; mean follow-up 23.7/24.1 years, respectively) were assessed. Morphologically, cases had a significantly shorter anterior external anal sphincter length compared with controls when evaluated by three-dimensional endoanal ultrasonography (8.6 vs 10.2 mm; P = 0.03). Functionally, cases with severe incontinence had a significantly shorter anterior sphincter length compared with cases with minor incontinence (7.7 vs 10.4 mm; P = 0.04). No correlation could be found between anal pressures and severity of incontinence in the case group. CONCLUSIONS Cases had a significantly shorter anterior external anal sphincter length. Functionally, anterior sphincter length correlated with increased severity of incontinence.
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Affiliation(s)
- M M Soerensen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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Panicucci S, Martellucci J, Menconi C, Toniolo G, Naldini G. Correlation between outcome and instrumental findings after stapled transanal rectal resection for obstructed defecation syndrome. Surg Innov 2014; 21:469-475. [PMID: 24132467 DOI: 10.1177/1553350613505718] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Several studies show that stapled transanal rectal resection (STARR) significantly improves constipation in most patients, while others remain symptomatic for obstructed defecation syndrome (ODS). The aim of the study was to analyze clinical, manometric, and endoanal ultrasonography results in order to find any possible correlation between clinical and instrumental data, particularly in dissatisfied patients, both for those who remain symptomatic for ODS and for patients with new-onset fecal disorders. PATIENTS AND METHODS All patients underwent a preoperative and postoperative assessment based on clinical evaluation, proctoscopy, defecography, anorectal manometry, and endoanal ultrasonography. Furthermore, we asked patients about a subjective satisfaction grading of outcome. RESULTS From January 2007 to December 2009, 103 patients were treated in our department with STARR for ODS. Postoperative endoanal ultrasound did not demonstrate any variations compared with the preoperative one. Postoperative scores showed statistically significant improvement, with respect to the preoperative value, with good and sufficient scores in 79.6% of patients, and an overall rate of satisfaction of 87.1%. Fecal disorders, including also the slightest alteration of continence, occurred in 24% of patients, in particular soiling 1.8%, urgency 7.4%, occasional gas leakage 5.5%, and liquid/solid leakage 9.3%. Anorectal manometry revealed a statistically significant reduction only in sensitivity threshold and maximum tolerated volume compared to patients with no disorders of continence. CONCLUSION Results indicate good satisfaction grading and a statistically significant improvement in scores of constipation. There is no close correlation between satisfaction grading and scores. Besides, the assessment of patient's satisfaction often does not match the objective functional outcome.
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Affiliation(s)
| | - Jacopo Martellucci
- University Hospital of Pisa, Pisa, Italy University of Siena, Siena, Italy
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Ohazuruike NL, Martellucci J, Menconi C, Panicucci S, Toniolo G, Naldini G. Short-term results after STARR versus internal Delorme for obstructed defecation: a non-randomized prospective study. Updates Surg 2014; 66:151-156. [PMID: 24430441 DOI: 10.1007/s13304-014-0247-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/04/2014] [Indexed: 12/17/2022]
Abstract
Obstructed defecation syndrome due to internal intussusception and rectocele is a common disease, and various transanal surgical techniques have been proposed. Aim of the present study was to compare the internal Delorme (ID) and the stapled transanal rectal resection (STARR) results in the treatment of patients with obstructed defecation syndrome. From September 2011 to May 2012, 23 patients were operated with STARR procedure and 12 patients with Delorme's procedure for obstructed defecation syndrome. All patients underwent preoperative assessment: clinical evaluation (Altomare ODS score, Wexner constipation scoring system), proctoscopy, defecography, anorectal manometry and endoanal ultrasonography. Surgery was proposed with: failure of medical therapy, incomplete defecation, and unsuccessful attempts with long periods spent in bathroom, defecation with digital assistance, use of enemas and defecography findings of rectoanal intussusception and rectocele. The average operative time was 28 min (range 15-65) for the STARR group and 56 min (range 28-96) for the ID group with a mean hospital stay of 2 days for both the procedures. The Wexner score significantly fell postoperatively from 17 to 4, 7 in STARR group and from 15.3 to 3.3 in the ID group. The Altomare score postoperatively fell from 18.2 to 5.5 for STARR group and from 16.5 to 5.3 for ID group. No statistically significant differences were observed between the two procedures considering the outcomes parameters and the complications. Both ID and STARR procedure seem to be effective in the treatment of ODS.
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Affiliation(s)
- N L Ohazuruike
- Department Section of Colonproctology and Perineal Surgery, Cisanello Hospital of Pisa, Pisa, Italy
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Norderval S, Røssaak K, Markskog A, Vonen B. Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:207-214. [PMID: 22125165 DOI: 10.1002/uog.10154] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed. METHODS Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score. RESULTS Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007). CONCLUSION Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair.
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Affiliation(s)
- S Norderval
- Department of Gynaecology and Obstetrics, Ålesund Hospital, Ålesund, Norway.
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Olsen IP, Wilsgaard T, Kiserud T. Development of the maternal anal canal during pregnancy and the postpartum period: a longitudinal and functional ultrasound study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:690-697. [PMID: 22253200 DOI: 10.1002/uog.11104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Normal anatomical and physiological development of the maternal anal canal during and after pregnancy has been documented scarcely. We aimed to study the position and volume of the anal canal, during and after pregnancy, in women without previous delivery. METHODS This was a longitudinal study in which transvaginal three-dimensional ultrasound was used to measure anatomical structures in the anal canal during rest and squeeze in 23 nulliparous women. The total anal canal volume (ACV), anorectal curvature (ARC), anovaginal angle (AVA) and anal canal length were determined at 18, 28 and 36 weeks of pregnancy and at 3 months postpartum. RESULTS Total ACV at rest increased from a mean of 10.17 cm(3) at 18 weeks to 12.37 cm(3) and 12.21 cm(3) at 28 and 36 weeks, respectively (P = 0.001 and P = 0.010 vs. first measurement). For anal canal length, the corresponding mean measurements were 3.91 cm, 4.07 cm (P = 0.13) and 4.21 cm (P = 0.017). Postpartum, the mean total ACV was 10.86 cm(3) and length was 3.90 cm (P = 0.10 and P = 0.70 vs. first measurement). No significant changes were observed in ARC and AVA during or after pregnancy. Compared to at-rest status, the anal length significantly increased on voluntary squeeze (P = 0.007, 0.007, 0.022 and 0.004 at the four time points), while no differences in total ACV were observed. In mid-pregnancy AVA significantly increased during squeeze (P = 0.006 and 0.002 at weeks 18 and 28, respectively). CONCLUSION Anal canal length and total ACV increase during pregnancy in women without previous delivery. Voluntary squeezing elongates the anal canal and increases the angle formed with respect to the direction of the vagina. During postpartum involution, the characteristics of the anal canal revert to those observed at 18 weeks of pregnancy.
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Affiliation(s)
- I P Olsen
- Department of Obstetrics and Gynecology, Hammerfest Hospital, Hammerfest, Norway.
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Ratto C, Litta F, Parello A, Donisi L, De Simone V, Zaccone G. Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review. Colorectal Dis 2012; 14:e297-304. [PMID: 22356165 DOI: 10.1111/j.1463-1318.2012.03003.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The long-term results of sphincteroplasty for faecal incontinence due to an anal sphincter lesion have been disappointing. Initially sacral nerve stimulation was used only in faecal incontinence of neurogenic origin but subsequently the indications have been extended to other conditions. The aim of this review was to evaluate sacral nerve stimulation for incontinence in the presence of a sphincter defect. METHOD The MEDLINE, Embase and Cochrane Library databases for the period between 1995 and 2011 were searched for studies in English, with no limitations concerning the study size or the length of follow-up. The major endpoints were clinical efficacy, changes in anorectal manometry and quality of life. RESULTS Ten reports (119 patients) satisfied the inclusion criteria. The quality of the studies was low (nine were retrospective, one was prospective). All reported a lesion of the external anal and/or internal anal sphincter on endoanal ultrasound. A definitive implant was performed on 106 (89%) of the 119 patients who underwent a peripheral nerve evaluation test. The weighted average number of incontinent episodes per week decreased from 12.1 to 2.3, the weighted average Cleveland Clinic Score decreased from 16.5 to 3.8, and the ability to defer defaecation, when evaluated, increased significantly. The features at anorectal manometry did not change. The quality of life improved significantly in almost all studies. CONCLUSION Sacral nerve stimulation could be a therapeutic option for faecal incontinence in patients with an anal sphincter lesion. However, the quality of the published studies is low. A randomized clinical trial comparing sacral nerve stimulation with other classical surgical procedures at long-term follow-up, although beset with difficulties, should be conducted.
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Affiliation(s)
- C Ratto
- Department of Surgical Sciences, Catholic University, Rome, Italy.
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Caldaro T, Romeo E, De Angelis P, Gambitta RA, Rea F, Torroni F, Foschia F, di Abriola GF, Dall'Oglio L. Three-dimensional endoanal ultrasound and anorectal manometry in children with anorectal malformations: new discoveries. J Pediatr Surg 2012; 47:956-63. [PMID: 22595581 DOI: 10.1016/j.jpedsurg.2012.01.051] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 01/26/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Fecal incontinence and constipation are common problems in follow-up of anorectal malformations (ARMs). We evaluated the anal sphincters using the 3-dimensional endoanal ultrasonography (3D-EAUS) and the anorectal manometry after ARMs repair. METHODS Seventeen patients, divided into 3 groups according to Wingspread classification, underwent anorectal manometry and 3D-EAUS. Clinical, manometric, and endosonographic scoring systems were used. RESULTS The average anal resting pressure (aARP) was significantly higher in low ARMs than in intermediate and high ARMs. The anal squeeze pressure was not statistically different between the 3 groups. Three-dimensional EAUS visualized internal anal sphincter (IAS) disruptions in 7 of 17 patients and absence of IAS in 6 of 17 children with high ARMs. Scars of the external anal sphincter were localized in low ARMs and generalized in the other groups. In the case of IAS disruption with aARP greater than 20 mm Hg, fecal incontinence and constipation improved with biofeedback and/or laxatives, whereas daily enemas were necessary in absence of IAS with aARP less than 20 mm Hg. Statistical correlation was observed between endosonographic and manometric findings and clinical outcomes. CONCLUSIONS Lesions of the anal sphincter are common in ARMs. Three-dimensional EAUS and anorectal manometry ensure a complete assessment of the anal sphincter and could provide useful information to define the most appropriate treatments to improve the quality of life.
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Affiliation(s)
- Tamara Caldaro
- Digestive Surgery and Endoscopy Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
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Valsky DV, Cohen SM, Lipschuetz M, Hochner-Celnikier D, Yagel S. Three-dimensional transperineal ultrasound findings associated with anal incontinence after intrapartum sphincter tears in primiparous women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:83-90. [PMID: 21845740 DOI: 10.1002/uog.10072] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Three-dimensional transperineal sonography (3D-TPS) performed in women following third- or fourth-degree intrapartum tears repaired with the overlapping technique demonstrates characteristic signs. The aim of this study was to investigate the correlation of these signs with clinical complaints of incontinence. METHODS This was a prospective observational study. Sixty primiparous women underwent 3D-TPS 3-42 (mean, 10.6) months after surgical repair of third- or fourth-degree postpartum sphincter tears with the overlapping technique and were evaluated for clinical degree of incontinence using the St Mark's Incontinence Score (SMIS) questionnaire. The following signs were assessed on 3D-TPS: interruption of the internal anal sphincter or external anal sphincter, 'half moon' sign, changes in the mucosal folds and thickening of the external anal sphincter in the area of sphincter repair. As a comparison group, 27 primiparous women after normal vaginal delivery, without clinically recognized anal sphincter tears, were evaluated similarly, 3-37 (mean, 9.9) months postpartum. RESULTS Abnormal sonographic signs were apparent in 35 (58.3%) of 60 women in the study group, and 39 (65%) of 60 had some clinical complaints of incontinence 3-42 months after delivery, most of a mild degree. Higher SMIS results were found in women of the study group than in those of the comparison group (mean (SD) 2.80 (0.481) vs. 1.15 (0.365); P = 0.018). The rates of incontinence were similar between the women in the study group with normal ultrasound findings and the women in the comparison group (9/25 vs. 10/27; relative risk (RR) = 0.97, 95% CI, 0.47-1.97). CONCLUSIONS Sonographic signs of anal sphincter tear and repair had disappeared at follow-up examination in almost half of the patients, and therefore this examination should be deferred from the early postpartum period. A substantial proportion of women report some complaint of incontinence after sphincter repair, most of a slight degree. Such complaints are associated with abnormal 3D-TPS findings at follow up, while in women with a normal 3D-TPS scan the rate of incontinence complaints is similar to that in women after normal delivery.
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Affiliation(s)
- D V Valsky
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Centers, Mount Scopus, Jerusalem, Israel.
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Salameh C, Canoui-Poitrine F, Cortet M, Lafon A, Rudigoz RC, Huissoud C. [Does persistent occiput posterior position increase the risk of severe perineal laceration?]. ACTA ACUST UNITED AC 2011; 39:545-8. [PMID: 21873097 DOI: 10.1016/j.gyobfe.2011.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 03/01/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the risk of severe perineal lacerations (III and IV degrees) during vaginal deliveries in occiput posterior position. PATIENTS AND METHODS We conducted a retrospective cohort study of 9097 vaginal deliveries in a teaching hospital's maternity between January 1st 2005 and December 31st 2008. Risk factors associated with tears of the 3rd or 4th degree were studied by a multivariate logistic regression. RESULTS Severe perineal lacerations occurred in 1.69% of cases (n=152) and did not significantly vary between 2005 and 2008. Parity was a protective factor (OR 0.42; P<0.001; IC(95%) 0.29-0.60) whereas instrumental extraction was associated with an increased risk: vacuum (OR 3.95; P<0.001, IC(95%) 2.23-7.00) and forceps (OR 3.55; P<0.001, IC(95%) 2.33-5.42). macrosomia. Risks were also increased in fetal macrosomia and episiotomy did not protect the mother (respectively OR 1.41 P<0.001, IC(95%) 1.19-1.68 and OR 1.73; P<0.001, IC(95%) 1.16-2.57). Persistent occiput posterior position was not significantly associated with an anal sphincter injury (OR=1.70 P=0.059; IC(95%) 0.98-2.94). DISCUSSION AND CONCLUSION In our series, occiput posterior position did not significantly impact the risk of severe perineal laceration. A manual rotation of the fetal head should be performed in case of associated risk factors.
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Affiliation(s)
- C Salameh
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 103 Grande-Rue-de-la-Croix-Rousse, Lyon cedex 04, France.
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Santoro GA, Wieczorek AP, Dietz HP, Mellgren A, Sultan AH, Shobeiri SA, Stankiewicz A, Bartram C. State of the art: an integrated approach to pelvic floor ultrasonography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:381-396. [PMID: 20814874 DOI: 10.1002/uog.8816] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/17/2010] [Indexed: 05/29/2023]
Abstract
Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available. In this review, pelvic floor ultrasonography, including two-dimensional (2D), three-dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor-urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome-is evaluated critically.
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Affiliation(s)
- G A Santoro
- Pelvic Floor Unit, I°Department of Surgery, Regional Hospital, Treviso, Italy.
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