To determine obstetric variables associated with the long-term prevalence of flatal and/or fecal incontinence among women who sustained obstetric anal sphincter injuries (OASIS).In a retrospective study of women who gave birth between January 1974 and December 1983 at the University Women's Hospital, Tuebingen, Germany, women with OASIS (n=460) were identified on the basis of chart review. Eligible women were recruited to participate in a telephone interview regarding symptoms and their retrospective preference about elective cesarean delivery.The records of 20 999 deliveries, including all modes of delivery, within the 10-year study period were reviewed, and 99 women who sustained OASIS agreed to participate. The mean follow-up was 27.5±2.4 years. Among the participants, 39.4% reported fecal or flatal incontinence. Operative vaginal delivery (forceps and/or vacuum) was significantly associated with fecal but not flatal incontinence (odds ratio, 3.27; 95% confidence interval, 1.12-9.56, P=0.026). Only 9% of women with flatal incontinence and 13% of women with fecal incontinence would have opted retrospectively for cesarean delivery.Operative vaginal delivery was significantly associated with fecal but not flatal incontinence. No other obstetric variables tested were associated with the long-term prevalence of fecal or flatal incontinence.Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Aim of the study was to estimate the prevalence of postpartum anal incontinence among women who delivered vaginally, and to assess the extent to which obstetric injuries to the anal sphincters are missed.All women (both primiparous and multiparous) who delivered vaginally and received any kind of sutures in the perineal area at Innlandet Hospital Trust Elverum in Norway between January 1, 2015 and June 30, 2016 were invited to answer a questionnaire on St. Mark's incontinence score and to participate in a clinical examination of the pelvic floor including endoanal sonography.In total 52,3% (n = 207) of the 396 invited women participated in the study. Mean St. Mark's score was 1.8 points (95% CI 1.4 to 2.1) at examination 14 months (mean) postpartum, and none of the participants suffered from weekly fecal leakage. Fecal urgency affected 11.7% (95% CI 7.1 to 16.3) of the participants, and 8.7% (95%CI 5.1 to 12.8) had weekly involuntary leakage of flatus. Nine women (9.3%, 95% CI 4.1 to 15.5) had a previously undetected third degree obstetric anal sphincter injury.The prevalence of anal incontinence among women who have delivered vaginally and received sutures due to 1st and 2nd degree perineal lacerations is low. Some obstetric anal sphincter injuries remain unrecognized at the time of delivery, but the symptoms of anal incontinence due to these injuries are in the lower half of the St. Mark's incontinence score. Women with persistent symptoms like fecal urgency or leakage of gas and/or feces should be referred to evaluation by a colorectal surgeon in order to achieve optimal treatment.

Obstetric anal sphincter injury is the primary modifiable risk factor for anal incontinence in women. Currently, endoanal ultrasound is most commonly used to detect residual anal sphincter defects after childbirth. Translabial ultrasound has recently been introduced as a noninvasive alternative.This study aimed to determine medium- to long-term outcomes in women after obstetric anal sphincter injuries diagnosed and repaired at delivery.This is a cross-sectional study.This study was performed in a tertiary obstetric unit.Between 2005 and 2015, 707 women were diagnosed with obstetric anal sphincter injuries; 146 followed an invitation for follow-up.Clinical examination, anal manometry, and translabial ultrasound were performed.The primary outcomes measured were the St Mark incontinence score and the evidence of sphincter disruption on translabial ultrasound.Of 372 contactable patients, 146 attended at a mean follow-up of 6.6 years (1.7-11.9), of which 75 (51%) reported symptoms of anal incontinence with a median "bother score" of 6 (interquartile range, 3-8). Median St Mark score was 3 (interquartile range, 2-5). Twenty-four (16%) had a score of ≥5. Women who had been diagnosed with a 3c/4th degree tear had more symptoms (58% vs 44%), significantly lower mean maximal resting pressure (p < 0.001), maximal squeeze pressure (p < 0.001), and more residual external (p < 0.001) and internal (p = 0.012) sphincter defects in comparison with those who had a 3a/3b tear. Women with residual external sphincter defects had lower mean maximal squeeze pressure (p = 0.02). Residual internal sphincter defects (p = 0.001) and levator avulsion (p = 0.048) are independent risk factors for anal incontinence on multivariate modeling.This study was limited by the lack of predelivery data of bowel symptoms and BMI and incomplete intrapartum documentation of tear grade.Symptoms of anal incontinence were highly prevalent (51%), with a high bother score of 6. St Mark scores were associated with residual internal anal sphincter defects and levator avulsion. Women who had a higher tear grade showed a higher incidence of residual sphincter defects and lower manometry pressures. See Video Abstract at http://links.lww.com/DCR/A824.

Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management.This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists.A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality.Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.

The primary aim was to study prevalence of obstetric anal sphincter injuries (OASIS) after normal vaginal deliveries (NVD) and operative vaginal deliveries (OVD) with a subgroup analysis of forceps (FD) vs. vacuum deliveries (VD). The secondary aim was to study the association betweenOASISand anal incontinence 15–23 years later.

To assess the prevalence of levator ani muscle injury in Chinese women after their first delivery and investigate associated factors.A prospective observational study was conducted involving Chinese nulliparous women recruited in the first trimester of pregnancy. Translabial ultrasound was performed at 35-38 weeks' gestation and 8 weeks postpartum and three-dimensional volume datasets were obtained. Offline analysis to detect levator ani muscle injury was performed by investigators blinded to the delivery details.339 women, with a mean age of 30.6 ± 3.9 years, completed the study. Overall, 201 (59.3%) had a spontaneous vaginal delivery, 62 (18.3%) an operative vaginal delivery (48 ventouse extraction and 14 forceps delivery), 14 (4.1%) an elective Cesarean section and 62 (18.3%) an emergency Cesarean section. No levator ani muscle injury was detected in any woman antenatally. After vaginal delivery, 57 (21.7% (95% CI, 16.7-26.7%)) women had levator ani muscle injury. The rates of injury for spontaneous vaginal delivery, ventouse extraction and forceps delivery were 15.4%, 33.3% and 71.4%, respectively. There was no levator ani muscle injury in the Cesarean section groups. Logistic regression analysis showed that only operative vaginal delivery (odds ratio, 3.09) was associated with an independent increase in the likelihood of levator ani muscle injury. Intrapartum epidural analgesics, duration of second stage of labor and infant birth weight were not independently associated with levator ani muscle injury.The prevalence of levator ani muscle injury in Chinese women after their first vaginal delivery was 21.7% (95% CI, 16.7-26.7%). Operative vaginal delivery was found to increase the likelihood of women suffering such injury. A longer follow-up of these women and future studies on the effects of episiotomy are proposed.Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth.OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the Istatistic.Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]).This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.

Puborectalis muscle rupture usually arises from peri-partum perineal trauma and may result in anterior, middle compartment prolapses, posterior compartment prolapse which includes rectocele and rectal prolapse, with or without associated anal sphincter damage. Patients with puborectalis muscle and levator ani rupture may present some form of incontinence or evacuation disorder, sexual dysfunction or pelvic organ descent. However, the literature on this subject is scarce. The aim of our study was to evaluate management and treatment of functional disorders associated with puborectalis and/or pubococcygei rupture at the level of the insertion in the pubis in a cohort of patients referred to a tertiary care coloproctology center.We conducted a prospective cohort study of patients with levator ani and puborectalis muscle avulsion in the Proctology and Pelvic Floor Unit, Division of Digestive Surgery of the University Hospitals of Geneva from January 2001 to November 2018. Clinical examination, anoscopy and ultrasound were performed on a routine basis. Rupture of the levator ani muscle was diagnosed by clinical examination and ultrasound. A Wexner incontinence score was completed before and 6 months after surgery. Levator ani muscle repair was performed using a transvaginal approach.Fifty-two female patients (median age 56 ± 11.69 SD years, range 38-86 years) were included in the study. Thirty-one patients (59.6%) had anal incontinence, 25 (48.1%) urinary incontinence, 28 (53.9%) dyschezia (obstructive defecation or excessive straining to defecate), 20 (38.5%) dyspareunia, 17 (32.7%) colpophony, and 13 (25.0%) impaired sensation during sexual intercourse. Deviation of the anus on the side opposite the lesion was observed in 50 patients (96.2%), confirmed with clinical examination and both endoanal and perineal ultrasound. Out of these 52 patients, levator ani rupture (including puborectalis rupture) were categorized into right sided, 43 (82.69%), left sided, 7 (13.46%) and bilateral, 2 (3.85%). Levator ani muscle repair was performed in all patients, associated with posterior repair and levatorplasty in 26 patients (50%) and with sphincteroplasty in 34 patients (63.4%). Four patients (7.7%) experienced postoperative complications: significant postoperative pain (n = 3; 5.77%), urinary retention (n = 2; 3.85%), hematoma (n = 1; 1.92%), and perineal abscess (n = 1; 1.92%). Forty-one patients (78.8%) had full restoration of normal puborectalis muscle function (Wexner score: 0/20) after surgery, and overall, all patients had an improvement in the Wexner score and in sexual function. Dyschezia was reported by 28 patients (53.9%) preoperatively, resolved in 18 (64.3%) and improved by 50% or more in 10 (35.71%).Diagnosis of levator ani and puborectalis muscle rupture requires careful history taking, clinical examination, endoanal and perineal ultrasound. Surgical repair improved anal continence as well as sexual function in all patients. Transvaginal levator ani repair seems to be well tolerated with good short-term results.

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives. The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.

Endoanal ultrasound is now regarded as the gold standard for evaluating anal sphincter pathology in the investigation of anal incontinence. The advent of three-dimensional ultrasound has further improved our understanding of the two-dimensional technique. Endoanal ultrasound requires specialised equipment and its relative invasiveness has prompted clinicians to explore alternative imaging techniques. Transvaginal and transperineal ultrasound have been recently evaluated as alternative imaging modalities. However, the need for technique standardisation, validation and reporting is of paramount importance. We conducted a MEDLINE search (1950 to February 2010) and critically reviewed studies using the three imaging techniques in evaluating anal sphincter integrity.

Fecal incontinence has a profound impact in a patient's life, impairing quality of life and carrying a substantial economic burden due to health costs. It is an underdiagnosed condition because many affected patients are reluctant to report it and also clinicians are usually not alert to it. Patient evaluation with a detailed clinical history and examination is very important to indicate the type of injury that is present. Endoanal ultrasonography is currently the gold standard for sphincter evaluation in fecal incontinence and is a simple, well-tolerated and non-expensive technique. Most studies revealed 100% sensitivity in identifying sphincter defect. It is better than endoanal magnetic resonance imaging for internal anal sphincter defects, equivalent for the diagnosis of external anal sphincter defects, but with a lower capacity for assessment of atrophy of this sphincter. The most common cause of fecal incontinence is anal sphincter injury related to obstetric trauma. Only a small percentage of women are diagnosed with sphincter tears immediately after vaginal delivery, but endoanal ultrasonography shows that one third of these women have occult sphincter defects. Furthermore, in patients submitted to primary repair of these tears, ultrasound revealed a high frequency of persistent sphincter defects after surgery. Three-dimensional endoanal ultrasonography is currently largely used and accepted for sphincter evaluation in fecal incontinence, improving diagnostic accuracy and our knowledge of physiologic and pathological sphincters alterations. Conversely, there is currently no evidence to support the use of elastography in fecal incontinence evaluation.

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.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.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.We found that performing EAUS in the puerperium following OASIS has limited value in predicting long-term AI.

Endoanal ultrasound is considered the gold standard when assessing the obstetric anal sphincter complex. Due to its relative intrusiveness and economic cost, other ultrasound modalities are on the rise, such as transperineal ultrasound with a convex probe. The aim of our study was to evaluate the agreement between endoanal ultrasound scores (EAUS score) and transperineal ultrasound scores (TPUS score) in assessing residual obstetric anal sphincter defects.

To explore the morphological characteristics and normal biometry of the anal sphincter complex in nulliparous Chinese women using three‐dimensional (3D) transperineal ultrasound.

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.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.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).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.Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.

The gold standard of postpartum anal sphincter imaging has been the 3D endoanal ultrasound (EAUS). Development of magnetic resonance imaging (MRI) has allowed anal sphincter evaluation without the use of endoanal coils. The aim of this study is to compare these two modalities in diagnosing residual sphincter lesions post obstetric anal sphincter injury (OASI).Forty women were followed up after primary repair of OASI with both 3D EAUS and external phased array MRI. Details of the anal sphincter injury and sphincter musculature were gathered and analysed.There was a moderate interrater reliability (κ = 0.510) between the two imaging modalities in detecting sphincter lesions, with more lesions detected by MRI. There was a moderate intraclass correlation (ICC) between the circumference of the tear (κ = 0.506) and a fair ICC between the external anal sphincter thickness measurements at locations 3 and 9 on the proctologic clock face (κ = 0.320) and (κ = 0.336).The results of our study indicate that the use of external phased array MRI is feasible for detecting obstetric anal sphincter lesions postpartum. This allows for imaging of the sphincter defects in centres where EAUS imaging is not available.• A two centre prospective study that showed external phased array MRI to be a valid imaging modality for diagnosing obstetric anal sphincter injuries.

The goal of this project was to create an up‐to‐date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

Obstetric anal sphincter injuries (OASISs) complicate up to 11% of vaginal deliveries; obstetricians must be able to recognize and manage these technically challenging injuries.The aim of this study was to share our approach for management of these challenging complications of childbirth based on a multidisciplinary collaboration between general obstetrician-gynecologists, maternal fetal medicine specialists, and female pelvic medicine and reconstructive surgeons established at our institution.A systematic literature search was performed in 3 search engines: PubMed 1946-, EMBASE 1947-, and the Cochrane Database of Systematic Reviews using keywords and Identification should begin with an assessment of risk factors, notably nulliparity and operative vaginal delivery, consistently associated with the highest risk of OASISs, and proceed with a thorough examination to grade the degree of laceration. Repair should be performed or supervised by an experienced clinician in an operating room with either regional or general anesthesia. The external anal sphincter may be repaired using either an overlapping or end-to-end anastomosis. Providers should be comfortable with both approaches as the degree of laceration may necessitate one approach over the other. We advocate for use of monofilament suture on all layers to decrease risk of bacterial seeding, as well as preoperative antibiotics and postoperative bowel regimen, which are associated with improved outcomes.Long-term sequelae, including pain, dyspareunia, and fecal incontinence, significantly impact quality of life for many patients who suffer OASISs and may be avoided if evidence-based guidelines for recognition and repair are utilized.

Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Obstetric anal sphincter injuries (OASIS) contribute significantly to the development of anal incontinence (AI) in women. The aim of this study was to establish the incidence of AI after OASIS and to study the influence on the quality of life (QoL) in patients with OASIS.This cohort study, with prospective case-control follow-up, involves women who were treated for OASIS between 2005 and 2012 in two academic medical centers in The Netherlands. Three hundred and thirteen patients and 780 controls were invited to complete a validated questionnaire (Defecation Distress Inventory, Wexner Incontinence Score, and Fecal Instrument Quality of Life) regarding symptoms and bother of AI subsequent and QoL after delivery. The main outcome measures were the presence of AI and the impact on QoL.The questionnaire was completed by 141 patients and 194 controls. Mean follow-up was 4 years (range 1-9 years) in both groups. In the patient group, 55 women (39 %) reported AI symptoms compared with 38 women (20 %) in the control group (odds ratio 2.7, 95 % confidence interval 1.66-4.47, p < 0.01). In women who experienced symptoms of AI as very bothersome, QoL was affected in 14 (82.0 %) patients and three (33.5 %) controls (p = 0.012).In this study, women with OASIS had a more than doubled risk of longer-term bothersome symptoms of AI compared with controls. Symptoms were experienced as bothersome and as having an influence on QoL.

The long-term prevalence of anal incontinence after vaginal delivery is unknown. The aim of the present study was to evaluate the prevalence of anal incontinence in primiparous women 5 years after their first delivery and to evaluate the influence of subsequent childbirth.A total of 349 nulliparous women were prospectively followed up with questionnaires before pregnancy, at 5 and 9 months, and 5 years after delivery. A total of 242 women completed all questionnaires. Women with sphincter tear at their first delivery were compared with women without such injury. Risk factors for development of anal incontinence were also analyzed.Anal incontinence increased significantly during the study period. Among women with sphincter tears, 44% reported anal incontinence at 9 months and 53% at 5 years (P =.002). Twenty-five percent of women without a sphincter tear reported anal incontinence at 9 months and 32% had symptoms at 5 years (P <.001). Risk factors for anal incontinence at 5 years were age (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0-1.2), sphincter tear (OR 2.3; 95% CI 1.1-5.0), and subsequent childbirth (OR 2.4; 95% CI 1.1-5.6). As a predictor of anal incontinence at 5 years after the first delivery, anal incontinence at both 5 months (OR 3.8; 95% CI 2.0-7.3) and 9 months (OR 4.3; 95% CI 2.2-8.2) was identified. Among women with symptoms, the majority had infrequent incontinence to flatus, whereas fecal incontinence was rare.Anal incontinence among primiparous women increases over time and is affected by further childbirth. Anal incontinence at 9 months postpartum is an important predictor of persisting symptoms.

The management of patients with fecal incontinence and an external anal sphincter (EAS) defect remains controversial. A retrospective series of overlapping anal sphincteroplasties performed between 1985–2013 from a single center, supplemented by selective puborectalis plication and internal anal sphincter repair is presented. Patients were clinically followed along with anorectal manometry, continence scoring (Cleveland Clinic Incontinence Score—CCS) and patient satisfaction scales. Patients with a suboptimal outcome were managed with combinations of biofeedback therapy (BFT), peripheral tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS) or repeat sphincteroplasty. There were 120 anterior sphincter repairs with 90 (75%) levatorplasties and 84 (70%) IAS repairs. Over a median follow-up of 120 months (IQR 60–173.7 months) there were significant improvements in the recorded CCIS values (90.8% with a preoperative CCIS &gt; 15 vs. 2.5% postoperatively; p &lt; 0.001). There were 42 patients who required ancillary treatment with four repeat sphincteroplasties, 35 patients undergoing biofeedback therapy, 10 patients treated with PTNS and three managed with SNS implants with an ultimate good functional outcome in 92.9% of cases. No difference was noted in ultimate functional outcome between those treated with sphincteroplasty alone compared with those who needed ancillary treatments (97.1% vs. 85.7%, respectively). Overall, 93.3% considered the outcome as either good or excellent. Long-term functional outcomes of an overlapping sphincteroplasty are good. If the initial outcome is suboptimal, response to ancillary treatments remains good and patients are not compromised by a first-up uncomplicated sphincter repair.

The pelvic floor biomechanics and sphincter functioning are essential for understanding pelvic floor dysfunction and the pathophysiology of the pelvic organs. The pelvic floor consists of muscles, fascial connections and ligaments. The Integral Theory Paradigm (ITP) explains the musculoskeletal entity of the sphincter mechanism and the pathophysiology of pelvic organ function. The ITP explains the pelvic floor function determined by 3 directional muscle forces: forward, backwards and downward-acting muscle vector forces that form an anterior and posterior resultant. The resultant equilibrium is essential for urinary continence, voiding and defecation. Loose ligaments disturb the equilibrium of the pelvic floor's muscular function with consequences for the organ function's continence, evacuation, and sensory perception.

To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle.A total of 61 nulliparous women were seen at 36-40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2-6 months postpartum.Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21-51%). Among those delivered vaginally, there were associations with higher maternal age (P =.10), vaginal operative delivery (P =.07), and worsened stress incontinence postpartum (P =.02).Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth.

Anal incontinence is a frequent pathological condition with devastating impact on quality of life. The prevalence is approximately 15% of the population, with higher incidence reported in the elderly and multiparous women, and several factors have a major role in its pathogenesis, such as anatomical sphincter defects (Glasgow and Lowry in Dis Colon Rectum 55(4): 482-490, 2012), delivery injuries, and colorectal, uro-gynecological, and perineal surgery. The direct surgical approach is the gold standard treatment for fecal incontinence, especially through anterior sphincteroplasty, although a permanent defect of continence persists over time. The aim of our study is to evaluate, throughout a systematic review of the literature, the short- and long-term outcomes of sphincteroplasty performed for obstetric injuries anal incontinence. A systematic review of the studies published in the literature from January 2000 to December 2021 was performed in accordance with the PRISMA guidelines. Of the 2543 studies extrapolated, only eight fulfilled the inclusion criteria and were admitted represented by retrospective and prospective studies. The data analyzed from the included studies were number and mean age of the female population, and incontinence improvement with preoperative and postoperative short- and long-term outcomes, as reported by QoL questionaries and incontinence scores. Overall 355 patients with obstetric sphincter damage underwent sphincteroplasty with an anterior external sphincter overlapping procedure. A consistent improvement in fecal incontinence at short-term follow-up with relative improvement in QoL was reported. In 7 of 8 studies, the authors found a progressive worsening of the incontinence symptoms on the long-term follow-up. However, it is not clear whether the decrease in long-term continence results is parallel to a simultaneous decrease in QoL scores. Nevertheless, compared to the preoperative findings, the improvement was maintained in the long-term follow-up. Despite the limited data in the literature, a properly performed sphincteroplasty can guarantee a consistent improvement of the continence in short term with encouraging outcomes, especially for solid stool continence, in long time. We believe that anterior sphincteroplasty, as a low cost, feasible, and safe procedure, still has a role in the treatment of fecal incontinence for obstetric injury. Further large cohort randomized clinical trials are necessary to validate these results.© 2023. Italian Society of Surgery (SIC).