Strong agreement between interview-obtained and self-administered Wexner and St. Mark's scores using a single questionnaire.

INTRODUCTION AND HYPOTHESIS: St Mark's incontinence score (SMIS) and the Wexner score have been constructed and validated as interview-based scoring systems. We developed a single questionnaire from which a separate SMIS or Wexner score could be derived. This study aimed to demonstrate the level of agreement between self-administered (sSMIS and sWexner) and interview-based (iSMIS and iWexner) scores using this questionnaire. METHODS: One hundred five consecutive patients (30 male) seen in the incontinence outpatient clinics at the Østfold Hospital Trust, Sarpsborg, and University Hospital of North Norway, Tromsø, completed the self-administered incontinence questionnaire prior to the appointment. Following clinical investigation, the patients were interviewed about their symptoms according to the SMIS and Wexner scores, with the interviewers blinded to the results from self-reported questionnaire. Agreement between total scores and between subscores of the various items were determined using interclass correlation coefficient (ICC) and kappa statistics, respectively. RESULTS: The self-administered questionnaire was incomplete in six cases (5.7%) and the interview-based was incomplete in two cases. Agreement was almost perfect between the iSMIS and sSMIS and between the iWexner score and sWexner score (ICC 0.90 and 0.92, respectively). Agreement was substantial to almost perfect for all items in both scoring systems, with kappa values ranging from 0.64-0.94. Mean iSMIS was 9.48 versus 9.53 for sSMIS (p = 0.90) and 8.26 versus 8.44 for the iWexner and sWexner score, respectively (p = 0.42). CONCLUSION: The SMIS and Wexner scores can be completed by the patients using a single questionnaire, and the derived SMIS and Wexner scores are highly consistent with scores obtained by interview.

Prevalence and predictors of anal incontinence 6 years after first delivery.

AIMS: The main aim of the present study, was to explore prevalence and predictors of anal incontinence (AI) experienced 6 years after first delivery. METHODS: In this longitudinal prospective cohort study, participants in a previous study answered questions about AI 6 years after first delivery using postal or digital questionnaires. Prevalence of AI was calculated, and multivariable logistic regression analyses were applied. RESULTS: A total of 731 (48%) of the original participants who gave birth to their first child between May 2009 and December 2010 responded 6 years after first delivery. There was a significant reduction in reports of one or more AI symptoms from late pregnancy (33%; 95%CI: 30.3, 37.2) to 6 years after first delivery (21%; 95%CI:18.4, 24.4, P = 0.028). Older age at first delivery, BMI (≥35), active bowel disease, and previous problems with bowel evacuation and urgency when going to the toilet predicted AI at 6 years. Long-term AI was also associated with instrumental first delivery (Odds ratio (OR):1.8; 95%CI:1.1, 2.8) and sustaining a perianal tear grade three or four at first delivery (OR:3.0; 95%CI:1.3, 6.8). CONCLUSIONS: Prevalence of AI was significantly reduced from late pregnancy, still 21% experienced AI 6 years after first delivery. Findings from the present study indicate that an added focus on modifiable risk factors for AI such as BMI, OASIS and history of PFDs increase the risk of AI in the long term, may be beneficial in reducing incontinence problems the short- and long-term.

Prevalence and predictors of double incontinence 1 year after first delivery.

INTRODUCTION AND HYPOTHESIS: Urinary (UI) and anal incontinence (AI) are common pelvic floor disorders (PFD), and postpartum women experiencing double incontinence (DI), the combination of UI and AI, tend to have more severe symptoms and a greater impact on quality of life. Our objective was to investigate the prevalence and predictors of postpartum DI and UI alone 1 year after first delivery. METHODS: In this prospective cohort study, 976 women reported the prevalence of DI and UI alone 1 year after their first delivery in one of two hospitals in Norway using the St Marks score and the ICI-Q UI SF. RESULTS: DI was significantly reduced from 13% in late pregnancy to 8% 1 year later, whereas 30% reported UI at both time points. Incontinence in late pregnancy predicted incontinence 1 year after delivery. Higher age was associated with UI alone. Compared with caesarean delivery, normal vaginal or instrumental delivery increased the risk of UI alone more than three and four times respectively. Obstetric anal sphincter injuries showed a four-fold increase in the risk of DI. CONCLUSIONS: Nearly 50% reported incontinence symptoms 1 year after first delivery. Continence status during pregnancy was one of the main predictors of postpartum continence status. Mode of delivery increased the risk of postpartum UI, whereas obstetric anal sphincter injuries increased the risk of postpartum DI.

Interview-based versus self-reported anal incontinence using St Mark's incontinence score.

INTRODUCTION AND HYPOTHESIS: St Mark's incontinence score (SMIS) was originally designed and validated for use in an interview setting (iSMIS), and there is conflicting evidence for the validity of the self-administered SMIS (sSMIS). Our objective was to compare self-administered and interview-based reports of anal incontinence (AI) symptoms. METHODS: A total of 147 women reported symptoms of AI on a sSMIS before inclusion in a clinical study investigating the effect of conservative treatment for AI 1 year after delivery. After clinical investigations, an iSMIS was completed by one of two consultant surgeons blinded to the sSMIS results. The correlation and agreement among the individual items of the iSMIS and the sSMIS were assessed using Spearman's rho and weighted kappa statistics, respectively. RESULTS: The mean iSMIS and sSMIS reported was 4.0 (SD: 3.6) and 4.3 (SD: 4.0), respectively. Spearman's rho showed a strong relationship between the two total SMIS scores (r = 0.769, n = 147, p < 0.001), and explained variance was 59% (r2=0.591). Except for the individual item about gas incontinence, women reported more frequent AI symptoms on the sSMIS than on the iSMIS. The assessment of consistency among the individual items of the iSMIS and sSMIS showed substantial agreement (κ ≥ 0.60) for all items except for fair agreement for the item about formed stool incontinence (κ = 0.22), and moderate for the item about any change in lifestyle (κ = 0.5). CONCLUSIONS: The level of consistency between the two methods of reporting anal incontinence symptoms suggests that the St Mark's score may be used as both an interview-based and a self-administered incontinence score.

Anal incontinence among first time mothers - what happens in pregnancy and the first year after delivery?

INTRODUCTION: Pregnancy- and delivery-related factors affect postpartum anal incontinence. We aimed to explore changes in continence status among primiparas from late pregnancy through the first year postpartum. MATERIAL AND METHODS: In this prospective cohort study set in two Norwegian hospitals, 862 healthy primiparas completed questionnaires about the main outcome measure anal incontinence, including flatus incontinence and urgency, at three time points; late pregnancy, 6 and 12 months postpartum. Socioeconomic and delivery-related data were obtained from hospital records. Logistic regression analyses were applied to determine the association between continence status at 12 months postpartum, and continence status in late pregnancy, 6 months postpartum, demographic and delivery-related characteristics. RESULTS: Among the 189 (22%) primiparas reporting anal incontinence in late pregnancy, 34 (18%) had persistent anal incontinence 1 year later. Forty-eight (43%) of the 113 women incontinent at 6 months postpartum experienced persistent anal incontinence at 12 months. Eight percent of previously continent women reported new onset anal incontinence at 6 and 12 months after delivery. Occipitoposterior presentation was the only delivery-related factor increasing the risk of postpartum anal incontinence [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.0-3.4]. Young age increased the risk of anal incontinence at 1 year after delivery, whereas incontinence in late pregnancy increased the risk of anal incontinence persisting through 6 and 12 months postpartum. CONCLUSION: In most first-time mothers with postpartum anal incontinence, the onset of anal incontinence was before delivery. Except for occipitoposterior presentation, no delivery-related factors increased the risk of postpartum anal incontinence. This may indicate that hormonal, mechanical or neuromuscular changes in pregnancy affect long-term anal incontinence more than vaginal delivery.

Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial.

OBJECTIVE: The objective is to test if the injection of a bulking agent in the anal canal is superior to sphincter training with biofeedback in the treatment of anal incontinence. BACKGROUND: Anal incontinence is traditionally treated with conservative measures, such as pads and constipating medicine. If this fails, sphincter training with biofeedback is often offered before more advanced surgical procedures are considered. The injection of a bulking agent in the anal canal is a relatively new and promising treatment option. METHODS: In a randomized, controlled, evaluator-blinded trial, 126 adult patients with anal incontinence were randomly assigned to a transanal, submucosal injection of 4 x 1 mL of dextranomer in hyaluronic acid or to sphincter training with biofeedback. The primary outcome was severity of incontinence, evaluated by St Mark's score for incontinence (0 = continence to 24 = complete incontinence) assessed at 2 years after the start of treatment. A mixed models analysis was applied. RESULTS: Of the 126 participants, 64 patients were randomly assigned to anal injections, and among them the mean St Mark's score improved from 12.9 (95% CI: 11.8-14.0) at baseline to 8.3 (95% CI: 6.7-9.8) at the end of follow up. Among the 62 patients who were assigned to sphincter training with biofeedback, there was a corresponding improvement in St Mark's score from 12.6 (95% CI: 11.4-13.8) to 7.2 (95% CI: 7.2-8.8). Comparisons of St Mark's scores between the groups showed no differences in effect between treatments. CONCLUSION: The efficacy of anal injections and biofeedback in treating anal incontinence did not differ in this randomized, single-blinded, controlled trial.