Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study.

OBJECTIVES: To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. METHODS: This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. RESULTS: Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. CONCLUSIONS: Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction?

OBJECTIVE: Avulsion of the levator ani muscle commonly occurs at vaginal birth. This condition is usually diagnosed by translabial ultrasound (TLUS) during pelvic floor muscle contraction (PFMC). Some patients are unable to achieve a satisfactory PFMC and in these cases avulsion is assessed at rest. The aim of this study was to validate the diagnosis of levator avulsion by means of TLUS at rest. METHODS: This was a retrospective study of 233 women seen at a tertiary urogynecological center. All women underwent four-dimensional TLUS in the supine position and after voiding. Volumes were obtained on maximal PFMC and at rest. Analysis of the volumes was performed with the observer blinded against all clinical data. Avulsion was defined as an abnormal levator ani muscle insertion that was visible in at least three consecutive axial plane slices, at and above the level of minimal hiatal dimensions, at 2.5-mm intervals. We examined the correlation between both assessment methods using Cohen's kappa coefficient and tested the association of each method with female pelvic organ prolapse on clinical examination, organ descent on ultrasound and hiatal ballooning. RESULTS: In total, datasets from 202 women were available for analysis. The correlation between a diagnosis of avulsion in volumes obtained at rest and those on PFMC was moderate, with a kappa value of 0.583 (95% CI, 0.484-0.683). Agreement for defects visualized on single slices was moderate, with a kappa value of 0.556 (95% CI, 0.520-0.591). When avulsion diagnoses at rest and on PFMC were tested against symptoms of prolapse, and prolapse on clinical examination and on ultrasound, neither of the two methods was superior. CONCLUSION: Although tomographic ultrasound imaging during PFMC enhances tissue discrimination, this may not translate to superior diagnostic performance. Hence, volumes obtained at rest may be used in women unable to contract their pelvic floor. The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid when performed at rest or on PFMC. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The 'bother' of obstructed defecation.

OBJECTIVE: To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment. METHODS: All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings. RESULTS: Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001). CONCLUSIONS: VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Laparoscopic sacrocolpopexy: how low does the mesh go?

OBJECTIVE: Laparoscopic sacrocolpopexy is becoming an increasingly popular surgical approach for repair of apical vaginal prolapse. The aim of this study was to document the postoperative anterior mesh position after laparoscopic sacrocolpopexy and to investigate the relationship between mesh location and anterior compartment support. METHODS: This was an external audit of patients who underwent laparoscopic sacrocolpopexy for apical prolapse ≥ Stage 2 or advanced prolapse ≥ Stage 3, between January 2005 and June 2012. All patients were assessed with a standardized interview, clinical assessment using the International Continence Society Pelvic Organ Prolapse quantification and four-dimensional transperineal ultrasound to evaluate pelvic organ support and mesh location. Mesh position was assessed with respect to the symphysis pubis whilst distal mesh mobility was assessed using the formula √[(XValsalva - Xrest )2 + (YValsalva - Yrest )2 ], where X is the horizontal distance and Y is the vertical distance between the mesh and the inferior symphyseal margin, measured at rest and on Valsalva. RESULTS: Ninety-seven women were assessed at a mean follow-up of 3.01 (range, 0.13-6.87) years after laparoscopic sacrocolpopexy, 88% (85/97) of whom considered themselves to be cured or improved, and none had required reoperation. On clinical examination, prolapse recurrence in the apical compartment was not diagnosed in any patient; however, 60 (62%) had recurrence in the anterior compartment and 43 (44%) in the posterior compartment. On ultrasound examination, mesh was visualized in the anterior compartment in 60 patients. Both mesh position and mobility on Valsalva were significantly associated with recurrent cystocele on clinical and on ultrasound assessment (all P < 0.01). For every mm that the mesh was located further from the bladder neck on Valsalva, the likelihood of cystocele recurrence increased by 6-7%. CONCLUSION: At an average follow-up of 3 years, laparoscopic sacrocolpopexy was highly effective for apical support; however, cystocele recurrence was common despite an emphasis on anterior mesh extension. Prolapse recurrence seemed to be related to mesh position and mobility, suggesting that the lower the mesh is from the bladder neck, the lower the likelihood of anterior compartment prolapse recurrence. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Does the Epi-No(®) birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective randomised controlled trial.

OBJECTIVE: Vaginal childbirth may result in levator ani injury secondary to overdistension during the second stage of labour. Other injuries include perineal and anal sphincter tears. Antepartum use of a birth trainer may prevent such injuries by altering the biomechanical properties of the pelvic floor. This study evaluates the effects of Epi-No(®) use on intrapartum pelvic floor trauma. DESIGN: Multicentre prospective randomised controlled trial. SETTING: Two tertiary obstetric units in Australia. POPULATION: Nulliparous women carrying an uncomplicated singleton term pregnancy. METHODS: Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester, and again at 3-6 months postpartum. Women randomised to the intervention group were asked to use the Epi-No(®) device from 37 weeks of gestation until delivery. MAIN OUTCOME MEASURES: Levator ani, anal sphincter, and perineal trauma diagnosed clinically and/or with translabial ultrasound imaging. RESULTS: Of 660 women randomised, 504 (76.4%) returned for assessment at a mean of 5 months postpartum. There was no significant difference in the incidence of levator avulsion [12 versus 15%; relative risk (RR) 0.82, 95% confidence interval (95% CI) 0.51-1.32; absolute risk reduction (ARR) 0.03, 95% CI -0.04 to 0.09; P = 0.39], irreversible hiatal overdistension (13 versus 15%; RR 0.86, 95% CI 0.52-1.42; ARR 0.02, 95% CI -0.05 to 0.09; P = 0.51), clinical anal sphincter trauma (7 versus 6%; RR 1.12, 95% CI 0.49-2.60; ARR -0.01, 95% CI -0.05 to 0.06; P = 0.77), and perineal tears (51 versus 53%; RR 0.96, 95% CI 0.78-1.17; ARR 0.02, 95% CI -0.08 to 0.13; P = 0.65). A marginally higher rate of significant defects of the external anal sphincter on ultrasound was observed in the intervention group (21 versus 14%; RR 1.44, 95% CI 0.97-2.20; ARR -0.06, 95% CI -0.13 to 0.05; P = 0.07). CONCLUSION: Antenatal use of the Epi-No(®) device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma. TWEETABLE ABSTRACT: No evidence of a protective effect of the Epi-No(®) device on intrapartum pelvic floor rauma.

Does it matter whether levator avulsion is diagnosed pre- or postoperatively?

OBJECTIVE: Levator ani muscle avulsion is found in 15-30% of parturients and is associated with recurrence of pelvic organ prolapse (POP) following surgery, although most published evidence on recurrence relates to postoperative diagnosis. We performed a study to determine whether a diagnosis of avulsion after pelvic floor surgery can be used as a proxy for preoperative diagnosis. METHODS: This was a retrospective study of 207 patients who were seen before and after surgery for POP between February 2007 and May 2013. All assessments included a three/four-dimensional transperineal tomographic ultrasound examination. Volume data were stored and analyzed at a later date by an operator who was blinded against all clinical data. The primary outcome measure was agreement between preoperative and postoperative diagnoses of avulsion, as evaluated by Cohen's kappa. Secondary outcome measures were the associations of pre- and postoperative diagnoses of levator avulsion with prolapse recurrence, defined as International Continence Society POP-Q Stage ≥ 2 in any compartment. RESULTS: Mean follow-up after surgery was 1.3 (range, 0.3-5.5) years. Levator avulsion was found preoperatively in 111 (53.6%) patients and postoperatively in 109 (52.7%). The kappa value for the association between pre- and postoperative avulsion was 0.864 (95% CI, 0.796-0.933), signifying high agreement. The odds ratio of prolapse recurrence in women with a preoperative diagnosis of avulsion was 2.5 (95% CI, 1.3-4.5) and in those with a postoperative diagnosis it was 2.3 (95% CI, 1.3-4.2). CONCLUSIONS: The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid before and after pelvic reconstructive surgery for POP, and both diagnoses show excellent agreement. This implies that a postoperative diagnosis of avulsion can be used as a proxy for preoperative diagnosis. Hence, avulsion can be identified postoperatively and used for subgroup analysis in prospective surgical intervention trials to define high-risk patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Perineal and vaginal tears are clinical markers for occult levator ani trauma: a retrospective observational study.

OBJECTIVES: Levator avulsion has been shown to be associated with anterior and central compartment prolapse and is a risk factor for prolapse recurrence. Diagnosis in the delivery room is usually impossible, as levator avulsion is commonly occult. The objective of this study was to determine if vaginal and major perineal tears are clinical markers of levator trauma as diagnosed by four-dimensional (4D) translabial ultrasound 3-6 months postpartum. METHODS: This was a retrospective observational study using data obtained in two perinatal trials. A total of 774 women seen, on average, 5 (range, 2.3-22.4) months after their first delivery of a term singleton cephalic baby underwent a standardized interview, clinical assessment and 4D translabial ultrasound examination. Clinical data were obtained from the institutional obstetric database, including information on vaginal and perineal tears. Levator avulsion was diagnosed using tomographic ultrasound, with operators blinded to the clinical data. RESULTS: Both third- and fourth-degree perineal tears and vaginal sidewall tears were independently associated with levator avulsion (P = 0.004 and P = 0.012, respectively). The odds ratio for avulsion in women suffering from such overt trauma was 3.44 (95% CI, 1.47-8.03) for third-/fourth-degree perineal tears and 3.35 (95% CI, 1.30-8.61) for vaginal sidewall tears. CONCLUSIONS: Vaginal sidewall and third-/fourth-degree perineal tears were found to be independent clinical indicators of an increased risk of levator trauma, as diagnosed by 4D translabial ultrasound 3-6 months postpartum. Such clinical markers may become useful in the identification of women at high risk of levator trauma and future pelvic floor disorders.

Warping of the levator hiatus: how significant is it?

OBJECTIVES: The levator hiatus is the largest potential hernial portal in the human body. Excessive distensibility is associated with female pelvic organ prolapse (POP). Distension occurs not just laterally but also caudally, resulting in perineal descent and hiatal deformation or 'warping'. The aim of this study was to quantify the warping effect in symptomatic women, to validate the depth of the rendered volume used for the 'simplified method' of measuring hiatal dimensions and to determine predictors for the degree of warping. METHODS: This was a retrospective study utilizing records of patients referred to a tertiary urogynecological service between November 2012 and March 2013. Patients underwent a standardized interview, clinical assessment using the POP quantification system of the International Continence Society and four-dimensional translabial ultrasound. The craniocaudal difference in the location of minimal distances in mid-sagittal and coronal planes was determined by offline analysis of ultrasound volumes, and provided a numerical measure of warping. We tested potential predictors, such as demographic factors, signs and symptoms of prolapse, levator avulsion and levator distensibility, for an association with warping. RESULTS: Full datasets were available for 190 women. The mean craniocaudal difference in location of minimal distances in mid-sagittal and coronal planes was -1.26 mm (range, -6.7 to 4.6 mm; P < 0.001). This measure of warping was associated with hiatal area on Valsalva maneuver (r = - 0.284; P < 0.0001) and signs of significant prolapse on clinical and ultrasound examination (both P < 0.0001). CONCLUSIONS: The plane of minimal dimensions of the levator ani hiatus is non-Euclidean, i.e. warped, and the degree of warping is associated with hiatal distension, or 'ballooning', and with POP. However, the degree of warping is minor, the largest difference we found in the location of the plane of minimal dimensions being 6.7 mm. Hence, our results support the determination of hiatal area in a rendered volume of 1-2 cm in depth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Anal sphincter trauma and anal incontinence in urogynecological patients.

OBJECTIVES: To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma. METHODS: This was a retrospective analysis of ultrasound volume datasets of 501 patients attending a tertiary urogynecological unit. All patients underwent a standardized interview including determination of St Mark's score for those presenting with AI. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS and the internal anal sphincter (IAS). RESULTS: Among a total of 501 women, significant EAS and IAS defects were found in 88 and 59, respectively, and AI was reported by 69 (14%). Optimal prediction of AI was achieved using a model that included four abnormal slices of the EAS on TUI. IAS defects were found to be less likely to be associated with AI. In a multivariable model controlling for age and IAS trauma, the presence of at least four abnormal slices gave an 18-fold (95% CI, 9-36; P < 0.0001) increase in the likelihood of AI, compared with those with fewer than four abnormal slices. Using receiver-operating characteristics curve statistics, this model yielded an area under the curve of 0.86 (95% CI, 0.80-0.92). CONCLUSIONS: Both AI and significant EAS trauma are common in patients attending urogynecological units, and are strongly associated with each other. Abnormalities of the IAS seem to be less important in predicting AI. Our data support the practice of using, as a minimal criterion, defects present in four of the six slices on TUI for the diagnosis of significant EAS trauma.

How large does a rectocele have to be to cause symptoms? A 3D/4D ultrasound study.

INTRODUCTION: Rectocele is a common condition, which on imaging is defined by a pocket identified on Valsalva or defecation. Cut-offs of 10 and 20 mm for pocket depth have been described. This study analyses the correlation between rectocele depth and symptoms of bowel dysfunction to define a cut-off for the diagnosis of "significant rectocele" on ultrasound. METHODS: A retrospective study using 564 archived data sets of patients seen at tertiary urogynaecological clinics. Patients underwent a standardised interview including a set of questions regarding bowel function, and translabial 3D/4D ultrasound. Assessments were undertaken supine and after voiding. Rectocele depth was measured on Valsalva. RESULTS: Out of 564, data on symptoms was missing in 18 and ultrasound volumes in 25, leaving 521. Mean age was 56 years (range 18-86), mean BMI 29 (17-56). Presenting symptoms were prolapse (51 %), constipation (21 %), vaginal digitation (17 %), straining at stool (46 %), incomplete bowel emptying (41 %) and faecal incontinence (10 %). A clinically significant rectocele (ICS POPQ stage ≥2) was found in 48 % (n=250). In 261 women a rectal diverticulum was identified, of an average depth of 17 (SD, 7) mm. On ROC statistics a cut- off of 15 mm in depth provided optimal sensitivities of 66 % for vaginal digitation and 63 % for incomplete emptying, and specificities of 52 and 57 % respectively. CONCLUSIONS: Rectocele depth is associated with symptoms of obstructed defecation. A "clinically significant" rectocele may be defined as a diverticulum of the rectal ampulla of ≥15 mm in depth, although poor test characteristics limit clinical utility of this cut-off.

Temporal latency between pelvic floor trauma and presentation for prolapse surgery: a retrospective observational study.

INTRODUCTION AND HYPOTHESIS: Levator avulsion is an etiological factor for female pelvic organ prolapse (POP) and generally occurs during a first vaginal birth. However, most women with POP present decades later. This study aimed to estimate latency between pelvic floor trauma and presentation for POP surgery. METHODS: This was a retrospective observational study in a tertiary urogynecological unit to which 354 patients presented for evaluation prior to prolapse surgery between June 2011 and December 2012. All underwent an interview, clinical assessment [International Continence Society Pelvic Organ Prolapse Quantification score (ICS POPQ) and 4D translabial ultrasound (US). Postprocessing analysis of US volumes was blinded against clinical data. The main outcome measure was temporal latency between first vaginal birth and prolapse presentation in women with levator avulsion. RESULTS: Three hundred and fifty-four patients presented with symptoms of prolapse, of whom 115 (32 %) were found to have an avulsion of the levator ani muscle. Of these, 30 patients were excluded due to previous prolapse surgery, leaving 85, all of whom showed significant prolapse on US and/or clinical staging. Mean latency between first vaginal delivery and presentation was 33.5 (3-66.3) years. There were no associations between latency and potential predictors, except for maternal age at first birth, which was associated with shorter latency (r = -0.45 , P < 0.001). There was a trend toward shorter latency after forceps delivery (P = 0.09). CONCLUSIONS: Average latency between first birth and presentation for prolapse surgery in women with avulsion was 33.5 (3-66) years. Maternal age at first vaginal birth and possibly forceps delivery were associated with shorter time to presentation.

Residual defects of the external anal sphincter following primary repair: an observational study using transperineal ultrasound.

OBJECTIVES: Obstetric anal sphincter tears are common and an important factor in the etiology of anal incontinence. The objective of the study was to evaluate the prevalence of residual defects of the external anal sphincter (EAS) after primary repair of obstetric anal sphincter injury using four-dimensional (4D) transperineal ultrasound and to correlate sonographic findings of residual defects and levator avulsion with significant symptoms of anal incontinence, defined as St Mark's fecal incontinence score (SMIS) of ≥ 5. METHODS: This was a retrospective observational study. One-hundred and forty women were seen after primary repair of obstetric anal sphincter tears in a dedicated perineal clinic at a tertiary hospital in Australia. They all underwent a standardized interview, and physical and 4D transperineal ultrasound examination. RESULTS: Mean follow-up interval was 1.9 months after delivery. Eighty-nine (64%) women had a 3a/3b tear, 28 (20%) a 3c/4(th) degree tear and 23 (16%) an unclassified 3(rd) degree tear. Thirty-five (25%) patients reported symptoms of anal incontinence. Nine had an SMIS of ≥ 5. A residual defect was found in 56 (40%) cases and levator avulsion in 27 (19%). On multivariate logistic regression, residual defects (P = 0.03; odds ratio (OR) = 6.38; 95% CI, 1.23-33.0) and levator avulsion (P = 0.047; OR = 4.38; 95% CI, 1.02-18.77) were found to be independent risk factors for anal incontinence. CONCLUSIONS: Residual defects of the EAS were found on transperineal ultrasound in 40% of women after primary repair of obstetric anal sphincter injuries. Although most were asymptomatic, residual anal sphincter defects and levator avulsion were associated with significant symptoms of anal incontinence as quantified using the SMIS.

Use of a visual analog scale for evaluation of bother from pelvic organ prolapse.

OBJECTIVES: A specified anatomical degree of prolapse may cause no bother in one individual and a severe form of bother in another. The aim of this study was to determine the factors contributing to the degree of bother due to a given degree of prolapse, to help with the clinical evaluation of patients and planning of preventive intervention trials and surgical treatment. METHODS: Consecutive patient records of 654 women who had attended a urogynecology unit between August 2011 and December 2012 were reviewed. All patients underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound scan. The degree of bother was evaluated using a visual analog scale. RESULTS: Six hundred and thirty-six women were included in the analysis, with ultrasound data available for cystocele, rectocele and enterocele descent and rectocele depth measurements and 442 for uterine descent. 313 women (49.2%) had subjective symptoms of female pelvic organ prolapse at a mean bother score of 6.0 ± 2.6. Average bother score for the complete dataset was 3.0 ± 3.5. Parity, vaginal delivery, levator avulsion, any significant clinical prolapse or prolapse seen on ultrasound were associated with prolapse bother and all clinical and ultrasound measures of pelvic organ descent remained significant or near significant on multivariate analysis. CONCLUSIONS: Quantification of prolapse bother using a visual analog scale is valid and repeatable and may represent a simple tool for use in clinical practice.

Pelvic floor trauma: does the second baby matter?

OBJECTIVE: To ascertain the effect of a second delivery on pelvic floor anatomy. METHODS: This was a retrospective analysis of data obtained in two perinatal imaging studies. Women were invited for antenatal and two postnatal appointments. All had answered a standardized questionnaire and undergone a clinical examination and translabial four-dimensional ultrasound. Ultrasound volumes were acquired at rest, on Valsalva maneuver and on pelvic floor muscle contraction, and analyzed by postprocessing on a PC. Avulsion was diagnosed on tomographic ultrasound imaging. This study reports data obtained in those women who delivered a second child between the first and second postnatal assessments. RESULTS: Of 715 participants, 94 reported a second birth at their second postnatal appointment on average 2.7 years after their first birth; 65 had a vaginal delivery and 29 a Cesarean section. There were nine attempts at vaginal birth after Cesarean section (VBAC), of which six were successful. When we analyzed the ultrasound findings before and after a second delivery, there was no significant change observed in bladder-neck descent, cystocele descent and hiatal area on Valsalva. Delivery mode of the second birth seemed to have little effect on changes observed between follow-ups, although there was a trend towards increased bladder-neck descent in women after vaginal delivery. On reviewing patients diagnosed with avulsion at their 2-3-year visit and comparing them with findings at the first follow-up visit, we found identical (normal) findings in 87 cases. In five there was an unchanged avulsion. In one case, findings had improved from complete to partial avulsion. There was one new avulsion, in a patient who had delivered her first baby by emergency Cesarean section and her second by vacuum delivery. CONCLUSIONS: A second pregnancy and delivery do not seem to have a major effect on bladder support and/or levator function. However, we documented a case of major levator trauma after VBAC. The issue of pelvic floor trauma after VBAC may have to be investigated further.

Prevalence of anal sphincter injury in primiparous women.

OBJECTIVE: To determine the prevalence of obstetric anal sphincter injuries (OASIS) in a cohort of primiparous women and to evaluate their association with demographic, obstetric and ultrasound parameters. METHODS: This was a retrospective analysis of the ultrasound volume datasets of 320 primiparous women, acquired at 5 months postpartum. Tomographic ultrasound imaging (TUI) was used to evaluate the external anal sphincter (EAS). A significant EAS defect was diagnosed if a defect of > 30° was seen in four or more of six TUI slices bracketing the EAS. RESULTS: Significant EAS defects were found in 69 women (27.9% of those delivered vaginally). In nine of those a third-degree tear was diagnosed intrapartum and was sutured. In 60 women with significant defects there was no documentation of sphincter damage at birth, implying unidentified or occult defects (60/69, 87.0%). Among them, 29 had had a second-degree tear, two a first-degree tear and three an intact perineum. In 31 cases an episiotomy had been performed, with five extensions to a third-degree tear. On multivariate analysis only forceps delivery was significantly associated with OASIS. CONCLUSIONS: In this cohort of primiparous women we found OASIS in 27.9% of vaginally parous women, most of which had not been diagnosed in the delivery suite. There seems to be a need for better education of labor-ward staff in the recognition of OASIS. On the other hand, it is conceivable that some defects may be masked by intact tissue. The significance of such defects remains doubtful. Forceps delivery was the only identifiable risk factor.