Risk factors and outcome of repair of obstetric anal sphincter injuries as followed up in a dedicated perineal clinic.

INTRODUCTION AND HYPOTHESIS: Faecal incontinence can be a devastating outcome with social, psychological and physical repercussions, and it occurs in 10-61% following obstetric anal sphincter injury (OASIS). The aim of our study was to determine the contributing factors in the development of severity of OASIS and to correlate anal sphincter tone with the extent of anal sphincter injury. METHODS: A prospective cohort study was performed of all patients attending the postnatal perineal clinic at 4-12 months postpartum, from January 2016 until October 2017. Women were categorised into minor tears (3a and 3b) and major tears (3c and 4th degree). RESULTS: The mean age was 33.9 years (4.2); the mean parity was 1.6 (range 1-5). A total of 75 women (17%) were reviewed following a major tear (4th degree, n = 28, 3c, n = 47) and 362 (83%) were reviewed following a minor tear (3a n = 188, 3b, n = 174). Following analysis of numerous obstetric variables, it was shown that women who had an instrumental delivery were more likely to have a major tear compared with those who had a spontaneous vaginal delivery (p = 0.05). A significant difference was found in the distributions of symptom score between groups (p < 0.001). Women with combined defects were most likely to have reduced anal tone (p < 0.001) compared with any other group. CONCLUSIONS: The perineal clinic provides a valuable resource for investigation and treatment of OASIS, providing a targeted pathway for management. We suggest that endoanal ultrasound and digital rectal examination are complimentary investigations which correlate well with each other.

Haemorrhoids and Anal Fissures in Pregnancy: Predictive Factors and Effective Treatments.

Introduction Haemorrhoids and anal fissures (HAF) are common in pregnancy and can severely affect the quality of life of those suffering from them. Despite the condition being common, there is limited evidence, formal guidelines or recommendations on treatment, and little is known about the natural course during pregnancy. Methods This was a prospective, observational cohort study conducted at a tertiary-referral university maternity hospital (The National Maternity Hospital, Dublin), conducted over a nine-month period. The first part of the study was a case-control study of antenatal patients over 34 weeks' gestation. The second part of the study involved a cohort of postnatal patients. Anonymous patient surveys were performed and analysed. Results Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021. Of the antenatal patients, 82/184 (45%) of these patients had symptoms of HAF and 102/184 (55%) antenatal patients were unaffected, acting as controls. In addition, 74 affected postnatal patients were also included. In the affected antenatal group, 36/82 (44%) of patients had self-reported HAF (symptoms or signs of HAF); 50/82 (61%) of patients diagnosed with HAF on their own. 12/82 (15%) noticed symptoms in the first trimester, 25/82 (30%) in the second and 45/82 (55%) in the third. 142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre. 144/184 (78%) used medical treatments including suppositories. Only one patient had surgery. 70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months. Conclusion HAF affect almost half of the pregnancies. Age over 35 was significantly associated with antenatal haemorrhoids or anal fissures. Concerningly, the majority of patients (64%) self-diagnose and manage the condition without either seeking or receiving guidance from medical professionals. In terms of the natural course of the disease, it was encouraging that 45% of patients' symptoms resolved within a few days. This will help when counselling patients with distressing symptoms. Conservative measures such as increased dietary fibre, increased fluid intake and bath salts were effective in relieving symptoms for the majority of patients.

Evaluation of the clinical performance of the cobas 4800 HPV test in patients referred for colposcopy.

The clinical performance of the cobas human papillomavirus (HPV) test for detection of high-grade disease in a colposcopy-referred population was compared with that of Hybrid Capture 2 (HC2). The overall agreement between the tests was 92.3%. Clinical sensitivity and specificity for detection of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) were 90.0% and 55.5% for cobas and 90.5% and 50.2% for HC2, respectively. In conclusion, both tests showed comparable performance for detection of CIN2+.

The impact of the CervicalCheck controversy on provision of colposcopy services in Ireland: A cohort study.

OBJECTIVES: In 2018, an inquiry into the Irish Cervical Cancer screening programme (CervicalCheck) was initiated, following publicised cases of non-disclosure regarding internal audit results of cytology screening in women diagnosed with cervical cancer. The inquiry attracted widespread media coverage and the government offered women free, out of programme screening. We investigated whether the controversy led to an increase in referrals based on clinical suspicion and the impact on waiting times for abnormal cytology. STUDY DESIGN: A retrospective cross-sectional analysis was performed, including all colposcopy referrals to The National Maternity Hospital, Dublin, before (March 2016-2018) and after (March 2018-2020) the media coverage. Chi-squared (χ2) and independent one-tailed t-tests were used to perform between-group analyses. RESULTS: Post-controversy, suspicious cervix referrals increased (10.1 %-14.2 %; p = 0.037 × 10-27), as did colposcopic impression of CIN (p = 0.000000016). While an increase in CIN1 histology (18.5 %-30.3 %) was diagnosed, a decrease in high-risk CIN2 (10 % to 8.6 %), CIN3 (6.2 % to 2.9 %), AIS (1.2 % to 0.3 %) and invasive cancer (2.8 % to 1.2 %; p = 0.0058 × 10-9) were diagnosed. Across all grades of cytological abnormality, significantly fewer patients were reviewed in the recommended waiting time post-controversy. Half of delayed abnormal cytology referrals had high-grade changes. CONCLUSIONS: This study highlights the profound impact that the CervicalCheck Controversy had on the women attending colposcopy and clinicians performing the screening tests, and the direct impact on women with confirmed cytological abnormalities. The increase in suspicious cervix referrals reflects a lack of confidence in both clinical practice and screening test results. The importance of public trust in the effective delivery of screening services cannot be ignored. Increased resources are required to ensure all women are seen within recommended time frames. Heightened anxiety and increased surveillance does not necessarily lead to better clinical outcomes for patients but can result in unnecessary distress for low-risk patients and delays to diagnosis for high-risk patients with concerning abnormalities.

Patient satisfaction with a multidisciplinary colorectal and urogynaecology service.

INTRODUCTION: Traditionally, the pelvic floor has been described as three separate compartments and problems in each compartment were managed separately. A more contemporary approach is to identify the entire pelvic floor as a single dynamic compartment. Multidisciplinary pelvic floor clinics such as ours with the support of physiotherapy, clinical nurse specialists, urodynamics, and endo-anal ultrasound are uncommon. The aim of this study was to assess patient satisfaction with a joint colorectal and urogynaecology clinic. METHOD: All women who attended our service in 2015 were identified. Women who saw both a colorectal surgeon and urogynaecologist at the same clinic were included. The Satisfaction with Outpatient Services questionnaire, a multi-dimensional outpatient survey, was mailed to all women. RESULTS: A total of 364 new women attended our service in 2015. One hundred thirty-six (35.2%) saw both a colorectal surgeon and urogynaecologist at the same visit. There was a 64% (87/136) response rate to the questionnaire. Overall, all questions regarding their attendance were responded to positively by 94% (82/87) of women. Confidence and trust in the doctor examining and treating them was reported by all women. Seeing multiple specialists was of benefit to 97% (84/87) of women and 94% (82/87) would recommend the Pelvic Floor Centre. CONCLUSION: There is a high level of satisfaction amongst women attending our outpatient service. Being seen by multiple specialities at a single clinic was felt to be of benefit by the majority of women and all expressed physician confidence. Our multidisciplinary service may reduce waiting times, increase satisfaction, and is likely cost-effective.

Obstetric anal sphincter injury: how to avoid, how to repair: a literature review.

Avoiding obstetrical injury to the anal sphincter is the single biggest factor in preventing anal incontinence among women. Any form of instrument delivery has consistently been noted to increase the risk of obstetric anal sphincter injury and altered fecal continence by between 2- and 7-fold. Routine episiotomy is not recommended. Episiotomy use should be restricted to situations where it directly facilitates an urgent delivery. A mediolateral incision, instead of a midline, should be considered for persons at otherwise high risk of obstetric anal sphincter injury. The internal anal sphincter needs to be separately repaired if torn. Women with injuries to the internal anal sphincter or rectal mucosa have a worse prognosis for future continence problems. All women, particularly those with risk factors for injury, should be surveyed for symptoms of anal incontinence at postpartum follow-up.

Anal sphincter disruption at vaginal delivery: is recurrence predictable?

OBJECTIVE: We prospectively evaluated the risk of recurrence of anal sphincter disruption ("third degree tear") at next vaginal delivery and whether this complication was predictable by antepartum anal functional assessment. STUDY DESIGN: Among 20,111 consecutive vaginal deliveries, where midline episiotomy was not performed, 342 (1.7%) third degree tears occurred, significantly more often in primiparae (2.9%) than multiparae (0.8%; P<0.001), all of whom underwent postpartum anal manometry and endosonography. Similar testing was performed antepartum and postpartum in 56 of 342 women who delivered again during the study period. RESULTS: Eleven of 56 women were delivered by caesarean in next pregnancy. Third degree tears recurred in 2 (4.4%) of 45 women at next vaginal delivery. Both recurrent injuries occurred in asymptomatic women with normal antepartum manometry and following spontaneous deliveries and were satisfactorily repaired. CONCLUSION: Although anal sphincter injury was increased five-fold at next delivery, compared with all multiparae, 95% of women delivering vaginally after previous third degree tear did not sustain further overt sphincter damage. Recurrence was not predictable using pre-delivery anal physiology testing.

Experience with an obstetric perineal clinic.

OBJECTIVE: To review the characteristics of patients attending a dedicated perineal clinic in a maternity hospital. METHODS: Case-note review of all new referrals over 2 years 1998 and 1999. RESULTS: A total of 399 women were referred with mean age of 34 years (range 18-77), parity of 1.7 (range 1-13) and duration of symptoms of 14 (range 1-156) months. A total of 213 (53%) women were assessed following a recognized third degree perineal tear, 78 (20%) because of fecal incontinence, 45 (11%) for determination of future mode of delivery following a previous perineal injury, 37 (9%) women for treatment of perineal pain and 26 (7%) for other miscellaneous complaints. A total of 83 (21%) required physiotherapy, 42 (11%) received dietetic manipulation, 29 (7%) were treated for perineal pain and 12 (3%) underwent vaginal surgery. A total of 24 (6%) women were referred for consideration of secondary anal sphincter repair and 11 (3%) for specialist gastroenterological investigation. CONCLUSIONS: The perineal clinic provides a valuable resource for investigation and treatment of postpartum perineal injury.

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery.

OBJECTIVE: To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously. METHODS: Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25±11 minutes; n=19); and forceps delivery for second stage arrest (137±26 minutes; n=19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n=129). RESULTS: Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P=0.07). CONCLUSION: Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.

Short-term and long-term effects of obstetric anal sphincter injury and their management.

PURPOSE OF REVIEW: During the past decade increasing attention has focused on the problem of obstetric anal sphincter damage. Although risk factors are now well known, the effects of such damage have received less study. This review focuses on the early and long-term problems that may arise subsequent to anal sphincter injury following childbirth and assesses therapeutic options. RECENT FINDINGS: Up to 25% of women experience altered faecal continence after vaginal delivery, with 4% having persistent symptoms. In those women who have sustained a recognized tear to the sphincter, the quality of primary repair is crucial. Nevertheless, evidence clearly supporting the superiority of overlap over approximation repair is still lacking. The importance of pudendal nerve damage in the aetiology of postpartum faecal incontinence is gaining increasing attention. Augmented biofeedback physiotherapy is the gold standard for treatment of women with such injury, whereas sacral nerve stimulation represents a newer treatment option. SUMMARY: The short-term and long-term effects of obstetric anal sphincter injury warrant increased attention, because with increasing longevity more women are surviving into their 80s and the prevalence of faecal incontinence in this population will increase if measures are not taken to address the problem. Prevention of such injury is not always possible and management options must be further explored. Adequate primary treatment of third-degree tears is of paramount importance.

Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence.

OBJECTIVE: The purpose of this study was to assess patterns of abnormal pudendal nerve function in women who complain of postpartum fecal incontinence. STUDY DESIGN: During a 12-month period, a cohort of 83 women underwent neurophysiologic assessment as part of an evaluation of fecal incontinence after vaginal delivery. Pudendal nerve assessment consisted of the measurement of the clitoral-anal reflex and quantitative electromyography of the external anal sphincter. Endoanal ultrasound examination and anal manometry were also performed in each patient. RESULTS: Thirty of 83 women (38%) with fecal incontinence were found to have abnormal neurophysiologic condition, among whom four identifiable patterns of abnormality emerged. Five women (17%) had evidence of pudendal nerve demylenation with a prolonged sensory threshold of the clitoral-anal reflex (>5.2 mA), although electromyography studies were normal. Eight women (27%) had abnormal electromyography results that were consistent with axonal neuropathy with or without reinervation, in whom the clitoral-anal reflex was normal. Thirteen women (43%) demonstrated a mixed demyelinating and axonal pudendal neuropathy, with evidence of reinervation. Four women (13%) had abnormal patterns of neurophysiologic condition that was not attributable directly to past obstetric trauma but to coincident medical problems. CONCLUSION: Four abnormal patterns of pudendal nerve function may be identified, three of which (demyelinating, axonal, and mixed demyelinating/axonal) can be attributed to specific past obstetric events, although a fourth radicular pattern is due to coincident medical or orthopedic problems. Assessment of pudendal nerve function is important in women with postpartum fecal incontinence because particular patterns of abnormality correlate with different symptoms and can influence treatment options.

Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery.

OBJECTIVE: To compare, in a prospective, randomised controlled trial, differences in anal sphincter function following forceps or vacuum assisted vaginal delivery in an institution practising standardised management of labour. DESIGN: Prospective, randomised controlled trial. SETTING: Tertiary-referral maternity teaching hospital. POPULATION: One hundred and thirty women. METHODS: Primiparous women were recruited antenatally and if an instrumental delivery was indicated, were randomised to either a vacuum or low-cavity, non-rotational forceps assisted delivery. Follow up consisted of a symptom questionnaire, anal manometry and endoanal ultrasound at three months postpartum. MAIN OUTCOME MEASURES: Faecal continence scores, anal manometry, endoanal ultrasound. RESULTS: Sixty-one women delivered with forceps assistance (40 for failure to progress in the second stage) and 69 with vacuum assistance (33 for failure to progress); 16/69 vacuum deliveries proceeded to a forceps assisted delivery (23%). There were no statistical differences in the antecedent antenatal factors between the two groups. A third degree perineal tear followed 10 (16%) forceps and 5 (7%) vacuum deliveries. Based on intention-to-treat analysis, 36 (59%) women complained of altered faecal continence after forceps delivery compared with 23 (33%) following vacuum delivery three months postpartum (RR 2.88, 95% CI 1.41-5.88). Endoanal ultrasound was reported as abnormal following 34 (56%) forceps deliveries and 34 (49%) vacuum deliveries (RR 1.3, 95% CI 0.65-258). After exclusion of 'failed vacuum', median anal canal resting pressure was significantly lower following forceps delivery compared with vacuum delivery alone (P = 0.004). There were no significant differences in degree of ultrasound abnormality between the two groups. CONCLUSIONS: Symptoms of altered faecal continence are significantly more common following forceps assisted vaginal delivery. Based on continence outcome, when circumstances allow, vacuum should be the instrument of first choice in assisted delivery.

A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence.

OBJECTIVE: To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function. DESIGN: Prospective, randomised, controlled trial.Tertiary referral maternity teaching hospital. POPULATION: One hundred and seventy nulliparous women randomised at full dilatation to immediate or delayed pushing. METHODS: A total of 178 nulliparous women, all with continuous epidural analgesia, were randomised at full cervical dilatation, but before the fetal head had reached the pelvic floor, to either immediate pushing or 1 hour delayed pushing. Labour outcome was analysed and all women underwent postpartum assessment of anal sphincter function, including anal manometry. Those women who had a normal delivery underwent neurophysiology studies, while those women who had an instrumental delivery underwent endoanal ultrasound. MAIN OUTCOME MEASURES: Mode of delivery; altered faecal continence. RESULTS: Ninety women were randomised to immediate pushing and 88 to delayed pushing. The spontaneous delivery rate was 56% (50/90) in the immediate pushing group and 52% (46/88) in the delayed pushing group. Mean duration of labour for the immediate pushing group was 427 minutes compared with 480 minutes for the delayed pushing group (P = 0.005). Eighty-four percent (76/90) of women in the immediate pushing group received oxytocin to augment labour, 21/76 (28%) in the second stage only. Eighty-one percent (71/88) of women in the delayed pushing group received oxytocin to augment labour, 22/71 (31%) in the second stage only. Fetal outcome did not differ between the two groups. Episiotomy rates were 73% and 69% in the immediate pushing and delayed pushing groups, respectively. 26% (23/90) of the immediate pushing group and 38% (33/88) of the delayed pushing group complained of altered faecal continence after delivery (NS). Manometry, ultrasound and neurophysiology studies did not differ significantly between the two groups. Overall, 55% of women after instrumental delivery had endosonographic evidence of damage to the external anal sphincter, while 36% of women after spontaneous delivery had abnormal neurophysiology studies. CONCLUSIONS: Rates of instrumental delivery were similar following immediate and delayed pushing, in association with epidural analgesia. Delayed pushing prolonged labour by 1 hour but did not result in significantly higher rates of altered continence or anal sphincter injury, when compared with immediate pushing.