Underdiagnosis of internal anal sphincter trauma following vaginal delivery.

OBJECTIVE: Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy. This study aimed to examine using endoanal ultrasonography the prevalence of IAS damage in women referred with Grade-3a or -3b obstetric anal sphincter injury (OASI) in a tertiary-referral perineal clinic. METHODS: This was a retrospective observational study of all women referred to a tertiary-referral perineal clinic after primary repair of OASI (Grade 3a-c, 4) diagnosed for the first time following vaginal delivery between January 2016 and December 2019, inclusive. Women were assessed using the Wexner bowel continence questionnaire, digital examination of sphincter tone and endoanal ultrasound. Injuries in each sphincter were classified as a scar (≤ 30°) or defect (> 30-90° or > 90°) on endoanal imaging in the axial plane. RESULTS: In total, 615 women were referred following primary repair of OASI. Sonographic evidence of damage to the IAS was seen in 9.1% (46/506) of women diagnosed with a Grade-3a/3b injury. In women referred with a Grade-3a/3b tear, symptom scores were statistically higher (P = 0.025) in those with an IAS defect > 30° compared to those with an intact or scarred IAS, although the median score was zero in both groups. The proportion of women in each group with severe symptoms (score > 9) was similar (2.6% vs 6.5%; P = 0.148). Among women referred with a Grade-3a/3b tear, sphincter tone was reduced more frequently in those with a defect of the IAS than in those with an intact or scarred IAS (52.2% vs 11.7%; odds ratio, 8.14 (95% CI, 4.26-15.67); P < 0.001). Regardless of the reason for referral, women with reduced sphincter tone on rectal examination were four times as likely to have had an IAS defect > 30° than were those with normal resting tone (risk ratio, 4.58 (95% CI, 3.25-6.45); P < 0.001). CONCLUSIONS: One in 11 women diagnosed with a Grade-3a or -3b tear have evidence of damage to their IAS on endoanal ultrasound. Damage to this muscle is linked to fecal incontinence in women and can have a significant impact on the planning of any future deliveries. This study highlights the importance of established perineal clinics with access to ultrasound. Nonetheless, if reduced sphincter tone is felt on rectal examination, a clinician should have a high index of suspicion for an occult IAS injury. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Patient satisfaction with joint colorectal-urogynaecology pelvic floor surgery

Introduction Pelvic floor dysfunction is a global term used to describe conditions such as pelvic organ prolapse, and faecal or urinary incontinence. The Pelvic Floor Centre is a multi-disciplinary clinic for pelvic floor dysfunction. The aim of this study was to assess patient satisfaction following joint colorectal-urogynaecology surgery in the Pelvic Floor Centre. Methods All patients who underwent a joint procedure in the Pelvic Floor Centre from 1st October 2015 to 31st October 2016 were contacted via telephone. Patient satisfaction was assessed using the Surgical Satisfaction Questionnaire (SSQ-8). Results Fifteen patients underwent joint surgeries between 1st October 2015 and 31st October 2016. All patients consented to the questionnaire. Patients underwent a variety of combined procedures including vaginal repairs, anal sphincter repairs, mid-urethral slings, perineal injections, and stapled trans-rectal resection of the rectum. Discussion Thirteen (86.7%) patients were satisfied with their surgery, and would recommend it to other patients with a similar condition. All patients were satisfied that their pain was well controlled after discharge. Eleven (73.3%) patients were satisfied with the time taken to return to daily activities, work, and their usual exercise routine. There is a high level of satisfaction amongst patients undergoing joint colorectal-urogynaecology surgery at the Pelvic Floor Centre. Further investigation into patient satisfaction with the clinic itself and international comparison is warranted.

Simulation analyses to evaluate alternative control strategies for the 2002 foot-and-mouth disease outbreak in the Republic of Korea.

Using the stochastic and spatial simulation model of between-farm spread of disease, InterSpread Plus, we evaluated the effect of alternative strategies for controlling the 2002 epidemic of foot-and-mouth disease (FMD) in the Republic of Korea. InterSpread Plus was parameterised to simulate epidemics of FMD in the population of farms containing susceptible animal species in the Korean counties of Yongin, Icheon, Pyongtaek, Anseong, Eumseong, Asan, Cheonan, and Jincheon. The starting point of our analyses was the simulation of a reference strategy, which approximated the real epidemic. The results of simulations of alternative epidemic-control strategies were compared with this reference strategy. Ring vaccination (when used with either limited or extended pre-emptive depopulation) reduced both the size and variability of the predicted number of infected farms. Reducing the time between disease incursion and commencement of controls had the greatest effect on reducing the predicted number of infected farms.

InterSpread Plus: a spatial and stochastic simulation model of disease in animal populations.

We describe the spatially explicit, stochastic simulation model of disease spread, InterSpread Plus, in terms of its epidemiological framework, operation, and mode of use. The input data required by the model, the method for simulating contact and infection spread, and methods for simulating disease control measures are described. Data and parameters that are essential for disease simulation modelling using InterSpread Plus are distinguished from those that are non-essential, and it is suggested that a rational approach to simulating disease epidemics using this tool is to start with core data and parameters, adding additional layers of complexity if and when the specific requirements of the simulation exercise require it. We recommend that simulation models of disease are best developed as part of epidemic contingency planning so decision makers are familiar with model outputs and assumptions and are well-positioned to evaluate their strengths and weaknesses to make informed decisions in times of crisis.