Occult obstetric trauma and anal incontinence

European Journal of Gastroenterology and Hepatology

Volumn 9, Issue 5, 1997, Pages 423-427

  Sultan, Abdul H ^a,b   Stanton, Stuart L ^a  

^a ST GEORGE S HOSPITAL   (United Kingdom)

^b MAYDAY UNIVERSITY HOSPITAL   (United Kingdom)

Author keywords

Anal endosonography; Anal incontinence; Forceps delivery; Obstetric trauma; Sphincter defect

Indexed keywords

ANUS SPHINCTER; CHILDBIRTH; ENDOSCOPIC ECHOGRAPHY; FECES INCONTINENCE; FEMALE; FORCEPS DELIVERY; HUMAN; OBSTETRIC OPERATION; PELVIS FLOOR; PRIORITY JOURNAL; REINNERVATION; SHORT SURVEY; VAGINAL DELIVERY;

EID: 0030985323     PISSN: 0954691X     EISSN: None     Source Type: Journal    
DOI: 10.1097/00042737-199705000-00002     Document Type: Short Survey

References (32)

1. Deen KI, Kumar D, Williams JG, et al.: The prevalence of anal sphincter defects in faecal incontinence: a prospective endosonic study. Gut 1993, 34:685-688. Forty-six patients with faecal incontinence had anorectal physiology lests and endosonography performed. A sphincter defect was demonstrated in 87%.
2. Snooks SJ, Swash M, Setchell M, et al.: Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984, ii:546-550. A preliminary report of the first prospective neurophysiological study before and after childbirth demonstrating evidence of denervation in up to 60% of multiparous women. This study has laid the foundation for other similar prospective studies.
3. Snooks SJ, Swash M, Henry MM, et al.: Risk factors in childbirth causing damage to the pelvic floor innervation. Int J Colorectal Dis 1986, 1:20-24. A detailed complete report of the prospective neurophysiological study before and after childbirth [2].
4. Snooks SJ, Swash M, Mathers SE, et al.: Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg 1990, 77:1358-1360. Fourteen women were re-studied from the original study [2] demonstrating that pudendal neuropathy due to vaginal delivery may be progressive.
5. Allen RE, Hosker GL, Smith ARB, et al.: Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynacol 1990, 97:770-779. This prospective study of 96 women has revealed evidence of re-innervation in the pelvic floor of 80% of primiparous women. Those who had a long active second stage of labour and heavier babies showed the most evidence of nerve damage.
6. Beersiek F, Parks AG, Swash M: Pathogenesis of anorectal incontinence: a histometric study of the anorectal musculature. J Neurol Sci 1979, 42:111-127. In patients with anorectal incontinence there was marked hypertrophy of both histochemical types of muscle fibres and histological evidence of a neurogenic disorder in the majority.
7. Neill ME, Swash M: Increased motor unit fibre density in the external anal sphincter in ano-rectal incontinence: a single fibre EMG study. J Neurol Neurosurg Psychiatry 1980, 43:343-347. Compared to normal subjects the motor unit fibre density in the external anal sphincter was significantly higher in patients suffering fom faecal incontinence.
8. Kiff ES, Swash M: Slowed conduction in the pudendal nerves in idiopathic (neurogenic) faecal incontinence. Br J Surg 1984, 71:614-616. Pudendal nerve terminal motor latency was significantly prolonged in patients suffering from idiopathic faecal incontinence.
9. Kitt ES, Barnes PRH, Swash M: Evidence of pudendal neuropathy in patients with perineal descent and chronic straining at stool. Gut 1984, 25:1279-1282. Anorectal neurophysiological tests were performed in 17 women with chronic constipation and abnormal perineal descent to demonstrate neurogenic damage to the external anal sphincter.
10. Henry MM, Parks AC, Swash M: The pelvic floor musculature in the descending perineum syndrome. Br J Surg 1982, 69:470-472. Anal reflex latency and histometric tests were performed to support the hypothesis that perineal descent may lead to pudendal neuropathy.
11. Sultan AH, Kamm MA, Hudson CN: Pudendal nerve damage during labour: prospective study before and after childbirth. Br J Obstet Gynaecol 1994, 101:22-28. Vaginal delivery and prolonged labour before caesarean section can both result in pudendal nerve damage which may be asymmetrical in extent. In the majority, however, pudendal nerve function returns to normal within 6 months of delivery.
12. Small KA, Wynne JM: Evaluating the pelvic floor in obstetric patients. Aust NZI Obstet Gynaecol 1990, 30:41-45. A prospective neurophysiological study of 72 women before and after delivery demonstrating evidence of denervation without change in anal electrosensitivity.
13. Cornes H, Bartolo DCC, Stirrat CM: Changes in anal canal sensation after childbirth. Br J Surg 1991, 78:74-77. Although anal canal sensation ran be impaired in incontinent patients, this impairment did not persist after childbirth except in the upper anal canal of those who sustained a third degree tear.
14. Kiff ES: The clinical use of anorectal physiology studies. Sir Alan Parks Symposium. Ann R Coll Surg Eng 1983, 27-29. The clinical use of anorectal studies is described.
15. Sun WM, Donnelly TC, Read NW: Impaired internal anal sphincter in a sub-group of patients with idiopathic faecal incontinence. Gastroenterology 1989, 97:130-135. Low resting pressures are associated with internal anal sphincter damage.
16. Law PJ, Bartram CI: Anal endosonography: technique and normal anatomy. Gastrointest Radiol 1989, 14:349-353. The first description of pioneering work in anal endosonography at St Mark's Hospital.
17. Sultan AH, Nicholls RJ, Kamm MA, et al.: Anal endosonography and correlation with in vitro and in vivo anatomy. Br J Surg 1992, 80:808-811. This study validates the interpretation of anal endosonographic images with histological confirmation.
18. Law PJ, Kamm MA, Bartram CI: Anal endosonography in the investigation of faecal incontinence. Br J Surg 1991, 78:312-314. Thirty-six per cent of patients thought to be suffering from neurogenic faecal incontinence were found to have external sphincter defects and 39% of these patients had an unsuspected internal sphincter defect.
19. Sultan AH, Kamm MA, Talbot IC, et al.: Anal endosonography: precision of identifying sphincter defects confirmed histologically. Br J Surg 1994, 81:466-469. A small but well designed study demonstrating superiority of anal endosonography over other methods of identifying sphincter defects.
20. Sultan AH, Kamm MA, Nicholls RJ, et al.: Internal anal sphincter division during lateral sphincterotomy. Prospective ultrasound study. Dis Colon Rectum 1994, 37:1031-1033. In women, lateral sphincterotomy was found to be more extensive than intended, resulting in compromised anal sphincter function, particularly in the presence of obstetric trauma.
21. Sultan AH, Kamm MA, Hudson CN, et al.: Anal sphincter disruption during vaginal delivery. N Engl J Med 1993, 329:1905-1911. This is the first and only prospective study to identify pudendal neuropathy and anal sphincter defects in both primiparous and multiparous women. Thirty-five per cent of women sustain trauma to the anal sphincters during their first delivery, one third of whom develop detecatory symptoms in the short term. Forceps delivery is the single independent factor associated with anal sphincter damage.
22. Sultan AH, Kamm MA, Hudson CN, et al.: Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994, 308:887-891. This study involving 8603 women has identified risk factors associated with third degree tears and that almost half the women who had a repaired third degree tear remained symptomatic. Residual anal sphincter defects were identified in the majority without any evidence of pudendal neuropathy.
23. Haadem K, Ohrlander S, Lingman G: Long-term ailments due to anal sphincter rupture caused by delivery - a hidden problem. Eur J Obstet Gynecol Reprod Biol 1988, 27:27-32. Forty-eight per cent of women were symptomatic 5 years after delivery.
24. Sorensen SM, Bondesen H, Istre O, et al.: Perineal rupture following vaginal delivery. Acta Obstet Gynecol Scand 1988, 67:315-318. Forty-two per cent of women reported anal incontinence at 7-year follow-up.
25. Neilsen MB, Hauge C, Rasmussen OO, et al.: Anal endosonographic findings in the follow-up of primarily sutured sphincteric ruptures. Br J Surg 1992, 79:104-106. Fifty-eight per cent were found to have sonographic defects and 29% had anal incontinence.
26. Sultan AH, Kamm MA, Bartram CI, et al.: Anal sphincter trauma during instrumental delivery. A comparison between forceps and vacuum extraction. Int J Gynecol Obstet 1993, 43:263-270. A non-randomized study which has demonstrated that forceps delivery is associated with significantly more occult anal sphincter damage and defecatory symptoms than vacuum delivery.
27. Johanson RB, Rice C, Doyle M, et al.: A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. Br J Obstet Gynaecol 1993, 100:524-530. A well conducted randomized controlled study involving 607 women demonstrating that forceps delivery is associated with considerably more maternal trauma than vacuum delivery. In addition, the condition of the neonate was assessed and no greater detrimental effect was associated with either instrument.
28. Snooks SJ, Henry MM, Swash M: Faecal incontinence due to external sphincter division in childbirth is associated with damage to the innervation of the pelvic floor musculature: a double pathology. Br J Obstet Gynaecol 1985, 92:824-828. Twenty patients with faecal incontinence following obstetric anal sphincter tears had neurophysiological tests performed and there was evidence of pudendal nerve damage in 60%.
29. Laurberg S, Swash M, Henry MM: Delayed external sphincter repair for obstetric tear. Br J Surg 1988, 75:786-788. Poor outcome of delayed repair is associated with evidence of denervation.
30. Jacobs PPM, Scheuer M, Kuijpers JHC, et al.: Obstetric fecal incontinence. Role of pelvic floor denervation and results of delayed sphincter repair. Dis Colon Rectum 1990, 33:494-497. Delayed sphincter repair gives excellent results (83% in follow-up of 7 months to 5 years) provided that denervation is not present.
31. Engel AF, Kamm MA, Sultan AH, et al.: Anterior sphincter repair after obstetric trauma. Br J Surg 1994, 81:1231-1234. This prospective study of 55 patients with anal endosonography and neurophysiological tests revealed that unsuccessful repair was related to persistent external sphincter defects rather than pudendal nerve motor latency.
32. Sultan AH, Kamm MA, Hudson CN: Obstetric perineal tears: an audit of training. J Obstet Gynaecol 1995, 15:19-23. This study has highlighted deficiency and dissatisfaction among doctors and midwives with their training in perineal anatomy and repair.