Fecal incontinence, occult lesions to the anal sphincter and related factors in primiparous patients without median routine episiotomy

Carlos Belmonte Montes; J  Andrés Cervera Servín; José Luis García Vázquez

2006, Number 6

<< Back Next >>

Cir Cir 2006; 74 (6)

Fecal incontinence, occult lesions to the anal sphincter and related factors in primiparous patients without median routine episiotomy

Belmonte MC, Cervera SJA, García VJL

Full text

How to cite this article

Language: Spanish
References: 27
Page: 449-455
PDF size: 77.96 Kb.

ABSTRACT

Background: Fecal incontinence is more frequent among women, mainly because of obstetrical trauma. The factors that induce these lesions have been widely studied. The Mexican Official Medical Regulations cancelled the routine use of episiotomy during vaginal delivery, taking into account many of these studies. We undertook this study to determine the frequency of anal sphincter lesions and fecal incontinence in primiparous women without episiotomy and related these lesions to maternal, obstetrical and newborn factors that could predispose to the origin of these lesions.
Methods: Primiparous women attended between May 2002 and May 2004, of any age, healthy, with uncomplicated term pregnancies were included. Before labor, a clinical examination, incontinence questionnaire and anal ultrasound were performed and the procedure was repeated 6 weeks after labor. Maternal, delivery and newborn factors were evaluated and compared in cases with fecal incontinence or anal sphincter lesions. Chi square test was utilized for categorical variables.
Results: We studied a total 122 patients, 62 were excluded (22 required Cesarean section and 40 failed to attend follow-up). Of these, postpartum incontinence was reported in 14 (23 %) (minor in 13, 22 %) and major in 1, 1.6 %), sphincter lesion in 7 (12 %), occult lesion in 3 (5 %); incontinence without sphincter lesion in 10 (71 %), and adverted partum canal lesion in 45 (75 %).
Conclusions: We found a high incidence of anal sphincter lesions in primiparous women without routine episiotomy but a reduced incidence of severe lesions and major fecal incontinence. There is a probable relation of lesions with newborn birthweight and height, duration of 2^nd partum period, adverted lesion and attending physician (not statistically demonstrated).

REFERENCES

1. Whitehead WE, Wald A, Norton NJ. Treatment options for fecal incontinence. Dis Colon Rectum 2001;44(1):131-139.
2. Mellgren A, Jensen LL, Zetterstrom JP, Wong WD. Long term cost of fecal incontinence secondary to obstetric injuries. Dis Colon Rectum 1999;42:857-867.
3. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-1911.
4. Belmonte MC, Chiapa CM. Ultrasonografía transanal. En: Colon, recto y ano, enfermedades médico-quirúrgicas. México: Editores de Textos Mexicanos; 2003. pp. 122-128.
5. Faltin DL, Boulvain M, Bretones S. Diagnosis of anal sphincter tears by postpartum endosonography to predict fecal incontinence. Obstet Gynecol 2000;95(5):643-647.
6. Sultan AH. Anal incontinence after childbirth. Curr Opin Obstet Gynecol 1997;9:320-324.
7. Zetterstrom J, López A, Anzen B, Norman M, Holmstrom B, Mellgren A. Anal sphincter tears at vaginal delivery. Risk factors and clinical outcome of primary repair. Obstet Gynecol 1999;94:21-28.
8. Carroli G, Balizan J. Episiotomy for vaginal birth. Cochrane Database System Review 2000;1:1-9.
9. Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labor. Prospective study before and after childbirth. Br J Obstet Gynaecol 1994;101:22-28.
10. Belmonte-Montes C, Hagerman G, Vega-Yepez PA, Hernández-de-Anda E, Fonseca-Morales V. Anal sphincter injury after vaginal delivery in primiparous females. Dis Colon Rectum 2001;44(9): 1244-1248.
11. Norma Oficial Mexicana. Apartado de Atención al parto; 1996.
12. Pirhonen JP, Grenman SE, Haadem K, et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland. Result of difference in manual help to baby’s head. Acta Obstet Gynecol Scand 1998;77:947-957.
13. Roman H, Robillard PY, Payet E, El Amrani R, Verspyck E, Marpeau L, Barau G. Factors associated with fecal incontinence after childbirth. Prospective study in 525 women. J Gynecol Obstet Biol Reprod 2004;33(6 Pt 1):497-505.
14. Yusuf SA, Jorge JM, Habr-Gama A, Kiss DR, Gama Rodrigues J. Evaluation of quality of life in anal incontinence: validation of the questionnaire FIQL (fecal incontinence quality of life). Arq Gastroenterol 2004;41(3):202-208.
15. Kwon S, Visco AG, Fitzgerald MP, Ye W, Whitehead WE. Validity and reliability of the Modified Manchester Health Questionnaire in assessing patients with fecal incontinence. Dis Colon Rectum 2005;48(2):323-331.
16. Fenner D, Genberg B, Brahma P, Marek L, DeLancey J. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003;189(6):1543-1549.
17. Sze EH. Prevalence and severity of anal incontinence in women with and without additional vaginal deliveries after a fourth-degree perineal laceration. Dis Colon Rectum 2005;48(1):66-69.
18. Willis S, Faridi A, Schelzig S, Hoelzl F, Kasperk R, Rath W, Schumpelick V. Childbirth and incontinence: a prospective study on anal sphincter morphology and function before and early after vaginal delivery. Langenbecks Arch Surg 2002;387(2):101-107.
19. Faridi A, Willis S, Schelzig P, Siggelkow W, Schumpelick V, Rath W. Anal sphincter injury during vaginal delivery—an argument for cesarean section on request? J Perinat Med 2002;30(5):379-387.
20. Oberwalder M, Dinnewitzer A, Baig MK, Thaler K, Cotman K, Nogueras JJ, et al. The association between late-onset fecal incontinence and obstetric anal sphincter defects. Arch Surg 2004;139(4):429-432.
21. Donnelly V, Fynes M, Campbell D, Johnson H, O’Conell, O’Herlihy C. Obstetrics events leading to anal sphincter damage. Obstet Gynecol 1998;92:955-61.
22. Fitzpatrick M, O’Brien C, O’Connell R, O’Herlihy C. Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence. Am J Obstet Gynecol 2003;189(3):730-735.
23. Sultan AH, Johansson RB, Carter JE. Occult anal sphincter trauma following randomized forceps and vacuum delivery. Int Gynecol Obstet 1998;61:113-119.
24. Bollard RC, Gardiner A, Duthie GS, Lindow SW. Anal sphincter injury fecal and urinary incontinence. A 34 years follow-up after forceps delivery. Dis Colon Rectum 2003;46(8);1083-1088.
25. Zetterstrom J, Mellgren A, Jensen LL, et al. Effect of delivery on anal sphincter morphology and function. Dis Colon Rectum 1999;42:1253-1260.
26. De Leeuw J-W, Vierhout ME, Struijk PC, et al. Anal sphincter damage after vaginal delivery. Dis Colon Rectum 2002;45(6):1004-1010.
27. Damon H, Henry L, Barth X, Mion F. Fecal incontinence in females with past history of vaginal delivery. Significance of anal sphincter defects detected by ultrasound. Dis Colon Rectum 2002;45(11):1445-1451.