Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5256_Библиотеки_им_академика_М_И_Перельмана.pdf
225
Fig. 11.2 Chronic
fourth-degree laceration or
cloaca-like defect.
(Reprinted with permission
from Dr. Marlene Corton)
11.4.2 Chronic Fourth-Degree Lacerations/
Cloacal-Like Deformities
If fourth-degree lacerations are clinically unrecognized or if breakdown occurs,
they may result in chronic fourth-degree lacerations, also known as cloacal-like
deformities (see Fig.11.2) [38]. Cloacal-like deformities occur in 0.3% of deliveries
complicated by fourth-degree obstetric laceration [38]. Cloacal-like deformities
occur when there is complete disruption of the perineal body with a wide-angle
anterior anal sphincter defect and loss of the rectovaginal septum. This allows for
potential ow of atus and stool material from the rectum into the vagina [38]. The
primary symptom of a cloacal-like defect is fecal incontinence with or without stool
passage from the vagina [38, 44]. Additional complaints include sexual dysfunction,
such as inadvertent entry of penis into the rectum, skin irritation, and emotional,
psychological, and social distress [38].
11.4.3 Risk Factors forObstetrical Anal Sphincter Injuries
Midline episiotomies are known risk factors for anal sphincter (third- or fourth-
degree) lacerations [3]. Mediolateral episiotomies, conversely, do not carry
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
226
increased risk of anal sphincter injury, and thus are preferred by some practitioners
when an episiotomy is clinically indicated [3]. A ten-year analysis of 170,969 pri-
miparous and multiparous women found that mediolateral episiotomy during both
vacuum and forceps-assisted deliveries resulted in a vefold to tenfold decrease in
the incidence of anal sphincter injury when compared to those without mediolat-
eral episiotomy [39]. One systematic review and meta-analysis found an increased
risk for obstetric anal sphincter injury with increased neonatal head circumfer-
ence [45].
Assisted operative vaginal delivery (forceps or vacuum) may also increase the
risk for anal sphincter tear [3, 41]. However, forceps use has been shown to double
the risk for fecal incontinence in comparison to vacuum-assisted deliveries [46]. It
has been suggested that cesarean delivery may be somewhat protective in preven-
tion of postpartum fecal incontinence [3]. However, studies have demonstrated this
is not always the case, as emergency cesarean deliveries performed in the second
stage of labor cannot protect against the already inuenced neurophysiological
damage to the pelvic oor [3]. In addition, a retrospective cohort study by Nygaard
etal. [44] showed that anal incontinence rates among middle age women do not
differ signicantly based on mode of previous delivery(ies). Fecal incontinence
rates were shown to be the same 30years postpartum, regardless of vaginal delivery
with or without obstetric anal sphincter injury or cesarean delivery [44]. This nd-
ing suggests that pregnancy itself may hold a more important role in the develop-
ment of anal incontinence [15, 47–49].
11.4.4 Rectovaginal andAnovaginal Fistula
Women who present with postpartum fecal incontinence should be evaluated for
rectovaginal or anovaginal stula (see Fig.11.3) [3]. Prevalence and incidence of
obstetric stulas is widely unknown but estimated to be around two million cases
globally [50]. In lower- and middle-income countries, the incidence of obstetric
related rectovaginal stulas is estimated to be between 10 and 150 cases per 100,000
women [50]. Rectovaginal stulas are not common in developed countries but when
diagnosed they are usually attributed to prolonged labor causing pressure necrosis,
breakdown of third- or fourth-degree laceration repairs, or infected episiotomy sites
[3]. In lower- and middle-income countries, risk factors include pregnancy at a
younger age, low level of health literacy, low socioeconomic status, nancial con-
straints, malnutrition, short stature, and lack of access to prenatal and appropriate
obstetric, and emergency care [50, 51].
Rectovaginal stula without disruption of the anal sphincter muscles (buttonhole
tear) is also possible during vaginal birth and highlights importance of digital rectal
exam post delivery [52, 53]. Women with a rectovaginal stula usually present with
complaints of fecal stool or drainage per vagina and/or chronic or recurrent vagini-
tis, while women with anal incontinence usually present with complaints of fecal
urgency with or without accidental bowel losses and/or loss of stool or atus from
the anus without awareness [53, 54].
C. Hicks and M. Corton
227
Fig. 11.3 Rectovaginal
Fistula. (Reprinted with
permission from Dr.
Marlene Corton)
11.4.5 Pudendal Nerve Injury
Pudendal nerve injury sustained during pregnancy or vaginal birth may also play a
role in the development of postpartum fecal incontinence [24]. During the second
stage of labor, mechanical damage to the anal sphincter muscles and/or their inner-
vation may result in compression or stretch injuries to the pudendal nerve, resulting
in neuropathy [24]. An electrophysiological study conducted on 71 postpartum
women suggested denervation injury to the pubococcygeus and anal sphincter mus-
cles was sustained in up to 42–80% of participants [48]. However, nerve damage
resolved within 2months postpartum and was not associated with fecal inconti-
nence symptoms [48]. It has also been suggested that pudendal nerve injury during
childbirth may lead to functional asymmetry of anal sphincter innervation, which
may be associated with the later development of fecal incontinence [49].
11.4.6 Hemorrhoids
Hemorrhoids are inamed veins in the rectum and anus that occur during preg-
nancy. When present, the anorectal nerves and muscles can become weak and
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
228
damaged, leading to bowel incontinence. When inamed, they can also prevent the
anus from closing completely which can cause fecal seepage [55]. Additionally,
fecal soiling can occur when hemorrhoidal tags make it difcult to clean the anus
after a bowel movement [56]. A high ber diet with good hydration intake may help
keep the stool bulky and formed to avoid fecal soiling from mushy or runny stool
that may get trapped in hemorrhoidal tags [56]. Over-the-counter creams and sitz
baths are common treatments for hemorrhoids. In severe cases, surgery may be
considered. However, it is important to consider 1/10 women who have hemorrhoid-
ectomy will develop fecal incontinence, as well [55].
11.4.7 Other Risk Factors forPostpartum Anal
andFecal Incontinence
Other risk factors that may inuence fecal incontinence in the postpartum period
include high body mass index, [20, 24, 51, 53, 57, 58] prolonged pushing in the
second stage of labor [29, 53], smoking cigarettes [53], fetal macrosomia [59], and
constipation [55]. Epidural analgesia may indirectly contribute, as it has been asso-
ciated with increased risks of prolonged labor [60] and operative delivery [61].
However, the role of epidural is controversial, as epidural analgesia may also relax
the pelvic oor and avert pelvic oor trauma and potential lacerations [61]. A recent
randomized trial that included 2414 nulliparous patients with epidural analgesia
during second stage of labor showed that delayed pushing did not contribute to sig-
nicant differences in perineal lacerations or pelvic oor symptoms at 6weeks and
6months postpartum [57]. Additionally, the Active Phase of Second Stage Labor
trial, known as Phase Active du Second STade (PASST), of 1618 women found that
neither moderate nor intense pushing with epidural analgesia increased the risk of
anal incontinence at 6months postpartum [58, 62]. Presence of anal incontinence
prior to pregnancy has been associated with a six-fold increase in anal incontinence
after childbirth [63]. A risk calculator based on two large independent international
cohort studies is available online [60, 64].
11.5 Fecal Incontinence inSubsequent Pregnancies
Recurrence of anal sphincter damage with subsequent deliveries is controversial
[59]. A landmark study by Sultan etal. in 1993 [65] showed that up to 35% of pri-
miparous vaginal birth deliveries are associated with occult (sonographically
detected) sphincter injuries. However, this rate was 12% in a study by Corton etal.
[66] that evaluated 107 primiparous women by endoanal sonography. This latter
study estimated a total of 17.8% of vaginally delivered primaparous women sus-
tained anal sphincter injury as detected by both clinical diagnosis and sonography
[66]. In a prospective study of 20,111 women who had consecutive vaginal deliver-
ies, 5% of those who sustained a third-degree perineal laceration during their rst
delivery sustained additional anal sphincter injury during subsequent vaginal birth
C. Hicks and M. Corton
229
[67]. A retrospective observational study of 1273 women who had vaginal births
found no signicant difference in the rate of external sphincter tears between pri-
maparous and multiparous women [62]. While other studies have suggested a ve-
to-seven-fold increase in risk for recurrent anal sphincter disruption and increased
risk with prior third- or fourth-degree laceration involving high birthweight infants
[68, 69]. In women who suffered transient fecal incontinence and/or occult sphinc-
ter tear with their rst child, there is an increased risk for fecal incontinence after
subsequent vaginal deliveries [6, 70]. In one retrospective study looking at vaginal
delivery after cesarean, there was not an increased risk for obstetric anal sphincter
injury in subsequent vaginal delivery [71]. However, in another study of 1490
women undergoing vaginal delivery after previous vaginal delivery with obstetric
sphincter injury, there was an increased risk for reoccurrence of obstetric anal injury
with subsequent increase in long-term fecal and anal incontinence [72]. In one case-
controlled study of 84 women with recurrent obstetric anal sphincter injury, anorec-
tal symptoms were the same compared to women with rst time obstetric anal
sphincter injury at 12weeks postpartum [73]. However, anal sphincter function and
integrity was worse among those with recurrent obstetric anal sphincter injury,
which may lead to future symptoms [73]. In women with prior obstetrical sphincter
injury and symptoms, planned cesarean has not shown any increased risk for anal
incontinence at second delivery up to 6months postpartum [22]. Other risk factors
for sustaining further anal sphincter damage in subsequent delivery include opera-
tive vaginal deliveries, episiotomy [59], maternal age, gestational age, occiput pos-
terior presentation, oxytocin augmentation, operative delivery, and shoulder
dystocia [74].
It is often recommended to women with obstetric anal sphincter injury, particu-
larly with fourth-degree tears, to consider cesarean section for subsequent preg-
nancy [75]. One retrospective observational study of 265 patients counseled in
mode of delivery for subsequent pregnancies found that most women will follow
recommendations for mode of delivery with subsequent decrease in reoccurrence of
obstetric anal sphincter injuries and higher rates of cesarean delivery [76]. However,
another survey study of 115 women reports that 82% women will still elect a vagi-
nal delivery after sustaining an obstetric anal sphincter injury during previous preg-
nancy labor, and over 54% report they had no regret over continuing with a vaginal
delivery [77]. More regret was experienced among older women and those with
fecal incontinence [77].
11.6 Prevalence andRisk Factors forAnal andFecal
Incontinence inPostpartum Women
andSubsequent Pregnancies
In an observational cohort study of 8774 surveys of postpartum women, there was a
reported 29% incidence of fecal incontinence with nearly half of these women
reporting incontinence of stool and 38% reporting incontinence of atus only [53].
Nearly half of women reporting fecal incontinence stated that they started
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
230
experiencing fecal incontinence after their rst delivery, and more than 25% of
these women began to experience fecal incontinence within the rst 6months post-
partum [53]. In another observational cohort study of 343 women, the incidence of
postpartum fecal incontinence among primaparous women who sustained obstetri-
cal anal sphincter injuries was reported to be 7% at 6weeks postpartum, 4% at
12weeks postpartum, and 9% at 24weeks postpartum, while anal incontinence was
reported to be 24% at 24weeks postpartum [23].
Roughly two-thirds of women with atus incontinence after vaginal delivery will
have resolution of symptoms by 12months postpartum [6]. In a prospective 5-year
cohort study of 349 nulliparous women, data suggests that if anal incontinence per-
sists at or after 9months postpartum, it will most likely persist and worsen with time
[70]. In primaparous women with obstetrical anal sphincter injuries and fecal incon-
tinence persisting at 9months postpartum, approximately 50% were reported to
have persistent symptoms 5years later [70]. Twenty ve percent of women without
clinically diagnosed anal sphincter injury reported anal incontinence at 9months
postpartum with 32% having persisting symptoms at 5years postpartum [70]. This
rate increased to 34% in women with subsequent deliveries [70]. This indicates that
a woman with a sphincter tear has an eight-fold increased risk for developing anal
incontinence at 5years postpartum if they had anal incontinence at 9months post-
partum [70]. Most studies regarding subsequent deliveries indicate that additional
childbirth incidences increase the risk for developing anal incontinence [70]. In this
prospective ve-year cohort study, anal incontinence symptoms were noted to
increase from 3% to 10% with a second vaginal delivery without anal sphincter
disruption [70]. Subsequent anal sphincter tear rates have been reported to be 4–8%
[24]. See Box 11.2 for further considerations in clinical decision-making and patient
education.
Box 11.2 Summary of Main Points to Consider in Clinical Decision Making and
Patient Education
• If a woman sustains an obstetrical anal sphincter injury with rst delivery,
she has a 7% chance of fecal incontinence within the rst 6weeks postpar-
tum, a 4% chance at 12weeks, and a 9% chance at 24weeks [20].
• In primaparous women who sustained obstetrical anal sphincter injuries
and report anal incontinence at 9months postpartum, there is a 50% chance
that their anal incontinence symptoms will persist or worsen within 5years
postpartum [39]. However, anal incontinence has not been shown to persist
at the same rate of 30years postpartum [25].
• If a primaparous woman sustained an obstetrical anal sphincter injury with
rst delivery, she has a 4–8% higher rate of another obstetrical anal sphinc-
ter injury with subsequent vaginal birth [19].
• If a woman sustained an obstetrical anal sphincter injury with rst delivery
with or without anal incontinence postpartum, a cesarean delivery may be
recommended with subsequent pregnancy [6].
(continued)
C. Hicks and M. Corton
231
11.7 History andPhysical: Special Considerations
In assessment of fecal continence among pregnant and postpartum women, one
must take into special consideration any co-morbidities or acute conditions that may
affect continence by taking a careful history and physical. One of the most common
bowel disorders, irritable bowel syndrome, may have an impact on fecal inconti-
nence in postpartum women [78]. In general, women with irritable bowel syndrome
may have irregular bowel consistency and defecation frequency [78]. These erratic
uctuations may cause alterations in continence [78]. One prospective observa-
tional study assessed 208 women prior to delivery and during the postpartum period,
as well as an additional 104 primigravid women postpartum only [78]. It was found
that in the rst 6weeks postpartum, irritable bowel syndrome symptoms may be
exacerbated and subsequently contribute to an increased risk for postpartum fecal
incontinence in women who deliver via vaginal delivery [78]. In contrast, women
who delivered via cesarean delivery were not reported to have higher rates of fecal
incontinence [78]. Irritable bowel syndrome symptoms were not associated with
any increased risk for obstetrical anal sphincter injuries [78]. In another prospective
cohort study of 211 patients divided into three groups of those with primary repair
of major obstetric anal sphincter injury, cesarean section, and primigravida without
obstetric anal sphincter injury, obstetric anal sphincter injury and residual sono-
graphic sphincter defects did not have effect on fecal incontinence independently,
but had a greater effect and impact on fecal incontinence in the presence of irritable
bowel syndrome [79]. Irritable bowel syndrome among women who underwent
cesarean section and among primigravida women also showed an increased impact
of irritable bowel syndrome on fecal incontinence suggesting irritable bowel syn-
drome may be an independent risk factor for fecal incontinence [79]. In patients
with both obstetric anal sphincter injury and irritable bowel syndrome, fecal incon-
tinence scores were comparatively severe [79].
Another prospective cohort study of 898 nulliparous women found that there is
an increased risk for fecal incontinence in late pregnancy which may support the
theory that pregnancy itself may contribute to fecal incontinence [80]. The prospec-
tive cohort study also found that there was an increased risk of fecal incontinence
during postpartum in those with obstructed defecation during pregnancy and post-
partum suggesting that fecal incontinence may also be related to incomplete bowel
evacuation [80]. Another prospective longitudinal study of 1571 primaparous
women with late pregnancy anal incontinence found an increased rate of anal
Box 11.2 (continued)
• Main risk factors for obstetrical anal sphincter injuries in primaparous
women are midline episiotomies, assisted operative vaginal delivery, high
body mass index, prolonged pushing during the second stage of labor,
smoking cigarettes, fetal macrosomia, constipation, connective tissue dis-
ease, and Asian, Indian, and Filipino race [3, 6, 30, 32, 33].
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
232
incontinence in women with bowel disease and bowel evacuation problems up to
6years postpartum [81]. In these circumstances, it is also imperative to rule out
inammatory bowel disease and colorectal cancer [54, 82]. Colorectal cancer may
often present with new onset of bowel changes, uctuating between constipation
and diarrhea or presenting with narrow ribbonlike stools [82]. In patients with
inammatory bowel disease, such as ulcerative colitis and Crohn’s disease, rectal
compliance may be poor, and some patients may experience chronic diarrhea [54].
These patients are at a higher risk for developing fecal incontinence [54]. However,
women in remission from inammatory bowel disease do not show higher rates of
postpartum anal incontinence [83]. If there is any suspicion for potential inamma-
tory bowel disease or colorectal cancer pathology, referral to a gastroenterologist is
warranted [82].
In regards to acute conditions, the most severe of differential diagnosis must
include cauda equina syndrome [84]. Lower back pain is common among pregnant
women and generally attributable to hormonal changes and increasing stress on the
lumbosacral spine from a gravid uterus [84]. However, lumbar disk herniation is
considered an obstetric emergency [84]. Cauda equina syndrome involves lumbar
disk herniation that may present with bilateral sciatica type pain, bilateral leg weak-
ness, and diminished sensation over the buttocks, perineum, and inner thighs, as
well as loss of continence, both urinary and fecal [82, 84]. If not treated immedi-
ately, it may progress to permanent neurological sequelae [82]. Symptoms warrant-
ing an advanced evaluation include severe back and/or leg pain in pregnancy [84].
Assessment should include rectal examination to determine anorectal sensation and
magnetic resonance imaging (MRI) of the lumbosacral spine [84]. Minor lumbar
disk herniation that does not lead to cauda equina syndrome may be managed con-
servatively [84]. Massive disk herniation that leads to cauda equina syndrome in
pregnancy is generally considered a surgical emergency [84].
Bothersome lumbar disk herniation only occurs in about 1/10,000 pregnancies,
and only a few cases have been reported to progress to cauda equina syndrome [84].
In a presented case study, anal sphincter dysfunction resolved after surgical inter-
vention, but anorectal sensation was diminished for an additional 6months [84].
The assessment and identication of cauda equina syndrome in pregnancy is imper-
ative in order to provide emergency care and avoid potential permanent motor loss
and permanent urinary and fecal incontinence or dysfunction [84].
11.8 Assessment ofAnal andFecal Incontinence
inPregnancy andPostpartum
Screening for anal and fecal incontinence in pregnancy and postpartum may improve
treatment and management outcomes, but there is little evidence around routine
screening in clinical practice [85]. It is expert opinion that one should consider care-
ful baseline assessment of anorectal symptoms during pregnancy. With up to 29%
of women experiencing fecal incontinence postpartum and surveys indicating fecal
incontinence occurring at 6months postpartum [53] and 9months postpartum [70],
C. Hicks and M. Corton
233
Fig. 11.4 Dovetail sign:
anterior separation of the
external anal sphincter.
(Reprinted with permission
from Dr. Marlene Corton)
postpartum assessment of pregnancy sequelae must continue past the standard
6–8weeks postpartum check-up [53]. Assessment may include physical examina-
tion to detect fecal smearing, obstetrical scarring, perineal descent, hemorrhoids,
anal warts, rectal prolapse, and/or the classic dovetail sign (see Fig.11.4) seen with
anterior disruption or separation of the external anal sphincter [54]. Examination
should also include assessment of the pudendal nerve by checking for the presence
of an anal wink in response to light stimulus, such as with a cotton swab, on the
perianal area [54]. Digital anorectal examination allows for evaluation of palpable
anorectal masses and/or fecal impaction [54]. In addition, the tone and contraction
of the anal sphincters can be assessed [54]. If reduced anal sphincter tone is found
on clinical examination, this may indicate possible occult internal anal sphincter
injury [86]. Valsalva maneuvers can aid in detection of perineal descent, pelvic
organ prolapse, and/or rectal prolapse [54]. In women who endorse accidental
bowel losses, additional evaluation should include validated condition specic
questionnaires [87]. If warranted by the initial history and physical examination,
some women may undergo anal endosonography, colonoscopy, and/or barium
enema [54], MR defecography, anorectal manometry [87], electromyography, or
pudendal nerve motor latency testing [54]. Anorectal manometry, electromyogra-
phy, and pudendal nerve motor latency testing may not be indicated for clinical
assessment, but are utilized more in the setting of clinical research [88]. However,
in a retrospective observational study of 1348 women with obstetric anal sphincter
injuries who either underwent endoanal sonography alone or with anal manometry,
the combination of both anal manometry and endoanal sonography has been shown
to detect more anal sphincter dysfunction than endoanal sonography alone [89].
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
234
This study found almost one-third of women with sphincter impairment would have
been missed on endoanal sonography alone [89].
11.9 Assessment forAnal Sphincter Injury
Evaluation with the use of the endoanal or transperineal sonography may aid in
detection of occult anal sphincter tears postpartum [90–93]. Some may prefer trans-
perineal sonography, as it is a non-invasive method of detection and follow-up [91].
If a sphincter defect is suspected on postpartum physical examination and noted by
endoanal or transperineal sonography, an anal sphincteroplasty can be considered
[90]. With up to 35% of primaparous women [65, 94] and 44% of multiparous
women [94] having anal sphincter defects, anal endosongoraphy provides a useful
tool in assessment and diagnosis of occult sphincter injuries [94]. Based on a multi-
center prospective cohort study of 251 primaparous women by the Pelvic Floor
Disorders Network, those with evidence of occult defects have greater risk of hav-
ing fecal incontinence compared to primaparous women with no sonographic evi-
dence of anal sphincter gaps or disruption [95].
Anal endosonography may be done at 6weeks postpartum to assess for anal
sphincter tears among any woman who has delivered vaginally [94]. Transperineal
and transvaginal ultrasound may also be utilized to assess for sphincter disruption
with minimal discomfort compared to anal endosonography [96]. Surgical interven-
tion may or may not be necessary depending on the presence of anal sphincter gaps
[95] and the relationship between ultrasound ndings and anorectal symptoms [97].
However, anal sphincteroplasty is not a simple or benign procedure. It carries risk
of further sphincter damage and risk of pudendal neuropathy [54]. Emphasis should
always be placed on aggressive behavioral measures and supervised pelvic oor
exercises with or without biofeedback [54].
Perhaps more important than sonographic evaluation is routine intrapartum ano-
rectal examination in the setting of a second-degree laceration or any extensive peri-
neal laceration [66]. In a prospective observational study of 107 women who
underwent postpartum endoanal sonography with no clinical evidence of obstetrical
anal sphincter injuries at the time of delivery, 12.1% of women demonstrated anal
sphincter defect compared with 6.5% diagnosed by clinical observation [66]. A sig-
nicant number of anal sphincter defects were associated with second-degree peri-
neal tears [66]. This indicates that second-degree tears should warrant further
evaluation by rectal examination in order to prevent misdiagnosis of potential anal
sphincter defects [66]. A thorough intrapartum evaluation of the anorectum can be
performed by inserting the gloved index nger of the non-dominant hand to distend
the rectum and by placing the index and middle ngers of the dominant hand intra-
vaginally to separate the borders of the laceration in order to visualize the deepest
layer of tissue involved [66]. Appropriate lighting and irrigation should be used
during this process.
Expert opinion suggests that all women should be screened for anal incontinence
at every postpartum visit. Screening may present opportunities for early behavioral
C. Hicks and M. Corton