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fer from those used outside of France, and the follow-

up was very short (6 weeks). In a different type of

study, Bollard and colleagues identified women from

a 1964 delivery database and assessed the prevalence

of incontinence 34 years later [66]. They found a

strong association between forceps delivery and

sphincter defect on ultrasound but no significant

increase in incontinence following forceps delivery.

Episiotomy was at one time believed to be protec-

tive to the perineum during childbirth and was used

to prevent the occurrence of third- and fourth-degree

tears [67]. There is now evidence that episiotomy not

only fails to protect the perineum [68] but has been

associated with increased tearing and anal sphincter

injury [69–72]. Signorello and colleagues [73] studied

the relationship between episiotomy and postpartum

anal incontinence. They found no protective benefit

but found impaired continence. The authors com-

pared women who had episiotomies with women

who had an intact perineum and women who spon-

taneously tore; in all comparisons, episiotomy dou-

bled or tripled the risk of incontinence.

In addition to direct trauma to the sphincter mus-

cle, pudendal neuropathy is another consequence of

vaginal delivery, which contributes to fecal inconti-

nence. The pudendal nerve is believed to be damaged

by the fetal head, which compresses the nerve, caus-

ing ischemia or stretching its branches [74, 75]. The

result is partial denervation of the external sphincter

muscle and muscles of the pelvic floor. Pudendal

damage is particularly a problem with a prolonged,

complicated delivery of a large baby. In some

women, this damage manifests early after delivery as

incontinence, then reinnervation occurs and the

symptoms spontaneously disappear; this suggests

that early intervention is not necessary [74, 76]. In

other cases, repeated pregnancies and deliveries add

to the damage, the neuropathy progresses as the

woman ages, and the worsening over time causes sig-

nificant fecal incontinence that presents between 50

and 60 years of age [77,78]. Different patterns of neu-

ropathy have been demonstrated on physiologic test-

ing, contributing to variation in symptoms and dif-

fering responses to treatment [79]. Pudendal neu-

ropathy may be an isolated consequence of delivery,

or patients may have “a double pathology”, both a

direct sphincter injury and pudendal nerve damage

[74].

Cesarean section has been advocated as an option

to protect the pelvic floor and reduce the incidence of

postpartum fecal incontinence; however, this issue is

controversial [80]. Cesarean section performed after

cervical dilation, especially if performed late in the

second stage of labor, is not entirely protective

against direct sphincter trauma or pudendal neu-

ropathy [77, 81, 82]. However, the risk of pelvic floor

morbidity has become an impetus for women to

choose elective cesarean section [42, 82]. Reducing

pelvic floor morbidity by increasing the cesarean sec-

tion rate would require a large number of cesareans

be done to prevent a small number of tears. At this

time, the best practice seems to be evaluation of a

woman’s risk factors, informed consent regarding

her risk of pelvic floor trauma from vaginal delivery,

proper recognition of injury at the time of delivery

[53, 83, 84], and effective postpartum evaluation [80].

Treating Sphincter Injuries: The Colorectal

Surgeon’s Role

Women with incontinence due to childbirth present

in three categories [49]. First are women who have an

injury that was recognized and acutely repaired. Sec-

ond are those who present with incontinence within

the first year after a delivery and a primary sphincter

repair. Third are those who present many years from

the time of delivery, usually in middle age. The first

group, the acute setting and primary repair of

injuries, has been discussed. The colorectal surgeon

most frequently evaluates and manages the second

and third groups of women.

Evaluation

The evaluation begins as a comprehensive history.

Questions to define the patients’ symptoms and their

onset and to exclude other causes of fecal inconti-

nence are essential. An obstetric history includes

number and mode of deliveries, birthweight, compli-

cations of the pregnancy or labor, whether an epi-

siotomy was performed, perineal wound complica-

tions, and postpartum infections. Prior anorectal

surgery is noted. Concomitant symptoms of urinary

continence and/or organ prolapse are also compo-

nents of a colorectal surgeon’s evaluation, as there is

evidence that combining sphincter repair with proce-

dures for treating urinary incontinence and pelvic

organ prolapse is cost effective, with favorable out-

comes [85].

To quantify symptom severity and the impact of

incontinence on the woman’s life, a number of scor-

ing systems have been developed. One popular sys-

tem is the Wexner Cleveland Clinic Florida Fecal

Incontinence (CCF-FI) score [37, 86]. Five areas are

scored: incontinence to solid stool, incontinence to

liquid stool, incontinence to gas, use of pads, and

alteration of lifestyle. A total score is obtained by

adding the frequency of each area (0 = never, 1 = less

than once per month, 2 = less than once per week but

greater than once per month, 3 = less than once per

276

J.C. Genua, S.D. Wexner

Chapter 29 Obstetric Lesions: The Coloproctologist’s Point of View

day but greater than once per week, 4 = at least once

per day). A score of 0 indicates perfect continence; a

score of 20 indicates complete incontinence. The

fecal incontinence score is very helpful in guiding

treatment decisions based on lifestyle alterations and

allows assessment of treatments both individually

and for research purposes [37] (Table 1).

A thorough physical examination is performed,

the key portions of which are the perianal and rectal

examination. The perianal area is inspected for soil-

ing, evidence of infectious diseases, skin excoriation,

or poor hygiene. Presence of a patulous anus, skin

tag, episiotomy scars, spontaneous hemorrhoidal

prolapse, drainage, fistulas, or fissures are noted. The

patient is asked to strain so that prolapse or perineal

descent can be evaluated, and anal sensation is test-

ed. External palpation excludes fissure, masses,

abscesses, or fistulas. Digital rectal examination eval-

uates for masses or tenderness and assesses resting

sphincter tone. The patient is asked to squeeze, and

the examiner feels for concentric contraction of the

sphincter muscle and estimates squeeze pressure.

Upon relaxation, contraction of the puborectalis

muscle is assessed for paradox. Anoscopy enables

visualization of the mucosa and provides further

assessment of hemorrhoids. A bidigital exam assess-

es the thickness of the perineal body. If there is sus-

picion of a rectovaginal fistula, a speculum examina-

tion will facilitate inspection of the vagina; a tampon

test using methylene blue may be employed at this

time. An office flexible sigmoidoscopy may be used

at this time to exclude proctosigmoiditis, inflamma-

tory conditions, polyps, or tumors. However, full

colonoscopic examination is performed according to

presenting symptoms and standard screening guide-

lines. Following the history and physical, physiologic

testing including anal ultrasound, pudendal nerve

testing, EMG, anal manometry, and defecography are

helpful.

After the surgeon has excluded other medically

treatable causes of incontinence and the inconti-

nence has been defined, the first variable determin-

ing treatment is severity. For patients who are conti-

nent to solid stool but have difficulties with control

of liquid stool or flatus, aggressive medical therapy

consisting of high-fiber diet, fiber supplementation,

and antimotility agents may be successful. Perineal

muscle strengthening exercises are another conser-

vative option for patients with mild symptoms [37].

Biofeedback therapy is a more formal method of per-

ineal muscle strengthening [87, 88]. A trained thera-

pist monitors the voluntary contraction of the exter-

nal anal sphincter and guides the patient in more

effectively contracting. Patient motivation, commit-

ment, and cooperation is necessary; however for the

proper patient, this is a good option.

For women with more severe incontinence, the

first question a colorectal surgeon asks is whether

there is defect of the sphincter muscle. A sphincter

defect in the setting of significant incontinence fol-

lowing vaginal delivery is usually repaired. The

patient is preoperatively assessed for pudendal neu-

ropathy, which has been a predictor of poor success

of sphincter repair in treating incontinence [49, 89,

90]. However, all patients with fecal incontinence and

an external sphincter defect can be offered sphincter

repair as long as the expectations of success are real-

istic [89]. With concomitant pudendal neuropathy,

even if the sphincter repair is successful, success may

be transient. The patient should realize that either

repeat sphincter repair or other surgical options may

subsequently be required. They should also realize

that even with “success”, function may be subopti-

mal (Table 2).

Surgical Treatment: Sphincter Repair

There are three methods of repairing the sphincter:

apposition, plication/reefing, and overlapping

sphincteroplasty [37]. Apposition has classically been

associated with low success rates [91]. Scar tissue

277

Table 1. Cleveland Clinic Florida Fecal Incontinence (CCF-FI) score

. From [37]

Type of incontinence Frequency

Never <1/month <1/week <1/day

ⱖ1/day

ⱖ1/month ⱖ1/week

Solid 0123 4

Liquid 0123 4

Gas 0123 4

Wears pads 0123 4

Lifestyle alteration 0123 4

0 = perfect continence, 20 = complete incontinence

excision was later implicated in the failure of the

apposition technique [37]. More recently, in a study

of 40 patients with sphincter trauma over a 15-year

period, an end-to-end apposition was performed with

excellent results [95]. The technique involves mini-

mizing dissection of the injured muscle to preserve

vascularity and the preservation of scar tissue to help

anchor the overlapped muscle. The authors advocate

the apposition repair because of its simplicity and

effectiveness. Plication or reefing can be performed

anteriorly (vaginal mobilization, external sphincter

division, levator ani plication followed by puborectal-

is and external sphincter repair, or posterior plication

of the external sphincter and levators) [96]. In 1975,

Parks described the “postanal repair” for inconti-

nence associated with rectal prolapse and idiopathic

incontinence [97]. The postanal repair involves poste-

rior plication of the puborectalis muscle to restore the

normal anorectal angle. The postanal repair is used

when pudendal neuropathy rather than sphincter

trauma is the cause of incontinence.

The most popular repair method, which has been

shown to improve symptoms of continence and

physiologic studies, is dividing and preserving the

anterior sphincter and overlapping the muscle [94,

98–101]. In a randomized controlled trial of overlap-

ping sphincter repair vs. direct end-to-end anterior

repair, no benefit of the overlapping repair was

demonstrated [101]. However, most authors main-

tain their practice of overlapping scarred, fibrotic

muscle. Short-term results of anterior repair are

quite successful, with rates between 69% and 97%

[102]. At least one study demonstrated no significant

change in short-term and long-term success [103].

However, most studies of long-term success of over-

lapping anterior repair demonstrate a decrease over

time to a 35–50% success rate [104–106]. Some stud-

ies cite age as a factor predicting poorer outcome

[107]. However, other studies report outcomes in

elderly women are comparable with those in younger

women [98, 108] (Tables 3 and 4).

Our preferred method of repairing sphincter

defects is the overlapping sphincteroplasty. The

patient undergoes full mechanical and antibiotic

bowel preparation and receives prophylactic antibi-

otics. After induction of general or spinal anesthesia,

a Foley catheter is placed, and the patient is posi-

tioned in the prone jackknife position. A mixture of

0.5% Xylocaine, 0.25% bupivacaine, and 1:400,000 U

epinephrine is injected; this solution facilitates dis-

section by defining planes of scar and normal muscle

and tissue. An anterolateral circumanal incision of

approximately 120° is made with diathermy. Allis

clamps are placed on the anoderm and vaginal

278

J.C. Genua, S.D. Wexner

Table 2. Influence of pudendal neuropathy on success of sphincter repair

Author Year Number Success without Success with P

neuropathy neuropathy value

Laurberg [92] 1988 19 42% 5%<0.05

Londono-Schimmer [93] 1994 94 60% 14%<0.001

Sitzler [94] 1996 29 48% 24%–

Gilliland [89] 1998 72 51% 3%<0.01

Table 3. Overlapping sphincter repair: short-term results

Author Year Number Obstetric/ Results (%)

operative trauma

(%) Excellent/good Fair Poor

Fleshman [100] 1991 55 100 72 22 6

Wexner [50] 1991 16 100 76 19 5

Fleshman [99] 1991 28 100 75 21 4

Engel [109] 1994 55 100 79 – 21

Oliveira [98] 1996 55 99 71 9 20

Felt-Bersma [110] 1996 18 94 72 – 28

Nikiteas [111] 1996 42 88 60 17 24

Sitzler [94] 1996 31 87 74 – 26

Ternent [112] 1997 16 100 44 31 25

Zorcolo [102] 2005 93 100 65 9 27

Barisic [105] 2006 65 86 74 17 9

Chapter 29 Obstetric Lesions: The Coloproctologist’s Point of View

aspects to separate these two areas. During dissec-

tion, a finger is periodically placed in both the anus

and the vagina to avoid inadvertent injuries. Dissec-

tion of the external anal sphincter muscle com-

mences laterally in the ischiorectal fat then proceeds

medially where most of the scar will be encountered.

The edges of the muscle have usually retracted later-

ally to the right and left; when the two ends are iden-

tified, they are grasped and further defined using

cautery dissection. Once the edges of the muscle have

been defined, attention is turned to the intersphinc-

teric groove where the internal and external muscles

are separated. The injured internal sphincter muscle

is repaired separately and adds an extra layer of

strength overall to the repair.

Next, the surgeon decides the optimal configura-

tion of overlap of the ends of the external sphincter

muscles (right over left vs. left over right). Horizon-

tal mattress sutures are used to secure the overlap

configuration. In general, four to six sutures of Poly-

dioxanone are used. The senior author of this chap-

ter has demonstrated Polydioxanone as the optimum

suture choice; experience revealed Polypropylene

had a tendency to cause persistent sinuses and

Polyglactin absorbed too quickly for a solid repair.

Ultimately, the overlapping repair creates a cube of

tissue. An overlap of 3–4 cm of the ends of the mus-

cle is ideal. Caudad to cephalad, a new high-pressure

zone of at least 2–3 cm is created. Hemostasis is con-

firmed, and the skin is partially reapproximated with

Polyglactin suture, leaving the central portion open

for drainage. Perioperative antibiotic coverage is

given; oral antibiotics are continued beyond this

period only if clinically warranted. No postoperative

bowel confinement is used. A regimen of fiber sup-

plementation, Sitz baths, and analgesia is prescribed,

and the wound generally heals within 4–6 weeks.

Anovaginal and Rectovaginal Fistula Repair

Anovaginal and rectovaginal fistulas are uncommon

injuries resulting from vaginal delivery; however,

obstetric injury is the most common cause of these

fistulas [114]. Injury to the perineum during vaginal

delivery and poor healing of primary repair of per-

ineal tears are the main causes of the obstetric-

induced rectovaginal fistula [115]. A small percent-

age will heal spontaneously; after resolution of acute

edema and inflammation, if the fistula is still present,

there is usually well-vascularized tissue that permits

successful healing following repair [116]. A patient

will classically complain of the passage of stool or fla-

tus via the vagina; physical exam usually reveals the

fistula. However, fistula symptoms may mask or con-

fuse incontinence symptoms. Anal ultrasound and

physiologic testing must be performed to evaluate for

concomitant sphincter damage, which would require

a sphincter repair in addition to surgical treatment of

the fistula [117].

If a rectovaginal fistula is present in addition to a

sphincter defect, our earlier technique of overlapping

sphincteroplasty is modified slightly into a transper-

ineal repair. The same technique is applied with

emphasis on separating the rectum and vagina and

careful cephalad dissection through the fistulous

communication and above the scarring. The vaginal

defect is cored to remove any granulation tissue, and

the defect is closed by imbrication. The rectal defect

is excised if distal; if quite large or cephalad, it is

repaired with an endorectal advancement flap. The

sphincters are repaired as described earlier, and the

result is a multilayer repair that simultaneously

repairs the fistulous defects, separates the anorectal

and vaginal components, and repairs the muscle

defect.

Conclusion

Modern advances in obstetric care have dramatically

decreased maternal morbidity and mortality. Howev-

er, when a significant intrapartum event occurs or

when the consequences of childbirth lead to inconti-

nence, a woman’s life is severely affected. Childbirth

and vaginal delivery have two consequences: injury

279

Table 4. Overlapping sphincter repair: long-term results

Author Year Number Obstetric/ Results (%)

operative trauma

(%) Excellent/good Fair Poor

Engel [113] 1994 28 92 75 25

Londono-Schimmer [93] 1994 94 90 50 26 24

Vaizey [103] 2004 21 100 52 10 38

Gutierrez [106] 2004 130 91 22 19 57

Zorcolo [102] 2005 73 100 63 19 18

Barisic [105] 2006 65 86 48 13 39

to the anal sphincter and injury to and innervation of

the pelvic floor. While severe perineal trauma result-

ing in overt sphincter injury is rare, occult sphincter

injury following vaginal delivery is well documented

by endoanal ultrasound in a significant number of

cases. Not all sphincter defects translate into inconti-

nence, and the development of incontinence is prob-

ably the result of multiple factors over time, includ-

ing age and repeated deliveries. A cooperative and

interdisciplinary approach is recommended to

decrease the chance of incontinence following vagi-

nal delivery. This method should involve an

endoanal ultrasound following complicated vaginal

deliveries to identify potentially problematic sphinc-

ter defects, inquiry about symptoms of incontinence

during the postpartum period, and establishing fol-

low-up clinics for continence assessment of women

at highest risk. Obstetricians are the most experi-

enced to deal with acute obstetric anal sphincter

injury and their primary repair. There is no convinc-

ing prospective evidence of improved outcomes by

involving a colorectal surgeon at the time of delivery,

and this involvement is likely not feasible, appropri-

ate, or beneficial.

Colorectal surgeons are most often asked to evalu-

ate two categories of incontinent women following

childbirth: women who develop incontinence shortly

after a vaginal delivery that was, usually, complicated

by a primarily repaired tear or episiotomy, and

women who develop incontinence later in life, usual-

ly at middle age. A colorectal consultation includes a

thorough history, which clarifies the symptoms and

quantifies the degree of incontinence and its effect on

the woman’s life; a physical exam; physiologic stud-

ies; and counseling regarding future deliveries, sur-

veillance, and treatment. If a sphincter defect is iden-

tified, it is repaired preferably with anterior overlap-

ping sphincteroplasty. Concomitant pudendal nerve

injury may decrease the success of sphincteroplasty

in achieving full continence; however, a colorectal

surgeon will continue along a treatment algorithm

that involves new and promising procedures such as

injectable sphincter bulking agents, sacral nerve

stimulation, stimulated or nonstimulated gracilis

transposition, and the artificial bowel sphincter. Rec-

tovaginal fistulas are rarer complications of vaginal

delivery but are associated with great morbidity.

Incontinence and a concomitant sphincter injury

should always be addressed; failure to do so will

result in decreased success of treatment.

References

1. Hamlin EC, Little J (2001) The hospital by the river: a

story of hope. Pan MacMillan, Sydney

2. Arrowsmith S, Hamlin EC, Wall LL (1996) Obstructed

labor injury complex: obstetric fistula formation and

the multifaceted morbidity of maternal birth trauma

in the developing world. Obstet Gynecol Sur

51(9):568–574

3. Leigh RJ, Turnberg LA (1982) Faecal incontinence: the

unvoiced symptom. Lancet 1:1349–1351

4. Johanson JF, Lafferty J (1996) Epidemiology of fecal

incontinence: the silent affliction. Am J Gastroenterol

91:33–36

5. Rothbarth J, Bemelman WA, Meijerink WJHJ et al

(2001) What is the impact of fecal incontinence on

quality of life? Dis Colon Rectum 44:67–71

6. Mellgren A, Jensen LL, Zetterstrom JP (1999) Long-

term cost of fecal incontinence secondary to obstetric

injuries. Dis Colon Rectum 42:857–867

7. Keighley MR, Bick D, MacArthur C (1995) Prevalence

and obstetric factors in childbirth related fecal incon-

tinence (meeting abstract). Dis Colon Rectum 38:P14

8. Venkatesh KS, Ramanujam PS, Lason DM, Haywood

MA (1989) Anorectal complications of vaginal deliv-

ery. Dis Colon Rectum 32:1039–1041

9. Haadem K, Dahlstrom JA, Ling L, Ohrlander S (1987)

Anal sphincter function after delivery room rupture.

Obstet Gynecol 70:53–56

10. Borgotta L, Piening SL, Cohen WR (1989) Association

of episiotomy and delivery position with deep perineal

laceration during spontaneous delivery in nulliparous

women. Am J Obste Gynecol 160:294–297

11. Fornell EK, Berg G, Hallbook O et al (1996) Clinical

consequences of anal sphincter rupture during vaginal

delivery. J Am Coll Surg 183

:553–558

12. Zetterstrom J, Mellgren A, Jensen L et al (1999) Effect

of delivery on anal sphincter morphology and func-

tion. Dis Colon Rectum 42:1253–1260

13. BuekensP, Lagasse R, Dramaix M, Wollast E (1985)

Episiotomy and third degree tears. Br J Obstet

Gynaecol 92:820–823

14. Moller Bek K, Laurberg S (1992) Intervention during

labor: risk factors associated with complete tear of the

anal sphincter. Acta Obstet Gynecol Scand 71:520–524

15. Zetterstrom J, Lopez A, Anzen B et al (1999) Anal

incontinence after vaginal delivery–a prospective

study in primiparous women. Br J Obstet Gynaecol

106:324–330

16. Sultan AH, Kamm MA, Hudson CN, Bartram CI (1994)

Third degree obstetric anal sphincter tears:risk factors

and outcome of primary repair. BMJ 308:887–891

17. Tetzschner T, Sorensen M, Lose G, Christiansen J

(1996) Pudendal nerve recovery after a non-instru-

mented vaginal delivery. Int Urogynecol J Pelvic Floor

Dysfunct 7:102–104

18. Law PJ, Bartram CI (1989) Anal endosonography:

technique in normal anatomy. Gastrointest Radiol

14:349–353

19. Gerdes B, Kohler HH, Zielke A et al (1997) The

anatomical basis of anal endosonography. Surg

Endosc 11:986–990

20. Eckardt VF, Jung B, Fischer B, Lierse W (1994) Anal

endosonography in healthy subjects and patients with

idiopathic fecal incontinence. Dis Colon Rectum

37:235–242

21. Law PJ, Kamm MA, Bartram CI (1990) A comparison

280

J.C. Genua, S.D. Wexner

Chapter 29 Obstetric Lesions: The Coloproctologist’s Point of View

between electromyography and anal endosonography

in mapping external anal sphincter defects.

33:370–373

22. Felt-Bersma RJF, Cuesta MA, Koorevaar M et al (1992)

Anal endosonography: relationship with anal manom-

etry and neurophysiological tests. Dis Colon Rectum

35:944–949

23. Tjandra JJ, Milsom JW, Schroeder T, Fazio V (1993)

Endoluminal ultrasound is preferable to electromyog-

raphy in mapping anal sphincter defects. Dis Colon

Rectum 36:689–692

24. Hull T (2002) Invited commentary. Dis Colon Rectum

45:1450–1451

25. Sultan AH, Kamm MA, Hudson CN et al (1993) Anal-

sphincter disruption during vaginal delivery. N Eng J

Med 329:1905–1911

26. Karoui S, Savoye-Collet, Koning C et al (1999) Preva-

lence of anal sphincter defects revealed by sonography

in 335 incontinent patients and 115 continent patients.

AJR Am J Roentgenol 173:389–392

27. Sentovich S, Wong WD, Blatchford GJ (1998) Accura-

cy and reliability of transanal ultrasound for anterior

anal sphincter injury. Dis Colon Rectum 41:1000–1004

28. Bollard RC, Gardiner A, Lindow S et al (2002) Dis

Colon Rectum 45:171–175

29. Oberwalder M, Connor J, Wexner SD (2003) Meta-

analysis to determine the incidence of obstetric anal

sphincter damage. Br J Surg 90:1333–1337

30. Abramowitz L, Sobhani I, Ganansia R et al (2000) Are

sphincter defects the cause of anal incontinence after

delivery? Dis Colon Rectum 43:590–598

. Varma A, Gunn J, Gardiner A et al (1999) Obstetric

anal sphincter injury: prospective evaluation of inci-

dence. Dis Colon Rectum 42:1537–1543

32. Fynes M, Donnelly V, Behan M et al (1999) Effect of

second vaginal delivery on anorectal physiology and

fecal continence: a prospective study. Lancet

354:983–986

33. Faltin DL, Boulvain M, Irion O et al (2000) Diagnosis

of anal sphincter tears by postpartum endosonogra-

phy to predict fecal incontinence. Obstet Gynecol

95:643–647

34. Damon H, Bretones S, Henry L et al (2005) Long-term

consequences of first vaginal delivery-induced anal

sphincter defect. Dis Colon Rectum 48:1772–1776

35. Beck DE, Wexner SD (eds) (1998) Fundamentals of

anorectal surgery, 2nd edn. W.B. Saunders, London

36. Laurberg S, Swash M (1989) Effects of aging on the

anorectal sphincters and their innervation. Dis Colon

Rectum 32:737–742

37. Jorge JMN, Wexner SD (1993) Etiology and manage-

ment of fecal incontinence. Dis Colon Retum 36:77–97

38. Bannister JJ, Abouzekry L, Read NW (1987) Effect of

aging on anorectal function. Gut 28:353–357

39. McHugh SM, Diamant NE (1987) Effect of age, gender

and parity on anal canal pressures. Dig Dis Sci

32:726–736

40. Oberwalder M, Dinnewitzer A, Baig K et al (2004) The

association between late-onset fecal incontinence and

obstetric anal sphincter defects. Arch Surg

139:429–432

41. Haadem K, Dahlstrom A, Ling L, Ohrlander AS (1987)

Anal sphincter function after delivery rupture. Obstet

Gynecol 70:53

–57

42. Fernando RJ, Sultan AH, Radley S et al (2002) Man-

agement of obstetric anal sphincter injury: a systemat-

ic review and national practice survey. BMC Health

Serv Res 2:9

43. Sultan AH, Kamm MA, Hudson CN, Bartram CI (1994)

Third degree obstetric anal sphincter tears: risk factors

and outcome of primary repair. BMJ 308:887–891

44. Khanduja KS, Yamashita HJ, Wise WE et al (1994)

Delayed repair of obstetric injuries of the anorectum

and vagina. Dis Colon Rectum 37:344–349

45. Fitzpatrick M, O’Connell PR, O’Herlihy C (2000) A

randomized clinical trial comparing primary overlap

with approximation repair of third-degree obstetric

tears. Am J Obstet Gynecol 183:1220–1224

46. Poen AC, Felt-Bersma RF, Strijers RL et al (1998)

Third degree obstetric perineal tear: long-term clinical

and functional results after primary repair Br J Surg

85:1433–1438

47. Pinta TM, Kylanpaa M-L, Salmi TK et al (2004) Prima-

ry sphincter repair:are the results of the operation

good enough? Dis Colon Rectum 47:18–23

48. Oppong FC, Freeman RM (2004) Prospective audit of

third- and fourth-degree obstetric anal sphincter

injuries. BR J Surgery 91:24

49. Cook TA, Mortensen NJ (1998) Management of fecal

incontinence following obstetric injury. Br J Surg

85:293–299

50. Wexner SD, Marchetti F, Jagelman DG (1991) The role

of sphincteroplasty for fecal incontinence reevaluated:

A prospective physiologic and functional review. Dis

Colon Rectum 34:22–30

51. Rieger N, Perera S, Stephens J et al (2004) Anal sphinc-

ter function and integrity after primary repair of third-

degree tear: uncontrolled prospective analysis. ANZ J

of Surg 74:122–124

52. Cook T, Keane D, Mortensen N (1999) Is there a role

for the colorectal team in the management of acute

severe third-degree vaginal tears? Colorectal Dis

1:263–266

53. Byrd LM, Hobbiss J, Tasker M (2005) Is it possible to

predict or prevent third degree tears? Colorectal Dis

7:311–318

54. Abramowitz L, Sobhani I, Ganansia R et al (2000) Are

sphincter defects the cause of anal incontinence after

vaginal delivery? Results of a prospective study. Dis

Colon Rectum 43:590–596

55. Belmonte-Montes C, Hagerman G, Vega-Yepez PA et

al (2001) Anal sphincter injury after vaginal delivery in

primiparous females. Dis Colon Rectum 44:1244–1248

56. Ryhammer AM, Bek KM, Laurberg S (1995) Multiple

vaginal deliveries increase the risk of permanent

incontinence of flatus and urine in normal pre-

menopausal women. Dis Colon Rectum 38:1206–1209

57. Sze E (2005) Prevalence and severity of anal inconti-

nence in women with and without additional vaginal

deliveries after a fourth-degree perineal laceration. Dis

Colon Rectum 48:66–69

58. Mazounia C, Bretelle F, Battar S et al (2005) Frequency

of persistent anal symptoms after first instrumental

delivery. Dis Colon Rectum 48:1432–1436

59. Hall W, McCracken K, Osterweil P, Guise JM (2003)

Frequency and predictors for postpartum fecal incon-

281

tinence. Am J Obstet Gynecol 188:1205–1207

60. Sultan AH, Johanson RB, Carter JE (1998) Occult anal

sphincter trauma following randomized forceps and

vacuum delivery. Int J Gynaecol Obstet 61:113–119

61. Nazir M, Carlsen E, Nesheim BI (2002) Do occult anal

sphincter injuries, vector volume manometry and

delivery variables have any predictive value for bowel

symptoms after first time vaginal delivery without

third and fourth degree rupture? A prospective study.

Acta Obstet Gynecol Scan 81:720–726

62. Sultan AH, Kamm MA, Bartram CI, Hudson CN (1993)

Anal sphincter trauma during instrumental delivery.

Int J Gynecol Obstet 43:263–270

63. Johanson RB, Rice C, Doyle M et al (1993) A random-

ized prospective study comparing the new vacuum

extractor policy with forceps delivery. Br J Obstet

Gynaecol 100:524–350

64. Sultan AH, Johanson RB, Carter JE (1998) Occult anal

sphincter trauma following randomized forceps and

vacuum delivery. Int J Gynaecol Obstet 61:113–119

65. deParedes V, Etienney I, Thabut D et al (2004) Anal

sphincter injury after forceps delivery: myth or reality?

A prospective ultrasound study of 93 females. Dis

Colon Rectum 47:24–34

66. Bollard R, Gardiner A, Duthie GS, Lindow SW (2003)

Anal sphincter injury, fecal and urinary incontinence.

A 34-year follow-up after forceps delivery. Dis Colon

Rectum 46:1083–1088

67. Thacker SB, Banta HD (1983) Benefits and risks of epi-

siotomy: an interpretive review of the English lan-

guage literature. Obstet Gynecol Surv 38:322–338

68. Thorp JM Jr, Bowes WA Jr (1993) Episiotomy: can its

routine use be defended? Am J Obstet Gynecol

160:1027–1030

69. Thorp JM Jr, Bowes WA Jr, Brame RG, Cefalo R (1987)

Selected use of midline episiotomy: effect on perineal

trauma. Obstet Gynecol 70:260–262

70. Helwig JT, Thorp JM Jr, Bowes WA Jr (1993) Does

midline episiotomy increase the risk of third- and

fourth-degree lacerations in operative vaginal deliver-

ies? Obstet Gynecol 82:276–279

71. Walker MPR, Farine D, Rolbin SH, Ritchie JWK (1991)

Epidural anesthesia, episiotomy, and obstetric lacera-

tion. Obstet Gynecol 77:668–671

72. Klein MC, Gauthier RJ, Robbins JM et al (1994) Rela-

tionship of episiotomy to perineal trauma and mor-

bidity, sexual dysfunction, and pelvic floor relaxation.

Am J Obstet Gynecol 171:591–598

73. Signorello LB, Harlow BL, Chekos AK, Repke JT (2000)

Midline episiotomy and anal incontinence: retrospec-

tive cohort study. BMJ 320:86–90

74. Jacobs PPM, Scheuer M, Kuijpers, JHC, Vingerhoets

MH (1990) Obstetric fecal incontinence. Role of pelvic

floor denervation and results of delayed sphincter

repair. Dis Colon Rectum 33:494–497

75. Snooks SJ, Swash M, Henry MM (1986) Risk factors in

childbirth causing damage to the pelvic floor innerva-

tion. Int J Colorect Dis 1:20–24

76. Snooks SJ, Swash M, Henry MM et al (1985) Injury to

the innervation of the pelvic floor musculature in

childbirth. Lancet 2:546–550

77. Goldberg RP, Kwon C, Gandhi S (2003) Prevalence of

anal incontinence among mothers of multiples and

analysis of risk factors. Am J Obstet Gynecol

189:1627–1631

78. Snooks SJ, Swash M, Henry SE (1990) Effect of vaginal

delivery on the pelvic floor: a 5-year follow-up. Br J

Surg 77

:1358–1360

79. Fitzpatrick M, O’Brien C, O’Connell PR. O’Herlihy C

(2003) Patterns of abnormal pudendal nerve function

that are associated with postpartum fecal inconti-

nence. Am J Obstet Gynecol 189: 730–735

80. O’Boyle AL, Davis GD, Calhoun BC (2002) Informed

consent and birth:protecting the pelvic floor and our-

selves. Am J Obstet Gynecol 187:981–983

81. Liebling RE, Swingler R, Patel RR et al (2004) Pelvic

floor morbidity up to one year after difficult instru-

mental delivery and cesarean section in the second

stage of labor: a cohort study. Am J Obstet Gynecol

191:4–10

82. Al-Mufti R, McCarthy A, Fisk NM (1996) Obstetri-

cian’s personal choice and mode of delivery. Lancet

347:544

83. McKenna DS, Ester JB, Fischer JR (2003) Elective

cesarean section delivery for women with a previous

anal sphincter rupture. Am J Obstet Gynecol

189:1262–1266

84. Lal M, Mann CH, Callender R et al (2003) Does cesare-

an delivery prevent anal incontinence? Obstet Gynecol

101:305–312

85. Halverson A, Hull T, Paraiso MF, Floruta C (2001)

Outcome of sphincteroplasty combined with surgery

for urinary incontinence and pelvic organ prolapse.

Dis Colon Rectum 44:1421–1326

86. Person B, Wexner SD (2005) Advances in the surgical

treatment of fecal incontinence. Surg Innovation

12:7–21

87. Engel BT, Nikoomanesh P, Schuster MM (1974) Oper-

ant conditioning to rectosphincteric responses in the

treatment of fecal incontinence. N Eng J Med

29:646–649

88. Macleod JH (1987) Management of anal incontinence

by biofeedback. Gastroenterology 93:291–294

89. Gilliland R, Altomare DF, Moreira H et al (1998)

Pudendal neuropathy is predictive of failure following

anterior overlapping sphincteroplasty. Dis Colon Rec-

tum 41:1516–1522

90. Gardiner A, Kaur G, Cundall J, Duthie GS (2004) Neur-

al network analysis of anal sphincter repair. Dis Colon

Rectum 47:192–197

91. Blaisdell PC. (1940) Repair of the incontinent sphinc-

ter ani. Surg Gynecol Obstet 70:692–697

92. Laurberg S, Swash M, Henry MM (1988) Delayed

external sphincter repair for obstetric tear. Br J Surg

75(8):786–788

93. Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ

et al (1995) Overlapping anal sphincter repair for fae-

cal incontinence due to sphincter trauma: five year fol-

low-up functional results. Int J Colorectal Dis

10(2):123

94. Sitzler PJ, Thomson JPS (1996) Overlap repair of dam-

aged anal sphincter: a single surgeon’s series. Dis

Colon Rectum 39:1356–1360

95. Arnaud A, Sarles JC, Sielezneff I et al (1991) Sphincter

repair without overlapping for fecal incontinence. Dis

Colon Rectum 34:744–747

282

J.C. Genua, S.D. Wexner

Chapter 29 Obstetric Lesions: The Coloproctologist’s Point of View

96. Corman ML (2005) Colon and rectal surgery, 5th edn.

Lippincott Williams & Wilkins, Philadelphia

97. Parks AG (1975) Anorectal incontinence. J R Soc Med

68:681–690

98. Oliveira L, Pfeifer J, Wexner SD (1996) Physiological

and clinical outcome of anterior sphincteroplasty. Br J

Surg 83:502–505

99. Fleshman JW, Dreznik Z, Fry RD, Kodner IJ (1991)

Anal sphincter repair for obstetric injury: manometric

evaluation of functional results. Dis Colon Rectum

34:1061–1067

100. Fleshman JW, Peters WR, Shemesh EI et al (1991) Anal

sphincter reconstruction: anterior overlapping muscle

repair. Dis Colon Rectum 34:739–743

101. Tjandra JJ, Han WR, Goh J et al (2003) Direct repair vs.

overlapping sphincter repair: a randomized controlled

clinical trial. Dis Colon Rectum 46:937–943

102. Zorcolo L, Covotta L, Bartolo DC (2005) Outcome of

anterior sphincter repair for obstetric injury: compar-

ison of early and late results. Disc Colon Rectum

48:524–531

103. Vaizey CJ, Norton C, Thornton MJ et al (2004) Long-

term results of repeat anterior anal sphincter repair.

Disc Colon Rectum 47:858–863

104. Halverson AL, Hull TL (2002) Long-term outcome of

overlapping anal sphincter repair. Dis Colon Rectum

45:345–348

105. Barisic GI, Krivokapic ZV, Markovic VA, Popovic MA

(2006) Outcome of overlapping anal sphincter repair

after 3 months and after a mean of 80 months. Int J

Colorectal Dis 21:52–56

106

. Gutierrez AB, Madoff RD, Lowry AC et al (2004) Long-

term results of anterior sphincteroplasty. Dis Colon

Rectum 47:727–732

107. Rasmussen O, Puggaard L, Christiansen J (1999) Anal

sphincter repair in patients with obstetric trauma: age

affects outcome. 42:193–195

108. Simmang C, Birnbaum EH, Kodner IJ et al (1994)

Anal sphincter reconstruction in the elderly:does

advancing age affect outcome? Dis Colon Rectum

37:1065–1069

109. Engel AF, Kamm MA, Sultan AH et al (1994) Anterior

anal sphincter repair in patients with obstetric trauma.

Br J Surg 81(8):1231–1234

110. Felt-Bersma RJ, Cuesta MA, Koorevaar M (1996) Anal

sphincter repair improves anorectal function and

endosonographic image. A prospective clinical study.

Dis Colon Rectum 39(8):878–885

111. Nikiteas N, Korsgen S, Kumar D, Keighley MR (1996)

Audit of sphincter repair. Factors associated with poor

outcome. Dis Colon Rectum 39(10):1164–1170

112. Ternent CA, Shashidharan M, Blatchford GJ (1997)

Transanal ultrasound and anorectal physiology find-

ings affecting continence after sphincteroplasty. Dis

Colon Rectum 40(4):462–467

113. Engel AF, van Baal SJ, Brummelkamp WH (1994) Late

results of anterior sphincter plication for traumatic

faecal incontinence. Eur J Surg 160(11):633–636

114. Chew S, Rieger N (2004) Transperineal repair of

obstetric-related anovaginal fistula. ANZ J Obstet

Gynecol 44:68–71

115. Venkatesh KS, Ramanujan PS, Larson DM, Haywood

MA (1989) Anorectal complications of vaginal deliv-

ery. Dis Colon Rectum 41:1141–1146

116. Rahman MS, Al-Suleiman SA, Rahman J (2003) Surgi-

cal treatment of rectovaginal fistula of obstetric origin:

a review of 15 years’ experience in a teaching hospital.

J Obstet Gynaecol 23:607–610

117. Khanduja KS, Yamashita HJ, Wise WE Jr et al (1994)

Delayed repair of obstetric injuries of the anorectum

and vagina: a stratified surgical approach. Dis Colon

Rectum 37:344–349

283

Repair of Third- and Fourth-degree

Perineal Lacerations:

Introduction

Data from the obstetrical literature show that about

0.4–3.7% of all vaginal deliveries result in a third- or

fourth-degree perineal laceration [1, 2]. Rarely, the

reported incidence can go as high as 20–39% [3, 4].

When a third- or fourth-degree perineal laceration

occurs during vaginal delivery, the standard repair is

to approximate the torn ends of the anal sphincter

using two to six interrupted mattress or figure-of-

eight stitches and close the vaginal and perineal tis-

sues in layers. Postpartum, the patient is typically put

on a soft diet and given a stool softener for 7–10 days.

This method of repair is described in the latest edi-

tion of Williams Obstetrics [5], the newest edition of

Gabbe et al. [6], and numerous other obstetrical text-

books.

This end-to-end method of repair seems to be

very effective in restoring the function of the torn

anal sphincter. Studies from the early and mid–1960s

showed that women who sustained a third- or

fourth-degree perineal laceration rarely, if ever,

experienced any significant complication postpar-

tum [3, 4]. Consequently, anal sphincter tear during

vaginal delivery was not regarded as a major com-

plication [3]. However, this absence of complication

was based on the finding that very few patients com-

plained of anal incontinence postpartum. In addi-

tion, these early studies did not state whether the

investigators ever asked their patients about anal

function postpartum or even saw most of these

women for follow-up [3, 4]. In contrast, more recent

studies found that women who sustained a third- or

fourth-degree perineal laceration during vaginal

delivery often develop anal incontinence (to flatus,

liquid, and solid stool) postpartum. Four cohort

studies demonstrated that within 12 months post-

partum, 17–44% of women who had a third- or

fourth-degree perineal laceration were incontinent

to flatus and up to 17% had fecal incontinence

(Table 1) [7–10]. These rates are significantly higher

than in women who delivered during the same time

period but did not have an anal sphincter tear. With

longer duration of follow-up, the outcome is even

worse. After 4–30 years, 38–63% of women with

third–or fourth–degree perineal laceration had anal

incontinence (Table 2) [1, 8, 11–13]. Although the ma-

jority were still incontinent to flatus, the proportion

that had fecal incontinence had increased signifi-

cantly. In addition, anal incontinence was more

severe among women who had a third- or fourth-

degree perineal laceration than those who delivered

with an intact sphincter (Table 3) [12–14].

Table 1. Prevalence of anal incontinence after an anal sphincter tear

Reference Degree of tear vs. control Number Flatus incontinence Fecal incontinence Follow-up

Zetterstrom et al. [7] 3rd/4th 46 39% 2% 9 months

Control 574 14% 1%

Pollack et al. [8] 3rd/4th 36 44% 0% 9 months

Control 206 24% 1%

Crawford et al. [9] 3rd/4th 35 17% 6% 9 – 12 months

Control 35 3% 3%

Borello-France 3rd/4th 335 23% 17% 6 months

et al. [10] Control 319 18% 8%

Obstetric Lesions:

The Gynaecologist’s Point of View

Eddie H.M. Sze, Maria Ciarleglio

Etiology of Incontinence

Many investigators believed that this deterioration in

anal continence after a third- or fourth-degree perineal

laceration is caused by neurological injury sustained

during the sphincter tear, because pelvic neuropathy is

frequently found in women with anal incontinence

[15–17]. Since this type of neurological injury is usually

not amenable to medical or surgical therapy, obstetri-

cians believed that there is very little they can do to

ensure that their patient will maintain continence after

sustaining a third- or fourth-degree perineal laceration.

In the early 1990s, an investigator from Great

Britain published a small study that involved 34

women who sustained a third-degree perineal lacera-

tion during vaginal delivery. Eighty-five percent of the

women in this small study had a persistent tear in their

anal sphincter 2–22 months after their third-degree

perineal laceration was repaired [18]. This finding

demonstrated that 85% of anal sphincter repairs had

failed. The failed repair usually involved both the inter-

nal and the external anal sphincters. Other investiga-

tors subsequently reported that 54–91% of their anal

sphincter repair failed (Table 4) [10, 18–21]. The pres-

ence of a failed repair is an important risk factor for

developing anal incontinence postpartum. Data from

seven studies revealed that approximately 55% of sub-

jects who failed anal sphincter repair were incontinent

postpartum [10, 18–23]. In contrast, only 20% of those

who had a successful repair were incontinent. These

findings demonstrated that anal sphincter repair out-

come plays an important role in determining whether

a woman will maintain continence after sustaining a

third- or fourth-degree perineal laceration.

286

E.H.M. Sze, M. Ciarleglio

Table 2. Long-term outcome after an anal sphincter tear

Reference Degree of tear Number Flatus incontinence Fecal incontinence Duration of

vs. control follow-up

Wagenius et al. [13] 3rd/4th 186 33% 25% 4 years

Control 348 15% 9%

Pollack et al. [8] 3rd/4th 36 53% 11% 5 years

Control 206 31% 5%

Haadem et al. [1] 3rd/4th 41 22% 46% 18 years

Control 38 3% 5%

Faltin et al. [12] 3rd/4th 259 46% 14% 19 years

Control 281 37% 5%

Nygaard et al. [11] 3rd/4th 29 31% 7% 30 years

Episiotomy 89 43% 18%

Table 3. Severity of anal incontinence after an anal sphincter tear

Reference Degree of tear Number Degree/type of incontinence and Duration of

vs. control quality of life (QOL) scores follow-up

Severe incontinence Very severe incontinence

Faltin et al. [12] 3rd/4th 445 13% 4% 18 years

Control 445 8% 1%

Fecal incontinence Affected QOL

Wagenius et al. [13] 3rd/4th 186 25% 30% 4 years

Control 348 9% 10%

Median (range

) flatus Median (range

) fecal

incontinence score incontinence score

Fornell et al. [14] Partial AST 33 4 (1–6) 4 (1–4) 10 years

Complete AST 72(1–4) 2 (1–6)

Control 19 5 (3–6) 6 (2–6)

AST anal sphincter tear

1 = severe problem, 6 = no problem

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