Obstetric anal sphincter injury in the UK and its effect on bowel, bladder and sexual function

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Abstract

Objective

To determine the incidence and factors associated with the development of bowel, urinary and sexual symptoms following obstetric anal sphincter injury (OASIS).

Study design

A prospective cohort study involving 435 women who sustained OASIS, over a five-year period, in a large UK teaching hospital. Details of bowel, urinary and sexual function were documented using a structured questionnaire. The outcome measures included the incidence of symptoms following OASIS and factors which modify the risk of developing symptoms.

Results

The majority (96%) of women were faecally continent three months after primary OASIS repair. Nevertheless, 34.2% reported faecal urgency, 25% suffered poor flatal control, and nearly 30% reported pain and bleeding on defaecation. Sixteen percent of women reported stress urinary incontinence, 15% experienced urgency and 20% reported urinary frequency. Fifty-seven percent of women had resumed intercourse but 32% of those women reported dyspareunia. Women who developed faecal symptoms were significantly more likely to develop urinary symptoms. Advancing maternal age and the use of forceps, in particular rotational forceps, significantly increase the risk of developing faecal and urinary symptoms.

Conclusions

Obstetric anal sphincter injuries continue to be responsible for significant morbidity, with approximately 30% of women reporting faecal, urinary or sexual symptoms, three months postpartum. This large prospective UK study provides up-to-date information relating to factors which increase the likelihood of such symptoms occurring. These data are useful for counselling and targeting more intensive follow up to women at higher risk of developing symptoms.

Introduction

Obstetric anal sphincter injuries (OASIS) occur in 0.5–9% of vaginal deliveries [1]. Women who have sustained OASIS are more likely to suffer from faecal incontinence than women who have undergone vaginal delivery without OASIS [2]. OASIS are responsible for significant physical, sexual and psychological sequelae [3]. The reported incidence of subsequent symptoms, such as faecal urgency and flatal/faecal incontinence, varies widely, however, from 25% to 67% [4], [5]. As a consequence it is difficult to counsel women accurately and provide relevant prognostic data following such an injury [1], [6]. Furthermore, factors associated with the development of faecal or urinary symptoms following OASIS remain poorly understood. Predicting outcome of primary OASIS repair is problematic due to considerable differences in study design and data collection.

Women who have sustained OASIS require more accurate, up to date information on the likelihood of developing faecal, urinary and sexual symptoms following primary repair. The aim of this study was to determine prospectively the incidence of bowel, urinary and sexual function following OASIS in a large UK Teaching hospital during a five-year period. In addition we identified factors associated with the development of symptoms following OASIS.

Section snippets

Materials and methods

In the five-year period from 2004 to 2009, 435 women who sustained an obstetric anal sphincter injury in Leeds were followed up three months postpartum in the perineal clinic. Details of their bowel, urinary and sexual function were documented using a structured questionnaire. The women had sustained OASIS following a variety of modes of delivery including spontaneous (normal), forceps (rotational and non-rotational) and ventouse deliveries. All sphincter injuries were diagnosed clinically and

Bowel function

Faecal incontinence was reported by 3.7% of women three months following primary OASIS repair (Table 2), but 34.2% reported faecal urgency and 25% suffered from poor control of flatus. Eight percent of women had little or no warning of the need to defaecate and nearly 30% of women reported pain and bleeding on defaecation. Three months after sustaining an obstetric anal sphincter injury 90% of women opened their bowels daily and 91% described the consistency of their motion as normal (Table 2).

Urinary and sexual function

Comments

Although there is good evidence to confirm that OASIS is an important risk factor for faecal and urinary incontinence, the precise impact of OASIS on pelvic floor function is unclear. It is difficult to counsel women regarding their individual risk of developing faecal, urinary or sexual symptoms following OASIS, as considerable variability and discrepancies exist within the literature. This is one of the largest UK studies to report outcome following primary repair of OASIS and also to

Conclusion

Obstetric anal sphincter injuries continue to be responsible for significant morbidity. Although the majority (96%) of women who sustain an obstetric anal sphincter injury are faecally continent three months after delivery, 34% report faecal urgency, 25% report poor flatal control and 30% have pain and bleeding on defaecation. This study reveals that when the anal sphincter is damaged, advancing maternal age and the use of forceps, in particular rotational forceps, significantly increase the

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