Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case–control study

• Published in: Ultrasound in obstetrics & gynecology Vol. 40; no. 2; pp. 207 - 214
• Main Authors: Norderval, S., Røssaak, K., Markskog, A., Vonen, B.
• Format: Journal Article
• Language: English
• Published: Chichester, UK John Wiley & Sons, Ltd 01-08-2012; Wiley; Wiley Subscription Services, Inc
• Subjects: Anal Canal - diagnostic imaging; Anal Canal - injuries; Anal Canal - surgery; anal incontinence; Biological and medical sciences; Case-Control Studies; Defects; Delivery. Postpartum. Lactation; endoanal ultrasonography; Endosonography - methods; Fecal Incontinence - diagnostic imaging; Fecal Incontinence - surgery; Female; Follow-Up Studies; Gastroenterology. Liver. Pancreas. Abdomen; grading systems; Gynecology. Andrology. Obstetrics; Humans; Lacerations - diagnostic imaging; Lacerations - surgery; Medical sciences; Medical treatment; Nephrology. Urinary tract diseases; Obstetric Labor Complications - diagnostic imaging; Obstetric Labor Complications - surgery; obstetric sphincter tears; Other diseases. Semiology; Postoperative Complications - diagnostic imaging; Postoperative Complications - surgery; Pregnancy; Reconstructive Surgical Procedures - methods; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; three‐dimensional; Urinary system involvement in other diseases. Miscellaneous; Urinary tract. Prostate gland; endoanal ultrasonography; Break; grading systems; Case control study; Anal sphincter; Voiding dysfunction; Histopathology; three-dimensional; Primary; Intestinal disease; Repair; Anorectal disease; Sonography; Urinary system disease; Evaluation scale; Gynecology; obstetric sphincter tears; Urinary tract disease; Obstetrics; Pregnancy; Urinary incontinence; Anatomic pathology; Length; Echography; External; Digestive diseases; Anal incontinence; Bladder disease; Delivery
• ISSN: 0960-7692; 1469-0705
• DOI: 10.1002/uog.10154

Objective
To determine if anatomic primary repair with end‐to‐end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end‐to‐end repair in which the IAS is not actively reconstructed.
Methods
Women who sustained third‐ or fourth‐degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three‐dimensional endoanal ultrasonography (3D‐EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score.
Results
Sixty‐three women were included in the study group and 61 in the control group, with mean follow‐up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow‐up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non‐significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007).
Conclusion
Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.