Article information
Abstract
Faecal incontinence is underestimated in most epidemiological studies, probably because women may feel unable to discuss the symptoms they experience and avoid seeking medical advice. The most common cause of faecal incontinence in healthy women is an injury during a vaginal delivery. In this article we review the classification and terminology, as well as the risk factors, for third and fourth degree perineal tears. We also comment on the different suture techniques, the follow-up of women who sustain third and fourth degree tears and the advice given to those women regarding future pregnancies and mode of delivery. We highlight the importance of the endoanal ultrasound on the diagnosis of occult anal sphincter injury.
Keywords:
Anal sphincter injury
Delivery
Faecal incontinence
Resumen
La incontinencia fecal es una condición subestimada en los estudios epidemiológicos debido a que muchas mujeres no acuden al médico a pesar de padecerla. La causa más frecuente de incontinencia fecal en las mujeres sanas es el traumatismo de etiología obstétrica. En este artículo se revisa la clasificación y la terminología, así como los factores de riesgo predisponentes a presentar una lesión obstétrica perineal de tercer y cuarto grado. También se repasan las diferentes técnicas de sutura y el seguimiento óptimo ulterior de las mujeres que sufren desgarros perineales, así como la conducta a seguir en las futuras gestaciones. Se recalca la importancia de la ecografía endoanal en el diagnóstico correcto de lesiones ocultas perineales de etiología obstétrica.
Palabras clave:
Lesión del esfínter anal
Parto
Incontinencia fecal
Full text is only aviable in PDF
References
[1.]
R.D. Madoff, S.C. Parker, M.G. Varma, A.C. Lowry.
Faecal incontinence in adults.
Lancet, 364 (2004), pp. 621-632
[2.]
S. Norderval, P. Oian, A. Revhaug, B. Vonen.
Anal incontinence after obstetric sphincter tears: outcome of anatomic primary repairs.
Dis Colon Rectum, 48 (2005), pp. 1055-1061
[3.]
P.B. Miner Jr.
Economic and personal impact of fecal and urinary incontinence.
Gastroenterology, 126 (2004), pp. S8-S13
[4.]
I. Nygaard, M.D. Barber, K.L. Burgio, K. Kenton, S. Meikle, J. Schaffer, et al.
Prevalence of symptomatic pelvic floor disorders in US women.
JAMA, 300 (2008), pp. 1311-1316
[5.]
T.M. Pinta, M.L. Kylanpaa, T.K. Salmi, K.A. Teramo, P.S. Luukkonen.
Primary sphincter repair: are the results of the operation good enough?.
Dis Colon Rectum, 47 (2004), pp. 18-23
[6.]
A. Arnaud, J.C. Sarles, I. Sielezneff, P. Orsoni, A. Joly.
Sphincter repair without overlapping for fecal incontinence.
Dis Colon Rectum, 34 (1991), pp. 744-747
[7.]
S. Norderval, D. Nsubuga, C. Bjelke, J. Frasunek, I. Myklebust, B. Vonen.
Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county.
Acta Obstet Gynecol Scand, 83 (2004), pp. 989-994
[8.]
M. Fitzpatrick, M. Behan, P.R. O’Connell, C. O’Herlihy.
A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears.
Am J Obstet Gynecol, 183 (2000), pp. 1220-1224
[9.]
M. Starck, M. Bohe, L. Valentin.
The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence.
Ultrasound Obstet Gynecol, 27 (2006), pp. 188-197
[10.]
E.U. Fornell, L. Matthiesen, R. Sjodahl, G. Berg.
Obstetric anal sphincter injury ten years after: subjective and objective long term effects.
BJOG, 112 (2005), pp. 312-316
[11.]
K. Davis, D. Kumar, S.L. Stanton, R. Thakar, M. Fynes, J. Bland.
Symptoms and anal sphincter morphology following primary repair of third-degree tears.
Br J Surg, 90 (2003), pp. 1573-1579
[12.]
M. Nazir, R. Stien, E. Carlsen, A.F. Jacobsen, B.I. Nesheim.
Early evaluation of bowel symptoms after primary repair of obstetric perineal rupture is misleading: an observational cohort study.
Dis Colon Rectum, 46 (2003), pp. 1245-1250
[13.]
C.M. Nichols, M. Nam, V. Ramakrishnan, E.H. Lamb, N. Currie.
Anal sphincter defects and bowel symptoms in women with and without recognized anal sphincter trauma.
Am J Obstet Gynecol, 194 (2006), pp. 1450-1454
[14.]
S.J. Burnett, C. Spence-Jones, C.T. Speakman, M.A. Kamm, C.N. Hudson, C.I. Bartram.
Unsuspected sphincter damage following childbirth revealed by anal endosonography.
Br J Radiol, 64 (1991), pp. 225-227
[15.]
S. Karoui, C. Savoye-Collet, E. Koning, A.M. Leroi, P. Denis.
Prevalence of anal sphincter defects revealed by sonography in 335 incontinent patients and 115 continent patients.
AJR Am J Roentgenol, 173 (1999), pp. 389-392
[16.]
RCOG. Green-top Guideline.
Gynaecol, (2007), pp. 1-11
[17.]
A. Eddy.
Litigating and quabtifying maternal damage following childbirth.
Clin Risk, 5 (1999), pp. 178-180
[18.]
A.H. Sultan.
Obstetric perineal injury and anal incontinence.
Clin Risk, 5 (1999), pp. 193-196
[19.]
Y.P. Sangwan, J.A. Solla.
Internal anal sphincter: advances and insights.
Dis Colon Rectum, 41 (1998), pp. 1297-1311
[20.]
J.W. de Leeuw, P.C. Struijk, M.E. Vierhout, H.C. Wallenburg.
Risk factors for third degree perineal ruptures during delivery.
BJOG, 108 (2001), pp. 383-387
[21.]
A. Williams, D.G. Tincello, S. White, E.J. Adams, Z. Alfirevic, D.H. Richmond.
Risk scoring system for prediction of obstetric anal sphincter injury.
BJOG, 112 (2005), pp. 1066-1069
[22.]
T.C. Dudding, C.J. Vaizey, M.A. Kamm.
Obstetric anal sphincter injury: incidence, risk factors, and management.
Ann Surg, 247 (2008), pp. 224-237
[23.]
S.B. Thacker, H.D. Banta.
Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860–1980.
Obstet Gynecol Surv, 38 (1983), pp. 322-338
[24.]
A.H. Sultan, M.A. Kamm, C.I. Bartram, C.N. Hudson.
Anal sphincter trauma during instrumental delivery.
Int J Gynaecol Obstet, 43 (1993), pp. 263-270
[25.]
A.H. Sultan, M.A. Kamm, C.N. Hudson, C.I. Bartram.
Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair.
BMJ, 308 (1994), pp. 887-891
[26.]
D.L. Faltin, M. Boulvain, O. Irion, S. Bretones, C. Stan, A. Weil.
Diagnosis of anal sphincter tears by postpartum endosonography to predict fecal incontinence.
Obstet Gynecol, 95 (2000), pp. 643-647
[27.]
M. Eogan, L. Daly, P.R. O’Connell, C. O’Herlihy.
Does the angle of episiotomy affect the incidence of anal sphincter injury?.
BJOG, 113 (2006), pp. 190-194
[28.]
National Institutes of Health state-of-the-science conference statement: Cesarean delivery on maternal request, March 27–29, 2006. Obstet Gynecol. 2006;107:1386.
[29.]
E.S. Lukacz, J.M. Lawrence, R. Contreras, C.W. Nager, K.M. Luber.
Parity, mode of delivery, and pelvic floor disorders.
Obstet Gynecol, 107 (2006), pp. 1253-1260
[30.]
C.I. Bartram.
Functional anorectal imaging.
Abdom Imaging, 30 (2005), pp. 195-203
[31.]
K.M. Groom, S. Paterson-Brown.
Can we improve on the diagnosis of third degree tears?.
Eur J Obstet Gynecol Reprod Biol, 101 (2002), pp. 19-21
[32.]
V. Andrews, A.H. Sultan, R. Thakar, P.W. Jones.
Occult anal sphincter injuries—myth or reality?.
BJOG, 113 (2006), pp. 195-200
[33.]
A.H. Sultan, M.A. Kamm, C.N. Hudson, J.M. Thomas, C.I. Bartram.
Anal-sphincter disruption during vaginal delivery.
N Engl J Med, 329 (1993), pp. 1905-1911
[34.]
C. Chaliha, A.H. Sultan, J. Bland.
Anal function: effect of pregnancy and delivery.
Am J Obstet Gynecol, 94 (1999), pp. 689
[35.]
A. Varma, J. Gunn, A. Gardiner, S.W. Lindow, G.S. Duthie.
Obstetric anal sphincter injury: prospective evaluation of incidence.
Dis Colon Rectum, 42 (1999), pp. 1537-1543
[36.]
H.E. Richter, J.R. Fielding, C.S. Bradley, V.L. Handa, P. Fine, M.P. FitzGerald, et al.
Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears.
Obstet Gynecol, 108 (2006), pp. 1394-1401
[37.]
D.L. Faltin, M. Boulvain, C. Stan, M. Epiney, A. Weil, O. Irion.
Intraobserver and interobserver agreement in the diagnosis of anal sphincter tears by postpartum endosonography.
Ultra- sound Obstet Gynecol, 21 (2003), pp. 375-377
[38.]
A.H. Sultan, A.K. Monga, D. Kumar, S.L. Stanton.
Primary repair of obstetric anal sphincter rupture using the overlap technique.
Br J Obstet Gynaecol, 106 (1999), pp. 318-323
[39.]
R. Fernando, A.H. Sultan, C. Kettle, R. Thakar, S. Radley.
Methods of repair for obstetric anal sphincter injury.
Cochrane Database Syst Rev, 3 (2006),
[40.]
A. Williams, E.J. Adams, D.G. Tincello, Z. Alfirevic, S.A. Walkinshaw, D.H. Richmond.
How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial.
BJOG, 113 (2006), pp. 201-207
[41.]
V. Garcia, R.G. Rogers, S.S. Kim, R.J. Hall, D.N. Kammerer-Doak.
Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques.
Am J Obstet Gynecol, 192 (2005), pp. 1697-1701
[42.]
J. Goh, M. Carey, J. Tjandra.
Direct end-to-end or overlapping delayed anal sphincter repair for anal incontinence: long tgerm results of prospective randomised study.
Neurourol Urodyn, 23 (2004), pp. 412-414
[43.]
A.F. Engel, M.A. Kamm, A.H. Sultan, C.I. Bartram, R.J. Nicholls.
Anterior anal sphincter repair in patients with obstetric trauma.
Br J Surg, 81 (1994), pp. 1231-1234
[44.]
E.E. Londono-Schimmer, R. Garcia-Duperly, R.J. Nicholls, J.K. Ritchie, P.R. Hawley, J.P. Thomson.
Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results.
Int J Colorectal Dis, 9 (1994), pp. 110-113
[45.]
R.J. Fernando, A.H. Sultan, S. Radley, P.W. Jones, R.B. Johanson.
Management of obstetric anal sphincter injury: a systematic review & national practice survey.
BMC Health Serv Res, 2 (2002), pp. 9
[46.]
R. Thakar, A.H. Sultan, R. Fernando, A.K. Monga, S. Stanton.
Can workshops on obstetric anal sphincter rupture change practice?.
Int Urogynecol J, 12 (2001), pp. S5
[47.]
P. Buppasiri, P. Lumbiganon, J. Thinkhamrop, B. Thinkhamrop.
Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth.
Cochrane Database Syst Rev, (2005),
[48.]
K. Haadem, J.A. Dahlstrom, G. Lingman.
Anal sphincter function after delivery: a prospective study in women with sphincter rupture and controls.
Eur J Obstet Gynecol Reprod Biol, 35 (1990), pp. 7-13
[49.]
K. Haadem, J.A. Dahlstrom, L. Ling, S. Ohrlander.
Anal sphincter function after delivery rupture.
Obstet Gynecol, 70 (1987), pp. 53-56
[50.]
C.J. Walsh, E.F. Mooney, G.J. Upton, R.W. Motson.
Incidence of third-degree perineal tears in labour and outcome after primary repair.
Br J Surg, 83 (1996), pp. 218-221
[51.]
E.K. Fornell, G. Berg, O. Hallbook, L.S. Matthiesen, R. Sjodahl.
Clinical consequences of anal sphincter rupture during vaginal delivery.
J Am Coll Surg, 183 (1996), pp. 553-558
[52.]
D.N. Kammerer-Doak, A.B. Wesol, R.G. Rogers, C.E. Dominguez, M.H. Dorin.
A prospective cohort study of women after primary repair of obstetric anal sphincter laceration.
Am J Obstet Gynecol, 181 (1999), pp. 1317-1322
[53.]
L.A. Crawford, E.H. Quint, M.L. Pearl, J.O. DeLancey.
Incontinence following rupture of the anal sphincter during delivery.
Obstet Gynecol, 82 (1993), pp. 527-531
[54.]
A.C. Poen, R.J. Felt-Bersma, R.L. Strijers, G.A. Dekker, M.A. Cuesta, S.G. Meuwissen.
Third-degree obstetric perineal tear: longterm clinical and functional results after primary repair.
Br J Surg, 85 (1998), pp. 1433-1438
[55.]
H. Gjessing, B. Backe, Y. Sahlin.
Third degree obstetric tears; outcome after primary repair.
Acta Obstet Gynecol Scand, 77 (1998), pp. 736-740
[56.]
J. Wood, L. Amos, N. Rieger.
Third degree anal sphincter tears: risk factors and outcome.
Aust N Z J Obstet Gynaecol, 38 (1998), pp. 414-417
[57.]
T. Tetzschner, M. Sorensen, G. Lose, J. Christiansen.
Anal and urinary incontinence in women with obstetric anal sphincter rupture.
Br J Obstet Gynaecol, 103 (1996), pp. 1034-1040
[58.]
A.R. Goffeng, B. Andersch, M. Andersson, I. Berndtsson, L. Hulten, T. Oresland.
Objective methods cannot predict anal incontinence after primary repair of extensive anal tears.
Acta Obstet Gynecol Scand, 77 (1998), pp. 439-443
[59.]
A.C. Poen, R.J. Felt-Bersma, G.A. Dekker, W. Deville, M.A. Cuesta, S.G. Meuwissen.
Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy.
Br J Obstet Gynaecol, 104 (1997), pp. 563-566
[60.]
R.J. Fernando, A.H. Sultan, C. Kettle, S. Radley, P. Jones, P.M. O’Brien.
Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial.
Obstet Gynecol, 107 (2006), pp. 1261-1268
[61.]
A.J. Malouf, C.S. Norton, A.F. Engel, R.J. Nicholls, M.A. Kamm.
Longterm results of overlapping anterior anal-sphincter repair for obstetric trauma.
Lancet, 355 (2000), pp. 260-265
[62.]
A.H. Sultan, R. Thakar.
Lower genital tract and anal sphincter trauma.
Best Pract Res Clin Obstet Gynaecol, 16 (2002), pp. 99-115
[63.]
K.M. Bek, S. Laurberg.
Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear.
Br J Obstet Gynaecol, 99 (1992), pp. 724-726
Copyright © 2009. Asociación Española de Cirujanos
