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Up to one in four primiparous women suffer from altered faecal continence following labour and about one in three demonstrate evidence of anal sphincter injury after vaginal delivery.
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Up to 50% of women with third or fourth degree perineal tears during childbirth suffer from faecal incontinence.
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Altered anal symptoms include faecal urgency and incontinence of flatus, liquid stool and solid stool. This condition may also present in women without obvious anal sphincter tears during labour and delivery (occult injury).
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Definitions
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Second Degree: involves the perineal muscles only.
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Third Degree: injury to the perineum involving the anal sphincter complex (EAS & IAS)
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3a: < 50% of external sphincter torn
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3b: > 50% external sphincter torn
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3c: internal sphincter torn
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Fourth Degree: involves anal sphincter & rectal mucosa
Under-reporting may be due to less than strict adherence to definition or unrecognised injuries.
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Review of literature
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- Episiotomy is not protective as greater than fifty percent women who sustain a third or fourth degree tear have had an episiotomy.
- There is a much higher incidence with midline episiotomy compared to right mediolateral episiotomy
- The majority of women with faecal incontinence symptoms following a third or fourth degree tear will experience resolution of their symptoms in the first six months following delivery.
- Women with persistent symptoms (>6 months) of altered faecal continence may suffer deterioration of symptoms with a further vaginal delivery.
- This underlines the importance of postpartum ultrasound screening of asymptomatic individuals who have had a third or fourth degree tear so that these women may be identified and be allowed to make an informed choice regarding the mode of subsequent delivery.
- Pelvic floor muscle training reduces the incidence of post partum incontinence in women who have experienced perineal trauma in childbirth.9
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Associated risk factors
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- Instrumental delivery - particularly failed ventouse / forceps
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Recognition
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- All women should be examined to assess degree of perineal /vaginal /rectal injury after vaginal delivery.
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- The external anal sphincter should be palpated between two fingers - one vaginal, one rectal.
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- All women who have an instrumental delivery or who have extensive perineal injury should be examined by a registrar or consultant trained in recognition and management of perineal tears.
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Repair technique for third and fourth degree tears
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- Extensive tears and all third and fourth degree tears should be repaired under adequate regional analgesia. (Optimally in the operating theatre)
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| Sultan et al 1999 describes having a special 'perineal repair pack' with specific instruments required for anal sphincter repair.1
| GA or regional anaesthetic is important to allow adequate muscle relaxation to retrieve retracted torn sphincter muscle and enable repair without tension.1
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| - A consultant or senior level trainee experienced in third and fourth degree tear repair should be present
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| - A single dose of a broad spectrum prophylactic antibiotic should be administered at the time of repair. For example, a first-generation cephalosporin 1 gram and metronidazole 500mg IV stat.
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| A Cochrane Review concluded that there are no RCTs to support the use of prophylactic antibiotics2 . However, RCOG guidelines recommend broad-spectrum intra-operative and post-operative antibiotics because 'the development of infection will pose a high risk of anal incontinence and fistula formation following breakdown of the anal sphincter repair'.3
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| - A repeat examination should be performed in theatre to adequately grade the repair
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| - If the rectal mucosa is disrupted then this should be repaired using 3.0 polyglactin (vicryl) sutures for interrupted sutures, or 3-0 polydioxanone (PDS) if submucosal continuous sutures are used.
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| There appears to be no advantage of one technique over the other (interrupted vs continuous) when repairing the anal mucosa in terms of the risk of fistula development 4. PDS is preferable if using submucosal continuous suturing but has a delayed absorption rate so knots may cause discomfort and should not be used in interrupted sutures if the knots are tied in the canal. There is conflicting advice as to whether knots should be tied inside or outside the anal canal and there is no good evidence to support one or the other.
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| - The torn ends of the external anal sphincter should be fully mobilized and repaired using an overlap technique with 2-0 PDS. If the sphincter is only partially torn (less than 50%) then repair using an end-to-end technique with interrupted mattress sutures is acceptable. Avoid using 'figure-of-eight' sutures', unless for haemostasis.
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| Cochrane Review on Method of repair for obstetric anal sphincter injury identified 3 RCTs ( Fitzpatrick et al 2000, Williams et al 2006, Fernando et al 2006) and concluded that on the limited data available, immediate primary overlap repair appears to be associated with reduced risk for faecal urgency, anal incontinence score and deterioration of anal incontinence symptoms. However, it was noted that in the Fernando RCT, repairs were undertaken by 2 experienced surgeons and surgeon experience was not addressed in the other 2 studies.5
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| - End-to-end technique may be more vulnerable to ischaemia, especially with figure-of-eight sutures due to retraction of apposed sphincter muscles.6
| It is preferable to use PDS over Vicryl or catgut as it is a delayed absorbable monofilament suture with a longer half-life and is less likely to precipitate infection than braided sutures. Non-absorbable sutures such prolene are also effective but appears to be associated with risk of stitch abscess and sharp ends may cause discomfort and need removal1. Although one RCT comparing vicryl to PDS showed no difference in suture morbidity7 there has been no Cochrane review.
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| - The internal anal sphincter should be identified and if torn, should be repaired separately with interrupted 3-0 PDS using end-to-end or overlap technique.
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| The internal anal sphincter contributes to most of the anal resting tone and dysfunction may be associated with flatus and passive faecal incontinence. The results of the Fernando RCT were based on a technique that included end-to-end repair of IAS separately if torn.6
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| - The perineal muscles and subcutaneous tissue should be repaired with 2.0 polyglactin.
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| - The perineal skin is approximated with (preferably) a subcuticular or interrupted polyglactin suture.
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| - Perform a rectal examination at the end to ensure the repair is intact.
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| - Post-operative laxatives or stool softeners are recommended post-operatively to maintain soft stool and constipating agents should be avoided.
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| A RCT of bowel confinement vs laxatives after 3rd degree perineal tear repair reported significantly earlier and less painful bowel motion, and earlier post-natal discharge in the laxative group. There was no difference in symptomatic or functional outcome at 3 months.8
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Post-repair management
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1. Ice therapy, to decrease swelling for first 48-72 hours. Apply an ice pack in a sanitary pad to the perineum for 20 minutes every 3-4 hours.
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2. Adequate analgesia, avoiding codeine containing analgesics as they may cause constipation such as a nonsteroidal anti-inflammatory analgesia, plus oral paracetamol.
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3. Rectal analgesia must be avoided.
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4. Laxatives or stool softners are advisable for about 7-10 days (such as lactulose +/- fybogel ) to avoid constipation.
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5. Adequate fluid intake (1.5 -2L day) especially if taking lactulose.
6. Commence a pelvic floor muscle rehabilitation program as soon as comfortable, usually at about 3 days post delivery. An individualised program can be recommended by the physiotherapist.
7. Women who sustain a fourth degree tear will be referred to the dietitian, and commenced on a low residue diet for approximately 7 days. The purpose of this is to have a delayed, then soft and easy to pass stool.
8. Referral to CNC Urogynaecology to arrange follow up in the Perineal Clinic (in 3 months post delivery).
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Clinical Nurse Consultant (CNC) - Urogynaecology Pelvic Floor Service: 9344 2781
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Tel: (03) 9344 2781
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6. Ensure ability to recruit pelvic floor muscles for long term pelvic floor rehabilitation. Commence pelvic floor muscle exercise regime in approximately four to six weeks.
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7. At 12 weeks all patients should be reviewed (Perineal Clinic -Tuesday Urogyneacology) with regard to assessment of sphincter integrity by endoanal ultrasound. Digital examination has only a 43% sensitivity rate for the identification of external anal sphincter defects compared with ultrasound. Some women may need ongoing treatment.
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Follow-up - Perineal clinic
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The Perineal Clinic offers a multidisciplinary approach to the management and follow up of anal sphincter injury. The team includes Urogynaecology, Colorectal, Dietitian, Midwifery/Continence Nursing, Physiotherapy and Sexual Counselling expertise.
The aim of the Perineal Clinic is to offer best practice in the management and follow up of anal sphincter injury and to prevent or minimise long term complications.
Appointments are arranged by Clinical Nurse Consultant (CNC) Urogynaecology: ph 9344 2781.
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- Physiotherapist @ 6 weeks
- Perineal Clinic Doctor / Physiotherapist @ 3 months
- Perineal Clinic Doctor @ 6 months
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References
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References
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Evidence Table
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Evidence Table
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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