Obstetric anal sphincter injuries : risk factors, episiotomy characteristics, and pelvic floor dysfunction

Obstetric anal sphincter injuries (OASIS) are well known and serious complications of vaginal delivery. The incidence in Norway increased from below 1.0% in the 1960s to 4.3% in 2004. As a consequence a national strategy to reduce the number of OASIS was initiated by the Directorate for Health and Social affairs/National Advisory Committee for Obstetrics. As a part of this strategy an interventional programme primarily focused on perineal support during the final part of second stage of labour was conducted at five hospitals in total. After the interventional programme the OASIS rate fell from 4-5% to 1-2%. The role of episiotomy has been subject for debate. Different techniques have been differently associated with increased risk of OASIS, and consensus is lacking regarding the role of mediolateral episiotomy. OASIS is, in addition to anal incontinence (AI), associated with urinary incontinence (UI) and sexual problems. Episiotomy is identified both as a risk factor and protective factor for OASIS as well as an independent risk factor for postpartum AI and sexual problems. The main aims of this PhD project were: to evaluate and compare the risk profile of sustaining OASIS after the OASIS rate was reduced from 4.6% to 2.0% following an interventional programme in four of the five hospitals and to investigate associated risks in five risk groups (low to high). Also, to investigate the association between the geometrical properties of episiotomies and OASIS and, and lastly to investigate AI, UI, and sexual problems in two groups of primiparous women with episiotomy, comparing women with and without OASIS, and assess associations between episiotomy characteristics and the dysfunctions: AI, UI, and sexual problems. In total, 40 154 vaginal deliveries in 2003-2009 were included in this multicentre interventional cohort study with before and after comparison. In a case-control study we compared two groups of women. Seventy-four women with episiotomy were included. Cases (n = 37) had sustained OASIS at birth, while controls (n = 37) had not. The episiotomy scar was photographed, and relevant measures taken. All women were scored for AI, UI and sexual problems by St. Mark’s scoring-tool and self-administered questionnaires. After the interventional programme the most significant decrease (65%) in OASIS was observed in low-risk births. The main risk factors for OASIS remained unchanged being 1st vaginal delivery, high birth weight ≥ 4500g, and forceps assisted delivery. We found that scarred episiotomies with depth > 16 mm, length > 17 mm, incision point > 9 mm lateral of midpoint and angle range 30–60° are significantly associated with less risk of OASIS. However, shrinkage of tissue must be considered. Lastly, women with OASIS had more AI and sexual problems. There was no association between episiotomy characteristics and dysfunctions except between episiotomy length and sexual problems in women without OASIS

Characteristics of women with chronic pelvic pain referred to physiotherapy treatment after multidisciplinary assessment: a cross-sectional study

Background and aims: Chronic pelvic pain (CPP) in women is a complex condition that can seriously impact health and quality of life. Clinical guidelines for CPP place great demands on healthcare professionals, as they require both specialized knowledge about the pelvic area and knowledge of the mechanisms of chronic pain. To ensure best possible assessment and treatment of these women it is important to bring about more knowledge of the special CPP features. The purpose of this paper is to describe the characteristics of women with CPP evaluated at the University Hospital of North Norway, and further referred to physiotherapy. The frequency of having a history of abuse or previous pelvic surgery will also be reported, and analyses performed to investigate if subjective health status differs between women With and without these experiences. Methods: We collected cross-sectional data from 62 women with CPP aged 20-65 (mean age 38.0), referred to physiotherapy after assessment by medical specialists. Data were collected by semi-structured interviews for demographic variables and medical history, and selfadministered questionnaires on pain intensity, sexual function, urinary incontinence (UI), anal incontinence (AI), obstructed defecation syndrome (ODS), subjective health complaints (SHC) and symptoms of anxiety and depression. Results: Pain duration of more than 10 years was reported by 42%, mean pain score was 4.7/10, and analgesics were used weekly by 48%. Previous pelvic or abdominal surgery was reported by 71%, and sick leave >12 weeks the last year by 34%. Reduced sexual desire was reported by 78%, dyspareunia by 73%, UI by 54%, AI by 23%, and ODS by 34%. More than 90% reported musculoskeletal or pseudoneurologic complaints. Anxiety and depression scores defined as requiring treatment were reported by 40%. Abuse was reported by 50%, and associated with significantly more reports of ODS (p=0.02), more SHC (p=0.02) and higher anxiety scores (p=0.009). Analgesic use and sick leave were significantly higher both among women with a history of abuse (p=0.04 and p=0.005) and among those with previous surgery (p=0.04 and p=0.02). Women with previous surgery reported significantly lower pain intensity during intercourse than those without previous surgery (p=0.008). Conclusions: Women with CPP have complex symptoms and high scores for both physical and psychological complaints. Women exposed to abuse have especially high scores related to analgesic use, sick leave, ODS, anxiety and SHC. Women with previous surgery report more analgesic use and sick leave, and lower pain intensity during intercourse, than those without previous surgery. Implications: This study illustrates the complexity of CPP and highlights the need for health professionals to have specialized knowledge of the possible features of the condition. Previous abuse seems to be more associated with poor scores on several health outcomes than surgery, but this needs to be investigated further

Characteristics of women with chronic pelvic pain referred to physiotherapy treatment after multidisciplinary assessment: a cross-sectional study

Background and aims - Chronic pelvic pain (CPP) in women is a complex condition that can seriously impact health and quality of life. Clinical guidelines for CPP place great demands on healthcare professionals, as they require both specialized knowledge about the pelvic area and knowledge of the mechanisms of chronic pain. To ensure best possible assessment and treatment of these women it is important to bring about more knowledge of the special CPP features. The purpose of this paper is to describe the characteristics of women with CPP evaluated at the University Hospital of North Norway, and further referred to physiotherapy. The frequency of having a history of abuse or previous pelvic surgery will also be reported, and analyses performed to investigate if subjective health status differs between women with and without these experiences. Methods - We collected cross-sectional data from 62 women with CPP aged 20–65 (mean age 38.0), referred to physiotherapy after assessment by medical specialists. Data were collected by semi-structured interviews for demographic variables and medical history, and self-administered questionnaires on pain intensity, sexual function, urinary incontinence (UI), anal incontinence (AI), obstructed defecation syndrome (ODS), subjective health complaints (SHC) and symptoms of anxiety and depression. Results - Pain duration of more than 10 years was reported by 42%, mean pain score was 4.7/10, and analgesics were used weekly by 48%. Previous pelvic or abdominal surgery was reported by 71%, and sick leave >12 weeks the last year by 34%. Reduced sexual desire was reported by 78%, dyspareunia by 73%, UI by 54%, AI by 23%, and obstructed defecation syndrome (ODS) by 34%. More than 90% reported musculoskeletal or pseudoneurologic complaints. Anxiety and depression scores defined as requiring treatment were reported by 40%. Abuse was reported by 50%, and associated with significantly more reports of ODS (p=0.02), more SHC (p=0.02) and higher anxiety scores (p=0.009). Analgesic use and sick leave were significantly higher both among women with a history of abuse (p=0.04 and p=0.005) and among those with previous surgery (p=0.04 and p=0.02). Women with previous surgery reported significantly lower pain intensity during intercourse than those without previous surgery (p=0.008). Conclusions - Women with CPP have complex symptoms and high scores for both physical and psychological complaints. Women exposed to abuse have especially high scores related to analgesic use, sick leave, ODS, anxiety and SHC. Women with previous surgery report more analgesic use and sick leave, and lower pain intensity during intercourse, than those without previous surgery. Implications - This study illustrates the complexity of CPP and highlights the need for health professionals to have specialized knowledge of the possible features of the condition. Previous abuse seems to be more associated with poor scores on several health outcomes than surgery, but this needs to be investigated further

Anal incontinence, urinary incontinence and sexual problems in primiparous women – a comparison between women with episiotomy only and women with episiotomy and obstetric anal sphincter injury

Background: Obstetric anal sphincter injuries (OASIS) might cause anal incontinence (AI) and sexual dysfunction, and might be associated with urinary incontinence (UI). Episiotomy has been identified both as a risk and a protective factor of OASIS. Lately, episiotomies with specific characteristics have shown to be protective against the risk of OASIS. However, little is known about episiotomy characteristics and pelvic floor dysfunction. This study investigates AI, UI, and sexual problems in primiparous women with episiotomy, comparing women with and without OASIS. Associations between episiotomy characteristics and AI, UI, and sexual problems were assessed. Methods: This is a matched case–control study investigating 74 women with one vaginal birth, all with an episiotomy. Among these, 37 women sustained OASIS and were compared to 37 women without OASIS. The two groups were matched for vacuum/forceps. AI, UI and sexual problem symptoms were obtained from St. Mark’s scoring-tool and self-administered questionnaires. The episiotomy characteristics were investigated and results assessed for the whole group. Results: The mean time from birth was 34.5 months (range1.3-78.2) for those with OASIS and 25.9 months (range 7.0-57.4) for those without OASIS, respectively. More women with OASIS reported AI: 14 (38%) vs. 3 (8%) p = 0.05 (OR 4.66, 95% CI 1.34-16.33) as well as more problem with sexual desire p = 0.02 (OR 7.62, 95% CI 1.30-44.64) compared to women without OASIS. We found no association between episiotomy with protective characteristics and dysfunctions. Conclusion: Women with OASIS had more AI and sexual problems than those without OASIS. Episiotomy characteristics varied greatly between the women. Episiotomy with protective characteristics was not associated with increased dysfunctions. OASIS should be avoided, and correct episiotomy used if indicated

Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study

Objectives  To investigate the association between the geometrical properties of episiotomy and obstetric anal sphincter injuries (OASIS) because episiotomies angled at 40–60° are associated with fewer OASIS than episiotomies with more acute angles. Design  Case–control study. Setting  University Hospital of North Norway, Tromsø and Nordland Hospital, Bodø, Norway. Sample  Seventy-four women who had one vaginal birth and episiotomy. Cases (n = 37) have sustained OASIS at birth, while controls (n = 37) had not. The groups were matched for instrumental delivery. Methods  Two groups of women with history of only one vaginal birth were compared. Episiotomy scar was identified and photographed and relevant measures were taken. Data were analysed using conditional logistic analysis. Main outcome measures  Mean episiotomy angle, length, depth, incision point. Results  The risk of sustaining OASIS decreased by 70% (odds ratio [OR] 0.30; 95% CI 0.14–0.66) for each 5.5-mm increase in episiotomy depth, decreased by 56% (OR 0.44; 95% CI 0.23–0.86) for each 4.5-mm increase in the distance from the midline to the incision point of the episiotomy, and decreased by 75% (OR 0.25; 95% CI 0.10–0.61) for each 5.5-mm increase in episiotomy length. Lastly, there was no difference in mean angle between groups but there was a “U-shaped” association between angle and OASIS (OR 2.09; 95% CI 1.02–4.28) with an increased risk (OR 9.00; 95% CI 1.1–71.0) of OASIS when the angle was either smaller than 15°or >60°. Conclusion  The present study showed that scarred episiotomies with depth > 16 mm, length > 17 mm, incision point > 9 mm lateral of midpoint and angle range 30–60° are significantly associated with less risk of OASIS. Shrinkage of tissue must be considered

Group-based multimodal physical therapy in women with chronic pelvic pain: A randomized controlled trial

Introduction: Chronic pelvic pain in women is a complex condition, and physical therapy is recommended as part of a broader treatment approach. The objective of this study was to compare structured group-based multimodal physical therapy in a hospital setting (intervention group) with primary-care physical therapy (comparator group) for women with chronic pelvic pain. Material and methods: Women aged 20-65 years with pelvic pain ≥6 months and referred for physical therapy were eligible. The primary outcome measure was change in the mean pelvic pain intensity from baseline to 12 months, measured using the numeric rating scale (0-10). Secondary outcomes were changes in scores of “worst” and “least” pain intensity, health-related quality of life, movement patterns, pain- related fear of movements, anxiety and depression, subjective health complaints, sexual function, incontinence, and obstructed defecation. The differences between the groups regarding change in scores were analyzed using the independent t test and Mann-Whitney U test. Sensitivity analysis of the primary outcome was performed with a linear regression model adjusted for the baseline value. A P value <.05 was considered statistically significant. Results: Of the 62 women included, 26 in the intervention group and 25 in the comparator group were available after 12 months for data collection and analysis. The difference between the groups for change in the mean pain intensity score was −1.2 (95% CI −2.3 to −0.2; P = .027), favoring the intervention group. The intervention group showed greater improvements in respiratory patterns (mean difference 0.9; 95% CI 0.2-1.6; P = .015) and pain-related fear of movements (mean difference 2.9; 95% CI −5.5 to −0.3; P = .032), and no significant differences were observed between the groups for the other secondary outcomes. Conclusions: Although the reduction in the mean pelvic pain intensity with group- based multimodal physical therapy was significantly more than with primary-care physical therapy, the difference in the change between the groups was less than ex- pected and the clinical relevance is uncertain

Group-based multimodal physical therapy in women with chronic pelvic pain: A randomized controlled trial

Introduction - Chronic pelvic pain in women is a complex condition, and physical therapy is recommended as part of a broader treatment approach. The objective of this study was to compare structured group‐based multimodal physical therapy in a hospital setting (intervention group) with primary‐care physical therapy (comparator group) for women with chronic pelvic pain. Material and methods - Women aged 20‐65 years with pelvic pain ≥6 months and referred for physical therapy were eligible. The primary outcome measure was change in the mean pelvic pain intensity from baseline to 12 months, measured using the numeric rating scale (0‐10). Secondary outcomes were changes in scores of “worst” and “least” pain intensity, health‐related quality of life, movement patterns, pain‐related fear of movements, anxiety and depression, subjective health complaints, sexual function, incontinence, and obstructed defecation. The differences between the groups regarding change in scores were analyzed using the independent t test and Mann‐Whitney U test. Sensitivity analysis of the primary outcome was performed with a linear regression model adjusted for the baseline value. A P value <.05 was considered statistically significant. Results - Of the 62 women included, 26 in the intervention group and 25 in the comparator group were available after 12 months for data collection and analysis. The difference between the groups for change in the mean pain intensity score was −1.2 (95% CI −2.3 to −0.2; P = .027), favoring the intervention group. The intervention group showed greater improvements in respiratory patterns (mean difference 0.9; 95% CI 0.2‐1.6; P = .015) and pain‐related fear of movements (mean difference 2.9; 95% CI −5.5 to −0.3; P = .032), and no significant differences were observed between the groups for the other secondary outcomes. Conclusions - Although the reduction in the mean pelvic pain intensity with group‐based multimodal physical therapy was significantly more than with primary‐care physical therapy, the difference in the change between the groups was less than expected and the clinical relevance is uncertain

Group‐based multimodal physical therapy in women with chronic pelvic pain: A randomized controlled trial

Introduction - Chronic pelvic pain in women is a complex condition, and physical therapy is recommended as part of a broader treatment approach. The objective of this study was to compare structured group‐based multimodal physical therapy in a hospital setting (intervention group) with primary‐care physical therapy (comparator group) for women with chronic pelvic pain. Material and methods - Women aged 20‐65 years with pelvic pain ≥6 months and referred for physical therapy were eligible. The primary outcome measure was change in the mean pelvic pain intensity from baseline to 12 months, measured using the numeric rating scale (0‐10). Secondary outcomes were changes in scores of “worst” and “least” pain intensity, health‐related quality of life, movement patterns, pain‐related fear of movements, anxiety and depression, subjective health complaints, sexual function, incontinence, and obstructed defecation. The differences between the groups regarding change in scores were analyzed using the independent t test and Mann‐Whitney U test. Sensitivity analysis of the primary outcome was performed with a linear regression model adjusted for the baseline value. A P value <.05 was considered statistically significant. Results - Of the 62 women included, 26 in the intervention group and 25 in the comparator group were available after 12 months for data collection and analysis. The difference between the groups for change in the mean pain intensity score was −1.2 (95% CI −2.3 to −0.2; P = .027), favoring the intervention group. The intervention group showed greater improvements in respiratory patterns (mean difference 0.9; 95% CI 0.2‐1.6; P = .015) and pain‐related fear of movements (mean difference 2.9; 95% CI −5.5 to −0.3; P = .032), and no significant differences were observed between the groups for the other secondary outcomes. Conclusions - Although the reduction in the mean pelvic pain intensity with group‐based multimodal physical therapy was significantly more than with primary‐care physical therapy, the difference in the change between the groups was less than expected and the clinical relevance is uncertain

Group-based multimodal physical therapy in women with chronic pelvic pain: A randomized controlled trial

Introduction - Chronic pelvic pain in women is a complex condition, and physical therapy is recommended as part of a broader treatment approach. The objective of this study was to compare structured group‐based multimodal physical therapy in a hospital setting (intervention group) with primary‐care physical therapy (comparator group) for women with chronic pelvic pain. Material and methods - Women aged 20‐65 years with pelvic pain ≥6 months and referred for physical therapy were eligible. The primary outcome measure was change in the mean pelvic pain intensity from baseline to 12 months, measured using the numeric rating scale (0‐10). Secondary outcomes were changes in scores of “worst” and “least” pain intensity, health‐related quality of life, movement patterns, pain‐related fear of movements, anxiety and depression, subjective health complaints, sexual function, incontinence, and obstructed defecation. The differences between the groups regarding change in scores were analyzed using the independent t test and Mann‐Whitney U test. Sensitivity analysis of the primary outcome was performed with a linear regression model adjusted for the baseline value. A P value <.05 was considered statistically significant. Results - Of the 62 women included, 26 in the intervention group and 25 in the comparator group were available after 12 months for data collection and analysis. The difference between the groups for change in the mean pain intensity score was −1.2 (95% CI −2.3 to −0.2; P = .027), favoring the intervention group. The intervention group showed greater improvements in respiratory patterns (mean difference 0.9; 95% CI 0.2‐1.6; P = .015) and pain‐related fear of movements (mean difference 2.9; 95% CI −5.5 to −0.3; P = .032), and no significant differences were observed between the groups for the other secondary outcomes. Conclusions - Although the reduction in the mean pelvic pain intensity with group‐based multimodal physical therapy was significantly more than with primary‐care physical therapy, the difference in the change between the groups was less than expected and the clinical relevance is uncertain