Is endoanal, introital or transperineal ultrasound diagnosis of sphincter defects more strongly associated with anal incontinence?

INTRODUCTION AND HYPOTHESIS: Our aim was to explore the association between anal incontinence (AI) and persistent anal sphincter defects diagnosed with 3D endoanal (EAUS), introital (IUS) and transperineal ultrasound (TPUS) in women after obstetric anal sphincter injury (OASI) and study the association between sphincter defects and anal pressure. METHODS: We carried out a cross-sectional study of 250 women with OASI recruited during the period 2013-2015. They were examined 6-12 weeks postpartum or in a subsequent pregnancy with 3D EAUS, IUS and TPUS and measurement of anal pressure. Prevalence of urgency/solid/liquid AI or flatal AI and anal pressure were compared in women with a defect and those with an intact sphincter (diagnosed off-line) using Chi-squared and Mann-Whitney U test. RESULTS: At a mean of 23.6 (SD 30.1) months after OASI, more women with defect than those with intact sphincters on EAUS had AI; urgency/solid/liquid AI vs external defect: 36% vs 13% and flatal AI vs internal defect: 27% vs 13%, p < 0.05. On TPUS, more women with defect sphincters had flatal AI: 32% vs 13%, p = 0.03. No difference was found on IUS. Difference between defect and intact sphincters on EAUS, IUS and TPUS respectively was found for mean [SD] maximum anal resting pressure (48 [13] vs 55 [14] mmHg; 48 [12] vs 56 [13] mmHg; 50 [13] vs 54 [14] mmHg) and squeeze incremental pressure (33 [17] vs 49 [28] mmHg; 37 [23] vs 50 [28] mmHg; 36 [18] vs 50 [30] mmHg; p < 0.01). CONCLUSIONS: Endoanal ultrasound had the strongest association with AI symptoms 2 years after OASI. Sphincter defects detected using all ultrasound methods were associated with lower anal pressure

The incidence of anal incontinence following obstetric anal sphincter injury (OASI) graded using the Sultan classification: A network meta-analysis.

OBJECTIVES: To systematically determine and compare the incidence of anal incontinence between the individual grades of OASI. DATA SOURCES: OVID Medline, Embase and the Cochrane Library were searched from January 2000 to April 2021. STUDY ELIGIBILITY CRITERIA: Observational studies investigating the incidence of anal incontinence following OASI graded using the Sultan Classification were eligible for inclusion. To allow comparison between individual tears grades (3a, 3b, 3c, 4th) a network meta-analysis was performed using Stata (version 15.1). STUDY APPRAISAL AND SYNTHESIS METHODS: For binary outcomes, odds ratios (OR), with corresponding 95% confidence intervals (95% CIs) were reported. OASI grades were ranked from the best clinical outcome to the worst clinical outcome. The percentage chance of each grade taking each rank with regards to outcome was calculated. Study quality and risk of bias was assessed using the relevant tool from the Joanna Briggs Institute. RESULTS: Of the 696 studies identified, 10 were eligible for inclusion and were included in the network meta-analysis (n=2467 women). The mean incidence of anal incontinence in 3a tears was 22.4% (range 6.1%-51.2%), 3b tears: 24.9% (range 6.9%-46.7%), 3c tears: 26.8% (range 0%-55.6%) and 4th degree tears: 28.6% (0-71.4%). Anal incontinence incidence was found to be significantly higher in 3c (OR 1.79 [95%CI 1.09, 2.94]) and 4th degree tears (OR 2.37 [95% 1.40, 4.02]) when compared to 3a. Additionally, anal incontinence incidence was significantly higher in 4th degree tears (OR 1.89 [95% 1.10, 3.22]) than 3b. 3a tears had the highest probability of the best clinical outcome, 3b; 2nd, 3c; 3rd and 4th degree tears had the highest probability of the worst clinical outcome. Overall, all studies had a high or unclear risk of bias across one or more assessed element. CONCLUSION: This is the first network meta-analysis comparing the incidence of anal incontinence in all grades of OASI. Increasing tear grade severity is associated with worse clinical outcomes. This study provides useful, clinically applicable information which, can assist clinicians in the counselling of women following OASI. Additionally, highlights the importance in accurate diagnosis of the OASI grade and subsequent appropriate repair

Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid‐urethral sling complications

Objectives To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid‐urethral sling (MUS) complications and examine the association between patient symptoms and findings on two‐dimensional (2D) perineal and three‐dimensional (3D) endovaginal ultrasound. Methods This was a cross‐sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis. Results A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non‐vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One‐third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2–50.9); P = 0.003). Voiding dysfunction was highest in those with C‐shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3–7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3–6.3); P = 0.01). Conclusions Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning

A one-stop perineal clinic: our eleven-year experience.

INTRODUCTION AND HYPOTHESIS: The perineal clinic is a dedicated setting offering assessment for various childbirth-related presentations including obstetric anal sphincter injuries (OASIs), perineal wound complications, pelvic floor dysfunction and other conditions such as female genital mutilation(FGM). We describe the clinical presentation and outcomes of women from a tertiary perineal clinic based on data collected over an 11-year period. METHODS: This is a retrospective observational study. A one-stop outpatient service was offered to all women who sustained OASIs (postnatally and antenatally in a subsequent pregnancy), perineal complications (within 16 weeks postpartum), FGM and/or peripartum symptoms of urinary/anal incontinence or prolapse. Assessment included history with validated questionnaires, examination and anal manometry and endoanal ultrasound when appropriate. Outcomes were compared among different grades of OASIs. Management of each type of presentation was reported with outcomes. RESULTS: There were 3254 first attendance episodes between 2006 and 2016. The majority (58.1%) were for OASIs, followed by perineal wound complications. Compared to the lower grades, the higher grades of OASI were associated with poorer outcomes in terms of symptoms, investigations and complications. Women with OASIs had unrelated symptoms such as urinary incontinence, perineal pain and wound infections that needed further intervention. A high proportion(42%) of wound complications required further specialist management. CONCLUSION: We describe a dedicated, one-stop perineal clinic model for antenatal and postnatal women for management of perineal and pelvic floor disorders. This comprehensive and novel data will enable clinicians to better counsel women regarding of outcomes after OASI and focus training to minimize risks of morbidities

Management of subsequent pregnancies following fourth-degree obstetric anal sphincter injuries (OASIS).

OBJECTIVES: The management of subsequent pregnancy in women who sustained OASIS remains an enigma. Nearly all studies include all grades of OASIS including fourth-degree tears. In addition, most protocols require endoanal ultrasound and anal manometric assessment to provide advice regarding mode of delivery. In reality, most women who sustain an OASI do not undergo these investigations. The aims of our study were firstly to evaluate outcomes of fourth-degree OASIS in terms of sphincter defects, anal manometry and anal incontinence symptoms. Secondly, we wished to review recommendations made regarding subsequent mode of delivery after fourth-degree OASIS according to different published protocols. STUDY DESIGN: An observational study of all women who had undergone a primary repair of a fourth-degree tear and seen in the perineal clinic of a tertiary urogynaecology unit between January 2006 and December 2017. Three-dimensional endoanal ultrasound and anal manometry were performed on all women, and symptoms assessed using the validated modified St Mark's Score for anal incontinence. Diagnostic test accuracy analysis was performed for use of symptoms in predicting abnormal investigations. RESULTS: 74 fourth-degree tears were identified (mean follow-up 5.9 months; SD 11.5). Endoanal scan showed an internal anal sphincter defect in 77 % and an external anal sphincter defect in 49 %. Only 18 % had no defect. The mean incremental pressure rise was 12.6 mmHg (SD 15.5). 61 % were asymptomatic with a mean St Mark's Score of 3.8 (SD 5.4). The presence of symptoms alone had poor accuracy in predicting abnormal investigations. Based on Royal College of Obstetricians and Gynaecologists guidance, only 7% would not be offered a caesarean section as they are asymptomatic women with normal scan and manometry findings and would be counselled for a vaginal delivery. CONCLUSIONS: Given that only a few units offer these specialist investigations to their OASI population, it would be reasonable to offer caesarean section to all women who have sustained a fourth-degree tear. However, in centres where endoanal ultrasound and anal manometry are available, individualised counselling can be offered

Early re-suturing of dehisced obstetric perineal wounds: A 13-year experience.

OBJECTIVES: To describe post-operative outcomes following early re-suturing of obstetric perineal wound dehiscence. STUDY DESIGN: This was a retrospective series of 72 women who underwent re- suturing of a dehisced perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 - December 2019). RESULTS: Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing. Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain (23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 % of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation (5.9 %). Of the women who developed two complications, four developed skin dehiscence with granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal pain. All complications were managed conservatively in an outpatient setting or surgically under local anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14) without signs of infection. CONCLUSIONS: This study demonstrates the positive outcomes of early re-suturing of perineal wound dehiscence with faster healing, reduced follow-up requirements and few major complications. It provides information to clinicians who are uncertain about the effects of early re-suturing of perineal wounds which can be used to help counsel mothers with wound dehiscence on their management options

Comparing the diagnostic accuracy of three ultrasound modalities for diagnosing obstetric anal sphincter injuries.

BACKGROUND: The optimal imaging modality of obstetric anal sphincter injuries (OASIs) needs to take into consideration convenience, availability and ability to assess the sphincter morphology. Endoanal ultrasound is currently regarded as the reference standard but is not widely available in obstetric units. Exoanal alternatives exist, such as three-dimensional (3D) introital or transperineal ultrasound, which are already readily available in most obstetrics and gynecology units. OBJECTIVES: The primary objective was to evaluate the diagnostic accuracy of 3D introital and 3D transperineal ultrasound compared to 3D endoanal ultrasound as the reference standard for the detection of anal sphincter defects in women who sustained obstetric anal sphincter injuries. The secondary objective was to correlate diagnosis of anal sphincter defect on imaging to symptoms of anal incontinence, and to assess patient discomfort experienced for each imaging modality STUDY DESIGN: A cross-sectional study of 250 women who sustained OASIs, all underwent 3D introital, transperineal and endoanal ultrasound. Introital and transperineal ultrasound were assessed using tomographic ultrasound imaging. All completed a validated modified St Mark's Score and Visual Analogue Score for discomfort. Optimal cut-off values for a significant defect on tomographic ultrasound imaging were defined as those with the greatest sensitivity and specificity based on Receiver Operating Characteristic curves with endoanal ultrasound as reference standard. Diagnostic test characteristics of introital and transperineal ultrasound using these optimal cut-offs were calculated. RESULTS: Optimal cut-off for a significant external anal sphincter defect was ≥3/7 slices; sensitivity and specificity were 0.65 and 0.75 on introital and 0.70 and 0.69 on transperineal ultrasound respectively. Optimal cut-off for a significant internal anal sphincter defect was ≥2/5 slices; sensitivity and specificity were 0.59 and 0.84 on introital and 0.43 and 0.97 on transperineal ultrasound. The Area Under the Curve for diagnosing external and internal anal sphincter defects ranged from 0.70 - 0.74 (p<0.001) for introital and transperineal. Positive predictive value for external and internal sphincter defects ranged from 0.37-0.63 and negative predictive value ranged from 0.85-0.93 for transperineal and introital ultrasound. Endoanal ultrasound was the only modality for a defect to correlate with symptoms; mean modified St Mark's score 2.4 (SD 4.1) for defect sphincter and 0.9 (SD 2.7) for intact sphincter (p<0.01). Introital and transperineal ultrasound were associated with less discomfort than endoanal ultrasound. CONCLUSION: Endoanal ultrasound remains the most accurate diagnostic imaging modality. With low positive predictive values, introital and transperineal ultrasound are not suitable for identifying sphincter defects; however high negative predictive values show a good ability to detect an intact sphincter. The optimal cut-off number of slices on tomographic ultrasound imaging for external and internal anal sphincters allows for standardisation of a significant defect. In women with a history of OASI, introital and transperineal ultrasound are suitable to screen for an intact sphincter if endoanal ultrasound is not available. Women with defects seen should then have endoanal ultrasound to verify the diagnosis