分娩方式对产妇盆底支持组织功能的近期影响

目的 探讨不同分娩方式及产科相关因素对盆底支持组织功能的近期影响.方法 选取健康初产妇120例,其中阴道分娩72例(阴道分娩组),选择性剖宫产48例(剖宫产组),于分娩后6至8周间进行尿失禁问卷调查、盆底肌电图测定盆底肌肉收缩及舒张功能,并行相关性分析.结果 阴道分娩组与剖宫产组产妇分娩后SUI的发生率分别为21%(15/72)、10%(5/48).阴道分娩组盆底肌电图右侧活力值、功值分别为12.9±0.8和59±5,左右两侧平均功值为78±5;剖宫产组右侧活力值、功值分别为17.3±1.7和95±17,左右两侧平均功值109±15,两组各项值比较,差异均有统计学意义(P＜0.05).产妇的年龄(P＜0.01)、分娩前体重指数(P＜0.01)、新生儿出生体重(P＜0.01)及第二产程时间(P=0.003)是产后发生SUI的高危因素;年龄、分娩前后体重指数差、第一产程时间、会阴侧切口长度和角度对盆底肌电图的部分测量值有影响.结论 阴道分娩后SUI发生率与选择性剖宫产相似;产科相关因素可以影响产后尿失禁的发生率及盆底肌肉收缩及舒张功能.     

Quantitative electromyography of the anal sphincter after uncomplicated vaginal delivery

OBJECTIVE: Fecal incontinence in women is thought to be associated with sphincter laceration or pudendal nerve damage. A prolonged pudendal nerve terminal motor latency is evidence of profound nerve damage, but pudendal nerve terminal motor latency can be normal even when nerve injury has been sustained. We performed quantitative electromyography (EMG) to compare multiple motor unit action potential parameters between recently postpartum women and nulliparous women. METHODS: Standardized examinations were prospectively performed on 2 groups: 1) healthy nulliparous women without pelvic floor disorders (n = 28) and 2) asymptomatic women who were postpartum following vaginal delivery of their first child (n = 23). The examinations included pelvic organ prolapse quantification measurements, endoanal ultrasonography, pudendal nerve terminal motor latency, sacral reflexes, and concentric needle EMG using multiple motor unit action potential analysis. RESULTS: A mean of 11.5 (standard deviation [sd] 1.1) weeks had elapsed since first vaginal deliveries in the postpartum group. The mean fetal weight at delivery was 3,495 (sd 458) grams. There were no sphincter defects seen by ultrasonography. Compared with the nulliparous women, pudendal nerve terminal motor latency and sacral reflexes (clitoral-anal reflex, urethral-anal reflex) were not increased in the postpartum group. Each of the quantitative parameters (duration, amplitude, area, turns, and phases), measured from motor unit action potentials in the postpartum group, were larger than in the nulliparous group (P < or =.004, nested analysis of variance [ANOVA]). CONCLUSION: Quantitative EMG using multiple motor unit action potential analysis can detect the presence after vaginal childbirth of subtle nerve injury not demonstrable by pudendal nerve terminal motor latency. Even asymptomatic women show evidence of pelvic floor nerve injury after uncomplicated deliveries.     

Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one-year follow up

Objective To evaluate the long term effect of a postpartum pelvic floor muscle training course in prevention and treatment of urinary incontinence.
Design A prospective matched controlled trial.
Sample and methods All women who had participated in a matched controlled study evaluating the effect of an eight-week pelvic floor muscle training program in prevention and treatment of urinary incontinence in the immediate postpartum period were contacted by telephone one year after delivery. They were invited to participate in a follow up study. The study group consisted of 81 matched pairs (   n = 162  ), with a mean age (range) 28 years (19–40), and mean number (range) of deliveries 1.8 (1–5). Seventy-six pairs had normal vaginal deliveries and five elective caesarean sections. Registration of continence status was by structured interview and a standardised pad test. Clinical assessment of pelvic floor muscle function and strength were by vaginal palpation and vaginal squeeze pressure.
Main outcome measure Stress urinary incontinence.
Results At the one year follow up, significantly more women in the former control group than in the training group reported stress urinary incontinence and/or showed urinary leakage at the pad test (   P < 0.01  ). A significantly greater (   P < 0.01  ) muscle strength increase in the period between 16th week and one year postpartum was demonstrated in the former training group (mean 4.4 cm H₂ O, 95% CI 3.2–5.6) than in the control group (mean 1.7 cm H₂ O, 95% CI 0.8–2.7).
Conclusion This one year follow up study demonstrates that a specially designed postpartum pelvic floor muscle training course was effective in the prevention and treatment of stress urinary incontinence. The benefits from pelvic floor muscle training are still present one year after delivery.     

Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial

OBJECTIVE: Urinary incontinence is a chronic health complaint that severely reduces quality of life. Pregnancy and vaginal delivery are main risk factors in the development of urinary incontinence. The aim of this study was to assess whether intensive pelvic floor muscle training during pregnancy could prevent urinary incontinence. METHODS: We conducted a single-blind randomized controlled trial at Trondheim University Hospital and three outpatient physiotherapy clinics in a primary care setting. Three hundred one healthy nulliparous women were randomly allocated to a training (n = 148) or a control group (n = 153). The training group attended a 12-week intensive pelvic floor muscle training program during pregnancy, supervised by physiotherapists. The control group received the customary information. The primary outcome measure was self-reported symptoms of urinary incontinence. The secondary outcome measure was pelvic floor muscle strength. RESULTS: At follow-up, significantly fewer women in the training group reported urinary incontinence: 48 of 148 (32%) versus 74 of 153 (48%) at 36 weeks' pregnancy (P =.007) and 29 of 148 (20%) versus 49 of 153 (32%) 3 months after delivery (P =.018). According to numbers needed to treat, intensive pelvic floor muscle training during pregnancy prevented urinary incontinence in about one in six women during pregnancy and one in eight women after delivery. Pelvic floor muscle strength was significantly higher in the training group at 36 weeks' pregnancy (P =.008) and 3 months after delivery (P =.048). CONCLUSION: Intensive pelvic floor muscle training during pregnancy prevents urinary incontinence during pregnancy and after delivery. Pelvic floor muscle strength improved significantly after intensive pelvic floor muscle training.     

Immediate postpartum perineal examination as a predictor of puerperal pelvic floor dysfunction

OBJECTIVE: To determine the relation between postpartum perineal trauma and the development of puerperal pelvic floor dysfunctions. METHODS: A prospective study was conducted on 218 primiparae immediately after vaginal delivery. Women were divided in three groups according to perineal trauma: group A (n = 171) intact perineum or superficial tear, group B (n = 39) perineal muscle tears, group C (n = 8) anal sphincter tears with or without disruption of the rectal mucosa. Two months later, each woman was questioned about urogynecologic symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. RESULTS: No significant difference was found among the groups with regard to the incidence of stress incontinence, frequency/urgency, and urge incontinence, whereas anal incontinence was found more commonly in group C (group C versus group A: P =.003, odds ratio 18.78). No significant difference was found for digital test, perineometry, and uroflowmetric stop test. CONCLUSION: Immediate postpartum perineal examination is not a good predictor of stress incontinence and pelvic floor weakness but could identify women at risk for anal dysfunctions: intact perineum does not exclude the appearance of symptoms related to perineal trauma after vaginal delivery.     

Levator trauma after vaginal delivery

OBJECTIVE: To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle. METHODS: A total of 61 nulliparous women were seen at 36-40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2-6 months postpartum. RESULTS: Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21-51%). Among those delivered vaginally, there were associations with higher maternal age (P = .10), vaginal operative delivery (P = .07), and worsened stress incontinence postpartum (P = .02). CONCLUSIONS: Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth.     

Postpartum urinary stress incontinence: analysis of the associated risk factors and neurophysiological tests

AIM: The aim of this paper is to estimate the prevalence of postpartum urinary stress incontinence (USI) three months after vaginal delivery and to analyze the risk factors more frequently correlated with USI. Pelvic floor neurophysiology was performed to assess pudendal nerve damage in symptomatic women. METHODS: A total of 562 women were interviewed and underwent urogynecological evaluation three days after vaginal delivery. They were contacted by telephone 12 weeks later. Chart abstraction was conducted to obtain obstetrical data. Three months after delivery women presenting persistent USI were invited to return for electrophysiological tests. Univariate and logistic regression analyses were performed to reveal any significant association between USI and risk factors. RESULTS: Prevalence of postpartum USI three days after delivery was 15%, decreasing to 10.6% at follow-up three months later. Multivariate analysis of risk factors revealed that persistent USI was significantly associated with: preconception USI (P<0.05), USI developed de novo after delivery (P<0.05), family history of incontinence (P<0.05), chronic cough (P<0.05) and smoking (P<0.05). No obstetric variables were independently connected with incontinence. Neurophysiological tests revealed nerve damage in 36% of the symptomatic puerperae. CONCLUSION: Persistent postpartum incontinence is associated with several maternal and urogynecological risk factors that can help to detect women at risk for early intervention.     

Anal incontinence after vaginal delivery: a five-year prospective cohort study

OBJECTIVE: The long-term prevalence of anal incontinence after vaginal delivery is unknown. The aim of the present study was to evaluate the prevalence of anal incontinence in primiparous women 5 years after their first delivery and to evaluate the influence of subsequent childbirth. METHODS: A total of 349 nulliparous women were prospectively followed up with questionnaires before pregnancy, at 5 and 9 months, and 5 years after delivery. A total of 242 women completed all questionnaires. Women with sphincter tear at their first delivery were compared with women without such injury. Risk factors for development of anal incontinence were also analyzed. RESULTS: Anal incontinence increased significantly during the study period. Among women with sphincter tears, 44% reported anal incontinence at 9 months and 53% at 5 years (P = .002). Twenty-five percent of women without a sphincter tear reported anal incontinence at 9 months and 32% had symptoms at 5 years (P < .001). Risk factors for anal incontinence at 5 years were age (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0-1.2), sphincter tear (OR 2.3; 95% CI 1.1-5.0), and subsequent childbirth (OR 2.4; 95% CI 1.1-5.6). As a predictor of anal incontinence at 5 years after the first delivery, anal incontinence at both 5 months (OR 3.8; 95% CI 2.0-7.3) and 9 months (OR 4.3; 95% CI 2.2-8.2) was identified. Among women with symptoms, the majority had infrequent incontinence to flatus, whereas fecal incontinence was rare. CONCLUSION: Anal incontinence among primiparous women increases over time and is affected by further childbirth. Anal incontinence at 9 months postpartum is an important predictor of persisting symptoms.     

Anal sphincter injury in women with pelvic floor disorders

OBJECTIVE: 1) To estimate the rate of anal incontinence and anal sphincter injury in a group of women with pelvic floor disorders; 2) to evaluate the relationship between anal incontinence and anal sphincter injury as demonstrated by endoanal ultrasonography; 3) to explore any associations between operative vaginal delivery and anal sphincter injury in this population. METHODS: A cohort of 100 women with stage II or greater pelvic organ prolapse and/or urinary incontinence completed the Rockwood-Thompson Fecal Incontinence Severity Index Questionnaire (FISI). Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification system. Multichannel cystometry and endoanal ultrasonography were performed. Categorical data were compared using the chi(2) statistic. The FISI scores were correlated with degree of anal sphincter injury using the Pearson correlation coefficient (r). RESULTS: Fifteen women with pelvic organ prolapse only, 28 with urinary incontinence only, and 57 with both were evaluated. Mean age (+/- standard deviation) and body mass index were 57.1 +/- 13.2 years and 29.8 +/- 6.8 kg/m(2), respectively. Median parity was 3. Fifty-four percent of those studied had anal incontinence, and 52% had anal sphincter defects. Anal incontinence was significantly associated with sphincter injury (odds ratio 36.4, 95% confidence interval 12-114, P <.001). The FISI scores were positively correlated with increasing degrees of anal sphincter disruption (r = 0.81, P <.001). A history of operative vaginal delivery was significantly associated with anal sphincter injury (P =.023). CONCLUSION: Anal incontinence and anal sphincter injury are common in women with other pelvic floor disorders and are significantly related. Operative vaginal delivery may contribute to unrecognized anal sphincter trauma in this population. LEVEL OF EVIDENCE: III     

产后盆底肌肉训练对改善盆底功能的作用分析

目的评价产后盆底肌肉训练对盆底肌肉张力的影响及对盆底功能的作用。方法选择中山大学附属第二医院2007年1~3月收治的165例住院分娩产后6周的产妇进入研究,随机分成两组。锻炼组81例于产后6周进行1疗程盆底肌肉训练(包括生物反馈及电刺激)。对照组84例进行一般的产后健康教育。两组均于产后3个月进行一般情况问卷及国际尿失禁咨询委员会尿失禁问卷表简表(ICIQ-SF)调查,并进行盆底肌肉张力测定。产后12个月进行问卷调查及盆底肌肉张力测定和POP-Q分度,评价盆底肌肉训练的效果。结果锻炼组产后3个月、产后12个月盆底肌肉张力高于对照组。锻炼组及对照组产后3个月压力性尿失禁发生率分别为2.5%(2/81)和11.9%(10/81),两组比较P<0.05;锻炼组及对照组产后12个月压力性尿失禁发生率分别为3.7%(3/81)和11.9%(10/81),两组比较P<0.05。锻炼组及对照组产后12个月POP-QⅠ度脱垂发生率分别为33.3%(27/81)和48.8%(41/84),两组比较P<0.05。结论产后盆底肌肉训练能提高盆底肌肉张力,降低尿失禁发生率,改善阴道前壁脱垂。     

Fecal and urinary incontinence in primiparous women

OBJECTIVE: To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence. METHODS: The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site. RESULTS: Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8-4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2-3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence. CONCLUSION: Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders. LEVEL OF EVIDENCE: II-3.     

Urinary incontinence among mothers of multiples: the protective effect of cesarean delivery

OBJECTIVE: The purpose of this study was to assess the impact of delivery mode on the risk of urinary incontinence among women with previous multiple childbirth. STUDY DESIGN: A 77-item questionnaire was administered to 733 mothers of multiples. Multivariate regression was used to control for potentially confounding variables. RESULTS: The mean rate of stress urinary incontinence among women who were delivered by cesarean-only delivery was 39.6%, which was significantly lower than the 60.4% among women who reported previous vaginal births (P =.005). Cesarean-only delivery was associated with a markedly reduced risk (odds ratio, 0.52; P =.002) after controlling for age, parity, and body mass index by multivariate regression. Weaker associations were found for age (odds ratio, 1.08), body mass index (odds ratio, 1.06), and parity (odds ratio, 1.46). Urge incontinence was associated with parity, body mass index, and age, but not delivery mode (P =.76). CONCLUSION: Vaginal delivery represents a major risk factor for stress incontinence among mothers of multiples. Delivery by cesarean delivery only confers an independent protective effect.     

Does cesarean delivery prevent anal incontinence?

OBJECTIVE: To compare the incidence and severity of anal incontinence in primiparas after cesarean delivery versus spontaneous vaginal delivery. METHODS: A total of 184 primiparas who delivered by cesarean (104 emergency, 80 elective) and 100 who delivered vaginally were interviewed 10 +/- 2 months postpartum. A comprehensive bowel function questionnaire was completed. Bowel-specific questions included bowel habits, laxative use, urgency, flatus, urge and passive incontinence, soiling, and pad use, before and during pregnancy and postpartum. Obstetric details were confirmed from obstetric records. RESULTS: Anal incontinence was first present in nine (5%) mothers after cesarean delivery and eight (8%) after vaginal delivery (relative risk 0.611, 95% confidence interval 0.25, 1.53). Severe symptoms necessitating pad use affected two (3%) mothers after elective cesarean and one (1%) after vaginal delivery. Two (3%) mothers after elective cesarean, one (1%) after emergency cesarean, and two (2%) after vaginal delivery had at least two symptoms. Anal incontinence followed prelabor emergency cesarean in two mothers. Of the 22 mothers who sustained a second-degree tear, five (23%) had new anal incontinence compared with only one (3%) of 40 mothers with an intact perineum (Fisher exact test value = 9.697, P =.014). CONCLUSION: Because severe anal incontinence followed elective and prelabor emergency cesarean, it seems that pregnancy itself can lead to pelvic floor disorders. A high incidence of anal incontinence is associated with a second-degree tear. Measures to detect and reduce postpartum anal incontinence should target all pregnant women and mothers, even after prelabor cesarean delivery.     

The effect of childbirth on pelvic organ mobility

OBJECTIVE: To study the effect of child birth on pelvic organ mobility in a prospective observational study. METHODS: A total of 200 women were recruited early in their first ongoing pregnancy and examined by translabial ultrasound in the first/early second trimester, the late third trimester, and 2-5 months postpartum. Peripartal changes in the mobility of urethra, bladder, cervix, and rectal ampulla were correlated with labor and delivery data. RESULTS: A total of 169 women returned postpartum (84.5%). Highly significant increases in organ mobility on Valsalva were found after vaginal delivery (P <.001), with forceps causing the most marked changes. Length of second stage, especially active second stage, correlated with an increase in pelvic organ descent (P =.03 to P <.001). The influence of gestational age, length of first stage, and birth weight did not reach significance. CONCLUSION: Vaginal birth, in particular operative delivery, negatively affects pelvic organ support. This appears to be true for all three vaginal compartments. All forms of cesarean delivery were associated with relatively less pelvic organ descent. These findings may partly explain the protective effect of elective cesarean delivery for future symptoms of pelvic floor disorders.     

Urinary and anal incontinence after vacuum delivery

OBJECTIVES: To evaluate urinary and fecal incontinence symptoms, and occult anal sphincter defects in women after vacuum and spontaneous vaginal delivery. STUDY DESIGN: In a case-control study, 50 primiparous women delivered by vacuum extraction were compared to 50 women delivered spontaneously. Urinary and anal incontinence symptoms, pelvic floor muscle strength and sphincter defects on endoanal ultrasound were evaluated 6-24 weeks postpartum. RESULTS: New anal incontinence symptoms after childbirth were found in 30% of the vacuum group compared to 34% of the controls, new urinary incontinence symptoms in 28 and 42%, respectively (not significant). After excluding Grade III perineal tear, sonographic sphincter defects were found in 11 (27.5%) after vacuum delivery compared to 4 (10%) after spontaneous delivery (P<0.05, chi(2)-test). CONCLUSION: Anal and urinary incontinence symptoms are frequent after vaginal delivery. Vacuum delivery causes more sonographic sphincter defects but appears to cause no more harm to pelvic floor function than spontaneous vaginal delivery.     

Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears

OBJECTIVE: To estimate whether endoanal ultrasound findings are more prevalent in primiparous women with a history of anal sphincter tear than in women without this history and whether the findings are associated with fecal incontinence symptoms. METHODS: A total of 251 primiparous women at seven clinical sites underwent standardized ultrasound assessment of the internal and external anal sphincter 6-12 months after delivery. Participants were women in the three cohorts of the Childbirth and Pelvic Symptoms Study: 1) women with clinically evident third- or fourth-degree tear at vaginal delivery (n=106); 2) no tear at vaginal delivery (n=106); and 3) cesarean delivery without labor (n=39). Women completed the Fecal Incontinence Severity Index to assess fecal incontinence symptoms. RESULTS: Thirty-five percent of the sphincter tear group exhibited internal sphincter gaps compared with 3% of vaginal controls (odds ratio [OR] 18.4, 95% confidence interval [CI] 5.5-62.1) and 10% of cesarean controls. External sphincter gaps were identified in 51% of the tear group compared with 31% of vaginal controls (OR 2.3, 95% CI 1.3-4.0) and 28% of cesarean controls. In the tear group, fecal incontinence severity was greater in those with internal sphincter gaps compared with those with no internal sphincter gaps (Fecal Incontinence Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well as in those with external sphincter gaps (6.1+/-8.4 compared with 2.7+/-5.0, P=.01), and greatest in those with both internal and external sphincter gaps compared with at least one gap not present (7.2+/-8.1 compared with 3.4+/-6.4, P=.003). CONCLUSION: Anal sphincter gaps detected by ultrasonography are prevalent in postpartum primiparous women with a history of sphincter tear and are associated with fecal incontinence severity. LEVEL OF EVIDENCE: II-2.     

Risk of maternal postpartum readmission associated with mode of delivery

OBJECTIVE: To determine whether cesarean and operative vaginal deliveries are associated with an increased risk of maternal rehospitalization compared with spontaneous vaginal delivery. METHODS: A population-based cohort study was conducted by using the Canadian Institute for Health Information's Discharge Abstract Database between 1997/1998 and 2000/2001, which included 900,108 women aged 15-44 years with singleton live births (after excluding several selected obstetric conditions). RESULTS: A total of 16,404 women (1.8%) were rehospitalized within 60 days after initial discharge. Compared with spontaneous vaginal delivery (rate 1.5%), cesarean delivery was associated with a significantly increased risk of postpartum readmission (rate 2.7%, odds ratio [OR] 1.9, 95% confidence interval [CI] 1.8-1.9); ie, there was 1 excess postpartum readmission per 75 cesarean deliveries. Diagnoses associated with significantly increased risks of readmission after cesarean delivery (compared with spontaneous vaginal delivery) included pelvic injury/wounds (rate 0.86% versus 0.06%, OR 13.4, 95% CI 12.0-15.0), obstetric complications (rate 0.23% versus 0.08%, OR 3.0, 95% CI 2.6-3.5), venous disorders and thromboembolism (rate 0.07% versus 0.03%, OR 2.7, 95% CI 2.1-3.4), and major puerperal infection (rate 0.45% versus 0.27%, OR 1.8, 95% CI 1.6-1.9). Women delivered by forceps or vacuum were also at an increased risk of readmission (rates 2.2% and 1.8% versus 1.5%; OR forceps: 1.4, 95% CI 1.3-1.5; OR vacuum: 1.2, 95% CI 1.2-1.3, respectively). Higher readmission rates after operative vaginal delivery were due to pelvic injury/wounds, genitourinary conditions, obstetric complications, postpartum hemorrhage, and major puerperal infection. CONCLUSION: Compared with spontaneous vaginal delivery, cesarean delivery, and operative vaginal delivery increase the risk of maternal postpartum readmission. LEVEL OF EVIDENCE: II-2.     

Anal incontinence in women with and those without pelvic floor disorders

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.     

Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse

OBJECTIVE: To investigate risk factors and prevalence of anal incontinence among women with pelvic floor dysfunctions. METHODS: We evaluated 881 women with symptoms of urinary incontinence and/or genital prolapse. Each completed a bowel questionnaire and underwent a detailed medical, surgical, obstetric, and gynecologic history, and a pelvic examination. Additional testing, when indicated, included office cystometry or multichannel urodynamic evaluation. Multivariable analysis using logistic regression was used to test the overall significance of all variables significantly associated with anal incontinence, using univariate analysis. RESULTS: A total of 178 women had anal incontinence (20%). These patients were on average older, had a greater body mass index, and had larger birth weight infants than their anal-continent counterparts; 511 were diagnosed with urinary incontinence, and 122 (24%) also had anal incontinence. Women with urinary incontinence were more likely to report anal incontinence events than women continent of urine (24% versus 15%, P =.002). The following associations were found with anal incontinence: infant with birth weight 3800 g or greater (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1, 2.2), rectocele greater than grade 2 (OR 1.9, 95% CI 1.1, 3.3), urinary incontinence (OR 1.9, 95% CI 1.3, 2.8), hemorrhoidectomy (OR 2.7, 95% CI 1.1, 7.0), irritable bowel syndrome (OR 6.3, 95% CI 3.5, 11.5). CONCLUSION: Among women with symptoms of urinary incontinence and pelvic organ prolapse, the prevalence of anal incontinence was 20%. Urinary incontinence and severe rectocele were found to be associated with anal incontinence.     

The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery

OBJECTIVE: To evaluate the effect of mediolateral episiotomy on puerperal pelvic floor strength and dysfunction (urinary and anal incontinence, genital prolapse). METHODS: Five hundred nineteen primiparous women were enrolled 3 months after vaginal delivery. Puerperae were divided in 2 groups: group A (254 women) comprised the women who received mediolateral episiotomy and group B (265 women) the women with intact perineum and first- and second-degree spontaneous perineal lacerations. Each woman was questioned about urogynecological symptoms and examined by digital test, vaginal perineometry, and uroflowmetric stop test score. Data were subjected to Student t test and Fisher exact test to assess, respectively, the difference between the mean values and the proportions within the subpopulations. Using a simple logistic regression model to test an estimate of relative risk, we expressed the odds ratios of the variables considered with respect to the control population (group B). RESULTS: No significant difference was found with regard to the incidence of urinary and anal incontinence and genital prolapse, whereas dyspareunia and perineal pain were significantly higher in the episiotomy group (7.9% versus 3.4%, P =.026; 6.7% versus 2.3%, P =.014, respectively). Episiotomy was associated with significantly lower values, both in digital test (2.2 versus 2.6; P <.001) and in vaginal manometry (12.2 versus 13.8 cm water; P <.001), but not in uroflowmetric stop test. CONCLUSION: Mediolateral episiotomy does not protect against urinary and anal incontinence and genital prolapse and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain. LEVEL OF EVIDENCE: II-2