A. Leader-Cramer

Wound complications after obstetric anal sphincter injuries.

OBJECTIVE: To estimate the incidence of and risk factors for wound complications in women who sustain obstetric anal sphincter injuries. METHODS: This was a prospective cohort study of women who sustained obstetric anal sphincter injuries during delivery of a full-term neonate between September 2011 and August 2013. Women were seen in the urogynecology clinic within 1 week of delivery and at 2, 6, and 12 weeks postpartum for perineal wound assessment. A visual analog scale for pain was administered at each visit. RESULTS: Five hundred two women met inclusion criteria for the study, and, ultimately, 268 women (54%) were enrolled. Eighty-seven percent of the cohort was nulliparous and 81% had a third-degree laceration. The majority (n=194) underwent an operative vaginal delivery (66.0% forceps and 6.0% vacuum). The overall risk was 19.8% (95% confidence interval [CI] 15.2–25.1%) for wound infection (n=53) and 24.6% (95% CI 19.6–30.2%) for wound breakdown (n=66). Operative vaginal delivery was associated with wound complications (infection, breakdown, or both) (adjusted odds ratio [OR] 2.54, 95% CI 1.32–4.87, P=.008). Intrapartum antibiotic therapy for obstetric indications was associated with a decreased risk of wound complications (adjusted OR 0.50, 95% CI 0.27–0.94, P=.03). Women with a wound complication reported significantly more pain within 1 week of delivery than women with a normally healing perineum (visual analog scale: 40.1±25.6 compared with 31.0±23, P=.002); this persisted at 12 weeks postpartum (6.6±7.5 compared with 3.4±7.1, P=.005). CONCLUSION: Women who sustain obstetric anal sphincter injuries are at high risk for the development of wound complications in the early postpartum period, warranting immediate and consistent follow-up. LEVEL OF EVIDENCE: II

Changing Referral Patterns to Urogynecology

Objective The study aims to identify sources of and changes in referral patterns for pelvic floor disorders. Methods All new patient visits to urogynecology at our institution between January 2010 and December 2015 were identified. Patient demographics, referral source, insurance type, and visit diagnoses using ICD-9 codes were abstracted. ICD-9 codes were grouped into 18 urogynecologic diagnoses. Data were analyzed using SPSS (Version 20; Chicago, IL). Results Five thousand seven hundred ninety-nine new patient visits were included in the analysis. The mean age was 54 ± 17 years and 59% were Caucasian. Forty-four percent were referred by obstetrician/gynecologists (OB/GYNs), 32% by primary care providers (PCPs), 14% by self-referral, and 9% by other specialties. New patient visits increased overall by 280% over 6 years; self- and PCP referrals increased by 480% and 320%, respectively. In comparison, OB/GYN referrals increased by only 229%. Patients diagnosed with prolapse and stress incontinence were more likely to be referred by an OB/GYN (P < 0.001), whereas PCPs were more likely to refer for urinary tract infections (P < 0.005) and urgency urinary incontinence (P < 0.001) than OB/GYNs. Conclusions Demand for pelvic floor specialists is growing quickly, with PCP and self-referrals outpacing referrals from obstetrician-gynecologists to tertiary care urogynecology practices.

Anal penetrative intercourse as a risk factor for fecal incontinence

Objective The aim of the study is to investigate the relationship between anal penetrative intercourse (API) and pelvic floor symptoms, specifically, anal incontinence (AI). Methods This was an institutional review board–approved, cross-sectional, e-mail survey of women enrolled in the Illinois Womens Health Registry. Participants were anonymously queried about their sexual practices and the effects of these on bowel and bladder symptoms. Urinary symptoms were assessed using the urogenital distress inventory-6 and bowel symptoms with the fecal incontinence severity index (FISI). Results One thousand three women (mean age of 46 ± 15 years) completed the survey. Eighty percent were white, 56% were married, and 99% reported ever being sexually active. Thirty-two percent had API at least once, and 12% considered it “part of their sexual practice.” Sixty percent of the cohort reported a bothersome urinary symptom on the urogenital distress inventory-6, 70% reported AI on the FISI, and 15% reported fecal incontinence. Of women who engaged in API, 18% reported it changed their stool consistency, and 10% reported it caused AI. Having engaged in API within the last month was correlated with higher FISI scores (P = 0.05) and with fecal incontinence on the FISI (28.3% vs 14.4%; P = 0.01; odds ratio, 2.48). In addition, API was more commonly practiced among women who reported that vaginal intercourse caused dyspareunia (17% vs 12%, P = 0.05) or changes in bladder symptoms such as urgency or dysuria (44% vs 30%, P < 0.001). Conclusions Self-reported AI and FI (as measured by the FISI scores) are higher in women who have had API, and frequency of API may be important in determining the risk of bowel symptoms.

Anal Sphincter Injuries After Operative Vaginal Versus Spontaneous Delivery-Is There a Difference in Postpartum Symptoms?

Objective The aim of this study was to determine whether there is a difference in pelvic floor symptoms between women who had obstetric anal sphincter injuries (OASIS) after an operative vaginal delivery versus those who had OASIS after a spontaneous delivery. Methods This was a secondary analysis of a prospective cohort study of women who sustained OASIS. Women were evaluated at 1 week postpartum and again at 12 weeks; at both of these visits, they completed a battery of validated questionnaires including a visual analog scale for pain, Patient Health Questionnaire 9 depression inventory, Fecal Incontinence Severity Index, Urogenital Distress Inventory 6, and Incontinence Impact Questionnaire 7. Results Two hundred sixty-eight women with OASIS were included in this analysis (194 operative vaginal, 74 spontaneous). Ninety-one percent of those with operative vaginal delivery had a forceps-assisted delivery. After multivariate regression, operative OASIS was independently associated with greater Urogenital Distress Inventory 6 scores (P = 0.02), Fecal Incontinence Severity Index scores (P = 0.04), and visual analog scale pain scores (P = 0.03) and higher rates of urgency urinary incontinence (P = 0.04), stress urinary incontinence (P = 0.02), and anal incontinence (P = 0.04) at 1 week postpartum. At 3 months postpartum, symptoms were no different between the groups. Conclusions Women who sustain OASIS secondary to operative vaginal delivery report more bothersome urinary symptoms and higher rates of anal incontinence immediately postpartum as compared with women with OASIS secondary to spontaneous delivery. These differences may resolve by 3 months postpartum.

Wound Complications After Obstetric Anal Sphincter Injuries

The rate of obstetric anal sphincter injuries at the time of vaginal delivery varies from 0.0% to 23.9%; the highest and lowest rates represent studies with smaller sample sizes. The incidence of perineal wound breakdown is much less common; reported rates vary from 0.1% to 4.6%. Risk factors for obstetric anal sphincter injuries have been identified in previous studies, but few groups have assessed the factors associated with obstetric anal sphincter injury wound complications. The few studies available were retrospective and reported an incidence of approximately 5% to 13%. Infection is 1 of the most common sequelae of perineal wound complications and often leads to hospital readmission. No standard guidelines exist for follow-up of patients who sustain a severe perineal laceration, and many women are not routinely seen until their sixth postpartum week. The aim of this prospective cohort study was to estimate the incidence of and risk factors for wound complications in women who sustain obstetric anal sphincter injuries. All women included in the study group sustained these injuries during delivery of a full-term neonate between September 2011 and August 2014 at an academic, tertiary care obstetric center in Chicago and were seen for perineal wound assessment in the urogynecology clinicwithin 1week of delivery and at 2, 6, and 12weeks postpartum.At each visit, a visual analog scale for painwas administered. Among 615 women who sustained obstetric anal sphincter injuries, 502 met inclusion criteria, and 268 were enrolled. Most women (87%) were nulliparous and had a third-degree laceration (81%). The majority (n = 194) had undergone an operative vaginal delivery: 66.0% forceps and 6.0% vacuum. At the initial evaluation, the overall risk for wound infection was 19.8% (95% confidence interval [CI], 15.2%–25.1%; n = 53), and the overall risk for wound breakdown was 24.6% (95% CI, 19.6%–30.2%; n = 66). Operative vaginal delivery was a significant risk factor for wound complications (infection, breakdown, or both; the adjusted odds ratio was 2.54, with a 95% confidence interval of 1.32–4.87; P = 0.008). Women given intrapartum antibiotic therapy for obstetric indications had a decreased risk of wound complications (adjusted odds ratio, 0.50; 95% confidence interval, 0.27–0.94; P = 0.03). Significantly higher pain was reported by women with a perineal wound complication than those with a normally healing perineumwithin 1 week of delivery (visual analog scale: 40.1 ± 25.6 vs 31.0 ± 23.6; P = 0.002), and the difference persisted at 12 weeks (6.6 ± 7.5 vs 3.4 ± 7.1; P = 0.005). Wound complications after obstetric anal sphincter injuries are much more common than previously described, with approximately 1 in 4 women developing a wound breakdown, and 1 in 5 a wound infection. These findings support the need for early follow-up of such patients in the postpartum period.