C. N. Hudson

Anal-Sphincter Disruption during Vaginal Delivery

Background Lacerations of the anal sphincter or injury to sphincter innervation during childbirth are major causes of fecal incontinence, but the incidence and importance of occult sphincter damage during routine vaginal delivery are unknown. We sought to determine the incidence of damage to the anal sphincter and the relation of injury to symptoms, anorectal physiologic function, and the mode of delivery. Methods We studied 202 consecutive women six weeks before delivery, 150 of them six weeks after delivery, and 32 with abnormal findings six months after delivery. Symptoms of anal incontinence and fecal urgency were assessed, and anal endosonography, manometry, perineometry, and measurement of the terminal motor latency of the pudendal nerves were performed. Results Ten of the 79 primiparous women (13 percent) and 11 of the 48 multiparous women (23 percent) who delivered vaginally had anal incontinence or fecal urgency when studied six weeks after delivery. Twenty-eight of the 79 primiparous women (35 p...

Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair

Objectives To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. Design (i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements Setting: Antenatal clinic in teaching hospital in inner London. Subjects (i) All women (n=8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. Main outcome measures : Obstetric risk factors, defaecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. Results - (i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P=0.00001), primiparous delivery (85% v 43%; P=0.00001), birth weight >4 kg (P=0.00002), and occipitoposterior position at delivery (P=0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%;20P=0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P=0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. Conclusions Vacuum, extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.

Pudendal nerve damage during labour: prospective study before and after childbirth

Objective To establish the effect of childbirth on pudendal nerve function and identify obstetric factors associated with such damage.

Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence

Objective To investigate the aetiological importance of bowel dysfunction in patients with uterovaginal prolapse and urinary stress incontinence.

Anal sphincter trauma during instrumental delivery.

OBJECTIVES: To determine the incidence of defecatory symptoms, pudendal nerve damage and mechanical trauma to the anal sphincters during vacuum and forceps delivery. METHODS: Anal endosonography, manometry, pudendal nerve terminal motor latency (PNTML) measurements and perineometry were performed in 43 primiparae who had an instrumental delivery (17 vacuum and 26 forceps) and in 47 who had a normal vaginal delivery (controls). RESULTS: Defecatory symptoms developed in 10 (38%) women following a forceps delivery compared with 2 (4%) in the control group (P = 0.0003), and 2 (12%) following a vacuum extraction (P = NS). Anal sphincter defects occurred in 21 (81%) forceps deliveries compared with 17 (36%) controls (P = 0.0005) and 4 (21%) vacuum extractions (P = NS). Anal pressures were lower in those who developed a sphincter defect (P < 0.00001). PNTML was not significantly altered by the mode of delivery. CONCLUSIONS: Compared with vacuum extraction, forceps delivery is associated with significantly more damage to the anal sphincters and hence an increased incidence of defecatory symptoms.

Endosonography of the anal sphincters: normal anatomy and comparison with manometry.

To determine the normal and anatomy in vivo, and endosonography and manometry were performed in 93 nulliparous females, and endosonography alone in 21 healthy males. Endosonography did not reveal any plane of cleavage between the components of the external and sphincter, though a changing pattern at different levels conforming to a trilaminar arrangement was apparent. The deep (proximal) aspect of the external sphincter was annular in 72% of females and 76% of males. The superficial external sphincter was elliptical in 76% and 86%, the subcutaneous part conical in 56% and 57%, respectively. The external sphincter was shorter anteriorly in females. Aberrant insertions from the external sphincter anteriorly were identified in 14%. The longitudinal muscle layer could be distinguished sonographically in all males, as the external sphincter was relatively hypoechoic, but in 60% of the females the longitudinal muscle and external sphincter were of similar echogenicity and sonographically indistinguishable. The subepithelial tissues and internal sphincter were identified in each subject. The external sphincter was thicker bilaterally (P = 0.001) in males (8.6 +/- 1 mm, mean +/- S.D.) compared to females (7.7 +/- 1.1), which related to the higher weight of the males (73 +/- 7 vs 65 +/- 11 kg, P < 0.0001). The mean maximum lateral thickness of the internal sphincter (1.8 +/- 0.5 vs 1.9 +/- 0.6) and the longitudinal muscle (2.5 +/- 0.6 vs 2.9) in females and males were not significantly different. There was no relationship between the manometric resting or squeeze pressures in the anal canal, and the internal or external sphincter thickness.

Unsuspected sphincter damage following childbirth revealed by anal endosonography

Anal endosonography was performed in 62 consecutive patients with incontinence of flatus or faeces following obstetric trauma, and in 18 parous controls. Of the incontinent group, 90% had defects in the external sphincter, 65% in the internal sphincter and 44% disruption of the perineal body, compared with none of the controls. This triad of lesions is pathognomonic of obstetric trauma. Anal endosonography revealed a higher prevalence of sphincter damage than expected from anorectal physiology tests, and therefore has a role in screening patients following complicated or difficult deliveries.

Obstetric perineal trauma: An audit of training

SummaryThis study aimed to establish if trainee doctors and qualified midwives have adequate knowledge of perineal anatomy, if the classification of perineal tears is consistent, and to assess satisfaction with training. Seventy-five doctors (53 registrars and 22 senior house officers of at least 6 months training in obstetrics) and 75 qualified midwives were interviewed and a questionnaire was completed. More than half the doctors and midwives who named the muscles that were usually cut during an uncomplicated episiotomy wrongly named the levator ani. There was considerable variation in the definition of a third degree tear. Less than 20 per cent of doctors and less than 48 per cent of midwives considered their training in perineal anatomy, perineal repair and recognition and repair of anal sphincter tears to be of a good standard. Although perineal repair is frequently performed by doctors and midwives, perineal anatomy is poorly understood. Under-recognised trauma and inadequate repair can lead to dysp...

A RADICAL OPERATION FOR FIXED OVARIAN TUMOURS

MAIIGNANT disease of the ovary in Britain accounts for over 3,000 deaths per annum which is almost as many as the combined total due to carcinoma of cervix and corpus uteri together (Registrar-General, 1966). Too often the disease presents with ascites and widespread peritoneal metastases and the only surgery possible is removal of the main tumour masses and omentum. When the disease is confined to one or both ovaries with an intact capsule, the prognosis may not be unfavourable (Alment, 1963). This paper is concerned with an intermediate group of cases between these two extremes, in which there is local extension within the pelvis and the tumour is usually fixed to the peritoneal surface of nearby structures. Present surgical removal is too often a crude digital mobilization of the tumour with hysterectomy and removal of both ovaries. It is not surprising that the results are poor even with radiation and chemotherapy. This must particularly apply when macroscopic growth is left behind. Even in such cases, the tumour may remain confined to the pelvis for a very long time, so that an aggressive approach will occasionally result in a prolonged survival (Howkins, 1968). More radical surgery for ovarian cancer consisting of various forms of exenteration has been tried (Brunschwigg, 1954) but these procedures are mutilating and have such mortality and morbidity that they cannot often be justified. Posterior exenteration is the least severe, being the same operation as is performed for primary malignant or intractable inflammatory disease of the rectum. Posterior exenteration may, therefore, have a limited place in the treatment of carcinoma of the ovary, particularly

A pilot study of chemo‐radiotherapy in advanced carcinoma of the vulva

Summary. Advanced squamous cell carcinoma of the vulva (FIGO stages III and IV) has a poor cure rate even with exenterative surgery. We report a pilot study of combined pre‐operative chemo‐radiotherapy (CHT/RT) in all patients with advanced vulval carcinoma presenting to St Bartholomews Hospital between July 1987 and March 1989. Twelve patients have been treated, of whom nine had primary lesions (four FIGO stage III and five stage IV) and three had recurrent disease after simple or radical vulvectomy. Seven patients were treated with an initial split course of CHT/RT: there was one treatment‐related death and the others have all died following recurrence with a median disease‐free survival of 5 months (range 3–12) and a median survival of 7 months (range 3‐16). Five patients have received a continuous course of CHT/RT: one died before operation with pulmonary metastases, three patients are disease free at 6 to 9 months, and another patient has been treated with only palliative intent. Toxicity was acceptable in the continuous regimen and this treatment seems to have a promising role in the management of advanced carcinoma of the vulva. A review of the literature on combined therapy is presented.