Mary Cassidy

A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma

PURPOSE: This study was designed to compare prospectively the effects of augmented biofeedback with those of sensory biofeedback alone on fecal incontinence and anorectal manometry after obstetric trauma. METHODS: A consecutive cohort of 40 females with impaired fecal continence after obstetric anal sphincter injury were recruited from a dedicated perineal clinic. Patients were randomly assigned to receive either augmented biofeedback or sensory biofeedback alone. All patients were assessed before and after twelve weeks of biofeedback training, using a fecal continence questionnaire and anorectal manometry. RESULTS: Thirty-nine of 40 females recruited completed the study. Continence scores improved in both treatment groups, but the results were better for those who received augmented biofeedback. Anorectal manometry was unchanged by sensory biofeedback, whereas anal resting and squeeze pressures increased with augmented biofeedback. No change in anal vector symmetry was observed in either group. CONCLUSION: Augmented biofeedback training is superior to sensory biofeedback alone in the treatment of impaired fecal continence after obstetric trauma.

Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury.

OBJECTIVE To determine the influence of parity and method of primary anal sphincter repair on outcome following obstetrical third degree perineal tear. STUDY DESIGN Prospective study of 154 women after primary repair following third degree tear conducted over 2 years. Postpartum evaluation included a continence questionnaire, anal manometry and endoanal ultrasound. RESULTS Third degree tears occurred in 1.6% primiparae and 0.6% multiparae during the study period; in 42/112 (38%) primiparae and 10/42 (24%) multiparae, these tears occurred at instrumental deliveries. Mean birthweight (3.8+/-0. 43 kg) was similar in both groups, but prolonged latent second stage of labour (P=0.003), use of epidural analgesia (P<0.0001) and episiotomy extension (P1 quadrant) anal sphincter defect. CONCLUSION Outcome of anal sphincter repair was not influenced by parity or mode of repair. Despite good symptomatic outcomes, ultrasound evidence of significant anal sphincter injury was found in one-third of patients.

Experience with an obstetric perineal clinic

OBJECTIVE To review the characteristics of patients attending a dedicated perineal clinic in a maternity hospital. METHODS Case-note review of all new referrals over 2 years 1998 and 1999. RESULTS A total of 399 women were referred with mean age of 34 years (range 18-77), parity of 1.7 (range 1-13) and duration of symptoms of 14 (range 1-156) months. A total of 213 (53%) women were assessed following a recognized third degree perineal tear, 78 (20%) because of fecal incontinence, 45 (11%) for determination of future mode of delivery following a previous perineal injury, 37 (9%) women for treatment of perineal pain and 26 (7%) for other miscellaneous complaints. A total of 83 (21%) required physiotherapy, 42 (11%) received dietetic manipulation, 29 (7%) were treated for perineal pain and 12 (3%) underwent vaginal surgery. A total of 24 (6%) women were referred for consideration of secondary anal sphincter repair and 11 (3%) for specialist gastroenterological investigation. CONCLUSIONS The perineal clinic provides a valuable resource for investigation and treatment of postpartum perineal injury.

Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third‐degree tears (EBAPT Trial)

To compare early home biofeedback physiotherapy with pelvic floor exercises (PFEs) for the initial management of women sustaining a primary third‐degree tear.

Does anal sphincter injury preclude subsequent vaginal delivery

OBJECTIVE To assess continence and anal sphincter integrity during a subsequent pregnancy and delivery in women known to have a previous anal sphincter injury. DESIGN Prospective observational study. SETTING The National Maternity Hospital, Dublin, Ireland. POPULATION Antenatal patients with a documented obstetric anal sphincter injury at a previous delivery. METHODS Women underwent symptom scoring, endoanal ultrasound and manometry. MAIN OUTCOME MEASURES Recommended and actual mode of delivery, continence scores and endoanal ultrasound findings after index delivery. RESULTS 557 women were studied. 293 (53%) had no symptoms of faecal incontinence, 189 (34%) had mild symptoms and 75 (13%) moderate or severe symptoms. 408 (73%) had an endoanal ultrasound. 383(94%) had a normal or small (<1 quadrant) defect in the internal anal sphincter and 390 (96%) had a scar or small (<1e quadrant) defect in the external anal sphincter. 393 (70%) delivered vaginally. 164 (30%) were delivered by caesarean section. 197/557 (35%) returned for follow-up. There was no significant change in continence following either vaginal or caesarean delivery. 20 (5.1%) women had a recognised second anal sphincter tear during vaginal delivery. CONCLUSIONS The majority of women who sustain a third degree tear have minimal or no symptoms of faecal incontinence when assessed antenatally in a subsequent pregnancy. 70% go on to have a vaginal delivery, with little impact on faecal continence. These findings provide reassurance for patients and clinicians about the safety of vaginal delivery following anal sphincter injury in appropriately selected patients.

Are women having a vaginal birth after a previous caesarean delivery at increased risk of anal sphincter injury

To examine the incidence of obstetric anal sphincter injury in women who had a successful vaginal birth after a previous caesarean delivery (VBAC).