Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Postpartum Incontinence. Narrative Review
Journal Information
Vol. 93. Issue 6.
Pages 359-367 (June - July 2015)
Visits
8513
Vol. 93. Issue 6.
Pages 359-367 (June - July 2015)
Review article
Full text access
Postpartum Incontinence. Narrative Review
Incontinencia fecal posparto. Revisión de conjunto
Visits
8513
Rodolfo Rodrígueza,
Corresponding author
rodolforodriguez8700@gmail.com

Corresponding author.
, Rafael Alósb, M. Soledad Carcellerb, Amparo Solanab, Andrés Frangia, M. Dolores Ruiza, Roberto Lozoyaa
a Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de Sagunto, Valencia, Spain
b Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital de Manises, Valencia, Spain
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (3)
Show moreShow less
Tables (2)
Table 1. Classification of Obstetrical Tears.
Table 2. Risk Factors for the Development of Fecal Incontinence After Childbirth.
Show moreShow less
Abstract

The development of fecal incontinence after childbirth is a common event. This incontinence responds to a multifactorial etiology in which the most common element is external anal sphincter injury. There are several risk factors, and it is very important to know and avoid them. Sphincter injury may result from perineal tear or sometimes by incorrectly performing an episiotomy. It is very important to recognize the injury when it occurs and repair it properly. Pudendal nerve trauma may contribute to the effect of direct sphincter injury. Persistence of incontinence is common, even after sphincter repair. Surgical sphincteroplasty is the standard treatment of obstetric sphincter injuries; however, sacral or tibial electric stimulation therapies are being applied in patients with sphincter injuries not repaired with promising results.

Keywords:
Fecal incontinence
Sphincter injuries
Obstetric incontinence
Postpartum incontinence
Resumen

El desarrollo de incontinencia fecal tras el parto es un hecho frecuente. Esta incontinencia responde a una etiología multifactorial en la que el elemento más frecuente es la lesión del esfínter anal. Existen diversos factores de riesgo, que es muy importante conocer y evitar. La lesión esfinteriana puede producirse por desgarro perineal o en ocasiones por la realización de una episiotomía de forma incorrecta. Es muy importante reconocer la lesión cuando se produce y repararla de forma adecuada. El traumatismo de los nervios pudendos puede incrementar el efecto de las lesiones esfinterianas directas. Es frecuente la persistencia de incontinencia a pesar de la reparación esfinteriana primaria. La esfinteroplastia quirúrgica es el tratamiento estándar de las lesiones esfinterianas obstétricas, sin embargo, las terapias de estimulación eléctrica sacra o tibial están siendo aplicadas en pacientes con lesiones esfinterianas no reparadas, con resultados prometedores.

Palabras clave:
Incontinencia fecal
Lesiones esfinterianas
Incontinencia obstétrica
Incontinencia posparto
Full Text
Introduction

Fecal incontinence is very frequent after childbirth. Prevalence studies in different populations and postpartum series of women at certain hospitals have reported global incontinence rates ranging from 4% to 59%.1–11 In our setting, a series of Spanish cohorts with more than 1000 nulliparous women found an incidence of immediate postpartum fecal incontinence of 7.3%.12

The variability in the incidences published is quite striking. This is perhaps because women often do not mention incontinence to their physician, obstetricians do not consider this problem in all cases, the degree of soiling may vary greatly and also vary over time, and measuring subjective symptoms is difficult.

The etiology of postpartum fecal incontinence is multifactorial, and its treatment requires multidisciplinary action. Therefore, its management is occasionally complex and accompanied by disheartening treatment results.

The objective of this article is to provide an update on different key aspects in obstetrical fecal incontinence by reviewing the literature. We also provide the experience of our own group in order to determine what type of management is best for this condition.

Methodology

We have reviewed the existing literature in the PUBMED and COCHRANE databases. Search criteria included the following key words: postpartum fecal incontinence, obstetrical fecal incontinence, obstetrical injury and anal sphincter, perineal tears and anal sphincter, postpartum anal sphincter injuries. Included in the study were all those publications from 1990 to date.

Causes of Fecal Incontinence After Childbirth

During childbirth, there are several situations that can condition the development of injuries to the posterior compartment and potentially cause subsequent fecal incontinence.

First of all, perineal tears are frequent during delivery. These tears can occasionally affect the anal sphincter muscles, most frequently the external anal sphincter, which controls voluntary fecal continence. The rate of anal sphincter lesions is variable but ranges between 2% and 30% in different series.3,13–17

Episiotomies, which are sometimes done to favor the delivery of the fetus, can be strongly related with direct sphincter injuries by the episiotomy itself when done incorrectly and sphincter muscle fibers are cut.2,3,14,18

Another frequent lesion during childbirth is damage to the pudendal nerves.6,19–22 These injuries do not seem to be secondary to direct trauma during delivery, but instead to traction/stretching by the distension of the perineum during a lengthy labor.

Finally, the trauma to and injury of other perineal muscles, mainly the puborectalis and other components of the levator ani, can increase the injuries to the posterior compartment and sphincter apparatus, resulting in serious consequences.

The situation of the posterior perineal compartment with regard to the birth canal is the determining factor that frequently leads to injury of the compartment. Its shape forms a J, where the bottom of the J is the rectum. The axial forces developed during labor pivot on the posterior compartment, causing trauma.23

Classification of Perineal Tears

The classification of perineal tears caused during delivery is based on the injured anatomical layers in the mid and posterior compartments (skin, mucosa and musculature)24 (Table 1).

Table 1.

Classification of Obstetrical Tears.

Grade 1  Laceration of the vaginal epithelium 
Grade 2  +Laceration of the perineal musculature 
Grade 3  +Laceration of the anal sphincter 
3a  <50% thickness of the external sphincter 
3b  >50% thickness of the external sphincter 
3c  Affects the internal sphincter 
Grade 4  Injury to the anal epithelium 

Source: Sultan et al.24

It is based on the elements involved or damaged by the tear. The laceration generally initiates in the vaginal mucosa and can progress, depending on the intensity, and injure (from front to back) the perineal musculature, the external anal sphincter, internal anal sphincter, and, finally, the anal mucosa. This latter case would result in complete anovaginal contact; if it is not repaired, or done so incorrectly, a rectovaginal fistula could develop. When in doubt about which anatomical planes are affected during a tear, it should be classified as the higher grade.

Grade 3 and 4 injuries are those that affect the anal sphincter apparatus and can cause fecal incontinence.

Risk Factors Related With Sphincter Lesions During Delivery

There are a multitude of studies in the literature that try to apply scientific evidence to determine the factors of childbirth that favor the appearance of postpartum fecal incontinence or the production of sphincter lesions2,3,9,10,15,18,25,26 (Table 2).

Table 2.

Risk Factors for the Development of Fecal Incontinence After Childbirth.

Major risk factors 
Medial episiotomy 
Assisted delivery 
Fetus larger than 4kg 
Lengthy delivery 
First vaginal delivery 
 
Minor risk factors 
Occipito-posterior presentation 
Epidural analgesia 
Perineal edema 
Poor visualization of the perineum 
Deficient perineal protection 
Induced labor 
Active external abdominal pressure 

Episiotomy has been related with fecal incontinence due to direct sphincter injury.2,3,15,18 Some studies have demonstrated that systematic episiotomies have no advantages over their selective use in vaginal births, even in the case of operative vaginal deliveries.27–29 In the article by Signorello et al.18 the incidence of fecal incontinence was greater in the group of women who underwent medial episiotomy than in the group with spontaneous perineal tears. Medial–lateral episiotomy has the advantage over medial episiotomy of lower sphincter injury rates.2,30 This is due to the anatomical situation of the anal sphincter in a perineum that is distended during labor, in which the rectovaginal wall is thinning out and the anterior edge of the external anal sphincter is in close contact with the posterior vaginal edge. A medial skin incision may easily include muscle fibers of the external anal sphincter at a location (anterior) where the length of the sphincter is shorter and, therefore, the damage may have greater repercussions.

Instrumented vaginal deliveries are a risk factor for fecal incontinence.2,3,9,10,13–15,25,31 The use of forceps or vacuum is related to sphincter injuries during vaginal manipulation.17 The rate of injuries and aftereffects can be relatively high when sphincter functionality is reviewed in detail after operative deliveries; this rate may be higher with forceps than with vacuum extraction. In a randomized study of 130 women in whom anorectal function was studied after delivery by means of an incontinence questionnaire, endoanal ultrasound and anal manometry, a fecal incontinence rate of 59% was found in the forceps delivery group, while the rate in the vacuum group was 33%, with statistically significant differences. The sphincter injury rates were 56% in the forceps group and 49% in the vacuum group, with no statistical significance.31

In theory, elective Cesarean sections would avoid the perineal trauma of a vaginal birth and would reduce the probability of secondary incontinence. Studies have confirmed this correlation,25,32 and it has become a possible indication for a scheduled C-section at the request of the patient. Although there is no clear data from randomized series, 2 systematic reviews have not demonstrated the supposed protective effect of elective C-section.8,33 These data seem to indicate the existence of other etiopathogenic factors for the development of postpartum fecal incontinence that are not associated with pelvic floor trauma during vaginal delivery. It has also been proposed that pregnancy itself may be a risk factor for fecal incontinence, regardless of the type of delivery.12,34 In a recent cross-sectional study of 1571 first-time mothers, 37% developed fecal incontinence at the end of pregnancy, affecting their quality of life.35

Other Causes for Postpartum Fecal Incontinence

The appearance of postpartum fecal incontinence is a multifactorial process.3 Sphincter defects are associated with 50%–80% of cases of incontinence after childbirth.16,36 Although anal sphincter injury due to perineal tears is the most frequent cause, there are other causes that can cause incontinence themselves or in association with sphincter damage, resulting in worse consequences. The main cause is damage to the pudendal nerves.

Postpartum alternations to the pudendal nerves are more frequent and important than they seem.6,19,20,22 In one study19 that involved electrophysiological testing of the pudendal nerves after delivery, 46% of the group of women with incontinence but no documented sphincter injury had pudendal alterations. In this group, 44% of the sphincter injuries had not been recognized. In the group of women with recognized sphincter injury, 19% had electrophysiological alterations of the associated pudendal nerves. Nonetheless, 33% of the women who had undergone C-section also had damage to the pudendal nerves, which was associated with fecal incontinence in all cases. In this latter group, sphincter injuries were not demonstrated. These data seem to indicate that not even a Cesarean section can totally avoid the risk for incontinence. Perhaps lengthy labor can cause distension of the perineum and stretching of the pudendal nerves, even though a C-section is ultimately performed.

In recent years, the advances made in imaging techniques, such as magnetic resonance and 3-D vaginal/perineal ultrasound, have shown evidence of another type of obstetrical injuries that could be either the cause or coadjuvants in the development of fecal incontinence. These are deep injuries of the levator ani muscle and its different components.37 These injuries could be secondary to the perineal trauma during childbirth in any case.

Primary Tear Repair

It is important to recognize tears caused during delivery and determine the anatomical layers involved and, therefore, their grade. These tears must be repaired correctly in order to avoid later consequences.

When the injury affects the anal sphincter, reconstruction should be done more meticulously to avoid more serious sequelae.23 The repair can be done with regional anesthesia (epidural/spinal block), in the operating room, with adequate material and aseptic measures. It is important to suture plane by plane, started with the deepest plane and working up to the most superficial. There is no scientific evidence about what type of suture material to use or about whether continuous sutures or individual stitches are preferable.38 However, the sutures should stay within each plane, without tension and with good vascularization.

Some authors argue on the need to release the sphincter ends in order to repair them by overlapping and not with a mere apposition. There are several randomized studies comparing end-to-end repairs with overlapping, and they have found no differences in the fecal incontinence rates between the 2 techniques.39–43 However, in a randomized series44 and a later meta-analysis,45 the Fernando et al. group demonstrated that overlapping repairs may be associated with a lower incidence of fecal urgency, lower scores on postpartum incontinence scales and a lower risk for deterioration of incontinence symptoms 12 months later.

The complexity of the tear and, therefore, the repair required determine which professional should perform the repair: a gynecologist, general surgeon or proctologist.23 Surgical treatment of the sphincter is better left in the hands of surgeons with previous experience in anal reconstructive surgery, and perhaps they should be responsible for repairing Grade 3 and 4 injuries. There are data that indicate that, when the immediate repair of the obstetrical tear is done by a team trained in this type of techniques, 4-year postpartum incontinence rates do not differ from pre-birth rates.46 However, the organization of each hospital and the timing of the injury determine whether the repair can or cannot be done by an experienced team. In this regard, a randomized study demonstrated that deferring the repair for an average of 8–12h after the tear occurs does not lead to poorer functional results, infection or complication rates of the deferred sutures.47 This margin of time could be sufficient to organize deferred surgery by a surgeon with expertise in sphincter reconstructive techniques (Fig. 1).

Fig. 1.

Management algorithm for postpartum fecal incontinence.

(0.28MB).

Perioperative management is also important23 and should be individualized in each case. The use of wide-spectrum antibiotics is debatable. There is no scientific evidence that recommends their routine use,38 but they may be necessary in Grade 3–4 severe tears or when there has been much fecal contamination. The use of astringent medication after the repair is used to protect against possible direct mechanical trauma during the first bowel movement or fecal contamination. However, a randomized study seems to demonstrate that there are no functional, ultrasound or manometric differences after Grade 3 perineal tear repairs when astringent medication is administered compared with laxatives during the immediate postpartum. Conversely, the patient group that was prescribed laxatives had less pain during the first bowel movement, which was also earlier, while hospitalization was significantly shorter.48

Evolution of Postpartum Incontinence

The rate of persistent sphincter injuries after primary repair is 70%–75%.19,49 In addition, the appearance of fecal incontinence after the repair is 50%–60%.8,19,49 Meanwhile, there are unrecognized sphincter injuries in 18%–45%8,19,20 and asymptomatic sphincter injuries in 30%.16

These data show that many women will have fecal continence problems after childbirth, either because a sphincter injury was not identified or because, even if the injury were recognized, there is a high frequency of repair failure.

Primary repairs can fail due to several causes: misidentification of the sphincter ends, retraction associated with recuperated muscle tone after pregnancy, incomplete suture along the length of the sphincter, and postoperative factors like hematoma or infection.50

In the mid-term, complete involution of obstetrical incontinence is possible in the first 3 months postpartum.23 Possible causes involved in this regression include the resolution of the trauma to the pudendal nerves or improved perineal muscle tone. Some studies, however, have demonstrated that the persistence of incontinence after 9 months is a strong predictive factor of the persistence of the symptoms.23,51

In the long term, the sequelae of incontinence may persist for years. There are data about the persistence of fecal incontinence symptoms of up to 40% in women after sphincter injuries or incontinence immediately after delivery in surveys done 12 years52 and even 27 years53 later. The risk for fecal incontinence in primiparous women increases over time, especially with more vaginal births.36,51 With successive pregnancies, the injuries from previous deliveries can become aggravated. A second vaginal birth can often trigger fecal incontinence in a woman with a subclinical sphincter lesion caused during the first delivery. There are authors who recommend offering to schedule a C-section in women at high risk or with previous sphincter injuries, after assessing the risks and benefits.54

Pre- and postpartum physical therapy of the pelvic floor can be useful to improve incontinence symptoms.55 Nonetheless, this functional improvement does not seem to maintain itself over time. In a controlled study in which women with postpartum urinary and fecal incontinence had pelvic floor physical therapy, improved symptoms were observed 1 year later in the treatment group,56 but this did not persist in the long term (6 years57 and 12 years58). The initial physiological compensation can likely improve with proper rehabilitation, but, in the long term, reactive processes and exposure to further obstetrical trauma lead to deteriorated function.

Occasionally, mild sphincter lesions become evident after menopause, coinciding with the physical involution of the pelvic floor, leading to the development of clinical fecal incontinence.8,59

Diagnosis of Residual Injuries

The diagnosis of injuries caused during childbirth should begin at the postpartum obstetrical office visit.23 It is important to have recorded and described any type of tear, which should be assessed afterwards. At this first consultation, the patient should be asked about possible symptoms of fecal incontinence, urgency or soiling. If any symptoms are detected, pelvic floor physical therapy is recommended.55

In cases of persistent incontinence for more than 3 months, when the time for a possible spontaneous involution has passed,23 the patient should be referred to a specialized unit for study and treatment (Fig. 1). The diagnosis of the sphincter injury is usually done with endoanal ultrasound (Fig. 2), which determines the grade of the injury and its extension, while providing essential information for a proper repair.60 Generally, the injuries affect the external sphincter and are occasionally associated with discontinuity of the internal sphincter. Ultrasound shows a solution of continuity of the hyperechoic layer, which corresponds with the external sphincter, or the hypoechoic layer, which corresponds with the internal sphincter, in the anterior region.59 It is important to measure the angle of the retracted muscle ends in order to assess the reliability of a potential surgical repair. Occasionally, fibrous areas can be observed between the muscle endings, depending on the time transpired since the injury.

Fig. 2.

Endoanal ultrasound showing injury to both sphincters after obstetrical trauma; in the anterior region, the examiner's glove is observed in the vagina. EAS: external anal sphincter; IAS: internal anal sphincter.

(0.24MB).

The Stark scoring system,61 which assesses sphincter defects three-dimensionally (size, length and depth) using anal ultrasound, has been correlated with the long-term degree of fecal incontinence.62 It can also have prognostic utility and help determine which patients would benefit from an early secondary repair without waiting for a response to conservative measures.

Secondary Repair

Secondary repairs of obstetrical sphincter injuries are possible when diagnosed with endoanal ultrasound and when they are less than 120–180°. Sphincteroplasty consists of dissecting the sphincter ends, which are carefully released and overlapped without tension. It is recommended to not remove the fibrous scar tissue of the endings in order to create the suture, nor should the mucosa of the anal canal be cut60 (Fig. 3).

Fig. 3.

Anterior sphincteroplasty.

(0.16MB).

The results of sphincteroplasty are initially satisfactory in two-thirds of patients.63 These results, however, have been obtained in non-experimental studies with a limited number of cases. Furthermore, there are data that have demonstrated that the initial beneficial effects of sphincteroplasty may not endure over time.64–67 In the study by Halveson et al.64 with a mean follow-up of 69 months after sphincteroplasty, only 14% of the patients were totally continent. Another study65 evaluated a group of patients 3 and 40 months after sphincteroplasty and showed evidence of a reduction in the total rate of continence from 49% to 28% in this period, with an increased rate of fecal incontinence from 19% to 49%. In the study by Malouf66 after a mean follow-up of 77 months, out of a total of 38 patients who had not undergone stoma or any other surgery for incontinence, 100% presented some type of incontinence. Another study67 observed a significant variation of the Wexner scale score from 17.8 pre-op to 3.6 3 months after sphincteroplasty, and a worsened condition after 80 months with a mean score of 6.3. Separate dissection and repair of the external and internal sphincters have not been shown to improve the functional results.68 The association of pudendal neuropathy can worsen the sphincteroplasty results,69,70 although this result has not been corroborated in other studies.71,72

Other Treatments

In general, it seems that the repair of sphincter anatomy injuries is necessary but should be reinforced with other treatments that could improve functional results, especially in the mid to long term. Proper rehabilitation of the pelvic floor both pre- and post-op could be important, especially when the sphincter injury is old and the anatomical defect is associated with atrophy due to prolonged hypofunctionality. Biofeedback and sacral or tibial nerve stimulation treatments can also play an important role in improving the results. Furthermore, the indications for sacral neuromodulation have been extended to include patients with unrepaired sphincter defects, which has provided good results,73–79 although there have been no randomized studies comparing this technique with sphincteroplasty. Likewise, some groups have applied tibial stimulation in cases of fecal incontinence with sphincter defect, resulting in improved symptoms.80,81

Conclusions

The fecal incontinence rate after childbirth is high. It is important to detect and avoid, if possible, any possible factors and actions that involve risk (episiotomy, forceps, etc.). The etiopathogenesis of this incontinence is multifactorial; the most important related factors are perineal tears that affect anal sphincters, trauma to the pudendal nerves and injury to other components of the levator ani.

When sphincter injuries occur, it is essential to detect and treat them properly. Likewise, it is important to evaluate the appearance of fecal incontinence at the post-partum consultation. In cases with persistent sequelae, it is necessary to refer the patient to teams with experience in the treatment of fecal incontinence.

Anal sphincteroplasty is the standard treatment of obstetrical sphincter injuries. However, it may be necessary to include adequate pre-and post-operative physiotherapy or associate other treatments in some cases in order to improve mid- and long-term results. Electrical stimulation therapies seem to improve the functionality of patients with unrepaired sphincter lesions, although clinical trials are needed to compare this therapy with surgical sphincter repair.

Conflict of Interest

The authors have no conflict of interests to declare.

References
[1]
J.M. Guise, C. Morris, P. Osterweil, H. Li, D. Rosenberg, M. Greenlick.
Incidence of fecal incontinence after childbirth.
Obstet Gynecol, 109 (2007), pp. 281-288
[2]
E. Eason, M. Labrecque, S. Marcoux, M. Mondor.
Anal incontinence after childbirth.
CMAJ, 166 (2002), pp. 326-330
[3]
L. Abramowitz, I. Sobhani, R. Ganansia, A. Vuagnat, J.L. Benifla, E. Darai, et al.
Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study.
Dis Colon Rectum, 43 (2000), pp. 590-596
[4]
M. Lal, C.H. Mann, R. Callender, S. Radley.
Does cesarean delivery prevent anal incontinence?.
Obstet Gynecol, 101 (2003), pp. 305-312
[5]
J.P. Zetterström, A. López, B. Anzén, A. Dolk, N.M. Mellgren.
Anal incontinence after vaginal delivery: a prospective study in primiparous women.
Acta J Obstet Gynaecol, 106 (1999), pp. 324-330
[6]
T. Tetzschner, M. Sørensen, O.O. Rasmussen, G. Lose, J. Christiansen.
Pudendal nerve damage increases the risk of fecal incontinence in women with anal sphincter rupture after childbirth.
Acta Obstet Gynecol Scand, 74 (1995), pp. 434-440
[7]
S. Norderval, D. Nsubuga, C. Bjelke, J. Frasunek, I. Myklebust, B. Vonen.
Anal incontinence after obstetric sphincter tears: incidence in a Norwegian county.
Acta Obstet Gynecol Scand, 83 (2004), pp. 989-994
[8]
R.L. Nelson, M. Westercamp, S.E. Furner.
A systematic review of the efficacy of cesarean section in the reservation of anal continence.
Dis Colon Rectum, 49 (2006), pp. 1587-1595
[9]
M. Malek-mellouli, S. Assen, F. Ben Amara, H. Gada, K. Masmoudi, H. Reziga.
Incidence and risk factors of postpartum anal incontinence: a prospective study of 503 cases.
Tunis Med, 92 (2014), pp. 159-163
[10]
H.H. Johannessen, A. Wibe, A. Stordahl, L. Sandvik, B. Backe, S. Mørkved.
BJOG, 121 (2014), pp. 269-279
[11]
S.J. Brown, D. Gartland, S. Donath, C. MacArthur.
Fecal incontinence during the first 12 months postpartum: complex causal pathways and implications for clinical practice.
Obstet Gynecol, 119 (2012), pp. 240-249
[12]
M1 Solans-Domènech, E. Sánchez, M. Espuña-Pons, Pelvic Floor Research Group (Grup de Recerca del Sòl Pelvià; GRESP).
Urinary and anal incontinence during pregnancy and postpartum: incidence, severity, and risk factors.
Obstet Gynecol, 115 (2010), pp. 618-628
[13]
E. Jung, C.Y. Huh, B.K. Choe.
Anal incontinence after childbirth: incidence in the Korean population.
Gynecol Obstet Invest, 66 (2008), pp. 248-252
[14]
T.M. Pinta, M.L. Kylänpää, K.A. Teramo, P.S. Luukkonen.
Sphincter rupture and anal incontinence after first vaginal delivery.
Acta Obstet Gynecol Scand, 83 (2004), pp. 917-922
[15]
T.C. Dudding, C.J. Vaizey, M.A. Kamm.
Obstetric anal sphincter injury: incidence, risk factors, and management.
Ann Surg, 247 (2008), pp. 224-237
[16]
M. Oberwalder, J. Connor, S.D. Wexner.
Meta-analysis to determine the incidence of obstetric anal sphincter damage.
Br J Surg, 90 (2003), pp. 1333-1337
[17]
M.P. Hehir, H.D. O¿Connor, S. Higgins, M.S. Robson, F.M. McAuliffe, P.C. Boylan, et al.
Obstetric anal sphincter injury, risk factors and method of delivery – an 8-year analysis across two tertiary referral centers.
J Matern Fetal Neonatal Med, 26 (2013), pp. 1514-1516
[18]
L.B. Signorello, B.L. Harlow, A.K. Chekos, J.T. Repke.
Midline episiotomy and anal incontinence: retrospective cohort study.
BMJ, 320 (2000), pp. 86-90
[19]
J. Zetterström, A. López, B. Holmström, B.Y. Nilsson, A. Tisell, B. Anzén, et al.
Obstetric sphincter tears and anal incontinence: an observational follow-up study.
Obstet Gynecol Surv, 82 (2003), pp. 921-928
[20]
T. Sato, F. Konishi, H. Minakami, N. Nakatsubo, K. Kanazawa, I. Sato, et al.
Pelvic floor disturbance after childbirth: vaginal delivery damages the upper levels of sphincter innervation.
Dis Colon Rectum, 44 (2001), pp. 1155-1161
[21]
J. Pollack, J. Nordenstam, S. Brismar, A. Lopez, D. Altman, J. Zetterstrom.
Anal incontinence after vaginal delivery: a five-year prospective cohort study.
Obstet Gynecol, 104 (2004), pp. 1397-1402
[22]
M. Fitzpatrick, C. O’Brien, P.R. O’Connell, C. O’Herlihy.
Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence.
Am J Obstet Gynecol, 189 (2003), pp. 730-735
[23]
J. Zetterström, A. López, B. Anzén, M. Norman, B. Holmström, A. Mellgren.
Anal sphincter tears at vaginal delivery: risk factors and clinical outcome of primary repair.
Obstet Gynecol, 94 (1999), pp. 21-28
[24]
A.H. Sultan.
Obstetric perineal injury and anal incontinence.
Clin Risk, 5 (1999), pp. 193-196
[25]
S.J. Pretlove, P.J. Thompson, P.M. Toozs-Hobson, S. Radley, K.S. Khan.
Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review.
[26]
E. Samuelsson, L. Ladfors, U.B. Wennerholm, B. Gåreberg, K. Nyberg, H. Hagberg.
Anal sphincter tears: prospective study of obstetric risk factors.
BJOG, 107 (2000), pp. 926-931
[27]
A.S. Sulaiman, S. Ahmad, N.A. Ismail, R.A. Rahman, M.A. Jamil, A.Z. Mohd Dali.
A randomized control trial evaluating the prevalence of obstetrical anal sphincter injuries in primigravida in routine versus selective mediolateral episiotomy.
Saudi Med J, 34 (2013), pp. 819-823
[28]
D.J. Murphy, M. Macleod, R. Bahl, K. Goyder, L. Howarth, B. Strachan.
A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study.
[29]
M. Macleod, B. Strachan, R. Bahl, L. Howarth, K. Goyder, M. van de Venne, et al.
A prospective cohort study of maternal and neonatal morbidity in relation to use of episiotomy at operative vaginal delivery.
[30]
M. Stedenfeldt, J. Pirhonen, E. Blix, T. Wilsgaard, B. Vonen, P. Øian.
Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study.
[31]
M. Fitzpatrick, M. Behan, P.R. O’Connell, C. O’Herlihy.
Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery.
BJOG, 110 (2003), pp. 424-429
[32]
A. Griffiths, S. Watermeyer, K. Sidhu, N.N. Amso, B. Nix.
Female genital tract morbidity and sexual function following vaginal delivery or lower segment caesarean section.
J Obstet Gynaecol, 26 (2006), pp. 645-649
[33]
R.L. Nelson, S.E. Furner, M. Westercamp, C. Farquhar.
Cesarean delivery for the prevention of anal incontinence.
Cochrane Database Syst Rev, (2010), pp. CD006756
[34]
V. McKinnie, S.E. Swift, W. Wang, P. Woodman, A. O’Boyle, M. Kahn, et al.
The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence.
Am J Obstet Gynecol, 193 (2005), pp. 512-517
[35]
H.H. Johannessen, S. Mørkved, A. Stordahl, L. Sandvik, A. Wibe.
Anal incontinence and quality of life in late pregnancy: a cross-sectional study.
BJOG, 121 (2014), pp. 978-987
[36]
M. Fynes, V. Donnelly, M. Behan, P.R. O’Connell, C. O’Herlihy.
Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study.
[37]
N. Schwertner-Tiepelmann, R. Thakar, A.H. Sultan, R. Tunn.
Obstetric levator ani muscle injuries: current status.
Ultrasound Obstet Gynecol, 39 (2012), pp. 372-383
[38]
R.J. Fernando, A.H. Sultan, S. Radley, P.W. Jones, R.B. Johanson.
Management of obstetric anal sphincter injury: a systematic review & national practice survey.
BMC Health Serv Res, 2 (2002), pp. 9
[39]
V. Garcia, R.G. Rogers, S.S. Kim, R.J. Hall, D.N. Kammerer-Doak.
Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques.
Am J Obstet Gynecol, 192 (2005), pp. 1697-1701
[40]
S.A. Farrell, G. Flowerdew, D. Gilmour, G.K. Turnbull, M.H. Schmidt, T.F. Baskett, et al.
Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial.
Obstet Gynecol, 120 (2012), pp. 803-808
[41]
A.B. Rygh, H. Körner.
The overlap technique versus end-to-end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study.
Acta Obstet Gynecol Scand, 89 (2010), pp. 1256-1262
[42]
A. Williams, E.J. Adams, D.G. Tincello, Z. Alfirevic, S.A. Walkinshaw, D.H. Richmond.
How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial.
[43]
M. Fitzpatrick, M. Behan, P.R. O’Connell, C. O’Herlihy.
A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears.
Am J Obstet Gynecol, 183 (2000), pp. 1220-1224
[44]
R.J. Fernando, A.H. Sultan, C. Kettle, S. Radley, P. Jones, P.M. O’Brien.
Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial.
Obstet Gynecol, 107 (2006), pp. 1261-1268
[45]
R.J. Fernando, A.H. Sultan, C. Kettle, R. Thakar.
Methods of repair for obstetric anal sphincter injury.
Cochrane Database Syst Rev, 12 (2013), pp. CD002866
[46]
V. Andrews, S. Shelmeride, A.H. Sultan, R. Thakar.
Anal and urinary incontinence 4 years after a vaginal delivery.
Int Urogynecol J, (2013), pp. 55-60
[47]
J. Nordenstam, A. Mellgren, D. Altman, A. López, C. Johansson, B. Anzén, et al.
Immediate or delayed repair of obstetric anal sphincter tears – a randomised controlled trial.
[48]
R. Mahony, M. Behan, C. O’Herlihy, P.R. O’Connell.
Randomized, clinical trial of bowel confinement vs laxative use after primary repair of a third-degree obstetric anal sphincter tear.
Dis Colon Rectum, 47 (2004), pp. 12-17
[49]
T.M. Pinta, M.L. Kylänpää, T.K. Salmi, K.A. Teramo, P.S. Luukkonen.
Primary sphincter repair: are the results of the operation good enough?.
Dis Colon Rectum, 47 (2004), pp. 18-23
[50]
A.H. Sultan, M.A. Kamm, C.N. Hudson, C.I. Bartram.
Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair.
BMJ, 308 (1994), pp. 887-891
[51]
J. Pollack, J. Nordenstam, S. Brismar, A. Lopez, D. Altman, J. Ztterstrom.
Anal incontinence after vaginal delivery: a five-year prospective cohort study.
Obstet Gynecol, 104 (2004), pp. 1397-1402
[52]
C. McArthur, D. Wilson, P. Herbison, R.J. Lancashire, S. Hagen, P. Toozs-Hobson, ProLong study group, et al.
Faecal incontinence persisting after childbirth: a 12 year longitudinal study.
BJOG, 120 (2013), pp. 169-178
[53]
M.M. Soerensen, S. Buntzen, K.M. Bek, S. Laurberg.
Complete obstetric anal sphincter tear and risk of long-term fecal incontinence: a cohort study.
Dis Colon Rectum, 56 (2013), pp. 992-1001
[54]
D.S. McKenna, J.B. Ester, J.R. Fischer.
Elective cesarean delivery for women with a previous anal sphincter rupture.
J Obstet Gynaecol, 189 (2003), pp. 1251-1256
[55]
R. Boyle, E.J. Hay-Smith, J.D. Cody, S. Mørkved.
Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women.
Cochrane Database Syst Rev, 10 (2012), pp. CD007471
[56]
C.M. Glazener, G.P. Herbison, P.D. Wilson, C. MacArthur, G.D. Lang, H. Gee, et al.
Conservative management of persistent postnatal urinary and faecal incontinence: a randomised controlled trial.
BMJ, 323 (2001), pp. 593-596
[57]
C.M.A. Glazener, G.P. Herbison, C. MacArthur, A.M. Grant, P.D. Wilson.
Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up.
[58]
Glazener CM1, C. MacArthur, S. Hagen, A. Elders, R. Lancashire, G.P. Herbison, ProLong Study Group, et al.
Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial.
BJOG, 121 (2014), pp. 112-120
[59]
A.H. Sultan, M.A. Kamm, C.N. Hudson, J.M. Thomas, C.I. Bartram.
Anal-sphincter disruption during vaginal delivery.
Engl J Med, 329 (1993), pp. 1905-1911
[60]
C. Del Rio, S. Biondo, J. Martí Ragué.
Incontinencia fecal. Valoración del paciente. Tratamientos clásicos.
Cir Esp, 78 (2005), pp. 34-40
[61]
M. Starck, M. Bohe, L. Valentin.
Results of endosonographic imaging of the anal sphincter 2–7 days after primary repair of third- or fourth-degree obstetric sphincter tears.
Ultrasound Obstet Gynecol, 22 (2003), pp. 609-615
[62]
M. Starck, M. Bohe, L. Valentin.
The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence.
Ultrasound Obstet Gynecol, 27 (2006), pp. 188-197
[63]
R. Madoff.
Surgical treatment options for fecal incontinence.
Gastroenterology, 126 (2004), pp. S48-S54
[64]
A.L. Halverson, T.L. Hull.
Long-term outcome of overlapping anal sphincter repair.
Dis Colon Rectum, 45 (2002), pp. 345-348
[65]
S. Karoui, A.M. Leroi, E. Koning, J.F. Menard, F. Michot, P. Denis.
Results of sphincteroplasty in 86 patients with anal incontinence.
Dis Colon Rectum, 43 (2000), pp. 813-820
[66]
A.J. Malouf, C.S. Norton, A.F. Engel, R.J. Nicholls, M.A. Kamm.
Longterm results of overlapping anterior anal-sphincter repair for obstetric trauma.
[67]
G.I. Barisic, Z.V. Krivokapic, V.A. Markovic, M.A. Popovic.
Outcome of overlapping anal sphincter repair after 3 months and after a mean of 80 months.
Int J Colorectal Dis, 21 (2006), pp. 52-56
[68]
S1 Maslekar, A.B. Gardiner, G.S. Duthie.
Anterior anal sphincter repair for fecal incontinence: good longterm results are possible.
J Am Coll Surg, 204 (2007), pp. 40-46
[69]
R. Gilliland, D.F. Altomare, H. Moreira Jr., L. Oliveira, J.E. Gilliland, S.D. Wexner.
Pudendal neuropathy is predictive of failure following anterior overlapping sphincteroplasty.
Dis Colon Rectum, 41 (1998), pp. 1516-1522
[70]
Y.P. Sangwan, J.A. Coller, R.C. Barrett, P.L. Roberts, J.J. Murray, L. Rusin, et al.
Unilateral pudendal neuropathy. Impact on outcome of anal sphincter repair.
Dis Colon Rectum, 39 (1996), pp. 686-689
[71]
P.J. Sitzler, J.P. Thomson.
Overlap repair of damaged anal sphincter. A single surgeon's series.
Dis Colon Rectum, 39 (1996), pp. 1356-1360
[72]
W.D. Buie, A.C. Lowry, D.A. Rothenberger, R.D. Madoff.
Clinical rather than laboratory assessment predicts continence after anterior sphincteroplasty.
Dis Colon Rectum, 44 (2001), pp. 1255-1260
[73]
C. Ratto, F. Litta, A. Parello, L. Donisi, V. de Simone, G. Zaccone.
Sacral nerve stimulation in faecal incontinence associated with an anal sphincter lesion: a systematic review.
Colorectal Dis, 14 (2012), pp. e297-e304
[74]
R. Brouwer, G. Duthie.
Sacral nerve neuromodulation is effective treatment for fecal incontinence in the presence of a sphincter defect, pudendal neuropathy, or previous sphincter repair.
Dis Colon Rectum, 53 (2010), pp. 273-278
[75]
C. Ratto, F. Litta, A. Parello, L. Donisi, G.B. Doglietto.
Sacral nerve stimulation is a valid approach in fecal incontinence due to sphincter lesions when compared to sphincter repair.
Dis Colon Rectum, 53 (2010), pp. 264-272
[76]
D.J. Boyle, C.H. Knowles, P.J. Lunniss, S.M. Scott, N.S. Williams, K.A. Gill.
Efficacy of sacral nerve stimulation for fecal incontinence in patients with anal sphincter defects.
Dis Colon Rectum, 52 (2009), pp. 1234-1239
[77]
M.K. Chan, J.J. Tjandra.
Sacral nerve stimulation for fecal incontinence: external anal sphincter defect vs intact anal sphincter.
Dis Colon Rectum, 51 (2008), pp. 1015-1024
[78]
M.E. Jarrett, T.C. Dudding, R.J. Nicholls, C.J. Vaizey, C.R. Cohen, M.A. Kamm.
Sacral nerve stimulation for fecal incontinence related to obstetric anal sphincter damage.
Dis Colon Rectum, 51 (2008), pp. 531-537
[79]
J. Melenhorst, S.M. Koch, O. Uludag, W.G. van Gemert, C.G. Baeten.
Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence?.
Colorectal Dis, 10 (2008), pp. 257-262
[80]
A. Arroyo, P. Parra, A. Lopez, E. Peña, J. Ruiz-Tovar, J. Benavides, et al.
Percutaneous posterior tibial nerve stimulation (PPTNS) in faecal incontinente associated with an anal sphincter lesion: results of a prospective study.
Int J Surg, 12 (2014), pp. 146-149
[81]
A. Hotouras, M.A. Thaha, M.E. Allison, A. Currie, S.M. Scott, C.L. Chan.
Percutaneous tibial nerve stimulation (PTNS) in females with faecal incontinence: the impact of sphincter morphology and rectal sensation on the clinical outcome.
Int J Colorectal Dis, 27 (2012), pp. 927-930

Please cite this article as: Rodríguez R, Alós R, Carceller MS, Solana A, Frangi A, Ruiz MD, et al. Incontinencia fecal posparto. Revisión de conjunto. Cir Esp. 2015;93:359–367.

Copyright © 2014. AEC
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Quizás le interese:
10.1016/j.cireng.2023.07.008
No mostrar más