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Occult disruption: don't overlook anal sphincter lacerations.

PHIL ADELPHIA -- Many obstetricians may not be getting the full picture when it comes to obstetric anal sphincter lacerations and fecal incontinence.

Occult anal sphincter disruption, delayed onset and progressive deterioration of fecal incontinence, lack of long-term follow-up of primary repairs, and patient reluctance to talk about symptoms may contribute to a false sense of security among many obstetricians about repaired anal sphincter lacerations, according to Dr. Rebecca Rogers and Dr. Dorothy Kammerer-Doak, both of the University of New Mexico in Albuquerque.

The fundamentals of preventing obstetric anal sphincter lacerations hinge on the avoidance of episiotomy and forceps deliveries, they stressed at the annual meeting of the American College of Obstetricians and Gynecologists.

"I'm not saying never to use forceps. But if we do a forceps delivery, we need to counsel our patients on the permanent risk of fecal incontinence, because they can sue you if they develop problems, and they will win," Dr. Rogers said.

Even when all precautions are taken, obstetric anal sphincter lacerations still occur, and they often go unrecognized.

The prevalence of fecal incontinence has been estimated at anywhere from 0.5% to 13% in the general population, with rates between six and eight times higher in women, Dr. Rogers said.

Although studies suggest that overt sphincter damage is fairly low, around 6.4%, transperineal imaging detected occult sphincter disruption in 35% of primiparous women and 44% of multiparous women in one study (N. Engl. J. Med. 329[26]: 1905-11, 1993). Another study found evidence of occult disruption in 6.8% of primiparous women and 12.2% of multiparous women.

"How many of you have done a pelvic exam and seen fecal matter on the perineum, or had the patient pass gas during the exam? These are signs of possible fecal incontinence." Dr. Rogers said at the meeting.

"If urinary incontinence is part of your practice, then anal incontinence is, too," she added.

Repair of anal sphincter lacerations should attempt to restore the patient's normal anatomy, said Dr. Kammerer-Doak. This means repairing both the external and internal sphincter, reconstructing the perineum, and attaching the rectovaginal septum to the perineal body.

The procedure should be approached with the same exquisite care used in other surgical procedures.

"We were taught to repair these lacerations in the delivery room, in the dark, with soft music playing and stool in the operative field. But you need to have good light, good visualization, and adequate analgesia--even a general or a spinal to allow the musculature to properly relax," she said.

The rectal mucosa should be closed with fine (3-0 or 4-0) PGA interrupted sutures, with a second imbricating layer. The internal anal sphincter should be closed with the same fine interrupted or running sutures, and the external anal sphincter should be closed using 2-0 prolonged delayed absorbable (PDS/Maxon) sutures with either an overlapping or end-to-end technique. Finally the rectovaginal septum should be reattached to the perineal body.

Although there is very little in the literature regarding postoperative care, Dr. Kammerer-Doak said most experts recommend at least one dose of postoperative antibiotics. Sitz baths, stool softeners, and 8-10 weeks of "pelvic rest" (no tampons, douches, or intercourse) are also often recommended.


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Title Annotation:Obstetrics
Author:Johnson, Kate
Publication:OB GYN News
Date:Jun 15, 2004
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