Incontinence: General

Parasacral and perineal sphincteroplasty.
Korcek J, Bakos E, Klobusicky P
Tech Coloproctol. 2005 Dec;9(3):250-1.

Routine symptom screening for postnatal urinary and anal incontinence in new mothers from a district.
Bugg GJ, Hosker GL, Kiff ES
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):405-8. Epub 2005 May 13.

Parous middle-aged women present with urinary and faecal incontinence and childbirth trauma is thought to be a causal factor. Both symptoms are common after childbirth but usually go under-reported. It has been suggested that new mothers are likely to benefit from routine symptom screening because by actively identifying symptomatic women they could then be helped to access continence services. The main objective of this study was to pilot a programme of routine symptom screening for postnatal urinary and anal incontinence in new mothers from a district general hospital. Self-completion questionnaires for both urinary and anal incontinence were sent by post to 442 primiparous women who had delivered consecutively 10 months previously in a district general hospital. Two hundred and seventy-five new mothers responded to the survey. Ninety-two women had new symptoms of incontinence at 10 months, 82 had urinary incontinence and 25 had anal incontinence. However, only six new mothers had discussed the problem with a health professional. Although nine women requested a hospital appointment none of the women attended the appointment arranged for them. The domain scores on both questionnaires were significantly less for symptomatic new mothers when compared to women with established symptoms of incontinence. The programme of screening successfully identified women with symptoms of incontinence. However, all of the symptomatic women declined a follow-up appointment at hospital which questions the benefits of routine screening 10 months after childbirth.

Urinary and Anal Incontinence in Morbidly Obese Women Considering Weight Loss Surgery.
Richter HE, Burgio KL, Clements RH, Goode PS, Redden DT, Varner RE
Obstet Gynecol 2005 Dec;106(6):1272-1277.

OBJECTIVE: To estimate prevalence and correlates of urinary and anal incontinence in morbidly obese women undergoing evaluation for laparoscopic weight loss surgery. METHODS: From October 2003 to February 2005, 180 women with body mass index (BMI) of 40 or greater underwent evaluation for laparoscopic weight loss surgery. Using an established Web site, questionnaires were completed to assess symptoms of urinary incontinence, including the Medical, Epidemiological, and Social Aspects of Aging Questionnaire (MESA). Anal incontinence was assessed by asking, "Do you have any uncontrolled anal leakage?" A number of clinical and demographic variables were examined as potential risk factors for urinary incontinence and anal incontinence. RESULTS: Mean age was 39.8 years (range 16-55). Body mass index ranged from 40 to 81 (mean 49.5). Prevalence of urinary incontinence was 66.9% and anal incontinence was 32.0% (45.6% loss of gas only, 21.1% liquid stool only, 24.6% gas and liquid stool only, 8.8% solid stool). In simple logistic regression, presence of urinary incontinence was associated with age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01-1.09), number of children (OR 1.54, 95% CI 1.15-2.07), anal incontinence (OR 6.34, 95% CI 2.52-15.93), arthritis (OR 6.04, 95% CI 1.76-20.78), and sleep apnea (OR 2.30, 95% CI 1.21-4.37). Multivariable logistic regression identified 3 factors independently associated with urinary incontinence: number of children (OR 1.55, 95% CI 1.12-2.12), arthritis (OR 5.46, 95% CI 1.51-19.73), and anal incontinence (OR 6.27, 95% CI 2.42-16.26). Presence of anal incontinence was associated only with the presence of urinary incontinence (OR 6.34, 95% CI 2.52-15.93). CONCLUSION: Prevalence of urinary and anal incontinence is high in this group of morbidly obese women as compared with the general population. Studies are needed to determine the effect of weight loss on urinary and anal incontinence symptoms in the morbidly obese woman. LEVEL OF EVIDENCE: III.

Anal incontinence in women with and those without pelvic floor disorders.
Nichols CM, Ramakrishnan V, Gill EJ, Hurt WG
Obstet Gynecol 2005 Dec;106(6):1266-71.

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (>/= stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group. LEVEL OF EVIDENCE: II-2.

Combined urinary and faecal incontinence.
Kapoor DS, Thakar R, Sultan AH
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):321-8. Epub 2005 Feb 24.

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9-19% (urinary) and 5-10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.

Risk factors for obstetrical anal sphincter lacerations.
Dandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP, Hernandez E
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):304-7. Epub 2005 Apr 5.

The objective of this study was to identify the rate of anal sphincter lacerations in a large population-based database and analyze risk factors associated with this condition. Data were obtained from Pennsylvania Healthcare Cost Containment Council (PHC4) regarding all cases of obstetrical third and fourth degree perineal lacerations that occurred during a 2-year period from January 1990 to December 1991. Modifiable risk factors associated with this condition were analyzed, specifically episiotomy, forceps-assisted vaginal delivery, forceps with episiotomy, vacuum-assisted vaginal delivery, and vacuum with episiotomy. There were a total of 168,337 deliveries in 1990 and 165,051 deliveries in 1991 in Pennsylvania. Twenty-two percent (n = 74,881) of the deliveries were by cesarean section and were excluded from analysis. Among the remaining 258,507 deliveries, there were 18,888 (7.3%) third and fourth degree lacerations. Instrumental vaginal delivery, particularly with use of episiotomy, increased the risk of laceration significantly [forceps odds ratio (OR): 3.84, forceps with episiotomy OR: 3.89, vacuum OR: 2.58, vacuum with episiotomy OR: 2.93]. Episiotomy on the whole was associated with a threefold increase in the risk of sphincter tears. However, episiotomy in the absence of instrumental delivery seems to be protective with an OR of 0.9 [95% confidence interval (CI): 0.88-0.93]. Instrumental vaginal delivery, particularly forceps delivery, appears to be an important risk factor for anal sphincter tears. The risk previously attributed to episiotomy is probably due to its association with instrumental vaginal delivery. Forceps delivery is associated with higher occurrence of anal sphincter injury compared to vacuum delivery.

The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence.
Starck M, Bohe M, Valentin L
Ultrasound Obstet Gynecol 2005 Nov 22;.

OBJECTIVE: To describe and classify endosonographic obstetric sphincter defects at 1 week, 3 months and 1 year after primary repair, and to relate the endosonographic results to anal sphincter pressure and to symptoms of anal incontinence over time. METHODS: Forty-one women who had suffered a third- or fourth-degree perineal tear at delivery underwent anal endosonography and anal manometry 1 week, 3 months and 1 year after primary suture of the tear. The extent of the endosonographic defects was described using defect scores ranging from 0 (no defect) to 16 (maximal defect), the score taking into account the location and the longitudinal and circumferential extent of the defect. The women answered a questionnaire with regard to bowel function 1 and 4 years after delivery, the degree of incontinence being expressed as a Wexner score. RESULTS: Some 90% (37/41) of the women had endosonographic defects at 1 week, 3 months and 1 year. The endosonographic defect scores increased significantly between the first and second examinations and then remained unchanged. At 1 year there was a negative correlation between endosonographic sphincter defect score and sphincter pressure. At 1 and 4 years, 54% (22/41) and 61% (25/41) of the women, respectively, had a Wexner score >/= 1. There was a positive correlation between the endosonographic sphincter defect score at 1 week, 3 months and 1 year and the Wexner incontinence score at 1 and 4 years. The endosonographic sphincter defect score at 1 week was the variable that was most predictive of the Wexner score at 4 years (r = 0.48, P = 0.002). CONCLUSION: The higher the endosonographic sphincter defect score after primary repair of an obstetric sphincter tear the lower the sphincter pressure and the higher the risk of anal incontinence.

Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse?
Noblett K, Lane FL, Driskill CS
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):268-71. Epub 2005 Apr 26.

OBJECTIVE: To determine if women with anterior support stages 0 or I by pelvic organ prolapse quantification (POP-Q) system require Q-tip testing to assess urethral mobility. METHODS: A prospective study of 134 women presenting for urogynecologic evaluation were examined and assigned stages of anterior wall support according to the POP-Q system. A Q-tip test was performed and urethral hypermobility was defined as a straining angle > or =30 degrees. The Spearman correlation coefficient was used to assess degree of correlation between POP-Q point Aa position and Q-tip values. RESULTS: The correlation coefficient between point Aa position and Q-tip angle was r = 0.787 (P < 0.001). Urethral hypermobility was noted in 91% of stage I and 100% of stage II-IV patients. The positive predictive value of Q-tip angle > or =30 degrees in stage I-IV prolapse was 99%. CONCLUSION: The POP-Q system is highly predictive of straining urethral angle in all stages of prolapse.

Short-term and long-term effects of obstetric anal sphincter injury and their management.
Fitzpatrick M, O'herlihy C
Curr Opin Obstet Gynecol 2005 Dec;17(6):605-610.

PURPOSE OF REVIEW: During the past decade increasing attention has focused on the problem of obstetric anal sphincter damage. Although risk factors are now well known, the effects of such damage have received less study. This review focuses on the early and long-term problems that may arise subsequent to anal sphincter injury following childbirth and assesses therapeutic options. RECENT FINDINGS: Up to 25% of women experience altered faecal continence after vaginal delivery, with 4% having persistent symptoms. In those women who have sustained a recognized tear to the sphincter, the quality of primary repair is crucial. Nevertheless, evidence clearly supporting the superiority of overlap over approximation repair is still lacking. The importance of pudendal nerve damage in the aetiology of postpartum faecal incontinence is gaining increasing attention. Augmented biofeedback physiotherapy is the gold standard for treatment of women with such injury, whereas sacral nerve stimulation represents a newer treatment option. SUMMARY: The short-term and long-term effects of obstetric anal sphincter injury warrant increased attention, because with increasing longevity more women are surviving into their 80s and the prevalence of faecal incontinence in this population will increase if measures are not taken to address the problem. Prevention of such injury is not always possible and management options must be further explored. Adequate primary treatment of third-degree tears is of paramount importance.

Epidemiology of incontinence and prolapse.
Albertsen PC
J Urol 2005 Aug;174(2):613; discussion 613.

Coding of Perineal Lacerations and Other Complications of Obstetric Care in Hospital Discharge Data.
Romano PS, Yasmeen S, Schembri ME, Keyzer JM, Gilbert WM
Obstet Gynecol 2005 Oct;106(4):717-725.

OBJECTIVE: To assess the validity of obstetric complications, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Core Measure on perineal lacerations, in the California Patient Discharge Data Set. METHODS: We randomly sampled 1,611 deliveries from 52 of the 267 hospitals that performed more than 678 eligible deliveries in California in 1992-1993. We compared hospital-reported complications against our recoding of the same records. RESULTS: Third- and fourth-degree perineal lacerations were reported accurately, with estimated sensitivities exceeding 90% and positive predictive values exceeding 65% (weighted to account for the stratified sampling design) or 85% (unweighted). Based on in-depth review of discrepant cases, we estimate the actual positive predictive value at over 90%. Most coding discrepancies were between no injury and first degree, or between first and second degree. Most postpartum complications, including urinary tract and wound infections, endometritis, anesthesia complications, and postpartum hemorrhage were reported with less than 70% sensitivity, but at least 80% positive predictive value. Composite measures from HealthGrades and Solucient, which include these complication codes, also suffer from high false-negative rates. CONCLUSION: Third- and fourth-degree perineal lacerations are accurately reported on hospital discharge abstracts, confirming the validity of related quality indicators sponsored by the Agency for Healthcare Research and Quality and JCAHO. Administrative data seem less useful for monitoring other in-hospital postpartum complications. LEVEL OF EVIDENCE: II-3.


The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence.
McKinnie V, Swift SE, Wang W, Woodman P, O'Boyle A, Kahn M, Valley M, Bland D, Schaffer J
Am J Obstet Gynecol 2005 Aug;193(2):512-7; discussion 517-8.

OBJECTIVE: The purpose of this study was to determine the relative effects of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. STUDY DESIGN: This was a prospective, observational multicenter study of women presenting to 6 gynecology clinics. Demographic data collected included: height, weight, gravidity, parity, and number of vaginal deliveries. Patients were diagnosed with incontinence by questionnaire. Standard univariate logistic regression analyses' were performed to determine the contribution of pregnancy, mode of delivery, and BMI on the prevalence of urinary and fecal incontinence. RESULTS: One thousand and four women were enrolled over an 18-month period. Two hundred and thirty-seven and 128 subjects had urinary and fecal incontinence, respectively. Odds ratio (95% CI) calculated for the prevalence of urinary incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.46 (1.53-3.95), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.95 (0.99-3.80), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.53 (1.57-4.07), and any term pregnancy but no vaginal delivery (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 1.30 (0.77-3.95). Odds ratio (95% CI) calculated for the prevalence of fecal incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.26 (1.22-4.19), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.13 (0.43-2.96), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.41 (1.30-4.49), and any term pregnancy but no vaginal deliveries (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 2.15 (0.97-4.77). BMI and age did not impact these results. CONCLUSION: Pregnancy increases the risk of urinary and fecal incontinence. Cesarean section does not decrease the risk of urinary or fecal incontinence compared to pregnancy with a vaginal delivery.

Racial/ethnic differences in perineal, vaginal and cervical lacerations.
Hopkins LM, Caughey AB, Glidden DV, Laros RK Jr
Am J Obstet Gynecol 2005 Aug;193(2):455-9.

OBJECTIVE: To determine if variation exists between ethnicities for risk of perineal, vaginal, and cervical laceration at vaginal delivery. STUDY DESIGN: Retrospective cohort study of nulliparous women who underwent vaginal delivery of a vertex presentation. Predictor variable was ethnicity with outcome variables cervical, vaginal, and second-, third-, or fourth-degree perineal laceration. Logistic regression analysis was conducted to control for confounders. RESULTS: Of the 17,216 who met criteria, Filipino (OR = 1.92, 95% CI 1.64-2.25) and Chinese (OR = 1.60, 95% CI 1.33-1.92) women were at greatest risk for third- and fourth-degree laceration. Only Filipino (OR = 1.32, 95% CI 1.10-1.57) and other Asian (OR = 1.23, 95% CI 1.08-1.41) women were at slightly increased risk of vaginal laceration. No differences were seen for cervical laceration. CONCLUSION: Different ethnicities are at widely varying risk of perineal laceration, but little difference exists for vaginal or cervical lacerations. Research into the mechanisms behind this should investigate differences in perineal anatomy.

Long-Term Consequences of First Vaginal Delivery-Induced Anal Sphincter Defect.
Damon H, Bretones S, Henry L, Mellier G, Mion F
Dis Colon Rectum 2005 Jun 16;.

PURPOSE: This study was designed to investigate the long-term consequences of anal sphincter defects detected after a first vaginal delivery. METHODS: A cohort of 197 primiparous females was evaluated for anal continence and anal sphincter defects in 1997. In June 2003 (6 years later), a postal questionnaire was sent to 74 females of this cohort, and answers from 54 (73 percent) were analyzed. RESULTS: In 1997, a transanal ultrasound found 66 anal sphincter defects (33.5 percent). Twenty-one females (10.6 percent) had persistent signs of anal incontinence 12 weeks after the index delivery. There was a significant correlation between the presence of anal sphincter defect and anal incontinence. Six years later, 11 of 54 females reported signs of anal incontinence: 50 percent of females with anal sphincter defect and only 8.1 percent of females without (P = 0.002). Large defects were more frequently associated with anal incontinence. Anal incontinence after the index vaginal delivery also was significantly associated with anal incontinence six years later. Multivariate analysis showed anal sphincter defect to be the only variable predictive of anal incontinence (odds ratio, 10.5; 95 percent confidence interval, 2.1-52.4). CONCLUSIONS: Anal sphincter defects detected after the first vaginal delivery appear as the main risk factor for anal incontinence six years later.

Decreased anal sphincter lacerations associated with restrictive episiotomy use.
Clemons JL, Towers GD, McClure GB, O'Boyle AL.
Am J Obstet Gynecol 2005 May;192(5):1620-5.

OBJECTIVE: To determine whether restrictive episiotomy use was associated with decreases in anal sphincter lacerations and the risk of anal sphincter laceration attributable to episiotomy. STUDY DESIGN: This was a retrospective database study. Rates of episiotomy, anal sphincter laceration (third- or fourth-degree tear), and other confounding variables were compared among vaginal deliveries before (1999) and after (2002) restrictive episiotomy use was implemented at our institution. Logistic regression was used to estimate the odds ratio of anal sphincter laceration that was due to episiotomy and other variables. RESULTS: The episiotomy rate decreased 56% (37% to 17%, P < .001) between 1999 and 2002, whereas the anal sphincter laceration rate decreased 44% (9.7% to 5.4%, P < .001). There were no changes in age, race, nulliparity, prolonged second stage of labor, operative vaginal deliveries, birth weight, or macrosomia, although oxytocin use and epidural use decreased slightly (37% to 31%, P < .001, and 80% to 76%, P = .02, respectively). The adjusted odds ratio of anal sphincter laceration attributable to episiotomy decreased 55%, from 6.5 (95% CI: 3.8, 11.1) to 2.9 (95% CI: 1.7, 5.0), between 1999 and 2002. Conversely, the adjusted odds ratios of anal sphincter laceration attributable to the other independent risk factors all increased or remained the same: operative vaginal delivery, which increased from 4.4 (95% CI: 2.7, 6.9) to 6.3 (95% CI: 3.6 11.1); nulliparity, from 2.9 (95% CI: 1.8, 4.8) to 2.9 (95% CI: 1.4, 5.9); macrosomia, from 1.9 (95% CI: 1.1, 3.4) to 2.6 (95% CI: 1.3, 5.4); and prolonged second stage, from 2.0 (95% CI: 1.3, 3.0) to 2.1 (95% CI: 1.2, 3.7). CONCLUSION: With restrictive episiotomy use, the episiotomy rate, anal sphincter laceration rate, and risk of anal sphincter laceration attributable to episiotomy were all reduced by approximately 50%.

The impact of occiput posterior fetal head position on the risk of anal sphincter injury in forceps-assisted vaginal deliveries.
Benavides L, Wu JM, Hundley AF, Ivester TS, Visco AG.
Am J Obstet Gynecol 2005 May;192(5):1702-6.

OBJECTIVE: A forceps-assisted vaginal delivery is a well-recognized risk factor for anal sphincter injury. Some studies have shown that occiput posterior (OP) fetal head position is also associated with an increased risk for third- or fourth-degree lacerations. The objective of this study was to assess whether OP position confers an incrementally increased risk for anal sphincter injury above that present with forceps deliveries. STUDY DESIGN: This was a retrospective cohort study of 588 singleton, cephalic, forceps-assisted vaginal deliveries performed at our institution between January 1996 and October 2003. Maternal demographics, labor and delivery characteristics, and neonatal factors were examined. Statistical analysis consisted of univariate statistics, Student t test, chi2, and logistic regression. RESULTS: The prevalence of occiput anterior (OA) and OP positions was 88.4% and 11.6%, respectively. The groups were similar in age, marital status, body mass index, use of epidural, frequency of inductions, episiotomies, and shoulder dystocias. The OA group had a higher frequency of rotational forceps (16.2% vs 5.9%, P = .03), greater birth weights (3304 +/- 526 g vs 3092 +/- 777 g, P = .004), and a larger percentage of white women (48.8% vs 34.3%, P = .04). Overall, 35% of forceps deliveries resulted in a third- or fourth-degree laceration. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (51.5% vs 32.9%, P = .003), giving an odds ratio of 2.2 (CI: 1.3-3.6). In a logistic regression model that controlled for occiput posterior position, maternal body mass index, race, length of second stage, episiotomy, birth weight, and rotational forceps, OP head position was 3.1 (CI: 1.6-6.2) times more likely to be associated with anal sphincter injury than OA head position. CONCLUSION: Forceps-assisted vaginal deliveries have been associated with a greater risk for anal sphincter injury. Within this population of forceps deliveries, an OP position further increases the risk of third- or fourth-degree lacerations when compared with an OA position.

Severe perineal lacerations in nulliparous women and episiotomy type.
Aytan H, Tapisiz OL, Tuncay G, Avsar FA.
Eur J Obstet Gynecol Reprod Biol 2005 Jun 8;.

OBJECTIVE: To determine the patient-related factors associated with severe perineal lacerations in nulliparous women and to evaluate the effect of episiotomy type on the risk of severe perineal tears. STUDY DESIGN: In all, 400 nulliparous women admitted in labor between June and December 2001 were prospectively enrolled. Maternal height, perineal length, fetal birth weight, fetal head circumference, and severe perineal lacerations (third and fourth degrees) were recorded. RESULTS: The rate of severe perineal lacerations was 2% (8/400); 3% with midline, 1% with mediolateral groups. In patients with severe lacerations, perineal length was significantly (p<0.001) shorter and the head circumference of their babies in the midline significantly (p<0.05) greater than normal, and birth weights were also significantly (p<0.05) greater in the mediolateral group. A cut-off value for perineal length of 3.05cm was found for severe lacerations in the midline group. CONCLUSION: If episiotomy is to be performed, it must be borne in mind that patients with a perineal length of </=3cm have an elevated risk of severe perineal lacerations, and if clinical or ultrasound examination suggests that the fetal head is large, mediolateral episiotomy may be preferred. Otherwise, midline episiotomy must be considered.

Treatment of neurogenic detrusor overactivity in spinal cord injured patients by conditional electrical stimulation.
Hansen J, Media S, Nohr M, Biering-Sorensen F, Sinkjaer T, Rijkhoff NJ.
J Urol 2005 Jun;173(6):2035-9.

PURPOSE: The feasibility of automatic event driven electrical stimulation of the dorsal penile/clitoral nerve in the treatment of neurogenic detrusor overactivity (NDO) was evaluated in individuals with spinal cord injury. MATERIALS AND METHODS: The study included 2 women and 14 men older than 18 years with NDO, bladder capacity below 500 ml and complete or incomplete suprasacral spinal cord injury. Detrusor pressure (Pdet) was recorded during ordinary, natural bladder filling. In a similar subsequent recording Pdet was used to trigger electrical stimulation when pressure exceeded 10 cm H2O. RESULTS: Of the 16 patients enrolled in this study 13 had increased bladder capacity together with a storage pressure decrease as a result of automatic, event driven electrical stimulation. In 2 patients stimulation could not inhibit the first undesired contraction, leakage occurred and finally 1 could not tolerate stimulation. During stimulated filling Pdet never exceeded 55 cm H2O. Thus, storage pressure was sufficiently low to prevent kidney damage. An average bladder capacity increase of 53% was achieved. CONCLUSIONS: This study demonstrates the feasibility of automatic, event driven electrical stimulation in the treatment of NDO. Although the setup in this experiment is not suitable in a clinical setting, the treatment modality is promising and it warrants further investigation.

Bladder neck sling for treatment of neurogenic incontinence in children with augmentation cystoplasty: long-term followup.
Castellan M, Gosalbez R, Labbie A, Ibrahim E, Disandro M.
J Urol 2005 Jun;173(6):2128-31; discussion 2131.

PURPOSE: We retrospectively reviewed the outcome and long-term followup (mean 4.16 years) of bladder neck slings for the treatment of neurogenic urinary incontinence in 58 patients (15 males) who also underwent bladder augmentation. MATERIALS AND METHODS: A total of 58 patients with neurogenic bladder (43 females and 15 males, median age 11.4 years) underwent a rectus fascial sling procedure as part of the reconstructive efforts for continence between July 1991 and July 2003. Criteria for enhancement of bladder outlet resistance included a detrusor leak point pressure of less than 45 cm H2O, an open bladder neck during bladder filling at low detrusor pressures and clinical evidence of stress incontinence. RESULTS: Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). A total of 51 patients (88%) obtained good continence results. Five females and 2 males remained incontinent following the sling procedure. Four females underwent a secondary open bladder neck procedure at a mean of 18 months after the initial procedure (artificial urinary sphincter in 2, bladder neck closure in 2). Two male patients (5 and 17 years old) had daily underwear staining or dampness with exercise or transfer. CONCLUSIONS: We consider bladder neck slings the procedure of choice for the enhancement of bladder outlet resistance in the majority of patients with neurogenic bladder who need augmentation cystoplasty and whom we do not expect will be capable of voiding spontaneously. In males and females satisfactory long-term continence can be expected with the use of the rectus fascial sling.

The effect of oxybutynin treatment on cognition in children with diurnal incontinence.
Sommer BR, O'Hara R, Askari N, Kraemer HC, Kennedy WA 2nd.
J Urol 2005 Jun;173(6):2125-7.

PURPOSE: Oxybutynin is a powerful anticholinergic drug already known to impair cognition in the elderly. The impact of this drug on cognitive functioning in the pediatric population is unknown. We report the results of a study designed to assess the effect of oxybutynin on cognitive function in children. MATERIALS AND METHODS: A total of 25 patients presenting with the primary symptom of daytime enuresis were recruited for this nonrandomized trial. All subjects initially received 4 weeks of behavior modification, followed by an additional 4 weeks of behavior modification either alone or with oxybutynin for continued treatment of enuresis. Neuropsychological testing was performed at baseline (4 weeks) and after additional therapy (8 weeks). RESULTS: Patient demographics included a male-to-female ratio of 11:14 and a mean age of 7.2 +/- 1.8 years. A total of 10 patients were assigned to the control group receiving behavior modification, and 15 patients were assigned to the treatment group receiving behavior modification plus oxybutynin. The oxybutynin treated patients had a lower overall performance at baseline pretreatment testing. However, performance in this group improved following treatment with oxybutynin. CONCLUSIONS: Oxybutynin, a commonly used pharmacological agent in pediatric urology, was not associated with cognitive impairment following treatment. However, we observed lower baseline cognitive functioning in patients whose parents chose oxybutynin over behavior modification alone. This finding may represent a selection bias. However, it also supports the need for a multidisciplinary approach to the treatment of patients with dysfunctional voiding, as some may have cognitive difficulties that have not previously been explored.

Routine symptom screening for postnatal urinary and anal incontinence in new mothers from a district.
Bugg GJ, Hosker GL, Kiff ES. Int Urogynecol
J Pelvic Floor Dysfunct 2005 May 13;.

Parous middle-aged women present with urinary and faecal incontinence and childbirth trauma is thought to be a causal factor. Both symptoms are common after childbirth but usually go under-reported. It has been suggested that new mothers are likely to benefit from routine symptom screening because by actively identifying symptomatic women they could then be helped to access continence services. The main objective of this study was to pilot a programme of routine symptom screening for postnatal urinary and anal incontinence in new mothers from a district general hospital. Self-completion questionnaires for both urinary and anal incontinence were sent by post to 442 primiparous women who had delivered consecutively 10 months previously in a district general hospital. Two hundred and seventy-five new mothers responded to the survey. Ninety-two women had new symptoms of incontinence at 10 months, 82 had urinary incontinence and 25 had anal incontinence. However, only six new mothers had discussed the problem with a health professional. Although nine women requested a hospital appointment none of the women attended the appointment arranged for them. The domain scores on both questionnaires were significantly less for symptomatic new mothers when compared to women with established symptoms of incontinence. The programme of screening successfully identified women with symptoms of incontinence. However, all of the symptomatic women declined a follow-up appointment at hospital which questions the benefits of routine screening 10 months after childbirth.

The fate of intramuscularly injected fat autografts: an experimental study.
Guerrerosantos J
Aesthetic Plast Surg 2005 Jan-Feb;29(1):62. Epub 2004 Dec 2.

Risk factors for obstetrical anal sphincter lacerations.
Dandolu V, Chatwani A, Harmanli O, Floro C, Gaughan JP, Hernandez E
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 5;.

The objective of this study was to identify the rate of anal sphincter lacerations in a large population-based database and analyze risk factors associated with this condition. Data were obtained from Pennsylvania Healthcare Cost Containment Council (PHC4) regarding all cases of obstetrical third and fourth degree perineal lacerations that occurred during a 2-year period from January 1990 to December 1991. Modifiable risk factors associated with this condition were analyzed, specifically episiotomy, forceps-assisted vaginal delivery, forceps with episiotomy, vacuum-assisted vaginal delivery, and vacuum with episiotomy. There were a total of 168,337 deliveries in 1990 and 165,051 deliveries in 1991 in Pennsylvania. Twenty-two percent (n=74,881) of the deliveries were by cesarean section and were excluded from analysis. Among the remaining 258,507 deliveries, there were 18,888 (7.3%) third and fourth degree lacerations. Instrumental vaginal delivery, particularly with use of episiotomy, increased the risk of laceration significantly [forceps odds ratio (OR): 3.84, forceps with episiotomy OR: 3.89, vacuum OR: 2.58, vacuum with episiotomy OR: 2.93]. Episiotomy on the whole was associated with a threefold increase in the risk of sphincter tears. However, episiotomy in the absence of instrumental delivery seems to be protective with an OR of 0.9 [95% confidence interval (CI): 0.88-0.93]. Instrumental vaginal delivery, particularly forceps delivery, appears to be an important risk factor for anal sphincter tears. The risk previously attributed to episiotomy is probably due to its association with instrumental vaginal delivery. Forceps delivery is associated with higher occurrence of anal sphincter injury compared to vacuum delivery.

Risk of recurrence of anal sphincter lacerations.
Dandolu V, Gaughan JP, Chatwani AJ, Harmanli O, Mabine B, Hernandez E
Obstet Gynecol 2005 Apr;105(4):831-5.

OBJECTIVE: To estimate the rate of recurrence of anal sphincter lacerations in subsequent pregnancies and analyze the risk factors associated with recurrent lacerations METHODS: Data were obtained from the Pennsylvania Health Care Cost Containment Council, Division of In-Patient Statistics, regarding all cases of third- and fourth-degree perineal lacerations that occurred during a 2-year period (from January 1990 through December 1991). All subsequent pregnancies in this group of women over the next 10 years were identified, and the rate of recurrence of sphincter tears and risk factors for recurrence were analyzed. RESULTS: The rate of anal sphincter lacerations was 7.31% (n = 18,888) during the first 2 years of study (1990-1991). In the next 10 years, these patients with prior lacerations were delivered of 16,152 pregnancies. Of these, 1,162 were by cesarean. Among the 14,990 subsequent vaginal deliveries, 864 (5.76%) had a recurrence of a third- or fourth-degree laceration. Women with prior fourth-degree lacerations had a much higher rate of recurrence than those with prior third-degree laceration (7.73% versus 4.69%). The rate for recurrent lacerations was significantly lower than the rate for initial lacerations (odds ratio 1.29, 95% confidence interval [CI] 1.2-1.4). Forceps delivery with episiotomy had the highest risk for recurrent laceration (17.7%, odds ratio 3.6, 95% CI 2.6-5.1), whereas vacuum use without episiotomy had the lowest risk (5.88%, odds ratio 1.0, 95% CI 0.6-1.7). CONCLUSION: Prior anal sphincter laceration does not appear to be a significant risk factor for recurrence of laceration. Operative vaginal delivery, particularly with episiotomy, increases the risk of recurrent laceration as it does for initial laceration. LEVEL OF EVIDENCE: III.

Anal Incontinence After Obstetric Sphincter Tears: Outcome of Anatomic Primary Repairs.
Norderval S, Oian P, Revhaug A, Vonen B
Dis Colon Rectum 2005 Mar 22;.

PURPOSE: Obstetric sphincter tears lead to anal incontinence in 40 to 60 percent of affected women. Primary repair is usually performed without identifying the internal anal sphincter. Since 1999 digestive surgeons have participated in the primary repair of such tears at our hospital. The intention was to perform separate repair of the internal and external anal sphincter in cases of combined tears to achieve a lower incontinence rate than is usually reported after conventional primary repair. The aim of the present study was to evaluate our results after anatomic primary repair. METHOD: A follow-up study was undertaken after all primary repairs performed in 1999 and 2000. It included anal ultrasonography manometry and an assessment of incontinence (Wexner score). RESULTS: A total of 74 women sustained obstetric sphincter tears during the study period, and 71 (96 percent) were assessed after a median of 27 months (range, 14-39 months). Nine women declined investigation with ultrasonography/manometry. Incontinence was present in 22 women (31 percent), of whom 17 had gas incontinence only. The symptoms were mild (Wexner score 1-2) in 11 women (50 percent). None of 17 women with normal ultrasonography results were incontinent versus 20 of 45 with pathologic ultrasonographic results (P = 0.001). The mean sphincter length, squeeze pressure, and resting pressure were significantly higher in women with Wexner scores of 0-2 vs. women with a score of more than 2. Sphincter length was inversely correlated with the degree of incontinence (P < 0.001). CONCLUSIONS: The incontinence rate after anatomic primary repair is low compared with the last decade's reported results after conventional primary repair. A short anal sphincter after repair is associated with a poorer outcome.

Effect of intravaginal electrical stimulation on pelvic floor muscle strength.
Amaro JL, Gameiro MD, Padovani CR
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 13;.

The aim of this study was to evaluate the effect of intravaginal electrical stimulation (IES) on pelvic floor muscle (PFM) strength in patients with mixed urinary incontinence (MUI). Between January 2001 and February 2002, 40 MUI women (mean age: 48 years) were studied. Urge incontinence was the predominant symptom; 92.5% also presented mild stress urinary incontinence (SUI). Selection criteria were clinical history and urodynamics. Pre-treatment urodynamic study showed no statistical differences between the groups. Ten percent of the women in each group had involuntary detrusor contractions. Patients were randomly distributed, in a double-blind study, into two groups. Group G1 (n=20), effective IES, and group G2 (n=20), sham IES, with follow-up at 1 month. The following parameters were studied: (1) clinical questionnaire, (2) examiner's evaluation of perineal muscle strength, (3) objective evaluation of perineal muscle by perineometry, (4) vaginal weight test, and (5) urodynamic study. The IES protocol consisted of three 20-min sessions per week over a 7-week period using a Dualpex Uro 996 at 4 Hz. There was no statistically significant difference in the demographic data of both groups. The number of micturitions per 24 h after treatment was reduced significantly in both groups. Urge incontinence, present in all patients before treatment, was reduced to 15% in G1 and 31.5% in G2 post-treatment. The subjective evaluation of PFM strength demonstrated a significant improvement in G1. Objective evaluation of PFM force by perineometer showed a significant improvement in maximum peak contraction post-treatment in both groups. In the vaginal weight test, there was a significant increase in average number of cone retentions post-treatment in both groups. With regard to satisfaction level, after treatment, 80% of the patients in G1 and 65% of the patients in G2 were satisfied. There was no statistically significant difference between the groups. There was a significant improvement in PFM strength from both effective and sham electrostimulation, questioning the effectiveness of electrostimulation as a monotherapy in treating MUI.

Recurrent risk of anal sphincter laceration among women with vaginal deliveries.
Spydslaug A, Trogstad LI, Skrondal A, Eskild A
Obstet Gynecol 2005 Feb;105(2):307-13.

OBJECTIVE: The first aim of this study was to estimate the impact of anal sphincter laceration during the first delivery on the risk of recurrence in the second delivery. The second aim was to estimate the absolute risk of anal sphincter laceration in the second delivery according to the history of anal sphincter laceration and birth weight. METHODS: In this population-based cohort study, the study sample comprised all women included in the Norwegian Medical Birth Registry with 2 consecutive singleton vaginal deliveries during the period 1967-1998 (n = 486,463). The impact of prior anal sphincter laceration on recurrent anal sphincter laceration was estimated as crude and adjusted odds ratios (ORs). RESULTS: Anal sphincter laceration during first delivery increased the risk for a sphincter laceration in the next delivery, (adjusted OR 4.3, 95% confidence interval [CI] 3.8-4.8). Other risk factors were birth weight (adjusted OR 23.6, 95% CI 16.5-33.6, birth weight > 5,000 g versus birth weight < 3,000 grams), use of forceps (adjusted OR 5.1, 95% CI 4.3-6.0), use of vacuum (adjusted OR 1.4, 95% CI 1.1-1.7), and period of delivery (adjusted OR 4.3, 95% CI 3.7-5.0 for 1995-1998 versus 1967-1975). The absolute risks for anal sphincter laceration at second delivery for women with prior laceration were 1.3% (95% CI 0.4-3.2%) for birth weight less than 3,000 g and 23.3% (95% CI 11.8-38.6%) for birth weight more than 5,000 g. CONCLUSION: Only 10% of women with anal sphincter laceration at second delivery had a history of prior laceration. Prior anal sphincter laceration is associated with increased risk of laceration in second delivery, in particular in women who carry children with high birth weight. LEVEL OF EVIDENCE: II-2.

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