Diagnosis of Anal Sphincter Tears by Postpartum Endosonography to Predict Fecal Incontinence
ABSTRACT & COMMENTARY
Synopsis: Sonography of the anal sphincter immediately following delivery can predict later fecal incontinence.
Source: Faltin DL, et al. Obstet Gynecol 2000;95:643-647.
Fecal incontinence following childbirth is not a rare condition. Postpartum sonography has shown that at least some of these cases are due to unrecognized tears of the sphincter at the time of delivery.
The purpose of this study was to determine whether sonography performed immediately postpartum in the delivery suite could detect rectal sphincter disruption that was undetected by the clinician.
Nulliparous women were recruited for this study. After delivery, eligible cases (vaginal delivery without clinical evidence of sphincter disruption) had sonography before perineal repair. The procedure was said to have been tolerated well by all participants. Three months following delivery, each woman received a mail questionnaire that was designed to determine whether fecal incontinence was a problem for the woman.
At the time of delivery, 42 women were found to have a disruption of part or all of the rectal sphincter that was undetected by the attending staff. On the questionnaire, 22 women reported some type of fecal incontinence. (For this study, flatus incontinence was considered to be a form of fecal incontinence.) This incontinence was associated with three independent variables: birth weight more than 3500 g; fecal incontinence during pregnancy; and occult sphincter tear detected by sonography. Questionnaires were returned from 41 of the 42 women with occult tears and 15 (37%) of them reported fecal incontinence. In this study, instrument delivery was not associated with fecal incontinence.
COMMENT BY KENNETH L. NOLLER, MD
Only within the last few years has there been great attention paid to asking women about fecal incontinence. While many practitioners were (are) at ease asking about urinary incontinence, many did not ask about flatus and stool loss. The large number of studies that are now being reported about this common problem have improved our knowledge, but we still need more research.
This article is interesting for several reasons. First, it is clear that we cannot always tell, clinically, if the sphincter has been disrupted. Can you imagine how hard the delivering physicians looked for tears in this study since they knew that sonography was going to be done as soon as they said there was no tear? In the past when rectal incontinence occurred when we had not seen a sphincter tear at delivery, we had no explanation for it. Now we know that at least in some cases we missed the defect.
Second, there must be other mechanisms for fecal incontinence besides sphincter tears. This article documented an intact sphincter in several women who later reported incontinence. Nerve damage may well be the cause.
There are also problems with this study. We are never told how the sample of 150 was chosen from the 486 eligible women. We are not told if multiple gestations were included. The follow-up was performed only three months after delivery when healing and nerve regeneration might not be complete. Despite these shortcomings, the article is well done and contains useful information. However, I certainly hope that no one suggests that rectal endosonography become routine post-delivery. Overall, few of the women in this study had fecal incontinence. It would be much more clinically useful (and more cost effective) to reserve such studies for those women who report problems at perhaps six months postpartum. Of course, we have to remember to ask about symptoms.
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