UroToday - ICS 2006 - ABST[004] OBSTETRIC ANAL SPHINCTER INJURY – A PROSPECTIVE STUDY AT TWO YEARS, FOLLOWING STANDARDISED MANAGEMENT IN A DEDICATED PERINEAL CLINIC AT A TERTIARY HOSPITAL.

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ICS 2006 - ABST[004] OBSTETRIC ANAL SPHINCTER INJURY – A PROSPECTIVE STUDY AT TWO YEARS, FOLLOWING STANDARDISED MANAGEMENT IN A DEDICATED PERINEAL CLINIC AT A TERTIARY HOSPITAL.

ICS 2006 - ABST[004] OBSTETRIC ANAL SPHINCTER INJURY – A PROSPECTIVE STUDY AT TWO YEARS, FOLLOWING STANDARDISED MANAGEMENT IN A DEDICATED PERINEAL CLINIC AT A TERTIARY HOSPITAL.

Sloane K¹, Higgs P¹, Goh J¹, Carey M¹, Tan J², Tjandra J²

1. Royal Women's Hospital, Melbourne, 2. Royal Melbourne Hospital

Hypothesis / aims of study Childbirth can be associated to a change in pelvic floor function (1). Follow up of women who sustain anal sphincter tears commonly reveals anal symptoms and a change in anal sphincter anatomy and physiology (2). Women who sustain anal sphincter injury may be at risk for other pelvic floor dysfunction. This study aims to investigate, at a median of two years, the prevalence of pelvic floor symptoms in women who sustained, and had standardised management, for third and fourth degree tears during a given two year period.

Study design, materials and methods 146 women sustained third or fourth degree tears during 2003 and 2004 (1.9% of vaginal deliveries). Care was coordinated by a Clinical Nurse Consultant, and involved a multidisciplinary team approach. The women were seen within three days after delivery as in-patients, then at three months in the Perineal Clinic (out-patient care). Care from the multidisciplinary team included Urogynaecological and Colorectal assessment, physiotherapy, dietary advice, wound management, and debriefing about the factors leading to the injury and subsequent measures to promote healing and optimise function. At three months the women were assessed for pelvic floor dysfunction. Endoanal ultrasound and manometry testing was offered to all women. The median time of follow up was 23 months (13-35). At the follow up women were interviewed by telephone for symptoms of pelvic floor dysfunction, including a Cleveland Clinic Incontinence Score. A rating of satisfaction with their care in the clinic was obtained (0-100). Statistical analysis was performed using Stata 9.

Results 146 women sustained third or fourth degree tears in the years 2003 and 2004. (1.9% of vaginal deliveries) Of these women 75 returned at three months for follow up which included endoanal ultrasound and manometry testing. In January 2006, 55 of these women were available for a telephone follow up survey. A Cleveland Clinic Incontinence Score was taken independently in December 2005 at which time 61 women were available for survey.

Table 1 Anal symptoms at 2 year follow up

	Never (%) N=55	Sometimes (n)	Frequently (n)
Constipation	39 (71)	15 (27)	1 (1)
Flatal incontinence	34 (62)	17 (31)	4 (7)
Faecal urgency	2 (53)	23 (42)	3 (5)
Soiling	43 78)	11 (20)	1 (2)

Table 2 Cleveland Clinic Incontinence Score at 2 Year Follow up

Cleveland Clinic Score	3 months (%) N= (75)	2 years (%) N=61
0 - 3	68 (91)	58 (95)
4 - 7	6 (8)	2 (3)
8 -14	0 (0)	1 (2)
15-20	1 (1)	0 (0)

Table 3 Bladder Symptoms at 2 year follow up

	Never (%) N= 55	Sometimes (%)	Frequently (%)
Frequency	40 (73)	9 (16)	6 (11)
Urgency	35 (64)	19 (34)	1 (2)
Urge incontinence	41 (75)	14 (25)
Stress incontinence	30 (55)	23 (42)	2 (4)

Table 4 Vaginal symptoms at 2 year follow up

	No (%) N=55	Yes(%)
Dyspareunia - deep	49 (89)	6 (10)
Dyspareunia- superficial	40 (72)	15 (27)
Associated sex avoidance	46 (83)	9 (16)
Perineal pain at other times	46 (83)	9 (16)

Patient satisfaction rating of their care in Perineal Clinic indicated 76 % of the scores above 80%. Some of the women revealed psychosexual issues relating to their delivery and perineal trauma, and had sought counselling.

Interpretation of results Comparison of the Cleveland Clinic Incontinence Score at 3 months to 2 years indicated a trend of improved anal continence. Two years after delivery, 10-20 % of women had significant urinary symptoms or dyspareunia.

Concluding message Women who sustain anal sphincter tears at delivery show improvement in anal symptoms with time and conservative management in the Perineal Clinic. Women may have associated pelvic floor dysfunction involving bladder control, bowel control, or dyspareunia. The Perineal Clinic offers an opportunity for appropriate assessment and treatment of these symptoms within a multidisciplinary arena. Care for these women should include strategies to detect and treat all types of pelvic floor dysfunction. The multidisciplinary approach could be enhanced by including psychosexual counselling. Women who attended the Perineal Clinic indicated a high level of satisfaction with their care.

References

BJOG 2000;107;1460-1470.
Best Pract Res Clinical Obstet Gynaecol 2001;15:63-79.

Declaration of Helsinki Informed consent was obtained from the patients.

FUNDING:	NONE
DISCLOSURES:	NONE
HUMAN SUBJECTS:	This study did not need ethical approval because Clinial audit but followed the

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Table 2 Cleveland Clinic Incontinence Score at 2 Year Follow up

Table 3 Bladder Symptoms at 2 year follow up

Table 4 Vaginal symptoms at 2 year follow up

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