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Effect of pregnancy and childbirth on anal sphincter function and fecal incontinence

Authors
Christina Lewicky-Gaupp, MD
Dee E Fenner, MD
Section Editor
Linda Brubaker, MD, FACS, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG

INTRODUCTION

Fecal incontinence has a significant impact on quality of life [1-3]. Disorders of stool consistency and a wide variety of anorectal conditions can cause fecal incontinence. This topic will focus on the association between fecal incontinence and pregnancy, vaginal delivery, and anal sphincter laceration. The diagnosis and management of fecal incontinence and other effects of pregnancy and childbirth on the pelvic floor are reviewed elsewhere. (See "Fecal incontinence in adults: Etiology and evaluation" and "Urinary incontinence and pelvic organ prolapse associated with pregnancy and childbirth".)

TERMINOLOGY

International Urogynecological Association (IUGA) and International Continence Society (ICS) terminology includes [4]:  

Fecal incontinence is defined as the complaint of involuntary loss of feces

Anal incontinence is the complaint of involuntary loss of feces or flatus

Fecal incontinence will be the focus of this topic.

                                   

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Literature review current through: Nov 2016. | This topic last updated: Fri Sep 30 00:00:00 GMT+00:00 2016.
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References
Top
  1. Fialkow MF, Melville JL, Lentz GM, et al. The functional and psychosocial impact of fecal incontinence on women with urinary incontinence. Am J Obstet Gynecol 2003; 189:127.
  2. Handa VL, Zyczynski HM, Burgio KL, et al. The impact of fecal and urinary incontinence on quality of life 6 months after childbirth. Am J Obstet Gynecol 2007; 197:636.e1.
  3. Lo J, Osterweil P, Li H, et al. Quality of life in women with postpartum anal incontinence. Obstet Gynecol 2010; 115:809.
  4. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4.
  5. Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery. Am J Obstet Gynecol 2007; 196:344.e1.
  6. Jha S, Parker V. Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis. Int Urogynecol J 2016; 27:849.
  7. Rosen H, Barrett J, Okby R, et al. Risk factors for obstetric anal sphincter injuries in twin deliveries: a retrospective review. Int Urogynecol J 2016; 27:757.
  8. Chen C, Smith LJ, Pierce CB, et al. Do symptoms of pelvic floor disorders bias maternal recall of obstetrical events up to 10 years after delivery? Female Pelvic Med Reconstr Surg 2015; 21:129.
  9. Melville JL, Fan MY, Newton K, Fenner D. Fecal incontinence in US women: a population-based study. Am J Obstet Gynecol 2005; 193:2071.
  10. Donnelly V, Fynes M, Campbell D, et al. Obstetric events leading to anal sphincter damage. Obstet Gynecol 1998; 92:955.
  11. Guise JM, Morris C, Osterweil P, et al. Incidence of fecal incontinence after childbirth. Obstet Gynecol 2007; 109:281.
  12. Chaliha C, Kalia V, Stanton SL, et al. Antenatal prediction of postpartum urinary and fecal incontinence. Obstet Gynecol 1999; 94:689.
  13. Hall W, McCracken K, Osterweil P, Guise JM. Frequency and predictors for postpartum fecal incontinence. Am J Obstet Gynecol 2003; 188:1205.
  14. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311.
  15. Chaliha C, Sultan AH, Bland JM, et al. Anal function: effect of pregnancy and delivery. Am J Obstet Gynecol 2001; 185:427.
  16. Solans-Domènech M, Sánchez E, Espuña-Pons M, 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 2010; 115:618.
  17. King VG, Boyles SH, Worstell TR, et al. Using the Brink score to predict postpartum anal incontinence. Am J Obstet Gynecol 2010; 203:486.e1.
  18. Brincat C, Lewicky-Gaupp C, Patel D, et al. Fecal incontinence in pregnancy and post partum. Int J Gynaecol Obstet 2009; 106:236.
  19. Johannessen HH, Wibe A, Stordahl A, et al. Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study. BJOG 2014; 121:269.
  20. Stafne SN, Salvesen KÅ, Romundstad PR, et al. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG 2012; 119:1270.
  21. Gottvall K, Allebeck P, Ekéus C. Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007; 114:1266.
  22. Badiou W, Bousquet PJ, Prat-Pradal D, et al. Short vs long second stage of labour: is there a difference in terms of postpartum anal incontinence? Eur J Obstet Gynecol Reprod Biol 2010; 152:168.
  23. Borello-France D, Burgio KL, Richter HE, et al. Fecal and urinary incontinence in primiparous women. Obstet Gynecol 2006; 108:863.
  24. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000; 107:1460.
  25. Guise JM, Boyles SH, Osterweil P, et al. Does cesarean protect against fecal incontinence in primiparous women? Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:61.
  26. Pretlove SJ, Thompson PJ, Toozs-Hobson PM, et al. Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review. BJOG 2008; 115:421.
  27. Nelson RL, Furner SE, Westercamp M, Farquhar C. Cesarean delivery for the prevention of anal incontinence. Cochrane Database Syst Rev 2010; :CD006756.
  28. Handa VL, Blomquist JL, Knoepp LR, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol 2011; 118:777.
  29. MacArthur C, Glazener C, Lancashire R, et al. Exclusive caesarean section delivery and subsequent urinary and faecal incontinence: a 12-year longitudinal study. BJOG 2011; 118:1001.
  30. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994; 308:887.
  31. Hehir MP, O'Connor HD, Higgins S, 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 2013; 26:1514.
  32. Baumann P, Hammoud AO, McNeeley SG, et al. Factors associated with anal sphincter laceration in 40,923 primiparous women. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:985.
  33. Minaglia SM, Ozel B, Gatto NM, et al. Decreased rate of obstetrical anal sphincter laceration is associated with change in obstetric practice. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:1399.
  34. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001; 98:225.
  35. O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 2010; :CD005455.
  36. Hirsch E, Haney EI, Gordon TE, Silver RK. Reducing high-order perineal laceration during operative vaginal delivery. Am J Obstet Gynecol 2008; 198:668.e1.
  37. Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women. Am J Obstet Gynecol 2001; 185:444.
  38. Richter HE, Nager CW, Burgio KL, et al. Incidence and Predictors of Anal Incontinence After Obstetric Anal Sphincter Injury in Primiparous Women. Female Pelvic Med Reconstr Surg 2015; 21:182.
  39. Rockwood TH, Church JM, Fleshman JW, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum 1999; 42:1525.
  40. Andrews V, Shelmeridine S, Sultan AH, Thakar R. Anal and urinary incontinence 4 years after a vaginal delivery. Int Urogynecol J 2013; 24:55.
  41. Zetterström J, López A, Holmström B, et al. Obstetric sphincter tears and anal incontinence: an observational follow-up study. Acta Obstet Gynecol Scand 2003; 82:921.
  42. Sangalli MR, Floris L, Faltin D, Weil A. Anal incontinence in women with third or fourth degree perineal tears and subsequent vaginal deliveries. Aust N Z J Obstet Gynaecol 2000; 40:244.
  43. Zetterström J, López A, Anzén B, et al. Anal sphincter tears at vaginal delivery: risk factors and clinical outcome of primary repair. Obstet Gynecol 1999; 94:21.
  44. Pollack J, Nordenstam J, Brismar S, et al. Anal incontinence after vaginal delivery: a five-year prospective cohort study. Obstet Gynecol 2004; 104:1397.
  45. Nygaard IE, Rao SS, Dawson JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol 1997; 89:896.
  46. Abramowitz L, Sobhani I, Ganansia R, et al. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 2000; 43:590.
  47. Fenner DE, Genberg B, Brahma P, et al. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003; 189:1543.
  48. Aiken CE, Aiken AR, Prentice A. Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury. Birth 2015; 42:86.
  49. Meister MR, Cahill AG, Conner SN, et al. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol 2016; 215:310.e1.
  50. Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol 2004; 191:1199.
  51. Rathfisch G, Dikencik BK, Kizilkaya Beji N, et al. Effects of perineal trauma on postpartum sexual function. J Adv Nurs 2010; 66:2640.
  52. MacArthur C, Bick DE, Keighley MR. Faecal incontinence after childbirth. Br J Obstet Gynaecol 1997; 104:46.
  53. Richter HE, Fielding JR, Bradley CS, et al. Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears. Obstet Gynecol 2006; 108:1394.
  54. Barrett G, Pendry E, Peacock J, et al. Women's sexual health after childbirth. BJOG 2000; 107:186.
  55. Buhling KJ, Schmidt S, Robinson JN, et al. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet Gynecol Reprod Biol 2006; 124:42.
  56. Brown S, Lumley J. Physical health problems after childbirth and maternal depression at six to seven months postpartum. BJOG 2000; 107:1194.
  57. Stock L, Basham E, Gossett DR, Lewicky-Gaupp C. Factors associated with wound complications in women with obstetric anal sphincter injuries (OASIS). Am J Obstet Gynecol 2013; 208:327.e1.
  58. Fynes MM, Marshall K, Cassidy M, et al. A prospective, randomized study comparing the effect of augmented biofeedback with sensory biofeedback alone on fecal incontinence after obstetric trauma. Dis Colon Rectum 1999; 42:753.
  59. Mahony RT, Malone PA, Nalty J, et al. Randomized clinical trial of intra-anal electromyographic biofeedback physiotherapy with intra-anal electromyographic biofeedback augmented with electrical stimulation of the anal sphincter in the early treatment of postpartum fecal incontinence. Am J Obstet Gynecol 2004; 191:885.
  60. Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993; 329:1905.
  61. Varma A, Gunn J, Gardiner A, et al. Obstetric anal sphincter injury: prospective evaluation of incidence. Dis Colon Rectum 1999; 42:1537.
  62. Sultan AH, Kamm MA, Bartram CI, Hudson CN. Anal sphincter trauma during instrumental delivery. Int J Gynaecol Obstet 1993; 43:263.
  63. Frudinger A, Ballon M, Taylor SA, Halligan S. The natural history of clinically unrecognized anal sphincter tears over 10 years after first vaginal delivery. Obstet Gynecol 2008; 111:1058.
  64. Faltin DL, Boulvain M, Floris LA, Irion O. Diagnosis of anal sphincter tears to prevent fecal incontinence: a randomized controlled trial. Obstet Gynecol 2005; 106:6.
  65. Gåreberg B, Magnusson B, Sultan B, et al. Birth in standing position: a high frequency of third degree tears. Acta Obstet Gynecol Scand 1994; 73:630.
  66. Parnell C, Langhoff-Roos J, Møller H. Conduct of labor and rupture of the sphincter ani. Acta Obstet Gynecol Scand 2001; 80:256.
  67. Jandér C, Lyrenäs S. Third and fourth degree perineal tears. Predictor factors in a referral hospital. Acta Obstet Gynecol Scand 2001; 80:229.
  68. de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC. Risk factors for third degree perineal ruptures during delivery. BJOG 2001; 108:383.
  69. MacArthur C, Glazener CM, Wilson PD, et al. Obstetric practice and faecal incontinence three months after delivery. BJOG 2001; 108:678.
  70. Assimakopoulos E, Zafrakas M, Garmiris P, et al. Fetal abdominal subcutaneous tissue thickness measured by ultrasound at term is associated with birth weight and mode of delivery. Clin Exp Obstet Gynecol 2007; 34:171.
  71. Townsend MK, Matthews CA, Whitehead WE, Grodstein F. Risk factors for fecal incontinence in older women. Am J Gastroenterol 2013; 108:113.
  72. Chiarelli P, Murphy B, Cockburn J. Fecal incontinence after high-risk delivery. Obstet Gynecol 2003; 102:1299.
  73. Lewis C, Williams AM, Rogers RG. Postpartum anal sphincter lacerations in a population with minimal exposure to episiotomy and operative vaginal delivery. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:41.
  74. Burgio KL, Borello-France D, Richter HE, et al. Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastroenterol 2007; 102:1998.
  75. Rahmanou P, Caudwell-Hall J, Kamisan Atan I, Dietz HP. The association between maternal age at first delivery and risk of obstetric trauma. Am J Obstet Gynecol 2016; 215:451.e1.
  76. Faltin DL, Otero M, Petignat P, et al. Women's health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. Am J Obstet Gynecol 2006; 194:1255.
  77. Fritel X, Ringa V, Varnoux N, et al. Mode of delivery and fecal incontinence at midlife: a study of 2,640 women in the Gazel cohort. Obstet Gynecol 2007; 110:31.
  78. Baghestan E, Irgens LM, Børdahl PE, Rasmussen S. Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries. BJOG 2012; 119:62.
  79. Edozien LC, Gurol-Urganci I, Cromwell DA, et al. Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study. BJOG 2014; 121:1695.
  80. Payne TN, Carey JC, Rayburn WF. Prior third- or fourth-degree perineal tears and recurrence risks. Int J Gynaecol Obstet 1999; 64:55.
  81. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Risk factors of recurrent anal sphincter ruptures: a population-based cohort study. BJOG 2012; 119:1640.
  82. De Leeuw JW, Vierhout ME, Struijk PC, et al. Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstet Gynecol Scand 2001; 80:830.
  83. Bek KM, Laurberg S. Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear. Br J Obstet Gynaecol 1992; 99:724.
  84. Poen AC, Felt-Bersma RJ, Strijers RL, et al. Third-degree obstetric perineal tear: long-term clinical and functional results after primary repair. Br J Surg 1998; 85:1433.
  85. Fynes M, Donnelly V, Behan M, et al. Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study. Lancet 1999; 354:983.
  86. Sze EH. Anal incontinence among women with one versus two complete third-degree perineal lacerations. Int J Gynaecol Obstet 2005; 90:213.
  87. Farrar D, Tuffnell DJ, Ramage C. Interventions for women in subsequent pregnancies following obstetric anal sphincter injury to reduce the risk of recurrent injury and associated harms. Cochrane Database Syst Rev 2014; :CD010374.
  88. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol 2004; 191:917.
  89. Elfaghi I, Johansson-Ernste B, Rydhstroem H. Rupture of the sphincter ani: the recurrence rate in second delivery. BJOG 2004; 111:1361.
  90. McKenna DS, Ester JB, Fischer JR. Elective cesarean delivery for women with a previous anal sphincter rupture. Am J Obstet Gynecol 2003; 189:1251.
  91. Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 2006; :CD005123.
  92. Basu M, Smith D, Edwards R, STOMP project team. Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience. Eur J Obstet Gynecol Reprod Biol 2016; 202:55.
  93. Sultan AH, Thakar R. Third and fourth degree tears. In: Perineal and anal sphincter trauma, 1st ed, Sultan AH, Thakar R, Fenner DE (Eds), Springer-Verlag, London 2009. p.33.
  94. Bagade P, Mackenzie S. Outcomes from medium term follow-up of patients with third and fourth degree perineal tears. J Obstet Gynaecol 2010; 30:609.
  95. Samarasekera DN, Bekhit MT, Wright Y, et al. Long-term anal continence and quality of life following postpartum anal sphincter injury. Colorectal Dis 2008; 10:793.
  96. Bradley CS, Richter HE, Gutman RE, et al. Risk factors for sonographic internal anal sphincter gaps 6-12 months after delivery complicated by anal sphincter tear. Am J Obstet Gynecol 2007; 197:310.e1.