Jan. 25, 2000 (Minneapolis) -- Most women have continuing or even new bowel problems after surgery to repair an anal sphincter that's damaged while giving birth, according to British researchers who published their findings recently in the journal The Lancet. Although the surgery typically corrects the problem initially, the problems gradually come back, so patients can have recurrent or new difficulties a few years later.
Anal sphincters are the muscles that coordinate bowel movements. They may be damaged during vaginal deliveries. As many as one in three women have some degree of anal-sphincter trauma during their first vaginal delivery. Women will present to their physician with soiling weeks or even months following delivery.
"[A]lthough most patients improve after the procedure, [bowel control] is rarely perfect," the authors write. Their study involved questionnaires and telephone interviews with patients who had had repair surgeries at least five years previously. The surgery in the study, called overlapping anterior anal-sphincter repair, is one way to correct the damage for severe symptoms.
"We're not opposed to [the] surgery," co-author Christine S. Norton, RN, MA, tells WebMD. "The right people [need to be selected.] Those with severe symptoms are more likely to be satisfied ... while those with mild symptoms are more likely to be disappointed." She is a nurse specialist at St. Mark's Hospital in Harrow, England; her focus is patients with bowel control problems.
In this 55-patient study, 38 patients were eligible for the analysis. Of these, none was fully able to control both stool and gas passage. Six of the 38 had complete relief from urgency, the inability to postpone a bowel movement. Twenty still required an incontinence pad and 25 said their bowel problems restricted their lifestyle in some way.
"[A] high proportion of women presenting with incontinence have structural sphincter damage," the authors write. Incontinence is the inability to prevent a bowel movement resulting in soiling. Incontinence pads are often used so daily activities can continue more easily.
Several factors can increase the risk of damage to the anal sphincter during birth. These include a forceps-assisted birth and a baby that weighs over 8 lbs., 14 oz. Another risk is a posterior presentation, in which the back of the baby's head presses against the mother's spine, also known as "sunny-side up." Episiotomy does not prevent the damage, the authors write.
"There is room for reasonable disagreement among physicians as to whether it is advisable to overlap muscle tissue, [as was done by these investigators]," Leslie A. Sharpe, MD, tells WebMD. "Another repair technique ... sews into the sphincter's surrounding tissue. ... These two techniques may differ in how well the repair holds up over time." Sharpe, a clinical associate professor of obstetrics and gynecology at the University of Minnesota in Minneapolis and an attending physician at Health Partners and Regions Hospital in St. Paul, Minn., was not involved in the study.
"Awareness of ... fecal incontinence after vaginal delivery is growing," Michael Moen, MD, tells WebMD in an independent interview. "However, this study has limitations. For example, there was no information for 14% of the patients. ... We don't know whether the patients' problems were related to the repair or to other bowel problems." Moen is a staff gynecologist at Lutheran General Hospital in Chicago.
Women with mild symptoms may want to try conservative measures first, Norton tells WebMD. These include reducing fiber and caffeine in the diet and Kegel exercises, which involve alternately squeezing and releasing the sphincter muscles to build their strength.
- Many women who undergo surgery to repair an anal sphincter damaged during childbirth may initially experience relief, but go on to have bowel problems later.
- Researchers suggest that only those with the most severe symptoms should opt for the surgery, while those with mild symptoms should consider conservative treatment.
- A forceps-assisted birth, large baby, and position of the baby during delivery can increase the risk of damage, and episiotomy does not help to prevent damage.