Patient’s characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014–2016

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Patient ’ s characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014 – 2016

Suskhan Djusad, Raissa Liem*

DepartmentofObstetricsandGynecology,dr.CiptoMangunkusumoNationalGeneralHospital,FacultyofMedicine,UniversityofIndonesia,Jakarta, Indonesia

ARTICLE INFO Articlehistory:

Received19June2019

Receivedinrevisedform9June2020 Accepted11June2020

Availableonline18June2020 Keywords:

OASIS OASI

Fecalincontinence Analsphincterultrasound

ABSTRACT

Introduction:ObstetricAnalSphincterInjuries(OASIS)isacommoncomplicationofvaginaldelivery.The incidence was4.53%oftotalvaginaldeliveries.OASIS isassociatedwithanincreased riskoffecal incontinence(FI),whichaffectsone’squalityoflife.TheincidenceofOASISandFIvariedfromstudyto study.Inthisstudy,wedescribedthecharacteristicsofpatientswithOASISatthreeIndonesiantertiary hospitalsin2014 2016andFIoutcomeamongthosepatients.

Methodology:ThisisadescriptivestudyonthecharacteristicsofOASISpatientsafterprimaryrepairin three tertiaryhospitals:dr. CiptoMangunkusumoNationalGeneral Hospital,Persahabatan General HospitalandFatmawatiGeneralHospitalfrom2014to2016.Fromatotalof234patients,only58patients couldbecontactedandinterviewedusingRevisedFecalIncontinenceScore(RFIS)questionnaires.Outof the58patients,only16patientscamefortransperinealultrasound.DatawereanalyzedusingStatistical PackagefortheSocialSciences(SPSS)version20.

Results:Fromatotalof234patients,themeanagewas26.6yearsoldwithameanBodyMassIndex(BMI) of24.8kg/m².Mostofthepatientswerenulliparous(67.5%)andthemediandurationofsecondstageof laborwas45min.Episiotomywasnotperformedonmostpatients(59.4%)andmostofthemunderwent spontaneousvaginaldelivery(65.4%)withmeanbaby’sbirthweightof3217g.From58interviewed patients,threepatientscomplainedofFI(5.2%).Sixteenpatientscamefortransperinealultrasound examination, andonlyoneofthem hadFI.Anal sphincterdefectswereidentifiedinfivepatients, comprisingthreeexternalanalsphincter(EAS)andtwointernalanalsphincter(IAS)defects.Allfive patientsdidnotexperienceFI.OnepatientwhohadFIhadnoanalsphincterdefect.

Discussion:ThisisapilotstudyfortheincidenceofFIamongtheOASISpopulationinJakarta,Indonesia.

TheincidenceofFIobservedinthisstudywasrelativelylow(3outof58patients)comparedtoother studies.Thiscouldbeduetodifferencesinstudypopulation.ThefactthatthepatientwithFIhadintact analsphinctersuggeststhatotherfactorsmaycontributetothedevelopmentofFIinadditiontothe integrityoftheanalsphincter.Thesefactorsmayincludepelvicﬂoormuscleandinnervationofthe surroundingtissues.

Conclusion:TheoutcomesofprimaryrepairofOASISvariedbetweenstudies.Patients’characteristics mightplayanimportantroleinthedevelopmentofOASISaswellastheoutcomeafterrepair.Further studieswithlargersamplesizeareneeded.

Introduction

Obstetric Anal Sphincter Injuries (OASIS) is a common complication of vaginal delivery, which could be diagnosed directlyafterdelivery(overt)orlaterusingultrasoundoftheanal

sphincter(covert).TheincidenceofOASISvariedbetweenstudies.

In2012,theincidencewas4.53%oftotalvaginaldeliveriesindr.

CiptoMangunkusumoNationalCentralHospital,Jakarta.Thereare severalfactorsthatcontributetothedevelopmentofOASIS,such as primiparity, baby’s birthweight, use of instruments during delivery(vacuumandforceps),prolonged secondstageoflabor, episiotomy,etc[1].

OASISisaknownmajorriskfactorforfecalincontinence(FI).

However,noteverycaseofOASISwillresultinFI,especiallyafter

* Correspondingauthor.

E-mailaddress:[email protected](R.Liem).

http://dx.doi.org/10.1016/j.eurox.2020.100112

ContentslistsavailableatScienceDirect

European Journal of Obstetrics & Gynecology and Reproductive Biology: X

j o u r n al h o m e p a g e : w w w . el s e v i e r . c o m / l o c a t e / e u r o x

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primaryrepairofOASIS.FIaffectsthequalityoflifeandmayoccur in3.7%–74%ofthepopulation,dependingonthecharacteristicsof saidpopulation[2,3].Questionnairescanbeusedasatooltoassess FI,e.g.theRevisedFecalIncontinenceScore(RFIS),whichactsasa scoringsystemtomeasuretheseverityofFI[4].

Primary repairof OASIScarries a riskof failure, anddefects couldbeidentiﬁed atthe external anal sphincter(EAS) and/or internalanal sphincter (IAS).These defects can bedetected by usingtransperinealultrasound[5].Thisstudyaimstodescribethe characteristicsofpatientswithOASISandtheFIoutcomeatthree tertiaryhospitalsinIndonesia(Figs.1–4).

Materialsandmethods

ThisisadescriptivestudyobservingtheincidenceofOASISand FIoutcomesamongpatientsafterprimaryrepairofOASISusing RFIS.Interviewedpatientsweredividedinto4categoriesbasedon theirRFISscore:withoutorverymildFI(score0–3),mildFI(score 4–8),moderateFI(score9–12),andsevereorverysevereFI(score

>13).

The study population was all patients undergoing vaginal deliveryandhadanOASISin2014 2016atdr.CiptoMangunku- sumoNationalGeneral Hospital,Persahabatan GeneralHospital andFatmawatiGeneralHospital,alllocatedinJakarta,Indonesia.

Patients who underwent vaginal delivery outside of those hospitals,andthenreferredtothosehospitalstoundergoprimary repairinlessthan6hafterdeliverywerealsoincludedinthestudy.

Patientswithahistoryofpelvictrauma,hemorrhoid,stroke, diabetes mellitus, chronic diarrhea or constipation, FI prior to pregnancy/deliveryand hadanotherpregnancyafter theoccur- renceofOASISwereexcludedfromthestudy.

ThisstudywasconductedfromAugust2017toFebruary2018.

Initialdatawerecollectedfromthemedicalrecordofpatientswith OASISin2014 2016.Therewereatotalof234patients,54patients from dr. Cipto Mangunkusumo National General Hospital, 73 patientsfromFatmawatiGeneralHospital,and107patientsfrom PersahabatanGeneralHospital.Thepatientswerecontactedand interviewedregardingtheFIcomplaintsusingRFIS.Ofallpatients, only21patientsfromdr.CiptoMangunkusumoNationalGeneral Hospital,10 patientsfrom Fatmawati GeneralHospital, and 27 patientsfromPersahabatanGeneralHospitalcouldbecontacted andinterviewed.Among58patients,only16patientscouldcome tothehospitalandunderwenttransperinealultrasoundforanal sphincterevaluation.Datacomprisingage,BodyMassIndex(BMI), paritystatus,deliverymethod,degreeofperinealrupture,baby’s birthweight, and episiotomy were collected through medical records.

Transperineal ultrasound examination was conducted by a urogynecologistconsultantwhowasblindedtothedeliverydata, including degree of perineal rupture. The examination was conductedusingGEVolusonE8ExpertBT09(GEMedicalSystem, Zipf, Austria) with 4.0–9.0 MHz convex volume probe RIC5-9-D whichwascoveredwithcondomsandultrasoundgel.Theprobe was placed at perineum in transverse position to achieve transversal 2Dpictureof theanal sphincter,at restand during Fig.2. AnalsphincterultrasoundofpatientB,28yearsoldwithhistoryofgradeIIIA

perineal rupture. The patient currently had no FI complaints. Ultrasound examinationrevealedintactEASandIAS.

Fig.1.AnalsphincterultrasoundofpatientA,26yearsoldwithahistoryofgrade IIIB perinealrupture. Thepatient came with mildFI symptoms and had no complaintsofotherpelvicﬂoorproblems.BothEASandIASwereintact.

Fig.3. AnalsphincterultrasoundofpatientC,23yearsoldwithhistoryofgradeIV perineal rupture. The patient currently had no complaint of FI. Ultrasound examinationrevealedIASdefectat12o’clockwithintactEAS.

Fig.4.AnalsphincterultrasoundofpatientD,27yearsoldwithhistoryofgradeIIIC perineal rupture. The patient currently had no complaint of FI. Ultrasound examinationrevealedEASdefectat11o’clock,withintactIAS.

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contraction.Three-dimensionalpicturesweresubsequentlytaken withtheanalsphincterastheareaofinterest,resultinginmid- sagittal and transversal picture, thus allowing the operator to clearly identify the EAS and IAS as well as the fascial plane.

Afterwards,theultrasoundmodewasmodiﬁedintotomographic ultrasoundimaging(TUI)withsliceintervalrangedfrom1.0to2.5 mm.

Dataanalysis

DataanalysiswasperformedusingStatisticalPackageforthe SocialSciences (SPSS)version20 (IBMCorp.,Armonk, NY).The incidence of FI among patients with OASIS was presented in number and percentage while the demographic data were presented in mean (interquartilerange) or median (minimum- maximumnumber).

Ethics

The study was approved by the Health Research Ethics Committee of Faculty of Medicine Universitas Indonesia with ethicalclearancenumber928/UN2.F1/ETIK/2017.Ethicalclearance wasgrantedonOctober9th,2017.

Results

Inthis study, datawerecollectedfromall patientssuffering fromobstetricanalsphincterrupture(perinealrupturegradeIII- IV)who underwent vaginal delivery in 2014 2016.Fromthree hospitalsin Jakarta,therewere84 cases(2.4 %of totalvaginal deliveries)ofOASISin2014,69(2.6%)casesin2015,and81(4.1%) casesin2016.Thecharacteristicsofthosepatientsarepresentedin Table1.

Fecalincontinence(FI)

Fromatotalof234OASISpatients,only58patientscouldbe contacted and interviewed using the RFIS. From those 58 patients, three patients complained of FI (5.2 %): one patient withhistoryofgradeIIIBperinealrupturehadamildFI(score4), one patient with history of grade IV perineal rupture had a moderateFI(score10),andonepatientwithhistoryofgradeIIIC perinealrupturehadsevereFI(score13).The RFISscoreof the remainingpatientswas0.

Transperinealultrasoundofexternalandinternalanalsphincter

Aftertheinterview,patientswereaskedtoundergoultrasound examinations,andonly16patientscamefortheexamination.Of the16patients,threepatientshadEASdefect,andtwopatientshad IASdefect.Fromthreepatientswhocomplainedof FI,onlyone patientcameforultrasoundexaminationandwasrevealedtohave normal EAS and IAS. The results of anal sphincter ultrasound examinationwerepresentedinTable2.

Belowweresomeultrasoundpicturesofpatientsafterprimary repairofOASIS.

Discussion

ThisisadescriptivestudyonOASISpatientsfrom2014to2016.

Subjectswererecruitedfromthree tertiaryhospitalsinJakarta, Indonesia,whichweredr.CiptoMangunkusumoNationalGeneral Hospital,FatmawatiGeneralHospital,andPersahabatanGeneral Hospital.Allhospitalsareteachinghospitals.Thecharacteristics described in the study include patient’s age, BMI, and baby’s birthweight.Themeanageofpatientsinthisstudywas26.6years old.Waldenstrom,etal.foundthatdeliveryinwomenagedover25 yearsincreasestheriskofOASIS,whichisoneof themain risk factors for FI [6,7]. Jhaet al. alsofound that increasing age is correlatedwithanincreasedriskofOASIS,withageover40years old being the cut-off point [8]. This can be explained by the stiffeningoftheperineumalongwithagingwhichincreasesthe riskforperinealtear[9].

In this study, the mean BMI was 24.8kg/m². Although the relationship between obesity and OASIS remains controversial, obesity couldbe linked to an increment of baby’s birthweight (macrosomia),thusincreasingtheriskofOASIS.Ontheotherhand, Kapaya,etal.foundthatBMIover30kg/m²decreasestheriskof OASISbymorethan50%(OddsRatio[OR]0.4;95%Conﬁdence Interval[CI]0.2–0.5)[10].ThiswassupportedbyLindhom,etal.,

Table1

CharacteristicsofpatientswithOASISpatientsin2014-2016.

PatientswithOASIS2014 2016 Total(n=234) GradeIIIA

(76)

GradeIIIB (67)

GradeIIIC (25)

GradeIV (66)

Age(MeanSD) 26.66.8 26.36.1 26.58.2 25.26.7 27.76.1

BMI(MeanSD) 24.82.5 24.92.6 25.22.5 24.92.6 24.52.4

Parity

Primiparity 158(67.5%) 56(73.7%) 48(71.6%) 20(80%) 31(47%)

Multiparity 76(32.5%) 20(26.3%) 19(28.4%) 5(20%) 35(53%)

Secondstageoflaborduration(minutes)(MedianIQR) 45.1440.7 3039 4045 3040 3055

Episiotomy

Yes 95(40.6%) 34(44.7%) 27(40.3%) 12(48%) 22(33.3%)

No 139(59.4%) 42(55.3%) 40(59.7%) 13(52%) 44(66.7%)

Birthweight(MeanSD) 3217.08449 3177454 3123405 3282445 3332468

DeliveryMethods

Spontaneous 153(65.4%) 44(57.9%) 36(53.7%) 17(68%) 56(84.8%)

Vacuum 49(20.9%) 21(27.6%) 19(28.4%) 5(20%) 4(6.1%)

Forceps 32(13.7%) 11(14.5%) 12(17.9%) 3(12%) 6(9.1%)

Table2

TransperinealUltrasoundResultsof16OASISPatientsafterPostPrimaryRepair.

AnalSphincter NoIncontinenece n(%)

FecalIncontinence n(%)

EASDefect 3(20%) 0

EASIntact 12(80%) 1(100%)

IASDefect 2(13,3%) 0(0%)

IASIntact 13(86,7%) 1(100%)

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whoreportedthatincreasedfattissueinobesepeopleincreases tissueelasticity, leadingtoreduction ofthe riskof tear[10,11].

Another study reported that obese people have higher skin resistancetowardstension[12],whichcouldbeprotectivetowards OASIS.

Anothercharacteristicdescribedinthisstudyisparitystatus.

Mostpatients(67.5%)inthisstudywerenulliparous.Thisﬁndingis in accordance with a previous study conducted in dr. Cipto Mangunkusumo National General Hospital in 2012, in which nulliparitywasfoundtobeoneoftheriskfactorsforOASIS.Thisis likelyduetothedifferenceinelasticityamongnulliparouspatients [1].

Themediandurationofthesecondstageoflaborinthisstudy was45minwithinterquartilerangeof40min.AstudybySimic, etal.foundthattheriskofOASISincreasesifthedurationofthe secondstageoflaborwasprolongedbymorethanonehour(OR 1.25;95%CI1.13–1.38)[13].Episiotomy,oneoftheriskfactorsfor OASIS,wasidentiﬁedin40.6%ofthis studysubjects.Jha,etal.

foundthatmediolateralepisiotomydecreasestheriskofOASIS[8]

althoughthisﬁndingremainscontroversialamongstudies.Thisis likelyduetothedifferencesinthemethodsofepisiotomyandthe unstandardizedlengthofepisiotomyincision[9].

Highbaby’sbirthweight(macrosomia)isalsooneoftherisk factorsforOASIS.Kapaya,etal.foundthatabirthweightofmore than4000gincreasestheriskofOASIS(OR2.6;95%CI2.0–3.3) [10].Moreover,useofinstrumentsduringdelivery(vacuumand forceps) also increases the risk of OASIS. In this study, the majorityofpatientsdeliveredtheirbabiesspontaneously(65.4%).

Jha,etal.foundthatforcepsextractionincreasestheriskofOASIS byupto3times(OR3.12;95%CI2.42–4.01)[8].Prageretal.also foundthatvacuumextractionincreasestheriskofOASISbymore than 2 times (OR 2.3; 95 %CI 1.38–3.81) [14]. This could be explained by the greater pressure and traction from the instrumentaldeliverycomparedtospontaneousones,therefore causingdisruptioninthemusclesandnervesattheperinealarea [15].

ThediagnosisofFIinthisstudywasestablishedbyRFISandwe found3outof58patients(5.2%)withFIafterprimaryrepairof OASIS(twopatientswithFIonlyandonepatientwithﬂatulence andmoderateFI).TheincidenceofFIfollowingprimaryrepairof OASISvariedfromstudytostudywith74%beingthehighest[3].

Thismightbecausedbyseveralfactors,includingdifferencesinthe study methods. Linneberg, et al. sent a questionnaire to their subjectsviapost,increasingthelikelihoodofresponse,whichin turnincreasedthepercentageofFIoutcomeafterprimaryrepairof OASIS [16]. Other studies also included patients that became pregnantaftertheoccurrenceofOASIS,whichfurtherincreasesthe riskofrecurrentOASISandFI[3,16,17].

In this study, the patients were asked to undergo an ultrasound examination for anal sphincter. However, only 16 patientscame,including1outofthe3patientswhocomplained ofFI.Mostofthepatientswereunreachableandsomehadmoved out of Jakarta or were living in areas far from dr. Cipto MangunkusumoNationalGeneralHospitalwheretheultrasound examinationwasconducted.From16patients,therewereﬁve(31

%)patientswhohadanalsphincterdefects,threepatientswith EAS defect and two patients with IAS defect. Visscher, et al.

performed anal sphincter ultrasound after primary repair of OASISandfoundthat40%ofthepatientshaddefectsontheiranal sphincter(EAS/IASonlyorboth)[18].AstudybyKirss,etal.also found 31 % failurerates in the primary repair of OASIS. They reportedthatfactors,suchastheleadsurgeon(p<0.001),repair performedduringon-callhours(p=0.039),aswellasthetypeof analgesicsadministered(p=0.003)might becorrelated tothe failures.Administrationofantibioticsandlaxativeswasassociat- edwithtreatmentsuccess(p<0.001)[19].

Thisstudyfoundthatallfivepatientswithsphincterdefects hadnoFIorotherpelvicfloorproblems.Therewasonepatient withFI that came toultrasound examinationbut we foundno sphincterdefect. This findingis in accordance witha study by Guzman,etal.whichreportedthatonly18%ofpatientswithEAS defectand29%ofpatientswithIASdefectsufferedfromFI[20].In addition,Murad-Regadas,etal.alsofoundthatnotallFIpatients had anal sphincter defect at follow-up. They investigated the defects on pubovisceral and anal sphincter muscles from 84 patientswithFIandfoundthat21(25%)patientshadnodefectson both muscles [21]. This finding could be explained with the pathophysiologyofFI,whichwasinfluencednotonlybyEASorIAS but also by other structures such as anal cushion, levator ani muscles,aswellasnervoussysteminperinealoranalregion[22].

ThisstudyprovidedthebasicinformationfortheincidenceofFI afterprimaryrepairofOASISatthreetertiaryhospitalsinJakarta, Indonesia.Furthermore,sincethestudywasconductedinteaching hospitals,thediagnosticmethodsandrepairtechniquesforOASIS were standardized. Those who conducted the examination (diagnosis)andrepairhadundergonetrainingandtests.However, thisstudyhadseverallimitations,includinghighlosttofollow-up numbersincealmostallpatientswerereferredanddidnotreside nearthestudy site;thepossibility ofrecall bias sincethis is a retrospectivestudy;andthequestionnairesweregivenatthesame timeforallpatientsthathadOASISin2014 2016.Inaddition,this studyonlyhadsmallsamplesizeforFIandOASISrepairfailuresoit mightnotberepresentativeforthegeneralpopulationinJakarta.

Conclusion

TheincidenceofOASISvariesfromcentertocenteranditmight beinﬂuencedbypatients’characteristics,e.g.age,paritystatus, baby’sbirthweight,deliverymethod,anddurationofthesecond stageoflabor.FI outcomemayalsovary, dependingontherisk factorsexistinginthepopulation.ThecomplaintofFIitselfisnot alwaysaccompaniedbyanalsphincterdefects.Thisstudyfound thattheincidenceofFIafterprimaryrepairofOASISwas5.2%;

however,itmightnotrepresentthegeneralpopulationinJakarta duetohighlosstofollowup.Therefore,itisnecessarytoconduct furtherstudieswithlargersamplesize.

DeclarationofCompetingInterest

The authors declare that they have no known competing ﬁnancial interest or personal relationships that could have appearedtoinﬂuencetheworkreportedinthispaper.

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