Objective: To determine whether HIV-positive patients have a longer time to healing, more complications and worse functional outcomes after Obstetric Anal Sphincter Injury (OASI) than an HIV-negative control group. HIV-positive women also have lower sexual function scores than their HIV-negative counterparts. Interestingly, the study reported that only 1.9% of women in the Western Cape were HIV positive.
Obstetric Anal Sphincter Injury (OASI)
- Incidence of OASI and Risk Factors
- Classification of Perineal Injury
- Pathophysiology of incontinence after OASI
- Postpartum Repair Techniques and Outcomes
The external component of the anal sphincter consists of striated muscles under voluntary control supplied by the pudendal nerve (S2,3,4). The technique involved separate end-to-end repair of the IAS (if identified as disrupted), with an overlap repair of the EAS. However, this review did not recommend the overlap over the end-to-end repair, on the grounds that the experience of the surgeon was not addressed in the reviewed studies.
Healing
Infections and Wound Healing
This finding is in agreement with a study by Ramin et al (1992), who also found infection to be associated with 79% of episiotomy dehiscences. Norderval et al (2005) also found that wound infection complicated 7% of OASIs and that these women had significantly worse functional outcomes as a result. Williams and Chames (2006) reported no association between pre-existing medical conditions and repair of the defect or infection.
HIV and Wound Infections
Compartmentalized perineal tear repair was associated with significant morbidity and the need for additional medical care, including longer hospital stays, more outpatient visits, additional theater time, and increased anesthetic and antibiotic requirements. In Malawi, studies showed that wound sepsis was increased in HIV-positive patients with compound tibial fractures.
HIV and Wound Healing in the Absence of Infection
There are varying reports on the impact of CD4 count on anorectal wound healing, with some studies showing no association (Eriguchi et al, 1997; Hewitt et al, 1996; Safavi et al, 1991) and others showing a significant association between lower numbers. and delayed wound healing (Morandi et al, 1999; Nadal et al, 1998). Literature is available examining the relationship between HIV infection, CD4 counts, wound sepsis and healing outcomes in emergency and elective surgery, but no studies currently describe these relationships with OASI repair outcomes.
Functional outcomes after OASI
- Anal Incontinence
- Urinary Incontinence
- Sexual function
- Perineal pain
Maximum resting pressure has been shown to be significantly lower in women with faecal incontinence and OASI (Fornell et al, 2005; Gjessing et al, 1998; Sultan et al, 1994). Maximum squeeze pressure is lower in women with OASI, and has been shown to worsen over time. Other studies have confirmed the increased incidence of dyspareunia at three months in women with higher order perineal lesions (Andrews et al, 2007).
Materials and Methods
- Study Aims
- Study Objectives
- Study Setting
- Study Design
- Patient Recruitment
- Data Collection
- Sample Size and Statistical Analysis
- Ethical Considerations
- Budget
It was during this follow-up visit that the second part of the study took place. The study was published in all three hospitals and data were collected by the principal investigators. Patients who enrolled in the study were reimbursed for transportation costs at their follow-up appointments.
Results
- Demographics
- CD4 counts and Treatment of HIV-positive patients
- Distribution of OASI
- Management of OASI
- Pre-pregnancy Functional Assessment
- Anal Continence
- Perineal Pain
- Urinary Function and Symptoms
- Sexual Function
- Postpartum Healing and Functional Assessment
- Postpartum Clinical Examination
- Postpartum Anal Continence Assessment
- Postpartum Pain Assessment
- Postpartum Urinary Symptoms and Function
- Sexual Function postpartum
- Relationship of Antibiotic Usage to Clinical Examination Findings
- Relationship of Overall Wexner Score to Technique of Repair
- Relationship of CD4 count to clinical healing
- Relationship of Anti-retrovirals to clinical healing
There was a statistically significant difference in age and ethnicity between HIV-positive and HIV-negative women with OASI (Table 1), with HIV-positive women being older and of black ethnicity. There was no statistically significant difference in type of injury between HIV positive and HIV negative women (Figure 3). There was no significant difference between the repair technique used if the patient was HIV positive or negative.
The only two domains in which the HIV-positive women achieved higher AFSQ mean scores were in the desire to have intercourse (Domain 3), and the frequency of intercourse (Domain 5) (Table 6). The HIV-positive women had a higher overall Wexner score at this time point, but the difference was not statistically significant (p=0.21) (Table 8). The HIV-positive women also had a higher mean Wexner score for liquid stool incontinence (0.3 vs 0.2), pelvic incontinence (0.4 vs 0.1) and pad use for the purpose of faecal incontinence (0.9 vs 0.3), but these differences did not achieve either. significance (Table 8).
The relative risk for solid stool incontinence in HIV-positive compared with HIV-negative women was 7.0, which approached but did not reach statistical significance. Ten (27.8%) women said they felt urgency, but the difference in urgency between the HIV-positive and -negative women was not statistically significant (p=0.11) (Table 11). Only five women resumed sexual activity at the follow-up visit, three of whom were HIV positive and two HIV negative (Table 12).
The mean ASFQ score was higher (indicating better functioning) in the HIV-negative women than in the HIV-positive women for all. One HIV-positive woman was not completely cured, and this patient had a CD4 count of less than 200 (Table 15). One patient with a CD4 count greater than 500 was the only HIV-positive patient with a total Wexner score greater than 10 out of 20 (Table 15).
Discussion
Limitations
The study was predominantly a clinical trial, as limited resources made objective measurements such as endoanal ultrasound and manometry impossible. This could have caused measurement bias, although the design of the study attempted to minimize this. Patients who completed the questionnaire may have made mistakes in remembering their pre-pregnancy functional status.
The tools used may have been inadequately sensitive measures, although to prevent this we used proven tools somewhere described and used. Patients were spoken to privately and every effort was made to minimize any embarrassment they might feel in reporting their functional status, as the investigators were well aware of the sensitive nature of the functions under investigation. This could have contributed to the resulting differences in results, as the study was not designed to match or pair study participants.
However, the generalizability of the results remains to be confirmed as this study was not sufficiently powered and is the first and only study to investigate the issue of OASI in relation to HIV infection. The study is underpowered due to the inability to enroll sufficient patients during the enrollment period. Unfortunately, while loss through follow-up is documented elsewhere in the literature, this has added to the limitation in the interpretation of our results in an already small-numbered study.
Due to the lack of power, the results of the study remain speculative, and should be interpreted with caution.
Conclusion
Sexual function data for our population is valuable because it draws attention to a grossly neglected area of study for our patients. Although more attention is given to female sexual function in the international data, there is still little for women in developing countries, and none for HIV-positive women in developing countries. The HIV-negative women scored higher for all domains except desire and frequency of intercourse.
The increased frequency of sexual intercourse may have played a role in the cause of the HIV infection. Two arousal domains did reach significance between the groups, namely frequency of vaginal lubrication during intercourse and amount vaginal. These findings all point to the need for further research into the sexual functioning of HIV-positive women, with more in-depth quantitative analyzes to pinpoint the exact magnitude and origin of any dysfunctions.
This study is the first in its field, and despite the small number, it has already yielded significant, interesting and disturbing findings. We recommend further and ongoing investigation into the impact of HIV on OASI, as well as urinary and sexual.
Appendices
UNIVERSITY OF CAPE TOWN
Toestemmings Vorm Studie op
Gesondheid en Werking van die Anus na ‘n Skeur tydens Geboorte in MIV-positiewe en MIV-negatiewe pasiënte
Patient Information Sheet
Only the doctors involved in the study will have access to the information provided in the questionnaire. Once the study is complete, the results will be written up in a thesis, presented to other doctors, and possibly published in a medical journal. Patients who will not participate in the study will still be followed up at the Groote Schuur hospital to make sure they do not have any complications.
Participating in the study will not provide you with any additional medical treatment or information that is not available to all patients. However, patients in the study will be reimbursed for transport costs to participate in the follow-up interview. All that is expected of you in the study is your consent to us having access to confidential information from your medical records, answering a questionnaire at registration and completing another questionnaire and undergoing a vaginal and rectal examination in the 6-week follow-up. -up visit.
Involvement in the study only involves the data collected in hospital, and at the 6 week follow-up visit. Any extra hospital visits or follow-up will be as a normal patient and not as part of the study. Jy is uitgenooi on deel to neem aan die studie ondat jy ‘n anale skeuring gehad het tydens normale geboorte.
Studiedeelname sluit slegs inligting in wat by die hospitaal en tydens die opvolgbesoek van 6 weke verkry is.
A prospective case-controlled study
Questionnaire
Data obtained from folder and/or patient
- Over the last 4 weeks, how often have you had pleasurable thoughts and feelings about sexual activity?
- Thinking of your sexual life over the last 4 weeks, how often did you look forward to sexual activity?
- Over the last 4 weeks, in general, how much “warmth” did you feel in your vagina/genital area when you took part in sexual activity?
- Over the last 4 weeks, in general, how much “pulsating” (“tingling”) did you notice in your vagina/genital area when you took part in sexual activity?
- Over the last 4 weeks, in general, how much vaginal wetness/lubrication did you notice when you took part in sexual activity?
- Over the last 4 weeks, how often did you have an orgasm when you took part in sexual activity (may be with or without a partner)?
- Over the last 4 weeks, in general, how pleasurable were the orgasms that you had?
During the past 4 weeks, how often have you had pleasant thoughts and feelings about sexual activity? Thinking about your sex life during the past 4 weeks, how often did you look forward to sexual activity? During the past 4 weeks, how often have you had a feeling of "warmth" in yourself? vagina/genital area when you have participated in sexual activity.
In the past four weeks, how much “warmth” did you generally feel in your vaginal/genital area when you engaged in sexual activity? vagina/genital area when you engaged in sexual activity. During the past 4 weeks, how often have you had the feeling of 'pulsing'? tingling”) in your vagina/genital area when you engaged in sexual activity. In the past four weeks, how many “pulsations” (“tingling”) have you generally noticed in your vagina/genital area when you engaged in sexual activity?
During the past 4 weeks, in general, how much vaginal moisture/lubrication did you notice when you participated in sexual activity? I have not participated in sexual activity (-) No wet/lubricated (1) Slightly wet/lubricated (2) Moderately wet/lubricated (3) Very wet/lubricated (4) Very wet/lubricated (5) ). 13. During the last 4 weeks, how often did you have an orgasm when you participated in sexual activity (can be with or without a partner).
Moderately pleasurable (3) Very pleasurable (4) Extremely pleasurable (5) 15. How easy have you generally reached orgasm in the last 4 weeks.
Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in a United States obstetric ward. 33.Guidelines for good practice when conducting clinical trials in human participants in South Africa. Anorectal surgery in patients infected with human immunodeficiency virus: factors associated with delayed wound healing.
Anal sphincter function and integrity after primary repair of third-degree tear: uncontrolled prospective analysis. The prevalence of sexual dysfunction and potential risk factors that may impair sexual function in Malaysian women.
