Obstetric trauma, pelvic floor injury and fecal incontinence

A population-based case-control study

Adil Eddie Bharucha, Joel Garland Fletcher, L. Joseph Melton, Alan R. Zinsmeister

Research output: Contribution to journalArticle

54 Citations (Scopus)

Abstract

OBJECTIVES: Current concepts based on referral center data suggest that pelvic floor injury from obstetric trauma is a major risk factor for fecal incontinence (FI) in women. In contrast, a majority of community women only develop FI decades after vaginal delivery, and obstetric events are not independent risk factors for FI. However, obstetric events are imperfect surrogates for anal and pelvic floor injury, which is often clinically occult. Hence, the objectives of this study were to evaluate the relationship between prior obstetric events, pelvic floor injury, and FI among community women. METHODS: In this nested case-control study of 68 women with FI (cases; mean age 57 years) and 68 age-matched controls from a population-based cohort in Olmsted County, MN, pelvic floor anatomy and motion during voluntary contraction and defecation were assessed by magnetic resonance imaging. Obstetric events and bowel habits were recorded. RESULTS: By multivariable analysis, internal sphincter injury (cases - 28%, controls - 6%; odds ratio (OR): 8.8; 95% confidence interval (CI): 2.3-34) and reduced perineal descent during defecation (cases - 2.6±0.2 cm, controls - 3.1±0.2 cm; OR: 1.7; 95% CI: 1.2-2.4) increased FI risk, but external sphincter injury (cases - 25%, controls - 4%; P<0.005) was not independently predictive. Puborectalis injury was associated (P<0.05) with impaired anorectal motion during squeeze, but was not independently associated with FI. Grades 3-4 episiotomy (OR: 3.9; 95% CI: 1.4-11) but not other obstetric events increased the risk for pelvic floor injury. Heavy smoking (≥ 20 pack-years) was associated (P=0.052) with external sphincter atrophy. CONCLUSIONS: State-of-the-art imaging techniques reveal pelvic floor injury or abnormal anorectal motion in a minority of community women with FI. Internal sphincter injury and reduced perineal descent during defecation are independent risk factors for FI. In addition to grades 3-4 episiotomy, smoking may be a potentially preventable, risk factor for pelvic floor injury.

Original languageEnglish (US)
Pages (from-to)902-911
Number of pages10
JournalAmerican Journal of Gastroenterology
Volume107
Issue number6
DOIs
StatePublished - Jun 2012

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Fecal Incontinence
Pelvic Floor
Obstetrics
Case-Control Studies
Wounds and Injuries
Population
Defecation
Episiotomy
Odds Ratio
Confidence Intervals
Obstetric Delivery
Smoking
Habits
Atrophy
Anatomy
Referral and Consultation
Magnetic Resonance Imaging

ASJC Scopus subject areas

  • Gastroenterology

Cite this

Obstetric trauma, pelvic floor injury and fecal incontinence : A population-based case-control study. / Bharucha, Adil Eddie; Fletcher, Joel Garland; Melton, L. Joseph; Zinsmeister, Alan R.

In: American Journal of Gastroenterology, Vol. 107, No. 6, 06.2012, p. 902-911.

Research output: Contribution to journalArticle

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abstract = "OBJECTIVES: Current concepts based on referral center data suggest that pelvic floor injury from obstetric trauma is a major risk factor for fecal incontinence (FI) in women. In contrast, a majority of community women only develop FI decades after vaginal delivery, and obstetric events are not independent risk factors for FI. However, obstetric events are imperfect surrogates for anal and pelvic floor injury, which is often clinically occult. Hence, the objectives of this study were to evaluate the relationship between prior obstetric events, pelvic floor injury, and FI among community women. METHODS: In this nested case-control study of 68 women with FI (cases; mean age 57 years) and 68 age-matched controls from a population-based cohort in Olmsted County, MN, pelvic floor anatomy and motion during voluntary contraction and defecation were assessed by magnetic resonance imaging. Obstetric events and bowel habits were recorded. RESULTS: By multivariable analysis, internal sphincter injury (cases - 28{\%}, controls - 6{\%}; odds ratio (OR): 8.8; 95{\%} confidence interval (CI): 2.3-34) and reduced perineal descent during defecation (cases - 2.6±0.2 cm, controls - 3.1±0.2 cm; OR: 1.7; 95{\%} CI: 1.2-2.4) increased FI risk, but external sphincter injury (cases - 25{\%}, controls - 4{\%}; P<0.005) was not independently predictive. Puborectalis injury was associated (P<0.05) with impaired anorectal motion during squeeze, but was not independently associated with FI. Grades 3-4 episiotomy (OR: 3.9; 95{\%} CI: 1.4-11) but not other obstetric events increased the risk for pelvic floor injury. Heavy smoking (≥ 20 pack-years) was associated (P=0.052) with external sphincter atrophy. CONCLUSIONS: State-of-the-art imaging techniques reveal pelvic floor injury or abnormal anorectal motion in a minority of community women with FI. Internal sphincter injury and reduced perineal descent during defecation are independent risk factors for FI. In addition to grades 3-4 episiotomy, smoking may be a potentially preventable, risk factor for pelvic floor injury.",
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AU - Zinsmeister, Alan R.

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N2 - OBJECTIVES: Current concepts based on referral center data suggest that pelvic floor injury from obstetric trauma is a major risk factor for fecal incontinence (FI) in women. In contrast, a majority of community women only develop FI decades after vaginal delivery, and obstetric events are not independent risk factors for FI. However, obstetric events are imperfect surrogates for anal and pelvic floor injury, which is often clinically occult. Hence, the objectives of this study were to evaluate the relationship between prior obstetric events, pelvic floor injury, and FI among community women. METHODS: In this nested case-control study of 68 women with FI (cases; mean age 57 years) and 68 age-matched controls from a population-based cohort in Olmsted County, MN, pelvic floor anatomy and motion during voluntary contraction and defecation were assessed by magnetic resonance imaging. Obstetric events and bowel habits were recorded. RESULTS: By multivariable analysis, internal sphincter injury (cases - 28%, controls - 6%; odds ratio (OR): 8.8; 95% confidence interval (CI): 2.3-34) and reduced perineal descent during defecation (cases - 2.6±0.2 cm, controls - 3.1±0.2 cm; OR: 1.7; 95% CI: 1.2-2.4) increased FI risk, but external sphincter injury (cases - 25%, controls - 4%; P<0.005) was not independently predictive. Puborectalis injury was associated (P<0.05) with impaired anorectal motion during squeeze, but was not independently associated with FI. Grades 3-4 episiotomy (OR: 3.9; 95% CI: 1.4-11) but not other obstetric events increased the risk for pelvic floor injury. Heavy smoking (≥ 20 pack-years) was associated (P=0.052) with external sphincter atrophy. CONCLUSIONS: State-of-the-art imaging techniques reveal pelvic floor injury or abnormal anorectal motion in a minority of community women with FI. Internal sphincter injury and reduced perineal descent during defecation are independent risk factors for FI. In addition to grades 3-4 episiotomy, smoking may be a potentially preventable, risk factor for pelvic floor injury.

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