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Results of Endosonographic Imaging of the Anal Sphincter 2 to 7 Days After Primary Repair of Third- or Fourth-Degree Obstetric Sphincter Tears

Starck, M.; Bohe, M.; Valentin, L.

Obstetrical & Gynecological Survey: June 2004 - Volume 59 - Issue 6 - p 418-419

Anal sphincter tears complicating delivery have become more common in Sweden in recent years. Approximately 1 in 3 affected women develops anal incontinence, even when primary sphincter repair is done shortly after delivery. Endosonographic sphincter defects are found 3 months or more after delivery in a majority of women having primary suturing of a third- or fourth-degree sphincter tear. The investigators imaged 48 such women within 2 to 7 days after primary repair. Defects were scored from 0 (no defect) to 16 (a defect exceeding 180° involving the entire length and depth of the sphincter). Clinical assessment showed a partial third-degree tear in 34 of 48 women (71%), a total third-degree tear in 11, and a fourth-degree tear in 3. All but 5 women had sonographic defects, which were invariably hypoechoic. Just over half the defects were limited to the proximal part of the anal canal and involved less than half of its length. Nearly two thirds of defects were limited to the external sphincter. Five of 9 women with a defect score of 8 or higher (56%) had undergone repair by a doctor in training. The figure was 23% for women having a score less than 8. Although 86% of injuries repaired by doctors in training were clinically partial third-degree tears, this was the case for 65% of tears sutured by a specialist. A score of 8 or higher was registered in 5 women having a clinical partial third-degree tear and in 4 having a clinical total third- or fourth-degree tear. The rate of interobserver disagreement about the presence or extent of a defect was 13%. Multiple logistic regression analysis indicated that the level of training, but not the clinical degree of the tear, determines the endosonographic defect score. Specialists would appear to have an indispensable role both in clinically classifying obstetric tears of the anal sphincter and in repairing them.

Departments of Surgery and Obstetrics and Gynecology, Malmö University Hospital, Lund University, Malmö, Sweden

© 2004 Lippincott Williams & Wilkins, Inc.