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Anal Sphincter Damage After Vaginal Delivery Using Three-Dimensional Endosonography

From the Departments of Intestinal Imaging and Surgery, St. Mark’s Hospital, and the Department of Obstetrics, Northwick Park Hospital, Harrow, Middlesex, United Kingdom; and the Department of Surgery, St. Thomas’ Hospital, London, United Kingdom.

Address reprint requests to: C. I. Bartram, FRCP Saint Mark’s Hospital Department of Intestinal Imaging Level 4V Northwick Park Harrow, HA1 3UJ United Kingdom E-mail: c.bartram{at}cc.ac.uk

Objective: To determine the incidence and functional consequences of external sphincter trauma compared with other perineal structures using a novel imaging technique, three-dimensional endosonography.

Methods: Fifty-five nulliparous women (mean age 30 years, range 18–47 years) had three-dimensional anal endosonography, anal manometry, and questionnaire assessment of continence at a median gestation of 33 weeks (23–42 weeks) and 10 weeks (7–22 weeks) after delivery.

Results: There was ultrasound evidence of postpartum trauma in 13 of 45 women who had a vaginal delivery (29%, confidence interval [CI] 16%, 44%), involving the external sphincter in five (11%, CI 4%, 24%), the puboanalis in nine (20%, CI 10%, 35%), and the transverse perineii in three (7%, CI 1%, 18%). In four, more than one structure was damaged. External sphincter trauma was associated with a significant decrease in squeeze pressure (P = .035) and an increase in incontinence score (P = .02) compared with those without trauma. Tears to the puboanalis or transverse perineii only did not affect pressure or incontinence scores. Coronal imaging of the external anal sphincter was a useful adjunct to the assessment of trauma.

Conclusion: The overall incidence of trauma to the sphincter complex was similar to that of previous reports, although actual damage to the external sphincter was less common and represented the only functionally significant component.

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