FECAL AND URINARY INCONTINENCE FOLLOWING VAGINAL DELIVERY WITH ANAL SPHINCTER DISRUPTION

D. Fenner, MD, R. Gensberg MS, P. Kartha BA, J. DeLancey MD

   Objective: To estimate the incidence of bowel and urinary incontinence as it relates to anal sphincter laceration in primiparous women, and to identify factors that are associated with anal sphincter laceration.

   Methods: From Jan 1, 1997 to March 30, 2000, 2941 primiparous women that delivered vaginally at the University of Michigan Medical Center and were mailed questionnaires concerning bowel and bladder function six months following delivery as part of an IRB approved study of postpartum urinary incontinence. Charts were reviewed for demographic and pertinent delivery variables. Perineal trauma was classified as no lacerations, first, second, third (partial or complete) or fourth degree lacerations found during childbirth. Information about delivery in 2855 women was analyzed. There were 86 women excluded from further analysis for having both vacuum and forceps delivery (9), missing charts (52) or pudendal block (25). There were 943 women who completed the urinary function questionnaire, and 831 women that completed the bowel function questionnaire. Univariant analysis was performed on all covariates. Multiple logistic regression was used for further analysis with the presence of third or fourth degree lacerations as the outcome.

   Results:  Third or fourth degree lacerations occurred in 506 deliveries (17.70%). Nearly one fifth (19.86%) of the women who completed the survey had sustained third or fourth degree lacerations. The women in the sphincter laceration group were more likely (23.03%) to have bowel incontinence than women in the control group (13.36%). The incidence of worse bowel control was nearly ten times higher in women with fourth degree lacerations (30.8%), when compared to women with third degree lacerations (3.60%). Macrosomia (OR 2.19; CI 1.61, 2.99), forceps assisted delivery (OR 4.75; CI 3.43, 6.57), and vacuum assisted delivery (OR 3.51; CI 2.64, 4.66) were associated with higher risks of third and fourth degree lacerations. Midline (OR 2.24; CI 1.81, 2.77) but not mediolateral (OR 0.66; CI 0.375, 1.19) episiotomy was associated with anal sphincter lacerations. Prolonged second stage of labor (P= 0.107), and use of epidural anesthesia (P= 0.150) did not prove to have significant associations with anal sphincter lacerations. Over half of women said their bladder function deteriorated after delivery (slightly worse (32.56%) or worse (27.57%). They also reported lifestyle modifications associated with urinary incontinence.

   Conclusions: Women with third and fourth degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Most notable, women with fourth degree lacerations were nearly ten times more likely to have worse bowel function than women with third degree lacerations. Anal sphincter lacerations are strongly associated with macrosomia, forceps and vacuum assisted delivery, and midline episiotomy. Decreased urinary control was present in greater than half of the primiparous women surveyed.

   Key Words: Fecal and Urinary Incontinence following vaginal delivery