Post-partum Anal Incontinence in SA: A myth or reality?

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1 Post-partum Anal Incontinence in SA: A myth or reality? TD Naidoo Consultant and Honorary Lecturer, Department of Obstetrics and Gynaecology, Grey s Hospital, Pietermaritzburg Metropolitan Hospitals Complex, University of KwaZulu-Natal, Natal Abstract Anal incontinence (AI) impacts negatively on the quality of life of affected individuals. Information regarding this condition in South Africa is sparse. Determining the true incidence of AI is often difficult. Sphincter disruption and nerve damage, as a complication of childbirth are thought to be the main contributory factors to the development of post-partum AI. Local studies suggest that pregnancy itself may be a risk factor for AI and there appears to be an interracial variation in incidence. There is no correlation between symptoms of AI and occult anal sphincter injury. Women with symptoms of AI should be offered assessment, treatment, and follow up evaluations. The reluctance of patients and health personnel to acknowledge or discuss it, compounds the difficulties in determining the true incidence of, and influence of the various etiological factors for AI in our South African population. Anal incontinence (AI) is defined as the unintentional loss of faeces or flatus. Faecal incontinence is defined as a complaint of involuntary loss of solid or liquid faeces, while flatal incontinence is defined as a complaint of involuntary loss of flatus. 1 AI in women results in embarrassing and debilitating, emotional, psychological and social problems which have been shown to impact negatively on the quality of life of affected individuals. 2-4 Information regarding this distressing condition in South Africa is sparse, with only two local studies to date. 6,7 Prevalence and risk factors Determining the true incidence of AI is often difficult, because women rarely volunteer symptom information unless specifically asked. 3-5 Variations in definitions, underlying causes and subjectivity of symptoms also impact on the incidence. 3,4 Furthermore many women only present with symptoms following the puerperium or later. Naidoo et al 6 in their questionnaire based study carried out in KwaZulu-Natal found that the incidence of flatal, faecal and anal incontinence at 6 weeks post-delivery was 61.1, 5.4 and 6.0% respectively (Table1); thus highlighting the fact that AI is indeed a problem in our setting. Correspondence T D Naidoo AI after childbirth Mechanical sphincter disruption and nerve damage, occurring as a complication of childbirth are thought to be the main contributory factors to the development of postpartum AI. 2-5,8.9 Prevalence rates vary from 13% to 44% between 6 weeks and 10 months post-partum, in primiparae and multiparae. 3-8 Up to 25% of primigravidae experience altered continence postnatally with one-third having evidence of anal sphincter injury. 4,5 It has been suggested that obstetric factors increase the risk of damage to the anal sphincter and subsequent development of AI. 3,5,8 These include prolonged second stage of labour, fetal macrosomia, posterior positions of the fetal skull, instrumental delivery, epidural analgesia, episiotomy, and most significantly rupture of the anal sphincter. 2,3,9 Naidoo and Moodley in their local study in 2014 reported that having an epidural was significantly associated with AI at 6 weeks post-delivery. 7 However having a 3 rd /4 th degree perineal tear was not significantly associated with AI. Induction of labour, a labour duration of 6.3 hours, having an episiotomy and maternal weight of 69 kilograms approached significance with reported symptoms of AI. Naidoo et al. 6 also highlighted a significant difference in the prevalence of AI between women delivered by elective caesarean and those labouring and delivering vaginally or by emergency caesarean. AI in pregnancy Studies highlight the prevalence of AI in pregnancy, with rates varying from 3-29% Some women with sphincter injury are continent, while others with intact sphincters are incontinent, suggesting other factors may play a role in the pathogenesis of AI. 16 Many of the problems associated with post-partum AI may be attributed to changes in ano-rectal function occurring in pregnancy. 10,12,17 Our local studies highlighted a high prevalence of AI in the antenatal Obstetrics & Gynaecology Forum Issue

2 period. 6,7 Women were more incontinent late in pregnancy than 6 months after delivery (Table 1 and 2). These findings suggest that pregnancy itself may be a risk factor for AI. Chaliha et al. in showed an increasing prevalence for AI from 1% prior to pregnancy to 7% in pregnancy. O Boyle et al. 13 showed a combined antenatal prevalence for flatal and faecal incontinence of 18% 29% among a group of pregnant nullipara. It is possible that that the hormonal changes in pregnancy and the weight of the conceptus, together with the alterations in the pelvic floor and changes in anal and perineal anatomy play a role in the pathophysiology of AI in pregnancy. MacLennan et al. 14 in their study in 2003 showed that pregnancy >20weeks regardless of mode of delivery greatly increased the prevalence of major pelvic floor dysfunction, including all types of incontinence. van Brummen et al. 12 showed that symptoms of flatus and faecal incontinence are already present in early pregnancy and are significantly predictive for reporting symptoms after delivery. Olsen et al. 15 looking at the development of the maternal anal canal during pregnancy in 2012 showed that the anal canal volume (ACV) increased by 20% between 18 and 28 weeks of pregnancy, and that there was a significant association between ACV and incontinence scores. Many of the problems associated with post-partum changes in pelvic floor mobility may be attributed to biomechanical changes occurring in pregnancy. 17 Demographic and Racial variation There appears to be an interracial variation in the incidence of AI in our population as evidenced by our local studies (Table 3). 6,7 Other local studies have highlighted important differences in the aetiology and pathogenesis of pelvic floor problems between the black and white subpopulations of South Africa. 18,19 Hoyte et al. 20, highlighted anatomical differences involving the levator ani and puborectalis muscles between African-American and White-American women, while Huang et al. 21, showed a lower AI incidence amongst Asian-American women compared to White-Americans(21% vs. 29 %, P=0.007). It is plausible that these differences could be attributed to variations in perineal anatomy, and differing body type, thus suggesting that while the underlying anatomic and physiologic causes for the pathogenesis of AI may be the same, there may well be ethnic or interracial variation in the AI incidence and associated risk factors. The very high prevalence of AI in our population could also be a reflection of the lower socioeconomic status of the majority of the population! Johannessen et al. 22 in 2013 showed that younger age, lower education and unemployment were associated with reporting symptoms of AI in late pregnancy. Occult sphincter injury and AI Endosonographicaly detected sphincter defects following vaginal delivery without clinically recognized sphincter tears occur in about 7 to 41% of cases. 16,23-31 The prevalence of these occult anal sphincter injuries (OASI) may vary between first and subsequent deliveries, and the mechanism of injury may differ. 25,26,32,33 Although some studies directly implicate postpartum OASI in the pathogenesis of faecal urgency and anal incontinence 33,26, endosonographic sphincter defects are not always associated with anal incontinence. 16,25,27-31 Up to 20% of non-pregnant nullipara, with no symptoms of anal incontinence may have sphincter defects on Table 1: Frequency of anal incontinence in the study cohort (n=1325) Anal Incontinence Prenatal prevalence Incidence at 6 weeks postpartum Persistence at 6 months postpartum Flatal 349/1325 (26.3) 542/887 (61.1) 54/849 (6.4 Fecal 165/1325 (12.4) 57/1054 (5.4) 10/1013 (1.0) Both 81/1325 (6.1) 68/1130 (6.0) 0/1086 (0.0) Values are given as number (percentage). Table 2: Frequency of flatal, faecal and AI antenataly, six weeks and six months post-partum (n=1248) Baseline Prevalence Six Weeks Post- Delivery Incidence Six Months Post-Delivery Incidence Flatal Incontinence 330 (26.4) 573 (45.9) 7 (0.6) Faecal Incontinence 669 (53.6) 942 (82.9) 2 (0.2) Anal Incontinence 722 (57.9) 1004 (81.0) 9 (0.7) Values are presented as n (%) Obstetrics & Gynaecology Forum Issue

3 Table 3: Bivariate Analysis of Demographics, Obstetric Characteristics and Flatal and Faecal Incontinence at 6 weeks postdelivery (n=1136) N=573 Flatal Incontinence N =942 Faecal Incontinence N=1004 Anal Incontinence Demographics Age ( 24 years) ( ) ( ) ( ) Weight ( 69 kg) ( ) ( ) ( ) Height ( 160 cm) ( ) ( ) ( ) Race (African) ( )** ( )* ( )* Social Status (high) ( ) ( ) ( ) Chi square, =0.05, *p<0.05; **p<0.001 Values are presented as odds ratios (95%CI) endosonography, suggesting that these may be normal variants or the result of unknown trauma. 34 In a study (unpublished) carried out in the Pietermaritzburg Metropolitan area in 2013 we prospectively followed 100 women over 6 months and determined the incidence of OASI. None of the primigravid patients had OASI in the antenatal period, while 26% of the multiparous patients had OASI. The post- delivery prevalence of OASI among the primigravidae was comparable to the pre-delivery prevalence amongst the multipare (22% vs. 26%). Amongst the multiparae the prevalence of OASI doubled post-delivery. Symptoms of urgency increased from nine percent in the antenatal period to 14.6% post-delivery, thereafter decreasing to 10.3% at six weeks post-delivery and 8.3% at six months post-delivery. Symptoms of AI increased from 10% in the antenatal period to 12.5% post-delivery and continued to increase to 17.6% at six weeks post-delivery. At six months post-delivery symptoms of AI were reported by 3.1% (Table 4). Primiparous and multiparous women who had normal vaginal deliveries had internal anal sphincter defects more frequently than external anal sphincter defects or a combination of internal and external sphincter defects. Similarly primiparous women who had deliveries by caesarean section had internal anal sphincter defects at six weeks and six months more frequently than other types of anal sphincter defects (Table5). We found no correlation between symptoms of AI and OASI suggesting that not all occult sphincter defects may be implicated in the pathogenesis of faecal urgency and anal incontinence. Conclusion Despite there being insufficient data for South Africa on AI we believe that our local findings highlight the prevalence, and associated obstetric predictors for AI amongst pregnant women in our population. Interracial variation is apparent, with mode of delivery influencing both incidence and persistence of AI. The findings of increased AI incidence at 6 weeks and the marked decline in persistence at 6 months is similar to evidence emanating from international centres. This reduction in persistence of AI over time is encouraging and suggests that symptoms may be transient in most women and pregnancy-related as suggested! In those women in whom AI Table 4: Symptoms of incontinence measured at each time point (%) Symptoms Antenatal (n=100) Post-partum (n=96) N (%) Six weeks (n=96) N (%) Six months (n=96) N (%) Urgency (yes) 9 14 (14.6) 10 (10.4) 8 (8.3) AI symptoms (12.5) 17 (17.7) 3 (3.1) Flatus (yes) 5 6 (6.3) 6 (6.3) 1 (1.0) Faeces Liquid (yes) 3 4 (4.2) 6 (6.3) 1(1.0) Faeces Solid (yes) 1-2 (2.1) 1(1.0) Both (yes) 1 2 (2.1) 3 (3.1) - Obstetrics & Gynaecology Forum Issue

4 Table 5: Anal sphincter Defects in women evaluated by EAUS at each time point. No. with defect (%) Mode of delivery and Parity group Anal sphincter defects Internal sphincter N (%) External sphincter N (%) Internal and external N (%) NVD Primiparous Antenatal (n=14) Post-delivery (n=15) 8 (53.3) 4 (26.7) 4 (26.7) Six weeks (n=8) 6 (75.0) 2 (25.0) 2 (25.0) Six months (n=7) 5 (71.4) 1 (14.3) 1 (14.3) Multiparous Antenatal (n=27) 3 (11.1) 4 (14.8) 2 (7.4) Post-delivery (n=28) 12 (42.9) 10 (35.7) 8(28.6) Six weeks (n=14) 9 (64.3) 8(57.1) 4 (28.6) Six months (n=14) 6 (42.9) 3 (21.4) 1 (7.1) Caesarean section Primiparous Antenatal (n=8) Post-delivery (n=8) 2 (25.0) 2 (25.0) 1(12.5) Six weeks (n=2) 2 (100.0) 1(50.0) 1(50.0) Six months (n=4) 2 (50.0) 1 (25.0) - Multiparous Antenatal (n=45) 10 (22.2) 9 (20.0) 6 (13.3) Post-delivery(n=45) 8 (17.8) 8 (17.8) 6 (13.3) Six weeks (n=6) 4 (66.7) 6 (100) 4 (66.7) Six months (n=12) 1 (8.3) 1 (8.3) 1 (8.3) In the antenatal phase 6 women did not have EAUS assessment persisted at 6 months, the factors involved in the pathophysiology may be obstetric-related, or it might be that the pregnancy related physiological and anatomical changes persist in some women; or are the pregnancy-related factors compounded by known obstetric risk factors. Women with symptoms of AI should be offered assessment, treatment, and follow up evaluations, many of which are considered intrusive, invasive and embarrassing to the affected individual. The nature of this distressing condition, the psychological sequelae, and the reluctance of patients and health personnel to acknowledge or discuss it, compounds the difficulties in determining the true incidence of, and influence of the various etiological factors for AI in our South African population. References 1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010; 21: Pretlove SJ,Thompson PJ, Toozs-Hobson PM,Radley S, Khan KS. Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systemic review. BJOG 2008;11:; Bols EMJ, Hendriks EJM, Berghmans BCM,Beaten CGMI, Nijhuis JG, Bie RA de.a systematic review of etiological factors for postpartum fecal incontinence. Acta Obstet Gynecol Scand 2010;89(3): Sharma A, Marshall RJ, Macmillan AK, Merrie AEH, Reid P, Bisset IP. Determining Levels of Fecal Incontinence in the Community: A New Zealand Cross-Sectional Study. Dis Colon Rectum 2011;54: Zetterstrom J. Lopez A,Anzen B,Dolk A, Norman M,Mellgren A. Anal incontinence after vaginal delivery: a prospective study in primiparous women. BJOG 1999;106: Naidoo TD, Moodley J,Esterhuizen TE. Incidence of postpartum anal incontinence among Indians and black Africans in a resourceconstrained country. Int J Gynecol Obstet 2012; 118: Naidoo TD, Moodley J. Postpartum anal incontinence in a resource- Obstetrics & Gynaecology Forum Issue

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