Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth

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Obstetrical anal sphincter laceration and analincontinence 5-10 years after childbirthEmily C. Evers, MPH; Joan L. Blomquist, MD; Kelly C. McDermott, BS; Victoria L. Handa, MD, MHS

OBJECTIVE: The purpose of this study was to investigate the long-termimpact of anal sphincter laceration on anal incontinence.

STUDY DESIGN: Five to 10 years after first delivery, anal incontinencend other bowel symptoms were measured with the Epidemiology ofrolapse and Incontinence Questionnaire and the short form of theolorectal-Anal Impact Questionnaire. Obstetric exposures were as-essed with review of hospital records. Symptoms and quality-of-lifempact were compared among 90 women with at least 1 anal sphincteraceration, 320 women who delivered vaginally without sphincter lacer-
tion, and 527 women who delivered by cesarean delivery.
Obstet Gynecol 2012;207:425.e1-6.

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RESULTS: Women who sustained an anal sphincter laceration weremost likely to report anal incontinence (odds ratio, 2.32; 95% confi-dence interval, 1.27–4.26) and reported the greatest negative impacton quality of life. Anal incontinence and quality-of-life scores were sim-ilar between women who delivered by cesarean section and those whodelivered vaginally without sphincter laceration.

CONCLUSION: Anal sphincter laceration is associated with anal incon-tinence 5-10 years after delivery.

Key words: anal incontinence, cesarean delivery, obstetrical anal
sphincter laceration, quality of life
Cite this article as: Evers EC, Blomquist JL, McDermott KC, et al. Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth. Am J

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Anal incontinence is a distressingdisorder that afflicts 2-24% of com-

munity-dwelling adults.1 Obstetric analphincter laceration is a known risk fac-or for anal incontinence. Specifically,bstetric anal sphincter laceration haseen associated consistently with an in-reased risk of anal incontinence in therst postpartum year.2-6 Long-term out-

comes for women with anal sphincterlaceration are less certain, although a

From the Department of Gynecology andObstetrics, Johns Hopkins School of Medicine(Ms Evers and Dr Handa); the Department ofObstetrics and Gynecology, Greater BaltimoreMedical Center (Dr Blomquist); and theDepartment of Epidemiology, Johns HopkinsBloomberg School of Public Health (MsMcDermott), Baltimore, MD.

Received Jan. 10, 2012; revised May 17,2012; accepted June 27, 2012.

Support provided by a grant from the NationalInstitutes of Health (R01HD056275).

The authors report no conflict of interest.

Presented as an abstract at the 38th AnnualScientific Meeting of the Society ofGynecologic Surgeons, Baltimore, MD, April13-15, 2012.

Reprints not available from the authors.

0002-9378/$36.00© 2012 Mosby, Inc. All rights reserved.

higher prevalence of anal incontinencehas been suggested.7-9 It is unclear

hether vaginal birth, in the absence ofphincter laceration, increases a wom-n’s risk of anal incontinence when com-ared with cesarean delivery. In the post-artum period, cesarean delivery ishought to protect against anal inconti-ence,3 albeit incompletely.In this study, we investigated anal in-

ontinence after anal sphincter lacera-ion among participants in the Mothers’

utcomes After Delivery (MOAD)tudy.10 In a population of parous

women 5-10 years after first delivery, wecompared anal incontinence in womenwho had sustained at least 1 anal sphinc-ter laceration, women who deliveredvaginally without sphincter laceration,and women who delivered by cesareansection. Our goal was to compare symp-toms of anal incontinence, degree ofbother, and impact on quality of lifeacross these exposure groups.

MATERIALS AND METHODSThis is an analysis of baseline data thatwere collected for the MOAD study,which is a prospective cohort study ofpelvic floor outcomes in women whohave been recruited 5-10 years after de-livery of their first child.10 Institutional

l was obtained for d

NOVEMBER 2012 Americ

this research, and all participants pro-vided written, informed consent. Re-cruitment of women into the study be-gan in 2008 and is ongoing.

This analysis was based on the original1011 women who were enrolled in thecohort. The study design and recruit-ment methods have been describedin detail previously.10 To be eligible,

omen must have given birth to theirrst child at Greater Baltimore Medicalenter 5-10 years before enrollment.articipants were identified from obstet-ics hospital discharge records. To verifyligibility and to confirm delivery type,ach hospital chart was reviewed by anbstetrician from our research team.Exclusion criteria for the MOAD

tudy (applied only to the index birth)ncluded maternal age �15 or �50 years,elivery at �37 weeks’ gestation, pla-enta previa, multiple gestation, knownetal congenital anomaly, stillbirth, pre-ious myomectomy, and abruption. Forhis analysis, we also excluded 4 womenith neurologic conditions that could

ontribute to bowel incontinence (ie,ultiple sclerosis and cerebral palsy).dditionally, because we did not haveccess to obstetrics records for sub-equent deliveries at other hospitals,e excluded multiparous women with
eliveries that did not occur at our ins-
an Journal of Obstetrics & Gynecology 425.e1

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titution, which left 937 women for thisanalysis.

The primary exposure of interest wasobstetric anal sphincter laceration thathad been documented in the hospital re-cord at the time of delivery. Based on ob-stetric history of all deliveries beforeenrollment into MOAD, women wereclassified into 1 of 3 groups. The exposedgroup (sphincter tear group) comprisedwomen with at least 1 clinically recog-nized, 3rd- or 4th-degree anal sphinctertear as defined by the American Collegeof Obstetricians and Gynecologists.11

There were 2 control groups. The firstcontrol group included women with atleast 1 vaginal birth but without a clini-cally recognized anal sphincter lacera-tion (vaginal control group). A secondcomparison group included women whodelivered only through cesarean section(cesarean control group).

In addition to these obstetric expo-sures, we considered the following con-founders: age at enrollment, race, mater-nal age at first delivery, multiparity, andobesity at the time of enrollment. Raceand parity were self-reported at studyenrollment. Each participant’s weightand height were measured, and bodymass index was calculated (weight/height2). Obesity was defined as a body

ass index of �30 kg/m2.The primary outcome was anal incon-

inence that was assessed at enrollmenteg, 5-10 years after the first delivery).nal incontinence symptoms were mea-

ured with the Epidemiology of Pro-apse and Incontinence QuestionnaireEPIQ), which is a validated, self-admin-stered questionnaire.12 The EPIQ in-ludes 3 questions that pertain to analncontinence: (1) “Do you lose gas fromour rectum that is beyond your con-rol?” (2) “Do you lose stool beyond yourontrol if your stool is loose or liquid?”nd (3) “Do you lose well-formed stooleyond your control?” For each symp-om that is endorsed by the participant,he is asked to describe the degree ofother, which is rated with a visual ana-

og scale that ranges from “not at all (0)”o “greatly (100).”12 An overall anal in-ontinence score is calculated as theean bother score for the 3 anal incon-

inence items. Previous research demon-

425.e2 American Journal of Obstetrics & Gynecolo

trated that an anal incontinence score of22.8 points is sensitive and specific

or the identification of women withothersome symptoms of anal in-ontinence.12 In this research, we used

the published EPIQ anal incontinencethreshold (score, 22.8 points) to distin-guish women with and without analincontinence.12

Additional information about anal in-continence is provided by the followingEPIQ items: (1) “Do you wear liners,pads, diapers, or toilet paper, or do youchange your undergarments to protectyour clothes from loss of stool?” (2)“Have you ever asked a doctor, nurse, orother healthcare professional for helpwith loss of stool or gas?” (3) “Have youhad any surgery to correct the loss ofstool or gas?”12 These items do not con-tribute to the anal incontinence scoreand therefore were considered separatelyin this analysis.

In addition, the EPIQ includes the fol-lowing questions that pertain to other as-pects of bowel function: (1) “Do you everhave difficulty having a bowel move-ment?” (2) “Do you ever have to push onyour vagina or around your rectum tohave or complete a bowel movement?”(3) “How often do you use laxatives orstool softeners (not including high fibersupplements)?” For each symptom thatwas endorsed by the participant, womenwere asked to describe the frequency ofoccurrence and degree of bother. Forthese items, the degree of bother wasrated with a visual analog scale thatranged from “not at all (0)” to “greatly(100).”12

Finally, women with bowel symptomswere asked to rate the impact on theirquality of life using the short form of theColorectal-Anal Impact Questionnaire(CRAIQ-7).13 This validated question-naire provides a measure of the impact ofbowel symptoms on 7 domains of qualityof life. The CRAIQ-7 was completed byparticipants answering “yes” to any ofthese 6 EPIQ bowel symptom questions:(1) “Do you ever have difficulty having abowel movement?” (2) “Do you everhave to push on your vagina or aroundyour rectum to have or complete a bowelmovement?” (3) “Do you lose gas from
your rectum that is beyond your con-
gy NOVEMBER 2012

trol?” (4) “Do you lose stool beyond yourcontrol if your stool is loose or liquid?”(5) “Do you lose well-formed stool be-yond your control?” (6) “Do you wearliners, pads, diapers, or toilet paper, ordo you change your undergarments toprotect your clothes from loss of stool?”Responses to the CRAIQ-7 are tradition-ally answered with a 4-point Likert scalewith values “not at all,” “somewhat,”“moderately,” or “quite a bit.”13 To im-

rove consistency within our survey, weodified the response options for theRAIQ-7 from the traditional Likert

cale to a visual analog scale thatatched the scale that was used for the

PIQ degree of bother questions. Thus,ach item from the CRAIQ-7 was scaledrom 0-100, with 100 representing thereatest impact from colorectal/analymptoms.

Tables were generated to estimate thenivariable associations between the ex-osure groups of interest (sphincter tear,aginal control, and cesarean control)nd possible confounders and then toompare the answers with differentowel symptom questions across the 3roups. The analysis of CRAIQ-7 dataas restricted to women who filled out

he CRAIQ-7 questionnaire (ie, thoseho answered yes to at least 1 of the 6PIQ bowel symptom questions). Prob-bility values were obtained with a Fisherxact test for categoric variables and aruskal-Wallis test for continuous vari-bles. Odds ratios (ORs) were calculatedith logistic regression. For all analyses,probability value of � .050 was consid-red statistically significant.

RESULTSOf 937 participants, 90 women had ex-perienced at least 1 anal sphincter lacer-ation. There were 320 women in the vag-inal control group and 527 women in thecesarean control group. Of the 90 partic-ipants in the sphincter tear group, 87women experienced 1 anal sphincter lac-eration; 2 women experienced 2 analsphincter lacerations, and 1 woman ex-perienced 3 anal sphincter lacerations.Of the 94 total anal sphincter tears, 79tears occurred at first delivery (84%); 14
tears occurred at second delivery (15%),

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and 1 tear occurred at third delivery(1%).

Maternal recall was noted to be poorwith respect to a history of anal sphincterlaceration. Specifically, of 90 partici-pants with documented lacerations, 26women did not recall an anal sphinctertear. Conversely, 12 women recalledsphincter lacerations, but there was nodocumentation of a sphincter laceration;in these cases, a lesser degree of perinealtrauma was documented in the deliveryrecord. In all cases in which there was adiscrepancy between maternal recall andmedical documentation, obstetrics re-cords were rereviewed independently bya second reviewer, and there were nocases in which the original review wasfound to be in error.

The median interval between firstdelivery and enrollment was 7.4 years(interquartile range, 6.3, 8.9). Descri-ptive characteristics of the participantsare presented by group in Table 1. Thegroups were similar with regards to ageat enrollment, race, maternal age �35years at first delivery, and multiparity.Women who delivered exclusively by ce-sarean section had a higher prevalence ofobesity (P � .001).

Prevalence of bowel symptoms anddegree of bother by anal incontinence ispresented in Table 2 by exposure group.

ased on EPIQ anal incontinence score,6 participants(10%) had anal inconti-ence (score, �22.8). Compared with

TABLE 1Characteristics of 937 study partic

Characteristic

Age at enrollment, yb

...................................................................................................................

Primary race, n (%)..........................................................................................................

White..........................................................................................................

Black..........................................................................................................

Other...................................................................................................................

Maternal age �35 years at first delivery, n (%...................................................................................................................

Multiparous at enrollment, n (%)...................................................................................................................

Body mass index �30 kg/m2 at enrollment, n...................................................................................................................a With a Kruskal-Wallis test for continuous variables and a Fis

Evers. Anal incontinence after anal sphincter laceration. A

omen in the cesarean control group,

omen in the sphincter tear group wereignificantly more likely to score abovehe EPIQ threshold for anal inconti-ence (OR, 2.32; 95% confidence inter-al [CI], 1.27– 4.26). Women in thephincter tear group also were moreikely to report incontinence of gas (OR,.52; 95% CI, 1.52– 4.18), liquid stoolOR, 2.50; 95% CI, 1.32– 4.76), and solidtool (OR, 4.04; 95% CI, 1.12–14.61).dditionally, participants in the sphinc-

er tear group were more likely to reporthe use of liners and pads or to changelothing to protect clothes from loss oftool (OR, 3.86; 95% CI, 1.55–9.59). Inontrast, the only difference in anal con-inence between the cesarean and vaginalontrol groups was seen in the odds ofncontinence of gas, which was increasedn the vaginal control group (OR, 1.65;5% CI, 1.16 –2.35). No difference wasound among groups in the proportionf women who had talked to a healthcarerovider about anal incontinence (53articipants; 6%) or in the proportionho reported previous surgery to cor-

ect anal incontinence (3 participants;1%).Operative delivery was significantlyore common in the sphincter tear

roup than the vaginal control group42% vs 13%; P � .001).14 We therefore

considered the impact of operative deliv-ery among women with and without ahistory of sphincter laceration. Withinthe vaginal control group, anal inconti-

nts, by exposure group

Sphincter tear(n � 90)

Control by deli

Vaginal (n � 3

40.2 (35.8–43.2) 39.9 (36.3–43.........................................................................................................................

.........................................................................................................................

77 (86) 268 (84).........................................................................................................................

9 (10) 40 (13).........................................................................................................................

4 (4) 12 (4).........................................................................................................................

27 (30) 89 (28).........................................................................................................................

61 (68) 237 (74).........................................................................................................................

) 11 (12) 52 (16).........................................................................................................................

xact test for categoric variables; b Data are presented as median

Obstet Gynecol 2012.

nence was similar between women with


and without a history of operative deliv-ery (10.5% vs 9.5%; P � .813). In con-trast, in the sphincter tear group, therewas a trend toward a higher rate of analincontinence among those women witha history of operative delivery, althoughthe difference was not statistically signif-icant (21.6% vs 15.3%; P � .5894).

Relative to the cesarean control group,women in the vaginal control group wereless likely to report difficult bowel move-ments (OR, 0.73; 95% CI, 0.54 – 0.98). Asimilar trend was seen with the sphinctertear group (OR, 0.61; 95% CI, 0.37–1.00). There was no difference betweengroups in the proportion of women whomanually splint the vagina or rectum fordefecation.

Table 3 shows the CRAIQ-7 quality-of-life scores among 449 women withat least 1 bowel symptom: 48 women(53%) in the sphincter tear group; 146women (46%) in the vaginal controlgroup, and 255 women (48%) in the ce-sarean control group. Even among thosewomen who reported bowel symptoms,most of them indicated no impact onquality of life. For example, among 449women with at least 1 bowel symptom,only 83 women indicated any impact re-lated to ability to do household chores.Among the 7 impact domains, womenwith bowel symptoms were most likelyto report feeling frustrated by bowelsymptoms and were least likely to reportimpact related to ability to do household

y type

P valueaCesarean (n � 527)

39.4 (35.7–43.0) .770..................................................................................................................

.509..................................................................................................................

420 (80)..................................................................................................................

79 (15)..................................................................................................................

28 (5)..................................................................................................................

154 (29) .880..................................................................................................................

354 (67) .095..................................................................................................................

169 (32) � .001..................................................................................................................

rquartile range).

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.1)......... .........

......... .........

......... .........

......... .........

......... .........

)......... .........

......... .........

(%......... .........

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experienced a quality-of-life impactfrom bowel symptoms (ie, impact score,�0) was not significantly different acrossthe 3 exposure groups for any of the do-mains that were considered. However, ofthose women who expressed any quality-of-life impact from bowel symptoms,

TABLE 2Bowel symptoms of 937 study part

Symptoms

Anal incontinence score, n (%)..........................................................................................................

0..........................................................................................................

�0, �22.8..........................................................................................................

�22.8..........................................................................................................

Unadjusted odds ratio (95% CI)b...................................................................................................................

Ever lose gas beyond your control?, n (%)..........................................................................................................


How much are you bothered by losing gas?c,d

...................................................................................................................

Ever lose liquid stool beyond your control?, n..........................................................................................................


How much are you bothered by losing liquidstool?c,e

...................................................................................................................

Ever lose well-formed stool beyond yourcontrol?, n (%)

..........................................................................................................


How much are you bothered by loss of well-formed stool?c,f

...................................................................................................................

Ever have difficulty having a bowel movemenn (%)

..........................................................................................................


Ever have to push on vagina/rectum to havebowel movement?, n (%)

..........................................................................................................


Do you wear liners, pads, etc, or do you chanundergarments to protect clothes from loss ostool?, n (%)

..........................................................................................................


Talked to healthcare professional for help witloss of stool or gas?, n (%)

..........................................................................................................


Surgery to correct the loss of stool or gas?,n (%)...................................................................................................................

CI, confidence interval.a Obtained with a Fisher exact test for categoric variables and

d n � 181; e n � 78; f n � 10.


women in the sphincter tear group con-


sistently reported higher degrees of im-pairment than those in the vaginal andcesarean control groups.

COMMENTOur findings suggest that anal sphincterlaceration is associated significantly with

pants, by exposure group

Sphincter tear(n � 90)

Control by de

Vaginal (n �

.........................................................................................................................

59 (66) 245 (77).........................................................................................................................

14 (16) 44 (14).........................................................................................................................

17 (19) 31 (10).........................................................................................................................

2.32 (1.27–4.26) 1.07 (0.67–.........................................................................................................................

28 (31) 73 (23).........................................................................................................................

2.52 (1.52–4.18) 1.65 (1.16–.........................................................................................................................

57.0 (22.0–94.0) 30.0 (19.0–7.........................................................................................................................

15 (17) 24 (8).........................................................................................................................

2.50 (1.32–4.76) 1.02 (0.60–.........................................................................................................................

90.0 (60.0–100.0) 50.0 (4.5–83

.........................................................................................................................

4 (4) 0

.........................................................................................................................

4.04 (1.12–14.61) Not available.........................................................................................................................

52.5 (24.0–80.0) Not available

.........................................................................................................................

24 (27) 97 (30)

.........................................................................................................................

0.61 (0.37–1.00) 0.73 (0.54–.........................................................................................................................

14 (16) 54 (17)

.........................................................................................................................

0.87 (0.47–1.61) 0.96 (0.66–.........................................................................................................................

8 (9) 8 (3)

.........................................................................................................................

3.86 (1.55–9.59) 1.01 (0.42–.........................................................................................................................

8 (9) 15 (5)

.........................................................................................................................

1.62 (0.72–3.65) 0.82 (0.43–.........................................................................................................................

1 (1) 2 (1)

.........................................................................................................................

skal-Wallis test for continuous variables; b Calculated with logisti


anal incontinence 5-10 years after a first

gy NOVEMBER 2012

delivery. Women who sustained an analsphincter laceration were significantlymore likely to meet our definition of analincontinence, and they were more likelyto report individual incontinence com-plaints that included incontinence ofgas, liquid stool, and solid stool. In addi-

ry type

P valuea)Cesarean section(n � 527)

.011..................................................................................................................

427 (81)..................................................................................................................

52 (10)..................................................................................................................

48 (9)..................................................................................................................

2) Reference..................................................................................................................

80 (15) � .001..................................................................................................................

5) Reference..................................................................................................................

) 50.0 (17.5–82.0) .241..................................................................................................................

39 (7) .020..................................................................................................................

2) Reference..................................................................................................................

66.0 (37.0–97.0) .030

..................................................................................................................

6 (1) .003

..................................................................................................................

Reference..................................................................................................................

50.0 (5.0–79.0) .831

..................................................................................................................

197 (37) .034

..................................................................................................................

8) Reference..................................................................................................................

92 (17) .924

..................................................................................................................

9) Reference..................................................................................................................

13 (2) .013

..................................................................................................................

7) Reference..................................................................................................................

30 (6) .496

..................................................................................................................

4) Reference..................................................................................................................

0 .059

..................................................................................................................

ression; c Data are presented as median (interquartile range);

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320

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......... .........

......... .........

1.7......... .........

......... .........

2.3......... .........

0.0......... .........

(%)......... .........

1.7......... .........

.5)

......... .........

......... .........

......... .........

......... .........

t?,

......... .........

0.9......... .........

......... .........

1.3......... .........

gef

......... .........

2.4......... .........

h

......... .........

1.5......... .........

......... .........

a Kru c reg

tion, they were more likely to wear liners

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to protect against anal incontinence. Al-though most of the women in ourstudy did not report condition-specificimpact on quality of life, among thosewho did report an impact, the impactwas significantly greater in the sphinc-ter tear group. All of these results sug-gest that obstetric anal sphincter lacer-ation has a statistically and clinicallysignificant negative impact on bowelcontinence for years after childbirth.Similar trends have been reported inEuropean studies.7-9

Operative delivery is known to have anassociation with sphincter lacerations.Furthermore, previous research in thiscohort has demonstrated increased oddsof anal incontinence after operative de-livery compared with cesarean birth,10

but not in comparison to spontaneousdelivery.14 The results from the presentanalysis provide additional insights. Spe-cifically, in the absence of a sphincter lac-eration, operative delivery did not signif-icantly increase a woman’s odds of anal

TABLE 3Quality of life among 449 women w

Variable

Women with bowel symptoms, n (%)...................................................................................................................

“Have your bowel/rectum symptoms affectedyour . . .”c

..........................................................................................................

Ability to do household chores?

..........................................................................................................

Physical recreation such as walking, swimor other exercise?..........................................................................................................

Entertainment activities (eg, movies, conc

..........................................................................................................

Ability to travel by car or bus �30 minutefrom home?..........................................................................................................

Participating in social activities outside yohome?..........................................................................................................

Emotional health (nervousness, depressionanger)?..........................................................................................................

Feeling frustrated?

...................................................................................................................a Generated by a Kruskal-Wallis test of the median scores o

Colorectal-Anal Impact Questionnaire scores were scaled fro


incontinence. Although there was a sug-

gestion of an additive effect of sphincterlaceration and operative delivery on therate of anal incontinence, a significant ef-fect was not identified. Taken together,these results suggest that anal sphincterlaceration may be the mechanism bywhich operative delivery results in analincontinence later in life.

The present study included a compar-ison group of women who had deliveredonly by cesarean section. Interestingly,anal incontinence symptoms were simi-lar in the cesarean and vaginal controlgroups. The only exception was inconti-nence of flatus, which was more commonamong women with at least 1 vaginal birthvs women who delivered exclusively by ce-sarean. Overall, the similarities betweenthe vaginal and cesarean control groupssuggest that vaginal delivery, in the ab-sence of anal sphincter laceration, is nota risk factor for anal incontinence. How-ever, the data from this report are limitedto one point in time, and additional dif-ferences may emerge as the cohort is fol-

at least 1 bowel symptom at baseli

Sphincter tear

Control by d

Vaginal

48 (53) 146 (46).........................................................................................................................

.........................................................................................................................

10.5 (3.0–24.0) 3.0 (1.0–................................................................................................

n � 10 n � 26.........................................................................................................................

g 25.0 (15.0–75.0) 6.0 (2.0–................................................................................................

n � 15 n � 37.........................................................................................................................

)? 25.0 (10.0–50.0) 3.0 (1.0–................................................................................................

n � 14 n � 31.........................................................................................................................

26.5 (7.5–50.0) 3.0 (2.0–................................................................................................

n � 12 n � 31.........................................................................................................................

14.0 (5.0–50.0) 4.0 (1.0–................................................................................................

n � 15 n � 38.........................................................................................................................

15.0 (6.0–50.0) 5.0 (2.0–................................................................................................

n � 17 n � 39.........................................................................................................................

32.5 (12.0–75.0) 15.0 (5.0–................................................................................................

n � 24 n � 61.........................................................................................................................

men who answered �0 across the 3 exposure groups, unlessnot at all) to 100 (greatly); median (interquartile range) was calcul


lowed longitudinally.


We found that women who deliveredall their children by cesarean sectionwere more likely to report difficult bowelmovements (although they were notmore likely to report splinting to defe-cate). The mechanism for this differenceis uncertain. To our knowledge, this out-come has not been examined previouslyafter cesarean vs vaginal birth. Addi-tional investigation would be required toconfirm this observation and to furtherexplore the possible reasons for thisassociation.

A limitation of this study is the lack ofprospective assessment of anal sphincterlaceration. We relied on medical recorddocumentation to identify lacerations.Misclassification of anal sphincter lacer-ation is therefore possible due to underdiagnosis at the time of delivery, over di-agnosis, or poor documentation. How-ever, misclassification, if present, wouldreduce the strength of the observed asso-ciations, in which case the true effectof anal sphincter laceration might be

by exposure group

very type

P valueaCesarean section

255 (48) .417b

..................................................................................................................

..................................................................................................................

5.0 (1.0–10.0) .165..................................................................................................................

n � 47..................................................................................................................

) 5.5 (2.0–22.5) .002..................................................................................................................

n � 60..................................................................................................................

) 5.0 (2.0–13.0) � .001..................................................................................................................

n � 57..................................................................................................................

) 5.0 (1.0–32.0) .015..................................................................................................................

n � 54..................................................................................................................

) 4.0 (1.0–11.0) .008..................................................................................................................

n � 59..................................................................................................................

) 6.0 (2.0–26.0) .118..................................................................................................................

n � 57..................................................................................................................

) 20.0 (5.0–49.0) .066..................................................................................................................

n � 114..................................................................................................................

erwise noted; b Obtained with a Fisher exact test; c Thewith scores only from women who gave an answer of �0.

ith ne,

eli

......... .........

......... .........

5.0).........

......... .........

min 20.0.........

......... .........

erts 10.0.........

......... .........

s 10.0.........

......... .........

ur 10.0.........

......... .........

, 37.0.........

......... .........

50.0.........

......... .........

f wo othm 0 ( ated

greater than observed here. Another lim-


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itation is that no data were available re-garding predelivery bowel symptoms.We also do not have information onother conditions that might affect bowelsymptoms, such as inflammatory boweldisease. Finally, because this is an obser-vational study, we cannot with certaintyascribe the incidence of anal inconti-nence to obstetric events.

Strengths of this study include the as-sessment of anal incontinence symp-toms and quality of life with validatedquestionnaires, the use of a relativelylarge sample size with longer duration offollow up than most previous studies,and the inclusion of both a vaginal andcesarean control group. Additionally,obstetric events were defined by obstet-ric hospital records, rather than mater-nal recall. Verification of obstetrics his-tory is critical; nearly one-third of theanal sphincter lacerations that were ex-perienced by our study population werenot reported by the participant. Theseresults are in keeping with past researchon the accuracy of maternal recall forcertain obstetric events.15-17 This resultis an important factor to consider forstudies that rely on maternal report ofevents without medical record review.

Further research that focuses on analincontinence and quality of life with ex-tended durations of follow-up evalua-tion will strengthen our understandingof the burden of this problem on womenafter childbirth. Longitudinal follow-upevaluation by the MOAD cohort isplanned and will allow us to assess thelong-term prognosis for women who re-ported mild symptoms at the time of en-rollment and those who reported symp-toms without impact on quality of life.

Our results also suggest an opportu-nity for enhanced dialogue betweenphysicians and their patients who havesustained an obstetric anal sphincter lac-
eration. Although 19% of participants

who had experienced an anal sphincterlaceration had anal incontinence, only9% reported having ever talked abouttheir symptoms with a healthcare profes-sional. This is similar to the findings of apopulation-based study that suggestedthat only one-third of individuals withfecal incontinence discuss the problemwith a physician.18 Thus, anal inconti-nence is underreported. Symptomaticpatients can be helped to treat their condi-tion through diet, bulking agents, and pel-vic floor exercises.19 Given that women

ho sustain anal sphincter laceration are atigher risk for anal incontinence, healthare providers should encourage theseomen to report anal incontinence symp-

oms and to seek intervention when symp-oms are bothersome. f

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Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth