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Meta-Analysis
. 2013 Dec 8;2013(12):CD002866.
doi: 10.1002/14651858.CD002866.pub3.

Methods of repair for obstetric anal sphincter injury

Ruwan J Fernando  1 , Abdul H Sultan, Christine Kettle, Ranee Thakar
Affiliations
Meta-Analysis

Methods of repair for obstetric anal sphincter injury

Ruwan J Fernando et al. Cochrane Database Syst Rev. .

Abstract

Background: Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair.

Objectives: To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS.

Data collection and analysis: Trial quality was assessed independently by all authors.

Main results: Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women).

Authors' conclusions: The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.

PubMed Disclaimer

Conflict of interest statement

Ruwan Fernando, Abdul Sultan and Chris Kettle conducted a randomised controlled trial for overlap and end‐to‐end repair for obstetric anal sphincter injury (Fernando 2006).

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 1 Faecal urgency.
1.2
1.2. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 2 Flatus incontinence.
1.3
1.3. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 3 Faecal incontinence.
1.4
1.4. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 4 Alteration in faecal continence.
1.5
1.5. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 5 One or more anal incontinence symptoms (Faecal urgency, flatus incontinence, faecal incontinence, alteration in faecal continence) not prespecified outcome.
1.6
1.6. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 6 Deterioration of anal incontinence symptoms.
1.7
1.7. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 7 Perineal pain.
1.8
1.8. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 8 Need for perineal injection at 3 months.
1.9
1.9. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 9 Perineal pain/dyspareunia.
1.10
1.10. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 10 Dyspareunia.
1.11
1.11. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 11 Quality of life scale 1: lifestyle.
1.12
1.12. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 12 Quality of life scale 2: coping and behaviour.
1.13
1.13. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 13 Quality of life scale 3: depression and self‐perception.
1.14
1.14. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 14 Quality of life scale 4: embarrassment.
1.15
1.15. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 15 Anal incontinence score.
1.16
1.16. Analysis
Comparison 1 Overlap versus end‐to‐end, Outcome 16 Anal incontinence score > 10.
See this image and copyright information in PMC

Update of

References

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References to studies excluded from this review

Goh 2004 {published data only}
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Johansson 2005 {published data only}
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References to other published versions of this review

Fernando 2000a
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