Main Findings
In spite of several preventive strategies, OASI is still a relatively
common complication of vaginal delivery and associated with significant
morbidity. The chance of anal incontinence following a primary repair is
related to the degree of OASI (12)
Only 35% of our patients had a known primary OASI repair. Many of our
patients were in the older age bracket and were not aware if they had a
primary repair with their index delivery as this had not been well
communicated to them, and some of our patients had occult OASI injuries.
Our study showed that the functional results of transvaginal AS repair
have sustained satisfactory outcomes with almost 70% of patients having
5 points or more improvement of their St Mark score at 57 months. This
outcome correlates with the fact that 70% of our women would recommend
this procedure to a friend.
Our study indicated that 73% of women have persistent urgency post
operatively, similar results of persistent urgency was also reported in
a large Danish study with 220 months follow up (13). Ongoing urgency
could be related to a persistent IAS defect. IAS defects are more
difficult to identify and repair; particularly in a delayed setting,
perhaps indicating that a sphincter repair should not be performed
solely for faecal urgency.
Overall rates of surgical complications after a sphincteroplasty range
from 5% to 27%. The most common adverse event after sphincteroplasty
is wound infection, which occurs in 6–35% of cases. In our cohort we
had a higher incidence of wound infection/perineal breakdown (45%).
This could be due to the fact most of our complications were patient
reported, the rates of infection may thus be overestimated as many of
our patients present with vaginal discharge as part of the healing
process, that does not necessarily indicate a wound infection.
Interestingly in our group of women with concurrent fistula repair all
of the women reported symptoms of infection. Importantly the presence of
wound infection or perineal breakdown did not change the outcomes in our
study.
Perineal wound infection is uncommon after vaginal repair but when an AS
repair is performed, the proximity to the anal canal dramatically
increases the risk of infection and breakdown. Possible preventive
measures for breakdown may be the use of drains, although this may cause
sinus formation. Prophylactic antibiotics may reduce infection but there
is no current evidence that prolonged antibiotic prophylaxis beyond the
intra operative dose has any added benefit (14).