How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial
Thank you for your comments on our article.
We agree with your comment on the Royal College of Obstetricians and Gynaecologists guideline on third and fourth degree perineal tears1 advocating the use of monofilament suture such as polydioxanone to reduce infection risk and possibly better outcome following sphincter repair.
Our study2 showed no difference in functional outcome; however, the study was not powered to look at change in infection risk, so we cannot really comment further.
A tear that involves the internal sphincter or rectal mucosa is more severe than the one that does not. Therefore, in our opinion, the classification remains valid. Our experience shows that it is difficult to positively identify the internal anal sphincter separately at the time of primary repair. Reassuringly, this problem does not appear to have affected outcome in terms of anal incontinence in our study.
As most district general hospitals do not have the luxury of a dedicated perineal clinic with the expertise and investigative tools, we believe that the use of a validated questionnaire is a useful method for prompt identification of women who may need referral to a specialist clinic.