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Keywords:

  • Anal;
  • childbirth;
  • delivery;
  • incontinence;
  • postpartum

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information

Objectives  To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.

Design  Systematic review of all relevant studies in English.

Data sources  Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.

Study selection and data extraction  Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 × 2 contingency tables were used to generate odds ratios.

Results  Eighteen studies met the inclusion criteria with 12 237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47–2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04–1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22–1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19–1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97–1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.

Conclusion  Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information

Anal incontinence is a distressing and disabling symptom affecting 4.3% (95% CI 3.5–5.9) women aged 15–60 years.1 It is increasingly acknowledged that childbirth is a risk factor for anal incontinence and that anal incontinence is an under-reported and under recognised symptom2 that has a negative impact on quality of life.3

There are different definitions for anal incontinence. The Royal College of Physicians suggests ‘the involuntary or inappropriate passage of faeces’.4 While this definition is clear, it makes no mention of urgency or flatus incontinence nor does it address the effect that the symptoms may have on the woman. This definition is refined by the International Continence Society to read ‘Anal incontinence is the involuntary loss of flatus, liquid or solid stool that is a social or hygienic problem’.5 This definition has the advantages of not only including incontinence of flatus but also acknowledging that different women may react in very different ways to what appear to be the same symptoms.

There has long been concern that vaginal delivery affects both urinary and anal continence, with some advocating caesarean section to protect the pelvic floor and anal continence mechanism. The correct identification6 and repair of tears involving the anal sphincter7 have been highlighted as ways of reducing the morbidity associated with anal incontinence. While these approaches have merit, avoidance of risk factors may reduce morbidity further. If the obstetric factors associated with postpartum anal incontinence can be identified reliably, this knowledge has the potential to be translated into development of prevention strategies and may help inform the design of future studies. Accurate data on the risks and benefits of vaginal delivery and caesarean section will also inform both patients and clinicians when obtaining consent.

Wide variation exists in the available literature as to the significant aetiological factors with many studies being small and underpowered, leading to risk of an inability to detect an association when one exists. A number of studies exist but with conflicting results. No relevant systematic reviews of postpartum anal incontinence has been performed, and a comprehensive systematic review of the current evidence is required.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information

We developed a protocol using widely recommended methods for systematic reviews of observational studies for this study. The QUOROM statement8 and guidelines were followed during the preparation of this review (Appendix S2).

Identification of studies

Search and study selection

The search focused on capturing studies in which the rates of anal incontinence in the first year postpartum according to the mode of delivery were reported.

A search strategy was developed based on existing advice for observational studies.9,10 Medline (1984 to October 2004) and Embase (1984 to October 2004) and the Cochrane library (2003:3) were searched electronically. Papers from the past 20 years were chosen, as changes in the management of labour would make the findings from studies before this irrelevant. The search of Medline and Embase captured citations combining relevant MeSH, keywords and word variants for the concept ‘anal incontinence and childbirth’ (Appendix S1). In addition, bibliographies of relevant articles were manually searched, and experts in the specialty were contacted to identify papers not captured by electronic searches. The search was restricted to papers in the English language literature; however, this only excluded a small number of studies.11–15

Studies were selected in a two-stage process. First, all abstracts or titles in the electronic searches were scrutinised (S.J.P.), and full manuscripts of potentially eligible citations were obtained. Second, studies meeting our predefined criteria were selected. Studies were selected if data on anal incontinence could be extracted for participants following childbirth. Observational studies where individuals had reported their symptoms, either using a questionnaire or by interview, and sufficient data were provided to compute 2 × 2 tables were selected. Studies without control groups were excluded as these do not help assess for aetiology as there is no comparative group. Where studies reported an odds ratio but no prevalence data was given, the results have been included in the data tables but not entered into the meta-analysis. Similarly, studies with a nonrepresentative control group are also included in the data tables but not entered into the meta-analysis. Studies with follow-up data which commenced less than 6 week or more than one year from the index delivery were excluded. Where more than one set of data was available for a cohort of women, the longest follow-up data less than 1 year was used. Studies that described singleton cephalic deliveries only were included and those relating to symptoms following multiple gestations or breech delivery were excluded.

Data extraction and study quality assessment

Data were extracted using a piloted form on participants’ characteristics, study quality and anal incontinence rates.

The quality10,16 of all selected papers was assessed for the following attributes: prospective continence assessment, prospective recruitment of population, adequate sampling of the selected population, method of ascertainment of risk factor, use of a validated measurement tool, temporality of the association and controls for confounding. Study design was examined to determine if continence assessment had been performed prospectively as the use of a continence diary would minimise recall bias. In aetiology studies, the participants selected should ideally be a representative cohort of postnatal women. Sampling was considered adequate if recruitment of participants was random or consecutive rather than performed for convenience. Another quality item was sought if the measurement tool to ascertain incontinence was developed rigorously17 and had been validated to ensure that patient responses were representative of disease. Ideally, studies should demonstrate the temporality of the association by only including those with new anal incontinence following childbirth. Temporality of the association was also assessed as a quality item.

Our definition of anal incontinence included involuntary loss of solid or liquid faeces or flatus. Information was extracted on whether studies evaluated solid, liquid and flatus incontinence or faecal urgency in isolation or in combination. In some studies, the existence of multiple symptoms among individuals could not be evaluated separately due to the structure of the questionnaire used and the manner of reporting. Where possible, we computed odds ratios for isolated and combined symptoms. Thus, all studies initially included did not contribute to the quantitative data synthesis for each of the three incontinence symptoms.

Data synthesis

Information from each study, stratified by mode of delivery was tabulated by symptoms. Data in individual studies were expressed as the odds ratio with 95% CI. Heterogeneity in rates was examined graphically and statistically. For graphical assessment, ‘forest’ plots of point estimates of rates and their 95% CIs were used. A random effects model18 was used in the light of heterogeneity.

We combined results for meta-analysis wherever appropriate in Review Manager 4.2.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information

The electronic search yielded a total of 300 citations (Figure 1). On examination of titles and abstracts, 60 were found to be relevant to the review, and full papers were obtained for these. The reference lists of these revealed two further papers, and contact with experts revealed one further paper. No relevant systematic reviews was identified. Eighteen studies19–37 with 12 237 participants met the inclusion criteria, of which seventeen (94%) were from the past 10 years. Study characteristics are shown in (Table 1). Study quality assessment (Figure 2, Table 2) revealed deficiencies in many areas of methodology. None of the studies met all six high-quality criteria. One study26 met five out of six criteria, and a further four studies met four criteria, but the remainder met three or less. Studies were not excluded for failure to meet quality criteria.

image

Figure 1. Result of literature search.

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Table 1.  Characteristics of included studies
Author and yearTotal number of participantsPopulation characteristics and response rate where statedRisk factor studiedDefinition of caseTime elapsed since exposure
  1. BMI, body mass index; IUD, intra-uterine death; OASI, obstetric anal sphincter injury.

Liebling et al.19 (2004)314393 women with term, singleton, cephalic pregnancies who required operative delivery at full dilatationInstrumental delivery; caesarean section at full dilatationNot explicitly defined1 year
Peschers et al.20 (2003)100Primiparous women delivering singleton cephalic fetuses by vacuum extraction plus controls who delivered spontaneously. Cases vs controls; number contacted: 187 vs 151; no address: 62 vs 53; not reached by telephone: 35 vs 29; declined to participate: 30 vs 15; pregnant or on second delivery: 5 vs 4; examined: 55 (29%) vs 50 (33%)Mode of deliveryNot stated6–24 weeks
Fitzpatrick et al.21 (2003)130Primiparae recruited antenatally requiring instrumental deliveryForceps vs ventouseModified anal incontinence score; Jorge223 months
Lal et al.23 (2003)184566 women invited (346 caesarean section and 220 vaginal deliveries). 126 uncontactable; 105 ineligible; 335 women were eligible; 286 participated (85% response rate)Caesarean section; unassisted vaginal deliveryBirmingham Bowel and Urinary Questionnaire; Hillier et al.8–12 months
Eason et al.24 (2002)949Women delivering in five hospitals in Quebec, Canada; 949 from 1198 responded (79.3%)Recognised sphincter damage; forceps assisted delivery; vacuum assisted delivery; Fetal macrosomia (>4000 g); median episiotomy; pre-pregnancy urinary incontinence‘Involuntary loss of stool or passage of flatus’3 months
MacArthur et al.25 (2001)7275Women attending antenatal clinics in Aberdeen, Birmingham and Dunedin. Response rate = 7879/10 989 (71.7%)Parity; mode of delivery; induction of labour; perineal trauma; length of second stage of labour; birthweight; maternal age; BMI; ethnic group; study centre‘Do you ever lose control of wind or bowel motions from your back passage in between visits to the toilet?’ (Flatus and faeces are differentiated in the results)3 months
Farrell et al.26 (2001)595Nulliparous women recruited antenatally; inclusion criteria: no history of any urinary or alimentary tract abnormality; no history of pelvic surgery; no significant medical illness; not using medication which would have an impact on urinary or alimentary function; 690 recruited; 94 had a miscarriage or moved from the province; one woman delivered at a different hospital; 595 women participated (86.23%)Mode of delivery; labour time; duration second stage; duration passive stage; duration active stage; duration head engaged; head circumference; birthweight; weight gain; maternal weight; maternal age (median); duration of epidural; BMI‘Do you accidentally lose flatus or stool from the rectum?’6 weeks and 6 months postpartum; 6 months data used in analysis
Meyer et al.27 (2000)107151 women enrolled in study antenatally; all eligible women asked to participate; acceptance rate was approximately 80%; 11 women dropped out; 33 had caesarean section; 82 had spontaneous delivery; 25 had forceps deliveryForceps delivery; unassisted vaginal deliveryClassed as: grade 1, incontinence of flatus; grade 2, incontinence of liquid stools; grade 3, incontinence of solid stools9 weeks and 10 months; 10 months data used in analysis
Faltin et al.28 (2000)150Women recruited in a previous study immediately postpartum without clinical OASI having delivered vaginally; 144/150 (96%) returned questionnaireMaternal age; maternal height; maternal BMI; birthweight; epidural use; duration of second stage of labour; instrumental delivery; intact perineum; episiotomy; fecal incontinence before pregnancy; fecal incontinence during pregnancyIncontinence to flatus, liquid and solid3 months
Damon et al.29 (2000)52Primiparous women following vaginal delivery of a cephalic baby more than 34 weeks of gestationForceps delivery‘Clinical symptoms of anal incontinence’12 weeks
Chaliha et al.30 (1999)549Nulliparous women attending antenatal clinic; all completed follow up; response rate not givenSpontaneous vaginal delivery; instrumental delivery; caesarean sectionFaecal incontinence included either incontinence of flatus, liquid or solid stool; faecal urgency ‘inability to defer defecation for more than 5 minutes’3 months
Groutz et al.31 (1999)300Consecutive unselected women delivering in Tel Aviv interviewed at 3 months postpartum by telephoneAnalgesia (none/epidural/narcotics); mode of delivery; episiotomy‘Any involuntary leakage of solid or liquid feces or gas’3 months
Fynes et al.32 (1998)234Primigravid women attending hospital antenatal clinics; 350 women recruited; 278 agreed to participate; 63 delivered with instrumental delivery excluded; 200 normal vaginal deliveries and 15 caesarean sections included; additional 19 caesarean sections recruited postnatally; total 34 caesarean sectionsNormal vaginal delivery; caesarean sectionModified Pescatori incontinence score6 weeks
Donnelly et al.33 (1998)184All primiparous women attending antenatal clinics in Dublin, Ireland informed of study; 290 agreed to initial interview; 47 (19%) declined to take part; 24 (8%) excluded because of pre-existing disease; 12 lost to follow up; 19 declined to take part postnatally; 1 IUD and 3 fetal congenital abnormalities were not asked to continue participation in studyGestation at onset of labour; mode of delivery; induction of labour; augmentation of labour and duration of oxytocic; analgesia use; occipitoposterior position; duration of active and passive second stage; duration of first stage; degree of perineal injury; episiotomy; manual removal of placenta; birthweight; fetal length; fetal BMI; fetal sex; fetal head circumferenceUsed Pescatori et al. questionnaire6 weeks
Meyer et al.34 (1998)149149 women recruited; acceptance rate ‘approximately 80%’Mode of deliveryClassed as: grade 1, incontinence of flatus; grade 2, incontinence of liquid stools; grade 3, incontinence of solid stools7–11 weeks
Rieger et al.35 (1997)18Women over 18 years, nulliparous with no history of incontinence or anorectal symptoms. Had no evidence of an injury to the pelvic floor or anal sphincter during deliveryMode of delivery; perineal traumaNot explicitly defined4–6 weeks
MacArthur et al.36 (1997)8771667 women delivering in Birmingham were sent questionnaires about postnatal health; 1606 were assumed to have received a questionnaire (not returned by the Post Office); 1278 responded to a questionnaire (80%); 1156 were contacted and 906 (78%) agreed to be interviewedParity; age; induction of labour; mode of delivery; perineal trauma; length of first stage of labour ≥ 10 hours; length of second stage of labour ≥ 2 hours; length of active second stage of labour ≥ 2 hours; birthweight ≥ 4000 g; head circumference ≥ 36 cmLoss of bowel control ‘no warning that she wanted to go’ (frank incontinence); soiling or staining of the underwear; or ‘felt the need to go but could not hold on’ (urgency)10 months
Crawford et al.37 (1993)70Primiparous women, 35 with anal sphincter rupture and 35 without, following vaginal deliveryOASIIncontinence of flatus, liquid or formed stool9–12 months
image

Figure 2. Quality assessment.

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Table 2.  Quality assessment of included studies on anal incontinence after childbirth
Author and yearStudy designRecruitment of study subjectsMethod of ascertainment of risk factorMethod of ascertainment of outcomeTemporality of associationControls for confoundingList of confounding factors
  1. BMI, body mass index; OASI, obstetric anal sphincter injury; RCT, randomised controlled trial.

Liebling et al.19 (2004)Prospective cohort but symptoms retrospectiveConsecutive women requiring operative delivery at full dilatationHospital recordsSelf-reported questionnaire; reported in paper as validated but on close inspection has been used widely in other studies but has not been formally validatedNoNoNot applicable
Peschers et al.20 (2003)Both women and symptoms identified retrospectivelyConsecutive women delivering by ventouse with matched controlsInterviewInterview, not stated if validatedYesYesFetal weight; episiotomy; perineal trauma
Fitzpatrick et al.21 (2003)Women identified antenatally but symptoms retrospectiveNot statedLabour partogramSelf-reported questionnaire? validated Jorge22Not statedNoNot applicable
Lal et al.23 (2003)Retrospective; case–control184 consecutive caesarean sections then matched controlsNot statedQuestionnaire with interviewer at home; questionnaire validatedYesMatched controlsAge; parity; catchment area; race; period of delivery
Eason et al.24 (2002)Women identified antenatally but symptoms retrospectiveConvenience; used for RCT of perineal massage and data usedMedical recordsSelf-reported postal questionnaire, not stated if validatedYesNoNot applicable
MacArthur et al.25 (2001)Both women and symptoms identified retrospectivelyConsecutiveHospital recordsSelf-reported postal questionnaire, not stated if validatedNoYesMaternal age; pre-pregnancy BMI; induction of labour; mode of delivery; perineal trauma; birthweight; study centre; Asian ethnic origin
Farrell et al.26 (2001)Women identified antenatally but symptoms retrospectiveWomen were recruited during routine antenatal visits—no further information givenHospital recordsSelf-reported questionnaire but contacted by telephone about any omissions, not stated if validatedYesYesForceps delivery; type of perineal repair; duration of labour
Meyer et al.27 (2000)Women identified antenatally but symptoms retrospectiveConsecutiveNot statedHistory of anal incontinence taken by interviewerYesNoNot applicable
Faltin et al.28 (2000)Women identified immediately postnatal. Symptoms retrospectiveWomen agreeing to participate in study of endoanal ultrasound immediately postpartumFrom previous studySelf-reported postal questionnaire; validated; Osterberg et al.38YesNoNot applicable
Damon et al.29 (2000)Women identified after delivery, symptoms evaluated retrospectivelyConsecutive primiparous women having a vaginal deliveryNot stated‘Clinical symptoms’Not statedNoNot applicable
Chaliha et al.30 (1999)Women identified antenatally but symptoms retrospectivelyNot statedPatient recordsInterview, not stated if validatedNoNoNot applicable
Groutz et al.31 (1999)Women identified as delivered but symptoms retrospectiveConsecutiveHospital recordsTelephone questionnaire by one author, not stated if validatedNo; all developed de novo incontinence after delivery except one womanNoNot applicable
Fynes et al.32 (1998)Women identified antenatally but further women needed in caesarean section group and these were identified postnatallyNoNot explicitly statedSelf-reported questionnaireYesNoNot applicable
Donnelly et al.33 (1998)Women identified antenatally but symptoms retrospectiveSelf-selectingLabour ward partogramsSelf-reported questionnaireYesMultiple logistic regressionEpidural analgesia; length of second stage; instrumental vaginal delivery
Meyer et al.34 (1998)Women identified antenatally but symptoms retrospectiveConsecutiveNot statedHistory of anal incontinence taken by interviewerNoNoNot applicable
Rieger et al.35 1997Women recruited antenatally but symptoms retrospectiveNot stated as subset of women from larger studyNot statedNot statedYesNoNot applicable
MacArthur et al.36 (1997)Both women and symptoms identified retrospectivelyConsecutiveHospital recordsInterview at home, not stated if validatedYesNoN/A
Crawford et al.37 (1993)Women identified postnatally and symptoms evaluated retrospectivelyWomen with OASI and then matched controls contacted by telephone to ask for consentHospital recordsTelephone interview, not stated if validatedNot statedControlled for confounding; with OASI but not with; incontinenceNot applicable

Women having any type of vaginal delivery compared with a caesarean section had an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47–2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04–1.68, P = 0.02).

Instrumental deliveries also resulted in more symptoms of anal incontinence compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22–1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19 to1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97–1.77, P = 0.08).

When studies examining severe symptoms of anal incontinence such as solid or liquid anal incontinence were analysed, although there was a trend towards more symptoms with vaginal delivery compared with caesarean section, this did not reach statistical significance. Only instrumental delivery compared with spontaneous vaginal delivery reached statistical significance for increased symptoms of solid and liquid anal incontinence (OR 1.91, 95% CI 1.00–3.67, P = 0.05).

Similarly, when comparing forceps and ventouse deliveries, when symptoms of flatus incontinence are included, forceps caused significantly more symptoms (OR 1.51, 95% CI 1.07–2.13, P = 0.02), but this difference between the instruments disappeared when analysed for solid and liquid anal incontinence alone (OR 1.63, 95% CI 0.26 to10.02, P = 0.06).

The results are displayed graphically in (Figure 3) and tabulated in (Tables 3 and 4).

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Figure 3. The effect of mode of delivery on symptoms of anal incontinence (the constituent studies are detailed in Tables 3 and 4). SVD, spontaneous vaginal delivery.

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Table 3.  Results from studies on aetiology of solid, liquid or flatus incontinence following childbirth
StudyExposureNot exposedExposed with incontinence/total exposed (%)Not exposed with incontinence/total not exposed (%)OR (95% CI)
  1. SVD, spontaneous vaginal delivery.

1.ForcepsCaesarean section 
MacArthur et al.25 (2001)ForcepsCaesarean section (el + em)89/654 (13.6)84/1140 (7.4)1.98 (1.44–2.71)
Groutz et al.31 (1999)ForcepsCaesarean section1/3(33.33)1/22 (4.55)10.50 (0.46–239.78)
2.InstrumentalCaesarean section 
MacArthur et al.25 (2001)InstrumentalCaesarean section123/983 (12.51)84/1140 (7.4)1.80 (1.34–2.41)
Groutz et al.31 (1999)InstrumentalCaesarean section11/43 (25.58)1/22 (4.55)7.22 (0.87–60.13)
3.VentouseCaesarean section 
MacArthur et al.25 (2001)VentouseCaesarean section34/329 (10.3)84/1140 (7.4)1.45 (0.95–2.21)
Groutz et al.31 (1999)VentouseCaesarean section10/40 (25)1/22 (4.55)7.00 (0.83–59.90)
4.SVDCaesarean section 
MacArthur et al.25 (2001)SVDCaesarean section474/4963 (9.6)84/1140 (7.4)1.32 (1.04–1.69)
Groutz et al.31 (1999)SVDCaesarean section9/235 (3.83)1/22 (4.55)1.20 (0.14–9.90)
5.ForcepsSVD 
MacArthur et al.25 (2001)ForcepsSVD89/654 (13.6)474/4963 (9.6)1.49 (1.17–1.90)
Faltin et al.28 (2000)Forceps (single instrument)SVD4/35 (11.43)11/88 (12.5)0.90 (0.27–3.05)
Damon et al.29 (2000)ForcepsSVD9/14 (63.29)15/38 (39.47)2.76 (0.77–9.85)
Groutz et al.31 (1999)ForcepsSVD1/3 (33.33)9/235 (3.83)12.56 (1.04–151.62)
6.InstrumentalSVD 
Peschers et al.20 (2003)VentouseSVD15/50 (30.0)17/50 (34)1.20 (0.52–2.79)
MacArthur et al.25 (2001)InstrumentalSVD123/983 (12.51)474/4963 (9.6)1.35 (1.10–1.67)
Faltin et al.28 2000InstrumentalSVD11/56 (19.64)11/88 (12.5)1.71 (0.69–4.26)
Damon et al.29 (2000)ForcepsSVD9/14 (63.29)15/38 (39.47)2.76 (0.77–9.85)
Groutz et al.31 (1999)InstrumentalSVD11/43 (25.58)9/235 (3.83)8.63 (3.32–22.44)
7.VentouseSVD 
Peschers et al.20 (2003)VentouseSVD15/50 (30.0)17/50 (34)1.20 (0.52–2.79)
MacArthur et al.25 (2001)VentouseSVD34/329 (10.3)474/4963 (9.6)1.09 (0.76–1.58)
Faltin et al.28 (2000)Ventouse (single instrument)SVD5/19 (26.31)11/88 (12.50)2.50 (0.75–8.31)
Groutz et al.31 (1999)VentouseSVD10/40 (25.0)9/235 (3.83)8.37 (3.15–22.25)
8.ForcepsVentouse 
Fitzpatrick et al.21 (2003)ForcepsVentouse36/61 (59.01)23/69 (33.33)2.88 (1.41–5.89)
MacArthur et al.25 (2001)ForcepsVentouse89/654 (13.6)34/329 (10.3)1.37 (0.90–2.08)
Faltin et al.28 (2000)Forceps (single instrument)Ventouse4/35 (11.43)5/19 (26.32)0.36 (0.08–1.55)
Groutz et al.31 (1999)ForcepsVentouse1/3 (33.33)10/40 (25)1.50 (0.12–18.36)
Table 4.  Results from studies on aetiology of solid and liquid faecal incontinence following childbirth
StudyExposedUnexposedExposed with incontinence/total exposed (%)Not exposed with anal incontinence/total not exposed (%)OR (95% CI)
  • SVD, spontaneous vaginal delivery.

  • *

    More than one data set available, data for 12 months postnatal used.

  • **

    More than one data set available, data for 10 months postnatal used.

1.ForcepsCaesarean section 
Eason et al.24 (2002)ForcepsCaesarean section3/74 (4.05)2/114 (1.75)2.37 (0.39–14.51)
Meyer et al.34 (1998)ForcepsCaesarean section1/25 (4.0)0/33 (0)
2.Instrumental deliveryCaesarean section 
Liebling et al.19 (2004) 12/12 PN*InstrumentalCaesarean section4/147 (2.72)4/167 (2.40)1.53 (0.34–6.95)
Eason et al.24 (2002)InstrumentalCaesarean section5/153 (3.27)2/114 (1.75)1.89 (0.36–9.93)
Donnelly et al.33 (1998) O&GInstrumentalCaesarean section5/22 (22.73)0/16 (0)
Meyer et al.34 (1998)ForcepsCaesarean section1/25 (4.0)0/33 (0)
3.VentouseCaesarean section 
Eason et al.24 (2002)VentouseCaesarean section2/79 (2.53)2/114 (1.75)1.45 (0.20–10.55)
4.SVDCaesarean section 
Eason et al.24 (2002)SVDCaesarean section21/681 (3.08)2/114 (1.75)1.78 (0.41–7.70)
Donnelly et al.33 (1998) O&GSVDCaesarean section2/146 (1.37)0/16 (0)
Fynes et al.32 (1998)SVDCaesarean section3/200 (1.5)0/34 (0)
Meyer et al.34 (1998)SVDCaesarean section5/81 (6.17)0/33 (0)
5.ForcepsSVD 
Eason et al.24 (2002)ForcepsSVD3/74 (4.05)21/681 (3.08)1.33 (0.39–4.56)
Meyer et al.27 (2000) 10/12 PN**ForcepsSVD1/25 (4)4/82 (4.88)0.81 (7.62)
Crawford et al.37 (1993)ForcepsSVD1/15 (6.67)0/55 (0)
6.InstrumentalSVD 
Peschers et al.20 (2003)VentouseSVD4/50 (8)4/50 (8)1.00 (0.24–4.24)
Eason et al.24 (2002)InstrumentalSVD5/153 (3.27)21/681 (3.08)1.06 (0.39–2.86)
Donnelly et al.33 (1998) O&GInstrumentalSVD5/22 (22.73)2/146 (1.37)21.18 (3.81–117.69)
Crawford et al.37 (1993)ForcepsSVD1/15 (6.67)0/55 (0)
7.VentouseSVD 
Peschers et al.20 (2003)VentouseSVD4/50 (8)4/50 (8)1.00 (0.24–4.24)
Eason et al.24 (2002)VentouseSVD2/79 (2.53)21/681 (3.08)0.82 (0.19–3.55)
8.ForcepsVentouse 
Eason et al.24 (2002)ForcepsVentouse3/74 (4.05)2/79 (2.53)1.63 (0.26–10.02)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information

This is the first systematic review of the obstetric factors associated with the occurrence of symptoms of anal incontinence in the first year postpartum. The mode of delivery appeared to influence the occurrence of symptoms of anal incontinence in the first year postpartum. However, the results are only statistically significant when incontinence of flatus is included in the analysis. When symptoms of solid and liquid anal incontinence are analysed alone, although there appears to be a trend towards increased symptoms with vaginal delivery compared with caesarean section, and with forceps or ventouse when compared with spontaneous vaginal delivery, this does not reach statistical significance.

The validity of the findings of this review is dependent on the rigor of its methodology.9 A prospective protocol was used and a concerted effort was made to identify all the available evidence in English. It met quality criteria laid down in the Meta-analysis of Observational Studies in Epidemiology statement.9 Additionally, continence data following delivery were available for 12 237 women, making this a very large cohort. Hence, this systematic review provides the most reliable evidence available on symptoms of anal incontinence according to mode to delivery in the first year postpartum.

The methodological quality of the included studies was poor. The studies were heterogeneous with variation in follow-up intervals, differing definitions for anal incontinence, variable inclusion of women with and without clinical sphincter disruption and inconsistencies in controlling/discussion of predelivery continence. Nonstandard measurement tools were used to record outcome, and this may have introduced bias.

A further potential source of bias were studies that recruited women following delivery as women at higher risk of anal incontinence may have been preferentially encouraged to enter the study. In 7 of the 18 studies (39%), women were recruited following delivery. In the symptom category of solid, liquid or flatus incontinence, six of the seven studies recruited women following delivery, with only 130 women from 7791 (1.67%) selected antenatally, regardless of delivery factors.

This systematic review provides compelling evidence of an association between mode of delivery and anal incontinence, but this does not necessarily confirm cause and effect. Mode of delivery may be a surrogate marker for other factors such as long labour or increased infant birthweight. The data gained from this systematic review need to be interpreted with care in the clinical situation. There is currently insufficient evidence to advocate caesarean section for reduction in major symptoms of incontinence in women without antenatal symptoms of anal incontinence.

Elucidating risk factors associated with postpartum anal incontinence enable development of studies that determine causation. In unravelling the aetiology of childbirth-related anal incontinence, studies need to be able to differentiate between pre-existing factors, which predispose women to anal incontinence and factors that occur at delivery, whether neurological39 or mechanical.7

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Supporting Information

The following supplementary materials are available for this article:

Appendix S1. Search strategy for Chapter 2 using Ovid to search Medline and Embase.

Appendix S2. The QUOROM statement checklist.

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