Anale Sphinkterschäden nach vaginaler Geburt und deren Auswirkung auf die anale Kontinenzleistung
Disturbance of anal continence is a well known problem after vaginal delivery. Anal incontinence is not restricted to patients with third- and forth- degree obstetric perineal ruptures. The introduction of anal endosonography led to the recognition of unsuspected defects in continent women thought to have an intact perineum by clinical examination. This fact has not escaped the attention of obstricians. Only few and incongruent data on the incidence and pathogenesis of postpartum incontinence are available. Therefore it was the aim of the present study to evaluate and characterize the effects of vaginal delivery on anal continence prospectively. On 72 unselected women anal vector manometry, endoanal ultrasound, measurement of the pudendal-nerve terminal motor latency (PNTML) and rectal sensibility was performed in the 32th week of pregnancy and after delivery. Continence was evaluated according to the Kelly-Holschneider-Score. Patients with occult anal sphincter defects were additionally followed-up additionally 12 weeks after delivery. To exclude any influence of pregnancy only, 10 patients with elective caesarian section served as controls. After delivery continence did not change significantly when compared with the pre-delivery evaluation. However, there was a significant reduction of postpartum anal squeeze and resting pressures in all patients. PNTML and rectal sensibility were not influenced by vaginal delivery. Additionally endosonography revealed occult lesions of the internal and external anal sphincter on 19% of women who clinically seemed to have an intact sphincter. It was not possible to find an influence between the different modes of delivery and the risk for lesions of the sphincter ani. Episiotomie and vaginal-operative delivery (forceps/ vacuum) increased the risc for obstretric tears and fecal incontinence. After caesarian section there were no changes of continence, anal pressures, rectal sensibility or PNTML. Apparent and occult sphincter tears and also the distension of the pudendal nerve during delivery seemed to be responsible for anal incontinence. The prevalence of occult sphincter tears is not influenced by episiotomy, sphincter tears I° or II°, or vaginal deliveries. There is no correlation between occult defects and bowel symptoms, indicating that the young women initially have sufficient residual sphincter function to maintain continence. The cumulative effects of other factors, such as subsequent deliveries, effects of aging and the menopause may cause sphincter insufficiency in the long term. The episiotomy is not aible to protect against sphincter tears. After midline episiotomy the risc of sphincter tears III° and IV° is increased and deteriorate the sphincter function. The restrictive indication for episiotomy can minimise the incidence of anal sphincter damage. It is very important to inform women about the problem of fecal incontinence after vaginal delivery and to show the benefit of prophylactic biofeedback training. In case symptoms of incontinence occur an additional sphincter repair is advisable.
info:eu-repo/classification/ddc/610, Medizin, Inkontinenz, okkulte Sphinkterschäden
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