MONTREAL — Obstetric anal sphincter injuries can cause fecal incontinence for decades, and also may wreak havoc on a couple's sex life, according to Jan Willem de Leeuw, M.D., a consultant ob.gyn. from the Ikazia Ziekenhuis hospital in Rotterdam, the Netherlands.
“Women told us that they were very surprised that we were asking about fecal incontinence during sex, but that it was a real problem. The women who were incontinent during intercourse and other sexual behavior were very reluctant to engage in sexual activity,” Dr. de Leeuw said in an interview.
In a study he presented at the annual meeting of the International Continence Society, Dr. de Leeuw identified 171 women who were surgically treated for obstetric anal sphincter injuries immediately after delivery from 1971 to 1990.
In 1995, these women and 131 controls, who were matched for parity and date of delivery, were mailed a questionnaire that asked about fecal and urinary incontinence. Women who responded were then sent a second similar questionnaire about 10 years later that contained additional questions about sexuality. The median follow-up period was 24 years.
Responses from the first questionnaire showed that the prevalence of anorectal complaints was much higher in the patients who had sphincter injury, compared with controls (40% vs. 15%). Similarly, fecal incontinence, urgency, and soiling were reported by 31%, 26%, and 10% of the patients, respectively, compared with 13%, 6%, and 1% of the controls.
Ten years later, the second questionnaire produced similar responses. Anorectal complaints were reported by 64% of sphincter injury patients, compared with 24% of controls. Fecal incontinence, urgency, and soiling were reported by 56%, 31%, and 15% of sphincter injury patients, respectively, compared with 16%, 12%, and 4% of controls.
Unlike the prevalence of urinary incontinence, which tends to equalize with increasing age between women who have delivered vaginally and those who have not, there was no such effect seen with fecal incontinence, Dr. de Leeuw said.
Perhaps the most interesting finding was the “hidden problem” of fecal incontinence during sex, he said. Few physicians think to ask about this, yet 13% of the sphincter injury patients reported this problem, compared with none of the controls.
In addition, superficial dyspareunia was more common in the patients (22%), compared with the controls (9%).
Menopausal status appeared irrelevant. “Our results do not corroborate the widespread theory that postmenopausal status has a deteriorating effect on these complaints,” he said.
Of the sphincter injury patients who were free of anorectal complaints at the first questionnaire, 46% developed anorectal complaints by the second questionnaire—but only 32% of these women were postmenopausal, he said.
The study's findings about the long-lasting and intimate consequences of obstetric sphincter damage underscore the need for primary prevention of these injuries, he said.
“This is of primary importance. I am still waiting for the randomized trial between midline and mediolateral episiotomies, because I think that midline episiotomies are a major risk factor, and this is quite common in the United States. I don't understand it.”