Management of Obstetric Anal Sphincter Injuries

A 50-year-old woman was referred with a several-year history of fecal incontinence, urgency, and peri-anal discomfort. These symptoms were having a significant impact on her quality of life. She reported FI to both liquid stool and air, associated with urgency. Her Cleveland Clinic Fecal Incontinence score was 15. Her medical history was significant for 3 vaginal deliveries 18 months apart beginning at the age of 25. Her first 2 deliveries were precipitous labors; however, her last SVD at 29 years-old was complicated by a prolonged second stage of labor with a forceps delivery resulting in a "tear."The patient reported it was repaired in her labor room. Physical examination was remarkable for reduced anal sphincter tone; however no overt anatomical deformity was seen. Conservative measures including fiber supplementation and pelvic floor rehabilitation had only partially improved her symptoms. Endoanal ultrasound demonstrated a partial external anal sphincter defect of 30%, extending from 9'oclock to 12 o'clock position. She underwent a successful a sphincteroplasty, using an over lapping technique with PDS. Post operatively laxatives were used for 6 weeks, at which time the patient recommenced pelvic floor physiotherapy. Follow-up 3 months postoperatively demonstrated her Cleveland Clinic Fecal Incontinence score decreased to 6.