Long-term postpartum anal incontinence – prevalence, risk factors and effect of conservative management

Obstetric anal sphincter injury (OASIS) is the main risk factor for short and long-term postpartum symptoms of anal incontinence (AI, leakage of stool, gas, and/or urgency) in women.

Anal incontinence significantly affects quality of life in social and family settings. Due to embarrassment, few anal incontinence sufferers reveal their symptoms voluntarily unless asked directly.

Costs of anal incontinence include medical care and treatment, as well as indirect costs such as loss of productivity and reduced work capacity.

Anal incontinence prevalence increases with age, and the world wide burden of AI is expected to increase with rising life expectancy.

Thus, recent national and international maternity care guidelines focus on prevention, adequate primary diagnostics, and suturing, and recommend postpartum conservative follow up including pelvic floor muscle training as first line management despite scarce evidence of the treatment effect.

Three work packages

Our overall aim is to improve postpartum maternity care by work package 1 and 2 documenting short and long-term incontinence symptoms and impact on quality of life following OASI.

Work package 3 explores the effect of conservative management including pelvic floor muscle training in a randomized controlled trial among women with postpartum anal incontinence.

Our results will add to the current evidence base and improve maternity care guidelines. Moreover, the results may improve the short and long-term impact on quality of life for the mother and her family as well as reduce personal and societal costs.

Aim to optimize postpartum care

Our main study aim is to optimize postpartum care following obstetric anal sphincter injury (OASI).

OASI is of major concern for women due to the association with short- and long-term anal incontinence (AI), and other pelvic floor disorders such as urinary incontinence, and sexual dysfunction.

In particular, anal incontinence is associated with stigma and taboo, restricts women in their daily activities, and quality of life is lower among women experiencing the combination of more than one pelvic floor disorder.

Few postpartum women talk openly about their pelvic floor symptoms unless asked directly, and estimations show that only one in four AI-suffers seek medical care.

The prevalence of anal incontinence increases with increasing age, and due to an ageing population, the prevalence, direct and indirect costs related to medical expenses and loss of productivity in paid and unpaid work are expected to rise in the future.

This study will describe women’s symptoms and how these symptoms affect women’s quality of life in the short- and long-term following OASI, and extend the knowledge about prevalence and risk factors of anal incontinence among medical doctors, midwives and women’s health physiotherapists.

Room for improvement in maternity care

There is room for improvement in maternity care of postpartum women experiencing symptoms of anal incontinence and co-existing pelvic floor disorders, and a need for high level evidence regarding the effect of conservative management of anal incontinence.

One of the main conservative management options available for postpartum anal incontinence, is pelvic floor muscle training, considered to be the first line treatment in recent national and international maternity care guidelines due to the non-invasive and inexpensive nature.

The evidence base for treatment effect of pelvic floor muscle training for postpartum anal incontinence in women with or without OASI is limited, but some studies show promising results.

Østfold Hospital Trust have routinely referred women sustaining OASI after vaginal delivery for routine follow-up.

The unique data material systematically collected for almost 15 years at Østfold Hospital Trust will allow us to describe the short-term consequences of OASI and anal incontinence.

Moreover, our study will improve the knowledge on the effect of pelvic floor muscle training as treatment for anal incontinence in general and after sustaining an OASI in particular.

Evaluation of the effect of pelvic floor training will

• update the existing evidence in the national and international maternity care guidelines
• potentially generate more awareness about symptoms and consequences of pelvic floor disorders following OASI among health professionals and the general public
• encourage open dialogue between health care providers and patients

This will result in a more optimal management for these suffering women.

St. Olav's Hospital, Trondheim University Hospital