Long-Term Outcome of Delayed

Primary or Early Secondary

Reconstruction of the Anal Sphincter
ORIGINAL after Obstetrical Injury
CONTRIBUTIONS
Mette M. Soerensen, M.D.1  Karl M. Bek, M.D., Ph.D.2 
Steen Buntzen, M.D., D.M.Sci.1  Karen-Elise Højberg, M.D., Ph.D.2 

Søren Laurberg, Prof., M.D., D.M.Sci.1

1 Surgical Research Unit Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
2 Department of Gynaecology and Obstetrics Y, Aarhus University Hospital, Brendstrupgårdsvej, Denmark

PURPOSE: Traditionally sphincter repair has not been
performed during the puerperium. This prospective study
was designed to determine the long-term outcome of
delayed primary or early secondary sphincteroplasty in
the puerperium.
METHODS: Between 1991 and 2005, 22 females underwent
delayed primary or early secondary repair after third-
degree or fourth-degree anal sphincter rupture. Delayed
primary reconstruction was performed more than
72 hours after delivery. Early secondary reconstruction
was performed within 14 days postpartum. The recon-
struction of the anal sphincter was performed without a
covering stoma, in all cases. A control group of 19 age-
matched and parity-matched females, without known
anal sphincter injury after vaginal delivery, were included.
Current degree of continence and associated quality of life
were determined by a fecal incontinence severity ques-
tionnaire and a quality of life questionnaire.
RESULTS: None of the females had complications post-
operatively. Mean follow-up was 50 (range, 2–155)
months in the case group and 60 (range, 12–132) months
in the control group. At time of follow-up, the Wexner
score was 4.1 (range, 0–13) in females with delayed
primary or early secondary reconstruction and 1.1 (range,
0–8) in the control group (P<0.01). The inconvenience of
incontinence after reconstruction was significantly higher
(P<0.01) compared with the control group, but the
quality of life was not significantly affected (P=0.75).
CONCLUSIONS: It is safe to perform a delayed primary or
early secondary reconstruction without a covering stoma
in females who have sustained a third-degree or fourth-
Poster presentation at the meeting of European Society of Coloproctology
(ESCP), Lisbon, Portugal, September 13 to 16, 2006.
Address of correspondence: Mette M. Soerensen, M.D., Department of
Surgery P, Aarhus University Hospital, Tage-Hansens Gade 2, DK-8000,
Aarhus, Denmark. E-mail: soerensen_mette@dadlnet.dk
degree obstetric tear. The long-term functional outcome
is acceptable.
KEY WORDS: Anal sphincter repair; Fecal incontinence;
Early secondary sphincteroplasty; Delayed primary repair;
Quality of life.
bstetric anal sphincter tear at vaginal delivery is a
O serious complication, and it is frequently associated
with fecal incontinence.1 The fecal incontinence may be
caused by a combination of injury to the anal sphincter
muscles, the pelvic floor, and/or pudendal neuropathy.
Sphincter injury occurs in 3 to 4 percent of all vaginal
deliveries. The majority of these females subsequently
develop varying degrees of anal incontinence.2–5
Generally primary reconstruction of the anal sphincter
is performed immediately after delivery. When primary
repair fails, a secondary sphincteroplasty can be performed,
traditionally after three to six months.6 Two former studies
have described short-term outcome after early secondary
repair of third-degree and fourth-degree perineal lacera-
tion.7,8 The long-term outcome is still unknown.
This study was deigned to determine the long-term
outcome of delayed primary or early secondary sphincter
repair of third-degree and fourth-degree obstetric tears
compared with an age-matched and parity-matched
control group. The outcome was assessed by using the
Wexner Continence Grading Scale,9 the St. Mark’s
incontinence score,10 and by evaluating the extent of
inconvenience and impact on the quality of life.
PATIENTS AND METHODS
Between February 1991 and March 2005, a total of 22
females underwent delayed primary or early secondary
reconstruction of the anal sphincter after obstetric injury.
Eighteen females gave birth at the University Hospital of
Aarhus; four gave birth at county hospitals and afterward
referred.

312 DOI: 10.1007/s10350-007-9084-4  VOLUME 51: 312–317 (2008)  ©THE ASCRS. 2007
SOERENSEN ET AL .: LONG - TERM O UTCOME OF S PHINCTER R EPAIR 313

Of the 22 females, 18 had a third-degree and 4 had a

fourth-degree sphincter laceration. Eighteen females were
primiparous: one had one previous vaginal delivery, and
two had a previous cesarean delivery. One female had two
previous vaginal deliveries with a third-degree tear at the
first delivery; the sphincter was not affected by the second.
At final follow-up, 15 (71.4 percent) females have had
no further deliveries. One was pregnant, two have had a
second vaginal delivery, and one had two. Two females
had a cesarean at second delivery.
An age-matched and parity-matched control group of
19 females were consecutively included. The inclusion
was performed by two general practitioners. Females were
included if the reason for the consultation was a smear
test or a scheduled child examination. Females with
known anal sphincter injury after vaginal delivery were
excluded. Eight were primiparous, ten had two vaginal
deliveries, and one had three previous deliveries.
At time of final follow-up, all questionnaires were
returned. One case was excluded because of inadequate
language skills to complete the questionnaire. Twenty-one
cases and 19 control subjects were included for analysis at
time of follow-up. None of the included participants FIGURE 1. Four-degree perineal laceration with dehiscence of
primary reconstruction and plenty of granulation tissue (A). The torn
suffered from diabetes, inflammatory bowel disease, ends of the dental line are marked with arrows (B).
anorectal diseases, or neurologic disorder.
Delayed primary reconstruction was defined as recon-
struction of the anal sphincter performed more than In early secondary repair, the previous repair was
72 hours after the vaginal delivery. In the majority of completely taken down and the wound was fully exposed.
females, the main symptoms were severe incontinence in Initially all necrotic and granulation tissue were removed
the puerperium, urgency, or sense of bearing down. In (Figs. 1 and 2). In fourth-degree perineal laceration, the
this study primary reconstruction was performed within anal epithelium was repaired separately by means of
three to six days after delivery. One patient had evident running submucosal sutures 2–0 Vicryl. When the
infection at time of operation. internal anal sphincter was involved, this was separately
Early secondary repair was performed after 6.6 (range, repaired followed by reconstruction of the external
1–15) days. The definition of early secondary repair was sphincter (Fig. 3). The torn ends of the external anal
reconstruction of the anal sphincter within 14 days after sphincter were identified and if necessary mobilized until
delivery. The main indication for early secondary recon- it could be approximated without tension. Reconstruction
struction was poor functional outcome, dehiscence of was performed by end-to-end approximation technique
primary reconstruction, or hematoma (n=5). Four patients (Fig. 4). The bulbocavernosus muscle and the superficial
had evident infection. There were no cases of wound transverse perineal muscle were identified and recon-
breakdown, septic complications, or fistula afterward. structed separately. Repairs were performed with a 2–0
Before reconstruction all females underwent a clinical long-lasting monofilament absorbable suture with two to
examination and an anal endosonography to confirm the four interrupted sutures in the muscle body. An inter-
lesions. All repairs were performed by one of two senior rupted 2–0 Vicryl suture was used to close the vaginal
obstetricians and in some cases in collaboration with a epithelium and the perineal skin (Fig. 5).
senior colorectal surgeon experienced in sphincter surgery. Postpartum care of the perineal laceration was stan-
A sphincter defect was confirmed at operation in all cases. dardized and included baths twice daily of the perineum
The reconstructions of the anal sphincter were all and baths after defecation as well as stool softeners. The
conducted under general anesthesia, in the operating patients were not allowed to carry their child as long as
room. There was no use of bowel preparation, and they they had sense of bearing down, and they were prohibited
were all performed without a covering stoma. Perioperative to sit for five days. All females were instructed by a
coverage with intravenous antibiotics (Cefuroxim 3 g i.v. physiotherapist to perform pelvic floor exercises from the
or Clindamycin 600 mg i.v. + Metronidazole 1.5 g i.v.) was first day postoperative and encouraged to continue these
used. In the five cases with obvious infection, antibiotics after discharged. All females were clinically examined the
were continued for five days postoperatively. seventh postoperative day.
314
FIGURE 2. The previous repair is completely taken down and the
wound fully exposed. All necrotic and granulation tissue is removed.
The superficial transverse perineal muscle (A), internal (B), and
external (C) anal sphincter are identified.
Five months postpartum all 22 females were reex-
amined by one consultant, including a clinical examina-
tion with digital examination of the anal canal and an anal
endosonography to estimate the integrity of the anal
sphincter and perineal body. If necessary, the females
were referred to a senior colorectal surgeon specialized in
anal physiology for a second opinion.
All females were interviewed about fecal incontinence,
urinary incontinence, urgency, dyspareunia, and postop-
FIGURE 3. Reconstruction of the internal anal sphincter (C)
separately. The torn ends of the external anal sphincter are identified
(A, B).
SOERENSEN ET AL .: L ONG -TERM OUTCOME OF SPHINCTER R EPAIR
FIGURE 4. Reconstruction of the external anal sphincter.
erative complications, especially symptoms that indicated
development of a rectoperineal fistula. No questionnaire
was used at that time. In addition, the females were asked
if they thought further treatment or evaluation at the
anorectal physiology unit was required.
For this study a final follow-up was performed by using
a questionnaire distributed by mail. Reminders were sent
after four weeks. The questionnaire recorded in detail the
current bowel function and continence as well as the
current restriction in activities related to bowel control
and current inconvenience of their way of life (quality of
life). We specifically addressed fecal urgency. The symp-
FIGURE 5. Closure of the perineal skin.
SOERENSEN ET AL .: LONG - TERM O UTCOME OF S PHINCTER R EPAIR
toms of anal incontinence were recorded and assessed by
the Wexner Continence Grading Scale9 and the St. Mark’s
incontinence score.10
Methods for statistical analyses included a Mann-
Witney U-test to assess nonpaired data and the Fisher’s
exact test. The limit of significance was chosen at < 0.05.
RESULTS
Twenty-two females with a mean age of 31 (range, 22–38)
years were treated with delayed primary or early second-
ary reconstruction of the anal sphincter after obstetrical
injury. At final follow-up, the mean time from sphincter
reconstruction was 50 (range, 2–155) months.
The control group had a mean age of 35 (range, 28–40)
years at time of inclusion. The mean time since last
vaginal delivery was 60 (range, 12–132) months.
Outcome at Five-month Follow-up
Twelve of the 22 females were classified as continent, 9
had symptoms of gas incontinence, and 1 had inconti-
nence of liquid stool. One female had symptoms of
urgency. Two females developed an anterior anal fissure:
one healed spontaneously and the other had a chronic
anal fissure and was referred to a colorectal surgeon. Two
females complained of dyspareunia but none of the
females complained of perineal pain. There were no cases
of rectovaginal or rectoperineal fistula, abscess, or
rerupture after secondary repair observed.
No females indicated a need for further treatment.
Three were referred to a senior colorectal surgeon who
specialized in anal physiology for a second opinion
because of incontinence. Two of these were treated with
biofeedback.
Outcome at Time of Final Follow-up
The continence status at time of final follow-up, for
females with delayed primary or early secondary repair
and the age-matched and parity-matched control group,
is reported in Table 1. In females with former anal
sphincter reconstruction, 5 of the 14 females with flatus
incontinence reported this to happen on a weekly basis,
and 4 had daily episodes. Two of three females with
Table 1. Incontinence at time of final follow-up after delayed
primary or early secondary repair compared with an age-
matched and parity-matched control group
Sphincter Control
rupture group
(n=21) (n=19)
Continent 2 7
Flatus incontinence 14 11
Incontinence to liquid stool 3 0
Incontinence to solid stool 2 1
Urgency 11 7
315
incontinence of liquid stool reported weekly episodes,
whereas the last female had it rarely. Of the two females
who reported incontinence of solid stool, one had
episodes weekly and one rarely.
In the control group, 9 of 11 females with flatus
incontinence reported this to happen once per month or
less; 2 females had one to four episodes per month. The
female with incontinence of solid stool had several
episodes during the week.
The mean Wexner score was 4.1 (range, 0–13) for
females with delayed primary or early secondary recon-
struction compared with 1.1 (range, 0–8) in the control
group (P<0.01). The functional results of females who
underwent delayed primary reconstruction were equiva-
lent to the long-term outcome of early secondary
reconstruction. There was no difference between the
results of the two senior obstetricians who performed all
the sphincter reconstructions or for the cases performed
in collaboration with a senior colorectal surgeon.
The distribution of the severity of the anal sphincter
lesions and the Wexner score as a function of time is
illustrated in Figure 6. Females with a fourth-degree tear
had a higher score than females with a third-degree tear
(Wexner: 7 vs. 3.4; St. Mark’s: 9.8 vs. 5.1). There was no
evidence that the effect of reconstruction deteriorates with
time. In fact the Wexner score was higher in the shortest
time of observation, but all the women with a fourth-
degree tear were represented here.
The outcome assessed as symptoms of incontinence
evaluated by the Wexner score is confirmed by the use of
St. Mark’s score. The mean St. Mark’s score was 6 (range,
0–16) in females with delayed primary or early secondary
repair and 2.6 (range, 0–8) in the control group (P<0.01).
The increase in the St. Mark’s score compared with the
Wexner score was caused by urgency, defined as the
inability to defer defecation for more than 15 minutes,
because none of the females in the two groups were taking
constipating medicines and four females used a pad. No
correlation was detected between maternal age at delivery
and the Wexner score at the final follow-up (Fig. 7).
Quality of Life
There was a significant increase (P<0.01) in inconve-
nience of incontinence between females with delayed
primary or early secondary reconstruction (mean score,
1.7; range, 0–3) compared with the control group (mean
score, 0.3; range, 0–1), but there was no significant effect
on quality of life (P=0.75).
Of the 19 females with sphincter reconstruction and
incontinence symptoms, 4 reported major inconvenience
of incontinence (flatus (n=1), liquid stool (n=2), solid
stool (n=1)), 4 had some inconvenience (flatus), 9 had
minor (flatus (n=8), solid stool (n=1)), and 2 had no
(flatus (n=1), liquid stool (n=1)) inconvenience of
incontinence.
316
Wexner
Score
14
Third-Degree Tear
12 Fourth-Degree Tear
10
8
6 repair,3–5,11–13 confirming that females with a history of
4 and incontinence than females with third-degree tears,14
2 although the internal anal sphincter was separately repaired.
0 20 40 60 80 100 120 140 160
Follow-Up
FIGURE 6. Comparison of Wexner score vs. length of follow-up in
females with sphincter reconstruction.
Of the 12 females in the control group with inconti-
nence symptoms, 4 reported incontinence of minor
inconvenience (flatus) and 8 had no inconvenience of
incontinence (flatus (n=7), solid stool (n=1)).
According to quality of life, females with delayed
primary or early secondary reconstruction had little impact
on their quality of life generally. Nine had no affect on
quality of life, six had minor, four had some, and two
major affect on quality of life because of accidental bowel
leakage. Three of 21 females had changed their way of life
because of incontinence. Assessed by their ability to do
preferred activities, two females had changed their weekly
activities because of incontinence: one because of soiling
and one because of gas. A further patient had changed her
activities once per month or less because of soiling. In
general, the females reported “some” limitations in their
ability to do preferred activities.
In the control group, ten (53 percent) of the females
had no affect on quality of life, seven had minor, and two
had some affect on quality of life because of accidental
bowel leakage. None of the females reported limitations in
their ability to do preferred activities and none had
changed their way of life because of incontinence.
DISCUSSION
This study shows that performing delayed primary or
early secondary reconstruction of the anal sphincter
without a covering stoma is a safe procedure with an
acceptable long-term functional outcome when per-
formed at a specialized unit by specialists. Despite this,
we found that an increase in the severity score of
incontinence (Wexner score) had a great impact on the
inconvenience of incontinence (P<0.01), whereas the
quality of life was not significantly affected compared with
a matched control group.
SOERENSEN ET AL .: L ONG -TERM OUTCOME OF SPHINCTER R EPAIR
To our knowledge, this is the first study in which long-
term outcome of delayed primary or early secondary
reconstruction of the anal sphincter is evaluated. Two
previous studies have shown excellent results at three-month
follow-up for early secondary repair of third-degree or
fourth-degree perineal laceration,7,8 but the long-term
outcome has not been published. The long-term outcome
in our study matches those of an immediate primary
fourth-degree tears have a higher rate of bowel symptoms
Malouf et al.12 reported that the initial results after
secondary reconstruction of the anal sphincter were good;
however, at five years only 50 percent had satisfactory
continence. In this study, there is no evidence that the
functional outcome deteriorates with time, when evaluated
as a cross-sectional survey. However, the interpretation
should be cautious and reassessment must be conducted in
five to ten years to consolidate this.
The conventional recommendation of sphincter repair
is “if early repair is not undertaken, repair should be
delayed at least six months to allow resolution of local
inflammation and maturation of scar tissue.”6 This
recommendation is founded in fear of the postoperative
complications and a worse functional result. Our results
show that the long-term outcome of delayed primary or
early secondary reconstruction is acceptable compared with
an age-matched and parity-matched control group. We
found no difference in development of incontinence or its
severity whether the indication for early secondary repair
was hematoma, dehiscence, or poor functional outcome of
primary reconstruction. Nor was there a difference between
FIGURE 7. Comparison of Wexner score vs. maternal age at delivery
in females with (red dots) and without (green dots) sphincter
reconstruction.
Wexner
Score
14
Cases
12 Controls
10
8
6
4 3
2 5
2
22 24 26 28 30 32 34 36 38 40
Age
X Total number of females having corresponding Wexner score.
SOERENSEN ET AL .: LONG - TERM O UTCOME OF S PHINCTER R EPAIR
delayed primary or early secondary repair. Also, there were
no severe complications, despite the decision not to use
covering stomas even in septic cases. Therefore, it seems
likely the traditional surgical recommendation of secondary
reconstruction requiring a long delay before repair is
unnecessary, especially if it means a temporary colostomy
and a secondary operation later.
In this study, all the reconstructions of the anal
sphincters were performed by senior obstetricians or a
colorectal surgeon highly experienced in sphincter sur-
gery, which can be recommended even if it requires
referring the patient.
Females, who after delayed primary or early secondary
repair develop persistent, substantial incontinence symp-
toms that do not respond to conservative treatment,
could be offered minimally invasive treatments with
injectable biomaterial or sacral nerve stimulation (SNS).
CONCLUSIONS
We recommend delayed primary or early secondary
reconstruction of obstetric sphincter rupture in females
who have sustained a third-degree or fourth-degree tear
that was not recognized at time of delivery or if primary
repair fails whatever the cause, instead of the usual six-
month delay, because the procedure is safe and the results
comparable. The procedure should be performed at
specialized units by specialists in sphincter surgery and
without a covering stoma.
REFERENCES
1. Zetterström J, López A, Anzén B, Norman M, Holmström
B, Mellgren A. Anal sphincter tears at vaginal delivery: risk
factors and clinical outcome of primary repair. Obstet
Gynecol 1999;94:21–8.
317
2. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third-
degree obstetric anal sphincter tear: risk factors and
outcome of primary repair. BMJ 1994;308:887–91.
3. Fornell EU, Matthiesen L, Sjodahl R, Berg G. Obstetric anal
sphincter injury ten years after: subjective and objective
long term effects. BJOG 2005;112:312–6.
4. Halverson AL, Hull TL. Long-term outcome of over-
lapping anal sphincter repair. Dis Colon Rectum 2002;45:
345–8.
5. Bek KM, Laurberg S. Risks of anal incontinence from
subsequent vaginal delivery after complete obstetric anal
sphincter tear. Br J Obstet Gynaecol 1992;99:724–6.
6. Abrams P, Cardozo L, Khoury S, Wein A. Incontinence.
France: EDITIONS, 2005:21.
7. Arona AJ, al-Marayati L, Grimes DA, Ballard CA. Early
secondary repair of third- and fourth-degree perineal lacera-
tions after outpatient wound preparation. Obstet Gynecol
1995;86:294–6.
8. Hankins GD, Hauth JC, Glistrap LC, Hammond TL,
Yeomans ER, Snyder RR. Early repair of episiotomy
dehiscence. Obstet Gynecol 1990;75:48–51.
9. Jorge JM, Wexner SD. Etiology and management of fecal
incontinence. Dis Colon Rectum 1993;36:77–97.
10. Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective
comparison of fecal incontinence grading system. Gut
1999;44:77–80.
11. Norderval S, Öian P, Revhaug A, Vonen B. Anal inconti-
nence after obstetric sphincter tear: outcome of anatomic
primary repair. Dis Colon Rectum 2005;48: 1055–66.
12. Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm
MA. Long-term results of overlapping anterior anal-
sphincter repair for obstetric trauma. Lancet 2000;355:
260–5.
13. Gutierrez AB, Madoff RD, Lowry AC, Parker SC, Buie WD,
Baxter NN. Long-term results of anterior sphincteroplasty.
Dis Colon Rectum 2004;47:727–31.
14. Nichols C, Lamb E, Ramakrishnan V. Differences in
outcomes after third- versus fourth-degree perineal lacer-
ation repair. A prospective study. Am J Obstet Gynecol
2005;193:530–4.