Original Research ajog.

org

GYNECOLOGY
Obstetric perineal ruptures—risk of anal incontinence
among primiparous women 12 months postpartum: a
prospective cohort study
Ditte Gommesen, MHSc; Ellen Aa. Nohr, PhD; Niels Qvist, MD; Vibeke Rasch, MD

BACKGROUND: Anal incontinence leads to impairment of the quality
of life and lower self-esteem with implications for social, physical, and
sexual health; anal incontinence after vaginal delivery is a major concern
for many women. Only about half of the cases of postpartum anal in-
continence can be related to anal sphincter injuries, and the remaining
cases must thus be related to other factors.
OBJECTIVE: The aim of this study was to examine the association
between maternal and obstetric characteristics, including the degree of
perineal rupture and anal incontinence 12 months postpartum. Further-
more, the aim was to investigate the association between anal sphincter
muscle defects, perineal length, and perineal strength and the risk of anal
incontinence.
MATERIALS AND METHODS: We conducted a prospective cohort
study at 4 Danish hospitals: Odense University Hospital, Aarhus Uni-
versity Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data
were obtained 2 weeks postpartum in relation to an evaluation of
perineal wound healing. Symptoms of anal incontinence were evalu-
ated 12 months postpartum by a Web-based questionnaire (St. Mark’s
incontinence score questionnaire). In addition, defects in the anal
sphincter muscles were examined using endoanal ultrasound, perineal
length was measured, and perineal strength was examined using anal
manometry. The main outcome measurement was anal incontinence
defined as a St. Mark’s score of >4. We performed multivariate an-
alyses to investigate the risk factors for anal incontinence and to
investigate the risk of anal incontinence according to endoanal ultra-
sound scanning and anal manometry findings.
RESULTS: A total of 603 primiparous women (203 with no/labia/first-
degree ruptures, 200 with second-degree ruptures, and 200 with
third-/fourth-degree ruptures) were included between July 2015 and
January 2018. At 12 months postpartum, 575 women (95%) answered
the questionnaire; 193 with no/labia/first-degree ruptures, 193 with
second-degree ruptures, and 189 with third-/fourth-degree ruptures. A
total of 499 women underwent an endoanal ultrasound scanning and 482
women underwent anal manometry. Anal incontinence with a St. Mark’s
score of >4 was reported by 7% and 9% of women with no/labia/first-
degree ruptures or second-degree ruptures, respectively, and by 14%,
15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4,
respectively. Compared to women with no or minor tears, women with anal
sphincter ruptures had a higher risk of anal incontinence (adjusted relative
risk, 2.46; 95% confidence interval, 1.28e4.71). Ruptures of degree 3c
and 4 were associated with a substantial increase in risk of anal incon-
tinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98e11.3;
and adjusted relative risk, 2.23; 95% confidence interval, 1.59e11.3,
respectively), especially if a defect in the external or internal anal sphincter
muscle was present (adjusted relative risk, 4.74; 95% confidence interval,
1.54e14.5; and adjusted relative risk, 6.58; 95% confidence interval,
3.35e12.9, respectively). The risk of anal incontinence increased by 8%
per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95%
confidence interval, 1.03e1.14).
CONCLUSION: Obesity with body mass index of >29.9 and a high-
degree rupture (3c or 4), especially with a persistent defect in the inter-
nal or external anal sphincter muscle, increased the risk of anal
incontinence.
Key words: anal incontinence, fecal incontinence, obstetric anal
sphincter injury, perineal laceration, postpartum maternal care

A nal incontinence (AI) after vaginal

delivery is a major concern for
many women. AI is defined as the
complaint of involuntary loss of liquid or
solid stool or the passage of gas.1 It is
supposedly an underreported condition
because of its stigmatizing nature.2,3 It
Cite this article as: Ditte Gommesen D, Nohr EAA,
Qvist N, et al. Obstetric perineal ruptures—risk of
anal incontinence among primiparous women 12 months
postpartum: a prospective cohort study. Am J Obstet
Gynecol 2019;XX:x.ex-x.ex.
0002-9378/$36.00
ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2019.08.026
occurs in approximately 50% of women
at long-term follow-up after anal
sphincter injuries4,5; however, the re-
ported prevalence of AI postpartum
varies markedly in the literature
depending on the definitions of AI/fecal
incontinence, often taking neither flatus
incontinence nor fecal urgency into ac-
count.6 Furthermore, different ques-
tionnaires and follow-up periods are
used.7,8 The prevalence of AI 6 months
postpartum has been reported to be as
high as 49% among primiparous women
in general, 9,10 and a large cohort study
from 2013 reported a 19% prevalence of
AI 1 year postpartum.11 Furthermore, AI
was found to be present among 48% of
primiparous women 20 years after
vaginal delivery in a large Swedish cohort
study.12 AI leads to impairment of the
quality of life and lower self-esteem with
implications for social, physical, and
sexual health.13e15 As a consequence of
AI, women describe a feeling of grieving
for loss of young adulthood, striving for
normality, and struggling to maintain
the complex roles that they play socially
throughout their life course.16
About 50% of AI cases after vaginal
delivery can be related to anal sphincter
injuries, and the remaining cases must be
related to other factors.17 Also, the
pathophysiological mechanisms of AI
are still not fully understood, and the

MONTH 2019 American Journal of Obstetrics & Gynecology 1.e1

Original Research GYNECOLOGY ajog.org

quality of life.27 The St. Mark’s incon-

AJOG at a Glance tinence score is an objective, validated
Why was this study conducted? questionnaire used to evaluate AI
Maternal morbidity after perineal ruptures is a major concern for many women. severity, with a total score ranging from
Only half of the cases of postpartum anal incontinence can be related to anal 0 (complete continence) to 24 (com-
sphincter ruptures, but few studies have investigated the association between plete incontinence) based on 7 ques-
perineal ruptures in general and anal incontinence. tions with different scores (A.1).27e29

Key findings Endoanal ultrasonography

Obese women and women sustaining perineal ruptures of degree 3c or 4 were at
higher risk for anal incontinence.
What does this add to what is known?
There is an increased risk of developing anal incontinence postpartum, especially
if a defect in the internal anal sphincter muscle is present. Focused training in
identifying and repairing anal sphincter ruptures is warranted.
condition remains an unsolved problem
for many patients.12,18 Increasing age,
parity, pudendal nerve damage, or gen-
eral weakening of pelvic floor muscles,
such as the puborectal muscle, are fac-
tors influencing the mechanisms of AI.
Most research on obstetric risk factors
related to AI has been conducted shortly
after delivery (6 months or less), when
spontaneous recovery is not expected,
and in cohorts of both primi- and
multiparous women.19e26 The objective
of this study was to examine the associ-
ations between maternal and obstetric
characteristics, including the degree of
perineal rupture, and AI 12 months
postpartum among primiparous
women. In addition, we wanted to
investigate the association between anal
sphincter muscle defects, perineal
length, perineal strength, and the risk of
AI.
Materials and Methods
Study setting
This study was a prospective cohort
study conducted at 4 hospital units in
Denmark: 2 university hospitals, Odense
(OUH) and Aarhus (AUH), and 2 gen-
eral hospitals, Esbjerg and Kolding, from
July 2015 until January 2019. The study
was approved by the Scientific Ethics
Committee for the Region of Southern
Denmark (S-20120213, 14.5.2013) and
by the Danish Data Protection Agency
(ID-2008-58-0035, 14.1.2015). All par-
ticipants provided written informed
consent.
Inclusion and follow-up procedure
Primiparous women, aged 18 years or
older, who were able to read and speak
Danish were eligible. After the delivery,
but before leaving the hospital, the
responsible doctor or midwife informed
eligible women about the study. If they
agreed, further information was sent by
e-mail and they were contacted by tele-
phone. For those who consented, a
baseline questionnaire including the pre-
pregnancy St. Mark’s incontinence score
was filled out, followed by a face-to-face
interview and a clinical examination
comprising a perineal inspection and a
digital palpation to assess wound infec-
tion and healing 2 weeks postpartum. At
12 months postpartum, all participants
received the St. Mark’s incontinence
score questionnaire by e-mail, including
an invitation to attend a gynecological
examination followed by an endoanal
ultrasonography (EAUS) and 3-
dimensional high-resolution anorectal
manometry (3D HRAM).
Outcome measurements
Primary outcome measurement was AI
defined as a St. Mark’s incontinence
score of >4.27 According to the St.
Mark’s score, the single complaint of
urgency defined as “the lack of ability
to defer defecation for 15 minutes” is
scored 4 points. We aimed to examine
AI more severe than the single
complaint of urgency. Furthermore, a
St. Mark’s score of >4 has previously
been shown to have an impact on
The first author (D.G.) performed all
EAUS examinations. A 360-degree
rotating 10-MHz endosonographic
anorectal 3-dimensional (3D) trans-
ducer (type Pro-Focus 2052; B-K
Medical, Herlev, Denmark) was used
to obtain axial images of the external
anal sphincter muscle (EAS) and the
internal anal sphincter muscle (IAS).
The transducer captures high-
resolution transrectal anatomy in 60
seconds, and the 3D Viewer software
constructs a 3D data cube, which
provides measurements of distance,
area, angle, and volume. The 3D cube
was analyzed for the presence of
sphincter defects in EAS and/or IAS
(yes/no). An EAS or IAS defect was
defined as any defect greater in
size than 30 degrees of the circum-
ference of the whole length of EAS or
IAS.30
Three-dimensional high-resolution
anorectal manometry
All 3D HRAM examinations were per-
formed by D.G. We used a rigid probe
with a diameter of 10.75 mm (Med-
tronic, Shoreview, MN) with 256 pres-
sure sensors arranged in 16 rows
(64-mm length), with 16 circumferential
sensors in each, and a balloon for infla-
tion placed on the disposable sheath.
Data were analyzed using ManoViewAR
software (Medtronic, Minneapolis,
MN). After anal insertion, a 1-minute
resting period was required before initi-
ating measurements. Resting and
maximal squeeze pressures were recor-
ded (mm Hg) for a 20-second resting
period, and three 5-second periods with
maximum squeezing. The maximum
values were used for the calculations.
During the clinical examination, partic-
ipants were placed in the dorsal
lithotomy position without bowel
preparation.

1.e2 American Journal of Obstetrics & Gynecology MONTH 2019

ajog.org
Exposure variables and covariates
Degrees of perineal ruptures
The classification of rupture degrees
described by Sultan and adopted by The
Green-top Guideline No.29 was used to
define the degree of perineal
rupture.31,32 First-degree ruptures were
defined as injury to perineal skin and/or
vaginal mucosa. Second-degree ruptures
were defined as injury to the perineum,
including perineal muscles but not the
anal sphincter. Third-degree ruptures
were defined as injury to the perineum
involving the anal sphincter complex,
divided into the following categories:
grade 3a ruptures, with less than 50% of
EAS thickness torn; grade 3b ruptures,
including more than 50% of EAS thick-
ness torn; and grade 3c ruptures,
including both EAS and IAS torn.
Finally, fourth-degree ruptures were
defined as an injury to the perineum
involving the anal sphincter complex
(EAS and IAS) and anorectal mucosa.
Labial ruptures were isolated to the labia.
Baseline information
At baseline, 2 weeks postpartum, we
collected information about age in years,
height in centimeters, pregestational
weight in kilograms, and smoking status
as “yes” or “no” from chart reviews.
Body mass index (BMI) was calculated
as kilograms per square millimeter (kg/
m2). Information about the pregnancy,
the birth, and the postpartum period was
obtained from the obstetric journal. It
included gestational or pre-gestational
diabetes mellitus (yes/no); duration of
active birth, defined as the duration from
the onset of regular uterine contractions
resulting in progressive effacement and
dilation of the cervix of at least 4 cm until
delivery (minutes); duration of the sec-
ond stage of labor (minutes), operative
delivery (yes/no), birthweight (grams),
and head circumference (centimeters).
Statistical analyses
A sample size calculation was performed
using a 2-sample proportions test that
was based on the Pearson c2 test to es-
timate the number of women needed for
this study. Based on available literature,
we assumed that 20% of women with an
anal sphincter rupture would experience
GYNECOLOGY
AI 12 months postpartum, as compared
to 10% in women with a second-degree
rupture.33,34 A total of 398 women, 199
with second-degree ruptures and 199
with an anal sphincter rupture, were
required to detect a difference of 10% in
AI rates with a significance level of 0.05
and a power of 80%.33,34 A group of
women with no, labia, or first-degree
ruptures were included to serve as the
reference group.
Baseline characteristics according to
the degree of rupture are presented using
descriptive statistics. For continuous
data, we used 1-way analysis of variance
to compare means across the rupture
groups. For categorical variables, the
Pearson c2 test was used to compare
frequencies.
To investigate the association between
the degree of rupture, EAUS findings, 3D
HRAM findings, and AI, a relative risk
regression was performed to estimate
relative risks (RRs) with 95% confidence
intervals (CIs). In a first model, we
adjusted for age and BMI as continuous
variables. In a second model, we addi-
tionally adjusted for smoking, diabetes,
and operative delivery as categorical
variables, and duration of the second
stage of labor, duration of active birth,
and birthweight as continuous variables.
Potential confounders were chosen a
priori based on directed acyclic graphs.35
All statistical tests were 2-tailed, and
P-values of <.05 were considered statis-
tically significant. The analyses were
carried out using STATA statistical soft-
ware version 15.0 (StataCorp, College
Station, TX).36
Results
Participants
A total of 832 women were invited to
participate. Of these, 81 declined, and
138 could not be reached by telephone.
This left us with 613 women who
consented to participate in the study 2
weeks postpartum. Ten women with-
drew their consent, and the study
population thus comprised 603 women.
The following 3 groups of women were
included in the study: (1) 203 women
with no, labial, or first-degree ruptures;
(2) 200 women with second-degree
ruptures; and (3) 200 women with
MONTH 2019 American Journal of Obstetrics & Gynecology
Original Research
anal sphincter ruptures. Women with
no/labial ruptures, first-degree rup-
tures, and second-degree ruptures were
included at OUH, whereas women with
anal sphincter ruptures were included
at all 4 hospitals.
At the 12-month follow-up, 575 of the
603 women completed the question-
naire, corresponding to 95.4%, and 499
women underwent EAUS, correspond-
ing to 82.8%. Fewer women (n ¼ 482)
underwent the 3D HRAM, because of
either rejection of the procedure or
technical problems with the equipment.
Characteristics according to degree
of rupture
Women sustaining third-/fourth-degree
ruptures were older than women sus-
taining second-degree ruptures and
women sustaining no/labia/first-degree
ruptures (P ¼ .02) (Table 1). Moreover,
a higher rupture degree was observed
with higher birthweight (P < .001) and
head circumference (P < .001), longer
second stage of labor (P < .001), and
longer active birth (P < .001). The fre-
quency of instrumental delivery was
higher among both women with second-
degree (15%) and third- or fourth-
degree ruptures (34%) compared to
women with no/labia/first-degree rup-
tures (3%) (only 1 instrumental delivery
was by forceps).
Risk of anal incontinence
All presented adjusted relative risk
(aRRs) are from the second adjusted
model. Overall, 11.1% of the partici-
pants (64/575) had a St. Mark’s score of
>4 (Table 2). Focusing on women with
grade 3c or 4 ruptures, the same applied
for 35% and 33%, respectively. Fecal
incontinence daily or weekly was expe-
rienced by 2%, whereas the most
frequent type of AI was escape of flatus
reported by 47.6% and on a daily or
weekly basis by 6.2% (not presented in
table). Of the 575 women, 40 women
(7%) reported experiencing fecal ur-
gency, defined as the lack of ability to
defer defecation for 15 minutes. Only 6
women had had AI before pregnancy (St.
Mark’s incontinence score of 5 or 6).
In general, women with anal sphincter
ruptures had a higher risk of AI,
1.e3
Original Research GYNECOLOGY ajog.org

TABLE 1
Characteristics according to degree of rupture among primiparous women in Denmark (n [ 575)
Group 1 Group 2 Group 3
(No/labia/first (Second (Third/fourth
Total degree) degree) degree)
(n ¼ 575) (n ¼ 193) (n ¼ 193) (n ¼ 189) P
n (%) n (%) n (%) n (%)
Age, y, mean (SD) 28.3 (4.1) 27.7 (4.1) 28.2 (4.1) 28.9 (4.0) .02a
25 145 (25.2) 64 (33.2) 51 (26.4) 30 (15.9)
2630 286 (49.7) 91 (47.2) 90 (46.6) 105 (55.6)
>30 144 (25.0) 38 (19.7) 52 (26.9) 54 (28.6)
2 b
Prepregnancy BMI, kg/m , mean (SD) 24.5 (4.6) 24.4 (4.5) 24.7 (5.0) 24.4 (4.4) .75a
<25 367 (63.9) 128 (66.3) 120 (62.5) 119 (63.0)
25e29.9 133 (23.2) 43 (22.3) 46 (24.0) 44 (23.3)
>29.9 74 (12.9) 22 (11.4) 26 (13.5) 26 (13.8)
Birthweight, g, mean (SD) 3503 (480) 3395 (493) 3460 (425) 3657 (483) <.001a
<2999 77 (13.4) 39 (20.2) 23 (12.0) 15 (7.9)
3000e3499 203 (35.3) 71 (36.8) 84 (43.5) 48 (25.4)
3500e3999 217 (37.7) 64 (33.2) 65 (33.7) 88 (46.6)
4000 78 (13.6) 19 (9.8) 21 (10.9) 38 (20.1)
Head circumference, cm, mean (SD) c
34.6 (1.6) 34.3 (1.6) 34.5 (1.6) 35.0 (1.6) <.001a
<34 145 (25.3) 59 (30.7) 52 (27.1) 34 (18.0)
34 121 (21.1) 46 (24.0) 37 (19.3) 38 (20.1)
35 137 (23.9) 35 (18.2) 54 (28.1) 48 (25.4)
>35 170 (29.7) 52 (27.1) 49 (25.5) 69 (36.5)
Second stage duration, min, mean (SD) 37 (17) 32 (24) 34 (24) 45 (30.0) <.001a
<16 113 (19.7) 41 (21.2) 49 (25.4) 23 (12.2)
16-30 196 (34.1) 80 (41.5) 61 (31.6) 55 (29.1)
31-45 94 (16.4) 32 (16.6) 27 (14.0) 35 (18.5)
>45 172 (29.9) 40 (20.7) 56 (29.0) 76 (40.2)
Active birth duration, min, mean (SD) 415 (266) 340 (222) 399 (241) 509 (302) <.001a
<220 144 (25.0) 71 (36.8) 47 (24.4) 26 (13.8)
221e340 145 (25.2) 45 (23.3) 54 (28.0) 46 (24.3)
341e570 149 (25.9) 50 (25.9) 50 (25.9) 49 (25.9)
>570 137 (23.8) 27 (14.0) 42 (21.8) 68 (36.0)
b
Smoker, yes 25 (4.4) 9 (4.7) 9 (4.7) 7 (3.7) .88d
Diabetes mellitus, yes 20 (3.5) 5 (2.6) 8 (4.2) 7 (3.7) .69d
Operative delivery, yes e
99 (17.2) 6 (3.1) 29 (15.1) 64 (33.9) <.001d
Episiotomy, yes 54 (9.4) - 32 (16.7) 22 (11.6) .17d
BMI, body mass index.
a
One-way analysis of variance; b One missing value, n ¼ 574; c Two missing values, n ¼ 573; d Pearson c2 test; e One operative delivery was by forceps.
Gommesen et al. Obstetric perineal ruptures and anal incontinence. Am J Obstet Gynecol 2019.

1.e4 American Journal of Obstetrics & Gynecology MONTH 2019

 ajog.org
TABLE 2
Relative risks of anal incontinence according to maternal and obstetric characteristics in primiparous women in Denmark (n [ 575)
Anal incontinence (St. Mark’s score)
Total Yes (score >4) No (score 4) Crude Adjusteda,b Adjusteda,c
n ¼ 575 n ¼ 64 (11.1%) n ¼ 511 (88.9%) RR (95% CI) RR (95% CI) RR (95% CI)
n n (%) n (%)
Degree of rupture
no/labia/first 193 13 (6.7) 180 (93.3) 1.00 Reference 1.00 Reference 1.00 Reference
Second (spontaneous) 161 15 (9.3) 146 (90.7) 1.38 (0.68e2.82) 1.31 (0.64e2.65) 1.31 (0.64e2.66)
Second (mediolateral episiotomy) 32 2 (6.3) 30 (97.7) 0.92 (0.22e3.92) 0.97 (0.23e4.08) 0.90 (0.21e3.80)
3a 88 12 (13.6) 76 (86.4) 2.02 (0.96e2.62) 2.00 (0.96e4.20) 1.94 (0.88e4.27)
3b 66 10 (15.2) 56 (84.9) 2.25 (1.03e4.89) 2.25 (1.03e4.90) 2.26 (0.96e5.33)
3c 20 7 (35.0) 13 (65.0) 5.20 (2.35e11.5) 5.75 (2.61e12.7) 4.74 (1.98e11.3)
4 15 5 (33.3) 10 (66.7) 4.95 (2.04e12.0) 5.03 (2.13e11.9) 4.23 (1.59e11.3)
Age, y, mean (SD) 28.7 (4.1) 28.2 (4.1)
25 145 13 (9.0) 132 (91.0) 0.69 (0.38e1.26) 0.73 (0.40e1.32) 0.73 (0.40e1.32)
26e30 286 37 (12.9) 249 (87.1) 1.00 Reference 1.00 Reference 1.00 Reference
>30 144 14 (9.7) 130 (90.3) 0.75 (0.38e1.26) 0.77 (0.43e1.37) 0.73 (0.41e1.29)
2d
BMI, kg/m , mean (SD) 26.0 (6.0) 24.3 (4.4)
MONTH 2019 American Journal of Obstetrics & Gynecology

<25 367 34 (9.3) 333 (90.7) 1.00 Reference 1.00 Reference 1.00 Reference

GYNECOLOGY
25e29.9 133 13 (9.8) 120 (90.2) 1.06 (0.57e1.94) 1.07 (0.58e1.96) 1.10 (0.59e2.02)
>29.9 74 17 (23.0) 57 (77.0) 2.48 (1.47e4.20) 2.47 (1.46e4.17) 2.47 (1.44e4.21)
Birthweight, g, mean (SD) 3616.0 (443.0) 3489.0 (483.0)
<2999 77 5 (6.5) 72 (93.5) 0.66 (0.26e1.70) 0.64 (0.25e1.63) 0.60 (0.23e1.53)
3000e3499 203 20 (9.9) 183 (90.1) 1.00 Reference 1.00 Reference 1.00 Reference

Original Research
3500e3999 217 29 (13.4) 188 (86.4) 1.36 (0.79e2.32) 1.24 (0.72e2.12) 1.24 (0.72e2.15)
4000 78 10 (12.8) 68 (87.2) 1.30 (0.64e2.65) 1.15 (0.56e2.36) 1.20 (0.59e2.47)
Second stage duration, min, 44.0 (30.0) 36.0 (26.0)
mean (SD)
<16 113 7 (6.2) 106 (93.8) 0.51 (0.23e1.14) 0.51 (0.23e1.14) 0.54 (0.24e1.22)
16e30 196 24 (12.2) 172 (87.8) 1.00 Reference 1.00 Reference 1.00 Reference
31e45 94 9 (9.6) 85 (90.4) 0.78 (0.38e1.62) 0.90 (0.43e1.87) 0.80 (0.38e1.68)
1.e5

Gommesen et al. Obstetric perineal ruptures and anal incontinence. Am J Obstet Gynecol 2019. (continued)
Original Research GYNECOLOGY ajog.org

compared to women with no ruptures or

ruptures smaller than a second-degree

Relative risk regression; P values <.05 were considered statistically significant; b Adjusted for age and BMI; c Adjusted for age, BMI, birthweight, second stage duration, active birth duration, smoking, diabetes, and operative delivery (second stage duration and
(0.64e1.93)

(0.66e2.81)

(0.91e3.30)
(0.54e2.28)
(0.99e4.96)
(0.16e2.34)
(0.81e2.68)
Reference
rupture (aRR, 2.46; 95% CI,
(95% CI)
1.28e4.71) (result not presented in ta-
ble). Sustaining ruptures of degree 3c or
Adjusteda,c

4 increased the risk of AI more than 4-

Relative risks of anal incontinence according to maternal and obstetric characteristics in primiparous women in Denmark (n [ 575) (continued)

1.11 fold (aRR, 4.74; 95% CI, 1.98e11.3;

1.36
1.00
1.73
1.11
2.20
0.62
1.47
and aRR, 4.23; 95% CI, 1.59e11.3,
RR

respectively) (Table 2).

Smoking and BMI seemed to be in-
(0.70e1.98)

(0.59e2.50)

(0.95e3.44)
(0.63e2.59)
(0.88e4.42)
(0.19e2.67)
(0.79e2.39)
Reference dependent risk factors. The risk for AI in
(95% CI)

smokers compared to nonsmokers more

than doubled (aRR, 2.20; 95% CI,
0.99e4.96) (Table 2). The same applied
Adjusteda,b

to obese women (BMI of >29.9)

compared to women with a BMI of <25
1.18

1.22
1.00
1.80
1.29
1.97
0.71
1.37
RR

(aRR, 2.47; 95% CI, 1.44e4.21). When

including perineal ruptures in the
regression model, the risk was fairly
(0.67e1.93)

(0.53e2.23)

(0.86e3.14)
(0.60e2.47)
(0.82e4.23)
(0.24e3.40)
(0.78e2.34)

much the same for women with BMI of

Reference
(95% CI)

>29.9 (aRR, 2.39; 95% CI, 1.40e4.07).

Furthermore, the risk of AI increased by
8% per 1-unit increase in BMI (aRR,
1.08; 95% CI, 1.03e1.14) (results not
Crude

presented in table).
1.14

1.08
1.00
1.65
1.22
1.86
0.90
1.35
RR

All but 1 woman with an EAS or IAS

active birth duration are not mutually adjusted for each other, and no variables are adjusted for themselves); d One missing value (n ¼ 574).

defect was diagnosed with an anal

sphincter rupture postpartum. However,
n ¼ 511 (88.9%)

6 women diagnosed with ruptures of

No (score 4)

degree 3a or 3b were found to have an

411 (265.0)
148 (86.0)

130 (90.3)
132 (91.0)
127 (85.2)
122 (89.0)
20 (80.0)
18 (90.0)
85 (85.9)

IAS defect, and another 5 women diag-

n (%)

nosed with a rupture of degree 3a were

found to have an EAS defect. Compared
to women with no defect in the EAS or
Anal incontinence (St. Mark’s score)

Gommesen et al. Obstetric perineal ruptures and anal incontinence. Am J Obstet Gynecol 2019.

IAS, women with an EAS defect had an

n ¼ 64 (11.1%)
Yes (score >4)

448.0 (274.0)

almost 5-fold higher risk of AI (aRR,

BMI, body mass index; CI, confidence interval; RR, relative risk ratio; SD, standard deviation.
24 (14.0)

22 (14.8)
15 (11.0)

14 (14.1)
5 (20.0)
2 (10.0)

4.74; 95% CI, 1.54e14.5), whereas

14 (9.2)
13 (9.0)

women having a defect in the IAS had an

n (%)

almost 7-fold higher risk of AI (aRR,

6.58; 95% CI, 3.35e12.9) (Table 3).
Women with AI had lower anal mean
resting pressure (62.5, range 27e110
n ¼ 575

mm Hg, vs 78.6, range 24e147 mm Hg;

Total

25
20
172

144

99
145
149
137

P < 0.001) and lower maximum squeeze

n

pressure (128.3, range 55e282 mm Hg,

Active birth duration, min, mean (SD)

vs 158.4, range 48e309 mm Hg; P <

.001). Furthermore, the risk of AI
decreased by 25% for every increase in
anal resting pressure of 10 mm Hg (aRR,
Operative delivery (yes)

0.75; 95% CI, 0.66e0.86), and for every

10mm Hg higher maximum squeeze
Diabetes (yes)
d

pressure performed, the risk of AI

Smoker (yes)
TABLE 2

decreased by 12% (aRR, 0.88; 95% CI,

221e340
341e570

0.82e0.94). Maximum duration of the

<220

>570
>45

squeeze did not seem to influence the

a

risk of AI.

1.e6 American Journal of Obstetrics & Gynecology MONTH 2019

ajog.org GYNECOLOGY Original Research

Comment
Principal findings

(1.54e14.5)
(3.35e12.9)
(1.86e18.5)

(0.66e0.86)

(0.82e0.94)

(0.90e1.14)
Reference
Relative risks for anal incontinence 12 months postpartum according to findings of endoanal ultrasonography (n [ 499) and high-resolution anorectal

This study adds to the sparse knowledge

95% CI on the long-term consequences of peri-
neal ruptures. We found that women
with anal sphincter ruptures in general
Adjustedc

had higher risks of AI 1 year postpartum,

1.00
4.74
6.58
5.86

0.75

0.88

1.01
RRa

compared to women with no, labia, or

first-degree ruptures. Women with a
rupture of degree 3c or 4 had a more
(1.36e11.9)
(4.52e14.4)
(2.29e22.0)

(0.66e0.86)

(0.82e0.94)

(0.87e1.11)
than 4-fold higher risk of AI compared
Reference

to women with no, labia, or first-degree

95%CI

CI, confidence interval; EAS, external anal sphincter; EAUS, endoanal ultrasonography; HRAM, high-resolution anorectal manometry; IAS, internal anal sphincter; RR, relative risk ratio; SD, standard deviation.
Relative risk regression; b Adjusted for age and body mass index; c Adjusted for age, body mass index, birthweight, second stage duration, active birth duration, smoking, diabetes, and operative delivery.
ruptures. The risk of AI was higher
among obese women compared to
Adjustedb

women of normal weight, and markedly

higher among women with a defect in
1.00
4.03
8.08
7.09

0.75

0.88

0.98
RRa

the EAS or IAS compared to women with

no defect. Furthermore, lower anal
resting pressure and maximum squeeze
(1.24e9.74)
(4.57e15.2)
(1.51e14.0)

(0.65e0.85)

(0.82e0.94)

(0.88e1.13)
pressure were both related to an increase
Reference

in risk of AI.
95% CI

Results in context of what is known

The number of women reporting AI
following perineal ruptures in the pre-
Crude

1.00
3.47
8.33
4.60

0.74

0.88

0.99
RRa

sent study was comparable to that found

in other studies, ranging between 15%
and 25% among women with third-/
No (score 4)

fourth-degree ruptures37-41 and 5% to

158.4 (48.7)
78.6 (22.1)

32.5 (23.1)

15% among women with first- or

Mean (SD)
454 (91.0)
438 (92.8)

438 (90.9)
9 (75.0)
4 (40.0)
3 (60.0)

second-degree ruptures.20,39
n (%)

Studies have suggested an association

between forceps delivery and AI, but not
manometry (n [ 482), among primiparous women in Denmark

between vacuum deliveries and AI.42 In

Gommesen et al. Obstetric perineal ruptures and anal incontinence. Am J Obstet Gynecol 2019.
Yes (score >4)

accordance with a large Australian

128.3 (50.2)
62.5 (18.9)

31.8 (27.7)

cohort study among 1500 primiparous

Mean (SD)
3 (25.0)
6 (60.0)
2 (40.0)
45 (9.0)
34 (7.2)

43 (8.9)

women,19 the present study found that

n (%)

neither instrumental delivery nor episi-

otomy had any substantial influence on
the risk of AI 1 year postpartum.
In our study, obese women were at
Total

5
12
10
499
472

482

higher risk for AI compared to women

n

who were of normal weight or under-

weight. The association between obesity
and postpartum AI has only been
Anal incontinence (St. Mark’s score)

Maximum squeeze pressure, mm Hg

sparsely described, but a recovery from

symptoms of fecal incontinence with
Rest squeeze pressure, mm Hg

decreasing BMI has been observed.43,44

Duration of squeeze, sec

In addition, in accordance with our

per 10 mm Hg higher

per 10 mm Hg higher
Defect in IAS and EAS

findings, Johannessen et al found that

per 10 sec longer
Defect in EAS only

more women with a BMI of 35 expe-

Defect in IAS only

rienced AI than women with a BMI of

HRAM total

<35.37 A plausible explanation could be

TABLE 3

EAUS total
No defect

that increased abdominal pressure is a

mechanism through which obesity in-
a

creases the development of AI.

MONTH 2019 American Journal of Obstetrics & Gynecology 1.e7

Original Research GYNECOLOGY
Theoretically, increased abdominal
pressure strains the muscles in the pelvic
floor, leading to overt structural damage
or neurologic dysfunction resulting in a
predisposition to AI.45 As obesity has
become the most common health care
problem in women of reproductive age
and a major concern in obstetrics, the
number of adverse maternal outcomes is
expected to rise.
Clinical implications
We found persistent defects in the EAS
and IAS to be associated with AI. An
association between sonographic defects
after primary repair of anal sphincter
ruptures and ongoing incontinence
symptoms has previously been
found.38,46 Further, Mahony et al found
an association between sonographic IAS
defects and severe symptoms of AI 3
months postpartum.47 In this study,
women with a persistent defect in the
IAS or combined defects of the IAS and
EAS were at higher risk for AI than
women with an isolated defect in the
EAS, 12 months postpartum. Despite the
low number of women with persistent
IAS defects or combined defects in our
study, this indicates an association be-
tween IAS defects and AI persisting
beyond 3 months, showing that the IAS
may play a more severe role in the eti-
ology of AI than previously expected. In
this study, women who had sustained a
grade 3c or 4 rupture had a poorer
outcome than those who had sustained a
grade 3a or 3b rupture or even smaller
ruptures. Among women with a persis-
tent defect, all but 1 woman were diag-
nosed with an anal sphincter rupture at
the time of delivery. However, the degree
of anal sphincter rupture may in some
cases have been underdiagnosed (eg,
diagnosed as degree 3a when actually
degree 3b). We did not find wound
dehiscence at 2 weeks postpartum to
increase the risk of either AI or defects in
the EAS or IAS. This indicates that the
cause of persistent defects 12 months
postpartum may be explained by
underdiagnosing of the degree or insuf-
ficient repair of the anal sphincter rup-
tures. Thus, it is important to identify
the full extent of injury in women who
sustain third- or fourth-degree ruptures,
1.e8 American Journal of Obstetrics & Gynecology MONTH 2019
and a specific focus is needed on the
repair of the IAS, as an IAS defect is
associated with increased risk of AI. This
is important, because it is difficult to
repair the IAS as a secondary procedure
when women present with inconti-
nence.40 Results from an audit con-
ducted to evaluate the effectiveness of a
structured hands-on workshop in the
management of anal sphincter ruptures
found that, prior to the course, only 66%
of attendees attempted to identify an IAS
defect and 60% tried to repair it.48
However, after training, improvement
was seen in both diagnosis and attempts
to repair the IAS defect.48 In addition, we
suggest that all repairs of anal sphincter
ruptures should be performed in a the-
ater under appropriate circumstances to
optimize diagnosis and repair. Moreover,
routine follow-up after the repair of anal
sphincter ruptures is important so as to
tackle any defecatory problems at an
early stage.
Research implications
To enable practitioners to counsel pa-
tients appropriately, the long-term ef-
fects of different grades of anal sphincter
ruptures on AI should be further estab-
lished in prospective study designs.
Moreover, studies are needed to evaluate
the most optimal ways of diagnosing and
repairing anal sphincter ruptures.
Strengths and Limitations
A major strength of this study is the in-
clusion of primiparous women based on
the degree of rupture, with women with
ruptures less than second-degree serving
as controls. This enabled us to assess the
association between the degree of
rupture and the risk of AI without in-
fluence of previous deliveries and rup-
tures. All women had a clinical
examination 2 weeks postpartum,
including a perineal inspection and a
digital palpation. This might have
minimized misclassification according
to exposure group. In addition, a thor-
ough clinical examination consisting of a
gynecologic examination, EAUS, and 3D
HRAM was conducted in all women at
12 months postpartum, to achieve a
nuanced assessment of the anatomical
structures and anal function.
ajog.org
The large group of women with third-
or fourth-degree ruptures allowed us to
subdivide this group into groups with
degree 3a, 3b, 3c, and 4 ruptures, and
thereby to investigate the impact of
different degrees of anal sphincter rup-
tures on AI. This has been conducted
only in a limited number of studies,
which all included fewer women or
combined primi- and multiparous
women.39,49,50 However, in our study,
the numbers of women with ruptures of
degree 3c and 4 were relatively small,
resulting in wide CIs.
The study had a high follow-up rate.
Approximately 95% of the women
answered the questionnaire, and more
than 80% participated in the clinical
examination.
All clinical examinations, EAUSs, and
3D HRAMs were performed by the same
examiner (D.G.) without evaluation of
the results by others. This leaves a risk of
systematic misclassification, particularly
in the evaluation of EAUS images, as this
involves some subjectivity. To avoid dif-
ferential misclassification, the exam-
iner’s evaluation of subjective symptoms
of AI was completed after the clinical
examination was performed. Further-
more, the examiner aimed to remain
unaware of which degree of rupture the
woman in question had sustained. This
was not possible in all cases, as women
included at AUH had all sustained third-
or fourth-degree ruptures and had their
12-month follow-up performed at AUH
because of logistic challenges. As women
with no, labia, first-degree, and second-
degree ruptures were all included from
1 hospital, whereas women with anal
sphincter ruptures were included from
all 4 hospitals, a risk of selection bias
exists. However, the women with anal
sphincter ruptures included at the
different hospitals did not differ in BMI,
age, smoking, or diabetes status, and
thus we believe the risk of selection bias
to be minimal. Furthermore, a pre-
pregnancy St. Mark’s incontinence
score was determined postpartum and
was thus prone to recall bias.
Conclusion
In conclusion, there is an increased risk
of developing AI 1 year postpartum after
ajog.org
anal sphincter ruptures, especially if a
defect in the IAS is present. Focused
training on identifying and repairing
anal sphincter ruptures may be war-
ranted. In addition, an added focus on
BMI and preventing anal sphincter
ruptures may be beneficial in reducing
postpartum AI problems among
women. n anal incontinence and chronic constipation on
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Author and article information
From the Department of Gynecology and Obstetrics (Mss
Gommesen and Nohr and Dr Rasch), Odense University
Hospital, Institute of Clinical Research, University of
Southern Denmark, Odense, Denmark; Department of
Gastroenterological Surgery (Dr Qvist), Odense University
Hospital, Institute of Clinical Research, University of
Southern Denmark, Odense, Denmark.
Received April 25, 2019; revised July 9, 2019;
accepted Aug. 17, 2019.
The authors report no conflict of interest.
This study was funded by Odense University Hospitals
Research Foundation, The Region of Southern Denmark,
University of Southern Denmark, the Department of Gy-
naecology and Obstetrics, Odense University Hospital,
The A.P. Moeller Foundation for the Advancement of
Medical Science (grant no.13-93), and The Danish As-
sociation of Midwives. The funding sources had no in-
fluence or involvement in the study.
Correspondence: Ditte Gommesen, MHSc. ditte.
gommesen@rsyd.dk
ajog.org GYNECOLOGY Original Research

SUPPLEMENTARY TABLE 1
St. Mark’s incontinence scoring system
Never Rarely Sometimes Weekly Daily
Incontinence for solid stool 0 1 2 3 4
Incontinence for liquid stool 0 1 2 3 4
Incontinence for gas 0 1 2 3 4
Alteration in lifestyle 0 1 2 3 4

No Yes
Need to wear a pad or plug 0 2
Taking constipating medicines 0 2
Lack of ability to defer defecation for 15 min 0 4
Never, no episodes in the past 4 weeks; rarely, 1 episode in the past 4 weeks; sometimes, >1 episode in the past 4 weeks but
<1 per week; weekly, 1 or more episodes per week but <1 per day; daily, 1 or more episodes per day.
Add 1 score from each row: minimum score ¼ 0 (perfect continence); maximum score ¼ 24 (totally incontinent).
Data from Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut
1999;44:77-80.
Gommesen et al. Obstetric perineal ruptures and anal incontinence. Am J Obstet Gynecol 2019.

MONTH 2019 American Journal of Obstetrics & Gynecology 1.e11