Best Approach for a Young Female with a Repaired OASI and Symptoms of Anal Incontinence: A Colorectal Surgeon's Opinion

Since I began treating patients with obstetrical anal sphincter injury (OASI), the idea of spreading the word on prevention of such traumatic injuries was always foremost in my mind. These patients are typically young women who are at risk for a severely impacted quality of life if appropriate treatment is not offered quickly for a successful outcome.

Anal incontinence can be a disastrous condition in any individual. It is defined as the involuntary loss of gas or stool and the inability to postpone an evacuation until socially convenient (Oliveira & Povedano 2020). More recently, the mechanisms involved in the pathophysiology of anal incontinence have been better understood (Knowles et al 2022). For these young female patients, the damage and ensuing trauma during vaginal delivery contributes to anal incontinence in the majority of cases (Sideris et al 2020).

It is interesting that what has been long considered a “normal” vaginal delivery can be a catastrophic event for a young female giving birth to her first child. In fact, OASI remains the most prevalent etiology for female patients who suffer with anal incontinence. In addition, the damage of important structures of the pelvic floor is associated with pelvic organ prolapse and other dysfunctional conditions. Therefore, it is crucial to bring OASI to the forefront, promote awareness and dialogue about this condition, and develop protocols – both for its evaluation and management.

The efforts of urogynecologists and societies such as IUGA, ICS, and ALAPP, among many others, in organizing such protocols are very crucial. One recent initiative was the publication of a joint report on the terminology for the assessment and management of obstetric pelvic floor disorders (Doumouchtsis et al 2023). The classification of OASI is now well established and helps caregivers to better understand the management of these traumatic injuries to the anorectal sphincters.

Establishing educational programs directed to gynecologists, such as those led by Dr. Abdul Sultan and Dr. Ranee Thakar, have been an important tool that have now been replicated and adopted around the world.

One very crucial aspect of caring for women with OASI is individualized care, specific to each patient. A 35-year-old female with anal incontinence may likely have greater anxiety and urgency to resolve this problem than a 78-year-old housebound woman who has learned to live with and manage weekly episodes of soiling. When taking into consideration the pathophysiology of anal incontinence, the role of neuromodulation to control the mechanisms and reflexes associated with urgency and fecal soiling has become more prominent (Knowles et al 2022). The optimal treatment of a patient with anal incontinence should be selected based on the severity of symptoms and the patient's quality of life. Anorectal function and anatomy of the sphincters should be evaluated with anal manometry and endoanal ultrasound (Badri et al 2023; Oliveira et al 2023).

Pelvic floor physiotherapy with associated electrostimulation can help patients to postpone an evacuation and should be included in the treatment algorithm. A sphincter repair, or sphincteroplasty, may be a viable option in the case of a cloaca or very loose and patulous anus due to a persistent external anal sphincter defect. Correction of the anatomy may offer temporary improvement, typically lasting up to 5 years. In the absence of a correctable anatomical gap, the best option to date is sacral neuromodulation.

Hopefully with collaboration among pelvic floor specialists and new and emerging options to treat OASI, such as stem cell injection, patients can be offered a more optimistic perspective in terms of successful treatment and better outcomes.

REFERENCES

Badri H, Fowler G, Lane S. The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI). Int Urogynecol J. 2023 Feb;34(2):399-404.

Doumouchtsis SK, de Tayrac R, Lee J, Daly O, Melendez-Munoz J, Lindo FM, Cross A, White A, Cichowski S, Falconi G, Haylen B. An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders. Int Urogynecol J. 2023 Jan;34(1):1-42.

Knowles CH, Dinning P, Scott SM, Swash M, de Wachter S. Annals of Laparoscopic and Endoscopic Surgery 2022;7:15.

Oliveira L, Brandao A, Silva JAM, Brito CGACB, Bastos MC, Burger NCS.

Physiologic and radiographic testing in patients with pelvic floor disorders and pelvic organ prolapse. Seminars in Colon and Rectal Surgery. 2023;34(1).

Oliveira LCC, Povedano A. Clinical evaluation of continence and defecation. In: Oliveira LCC, editor. Anorectal Physiology: A clinical and surgical perspective. Springer 2020.p47-63.

Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020 Sep; 252:303-312.