VOL: 103, ISSUE: 14, PAGE NO: 40
Rona Mackenzie, BA, SRN, SCM, DNCert, CertEd, is clinical nurse specialist in continence, West Essex PCT
Alison Clubb, RM, is continence link midwife, Princess Alexandra Hospital Trust, HarlowInjury to the anal sphincter during childbirth is the major cause of faecal incontinence in women and is estimated ...
Injury to the anal sphincter during childbirth is the major cause of faecal incontinence in women and is estimated to affect 5% of women who have a vaginal delivery each year in the UK (Fernando et al, 2002). The reported incidence of injury ranges from 2.5% to 11% (Sultan, 1997) but a study in the UK found that many are under-reported or wrongly classified and the rate on re-examination increased from 11% to 24.5% (Andrews et al, 2006). Women with unrecognised injuries may have problems with bowel control but fail to seek treatment and advice due to embarrassment and shame.
Anal sphincter injury and guidelines
Recommendations for management following the repair, follow-up care and counselling about subsequent deliveries are given. It also recommends that women with symptoms of poor bowel control should be offered investigations and referred to a colorectal surgeon for consideration of a secondary repair. Women should be advised to consult their GP if bowel control problems develop after one year.
Assessment of bowel function
Up to 59% of women have impaired bowel control after primary repair of anal sphincter defects (Sultan and Thaker, 2002) and it is important to identify women with problems or potential problems.
Urgency of stool resulting in a rush to the toilet and urge faecal incontinence indicates damage to the external sphincter.
Passive leakage of faeces or flatus is associated with internal-sphincter damage. Incontinence due to faecal impaction and overflow of faecal material is uncommon in this client group, but can occur in women with a history of constipation or fear of pain associated with the passage of stool, so must not be overlooked.
Many maternity units in the UK offer all women who sustain a third and fourth-degree perineal tear a routine appointment at six to eight weeks following delivery, with a senior obstetrician or an experienced nurse. The purpose of the consultation is to inform and educate the woman, identify any bowel-control problems, provide treatment and advice to resolve the symptoms and advise on the management of subsequent deliveries (Thaker and Sultan, 2003).
At the time of delivery and repair many women find it difficult to deal with information that they are given. When seen at the appointment, a detailed explanation of the nature of the injury and repair, the normal function of the lower bowel and control mechanisms is provided so that the woman is in a position to understand what is happening and can seek clarification.
Women are more willing to disclose symptoms using a self-completed questionnaire compared with direct questioning (Khullar et al, 1998). If a questionaire is sent with the appointment details, women have time to think about their symptoms and questions they want to ask.
During the appointment a standardised assessment form may be used to gather details of bladder, bowel and sexual function and obstetric, medical and surgical history may identify risk factors.
Past and present bowel habits, including frequency and consistency of stool, ability to delay defecation, control of stool and flatus will identify the type of control problem or incontinence. Information about how the woman manages her problems and the effect this has on her lifestyle and quality of life completes the initial assessment.
Examination of the vagina, perineum and anus is performed to check for healing, scar tenderness, sphincter tone and presence of haemorrhoids, skin tags or faecal soiling, also the anus should be observed for symmetry on voluntary contraction and reflex contraction on coughing.
The pelvic floor muscles should be assessed for symmetry, strength and endurance on slow contractions and speed and strength with fast contraction. It may be necessary to improve the function of the pelvic floor, in order to increase the anorectal angle, which contributes to bowel control. Endosonography and manometry are not available in all hospitals so cannot be routinely used to assess the degree of damage to the sphincter. Women with persistent problems should be referred to centres where this is available (Sultan and Abulafi, 2001).
Conservative treatment and advice provides the potential for resolution or reduction of symptoms for many women. Midwives or continence advisers should provide this in the initial postnatal period, but if problems occur later health visitors or practice nurses may be the main contacts.
After comprehensive assessment, advice given should be tailored to the symptoms and needs of the individual (Norton and Chelvanayagam, 2004). Advice includes:
- Identify 'normal' bowel habits. Establish a regular bowel routine and make time to respond to the sensation of needing to empty the bowel;
- Eat a balanced diet with regular meals. Have breakfast and take advantage of the gastrocolic response to initiate a bowel action in the morning while at home;
- Adjust the intake of fibre to achieve a consistency of stool that can be controlled. Identify any foods that cause loose stools or excessive wind. Sorbitol in low-calorie foods, drinks and chewing gum may cause softer stools;
- Ensure a fluid intake of more than 2L a day. This should be increased during breastfeeding or in warm climates. Caffeine, found in coffee, tea, cola and some chocolate is a gut stimulant and may exacerbate urgency;
- Loperamide and codeine phosphate are constipating medication and can be taken in titrated doses. They prolong the gut transit time and loperamide has the added benefit of reducing the amount of internal sphincter relaxation in response to rectal distension;
- Treat haemorrhoids;
- Perform pelvic floor exercise programme to treat weakness and dysfunction following pregnancy and vaginal delivery. Visual or vaginal assessment is required to identify any incorrect action that may exacerbate problems (Bo, 2002; Haslam, 2002);
- Carry out anal sphincter exercise programme based on the same principles as pelvic floor exercises. This should include maximal, sub-maximal and fast twitch contractions in order to increase muscle strength, endurance and speed of reaction;
- Use bowel habit training programme, to resist urgency of stool and gain confidence in the ability to delay bowel evacuation.
Computer-assisted biofeedback and neuromuscular stimulation are treatments that may be provided by specialist continence advisers or continence physiotherapists for women with very weak muscle function.
Disposable body-worn pads are designed to absorb urine and are not efficient in containing faeces, but do provide some protection against soiling of outer clothing. Faecal material on the skin can cause soreness or excoriation. Small amounts of passive leakage of stool can be managed with a panty liner held in place between the buttocks with thong style pants or an anal plug placed in the rectum. Anal plugs are not well tolerated by people with normal anorectal sensation, but may be of help in situations where it is vital that no leakage occurs.
Emotional support is required as few women are aware before delivery of the risk of anal sphincter trauma or bowel control problems. The demands of a new baby make this a stressful time and unreliable bowel control increases anxiety. Concerns may be expressed about the effects on sexual functioning and body image, and these issues need to be explored (Williams et al, 2005).
In the event of a subsequent pregnancy, it is important that women inform their obstetrician or midwife of the previous trauma and if they have bowel control problems. Women with continuing problems may be offered an elective Caesarean section. Health visitors and primary care nurses are most likely to have contact with women who do not have another pregnancy and it is recognised that many women are reluctant to report symptoms. Therefore, health professionals should identify any problems with sensitive questioning. Advice may be given, or referral to a GP or continence advisory service may be appropriate.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net
Norton, C., Chelvanayagam, S. (2004) Bowel Continence Nursing. Beaconsfield: Beaconsfield Publishers.
MacLean, A.B., Cardozo, L. (2002) Incontinence in Women. London: RCOG.