title: Perineal examination as a predictor of underlying external anal sphincter damage.
abstract: OBJECTIVE
  To assess the relation between perineal inspection and sphincter integrity in parous women.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  District general hospital.
  
  
  METHODS
  Fifty-seven consecutive parous women attending a gynaecology clinic for problems unrelated to the pelvic floor.
  
  
  METHODS
  A detailed history of bowel function and mode of delivery obtained; the perineum inspected to determine the presence and position of scarring, and anal endosonography performed.
  
  
  RESULTS
  In 19 women with an intact perineum on inspection, endosonography showed perineal scarring in five, with both perineal and sphincter scarring in three. Four had urge faecal incontinence. Three patients had a perineal tear only on inspection, but this group was too small for analysis and was discounted. Nine had an episiotomy scar only. Endosonography demonstrated perineal scarring in four, and combined perineal and sphincter scarring in two; one woman in this group had urge faecal incontinence. Twenty-six women had episiotomy and perineal tears on inspection. Endosonography revealed underlying perineal scarring in five women, with combined perineal and sphincter scarring in 14; six women in this group had urge faecal incontinence and one passive incontinence for flatus. Sonographically the scarring was anterior and circumferential rather than radial, and mostly left-sided, whereas on inspection episiotomy and perineal scarring were right sided.
  
  
  CONCLUSIONS
  A normal perineum on clinical examination does not exclude underlying sphincter damage. The incidence of sphincter damage increases significantly when an episiotomy scar is associated with a perineal tear.
authors.affiliation: St Mark's NHS Trust Hospital, Harrow.
authors.forename: A
authors.initials: A
authors.lastname: Frudinger
authors.forename: C I
authors.initials: CI
authors.lastname: Bartram
authors.forename: J A
authors.initials: JA
authors.lastname: Spencer
authors.forename: M A
authors.initials: MA
authors.lastname: Kamm
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000000981:diagnostic imaging / Q000293:injuries*; D002921:Cicatrix / Q000000981:diagnostic imaging; D005242:Fecal Incontinence / Q000000981:diagnostic imaging / Q000209:etiology; D005260:Female; D006801:Humans; D008875:Middle Aged; D010298:Parity; D010502:Perineum / Q000293:injuries*; D010808:Physical Examination; D011446:Prospective Studies; D011644:Puerperal Disorders / Q000000981:diagnostic imaging / Q000209:etiology*; D014463:Ultrasonography