title: Recurrent obstetric anal sphincter injury and the risk of long-term anal incontinence.
abstract: Women with an obstetric anal sphincter injury are concerned about the risk of recurrent obstetric anal sphincter injury in their second pregnancy. Existing studies have failed to clarify whether the recurrence of obstetric anal sphincter injury affects the risk of anal and fecal incontinence at long-term follow-up.
  
  
  
  The objective of the study was to evaluate whether recurrent obstetric anal sphincter injury influenced the risk of anal and fecal incontinence more than 5 years after the second vaginal delivery.
  
  
  
  We performed a secondary analysis of data from a postal questionnaire study in women with obstetric anal sphincter injury in the first delivery and 1 subsequent vaginal delivery. The questionnaire was sent to all Danish women who fulfilled inclusion criteria and had 2 vaginal deliveries 1997-2005. We performed uni- and multivariable analyses to assess how recurrent obstetric anal sphincter injury affects the risk of anal incontinence.
  
  
  
  In 1490 women with a second vaginal delivery after a first delivery with obstetric anal sphincter injury, 106 had a recurrent obstetric anal sphincter injury. Of these, 50.0% (n = 53) reported anal incontinence compared with 37.9% (n = 525) of women without recurrent obstetric anal sphincter injury. Fecal incontinence was present in 23.6% (n = 25) of women with recurrent obstetric anal sphincter injury and in 13.2% (n = 182) of women without recurrent obstetric anal sphincter injury. After adjustment for third- or fourth-degree obstetric anal sphincter injury in the first delivery, maternal age at answering the questionnaire, birthweight of the first and second child, years since first and second delivery, and whether anal incontinence was present before the second pregnancy, the risk of flatal and fecal incontinence was still increased in patients with recurrent obstetric anal sphincter injury (adjusted odds ratio, 1.68 [95% confidence interval, 1.05-2.70), P = .03, and adjusted odds ratio, 1.98 [95% confidence interval, 1.13-3.47], P = .02, respectively). More women with recurrent obstetric anal sphincter injury reported affected the quality of life because of anal incontinence (34.9%, n = 37) compared with women without recurrent obstetric anal sphincter injury (24.2%, n = 335), although this difference did not reach statistical significance after adjustment (adjusted odds ratio, 1.53 [95% confidence interval, 0.92-2.56] P = .10).
  
  
  
  Women opting for vaginal delivery after obstetric anal sphincter injury should be informed about the risk of recurrence, which is associated with an increased risk of long-term flatal and fecal incontinence.
authors.affiliation: Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev, Denmark. Electronic address: hanna@jango.se.
authors.forename: Hanna
authors.initials: H
authors.lastname: Jangö
authors.affiliation: Department of Obstetrics and Gynecology, Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Jens
authors.initials: J
authors.lastname: Langhoff-Roos
authors.affiliation: Section of Biostatistics, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Susanne
authors.initials: S
authors.lastname: Rosthøj
authors.affiliation: Department of Obstetrics and Gynecology, Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Abelone
authors.initials: A
authors.lastname: Sakse
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000293:injuries*; D036861:Delivery, Obstetric / Q000009:adverse effects*; D003718:Denmark; D005242:Fecal Incontinence / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D005865:Gestational Age; D006801:Humans; D010298:Parity; D011247:Pregnancy; D011788:Quality of Life; D012008:Recurrence; D012307:Risk Factors; D011795:Surveys and Questionnaires
keywords: anal incontinence; fecal incontinence; fecal urgency; obstetric anal sphincter injury; recurrent anal sphincter injury