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O’Keefe 1995 8.08 (5.34Summary 6.20 (4.9Men of unreported ageKalantar 2002 10.80 (7.74Perry 2002 2.80 (2.3Roche and 2001 gender: A systematic review and metaregressionanalysis.0.502.99 (1.5MacLennan 2000 2.30 (1.6Lam 1999 15.10 (11.21Drossman 1993 (0.2Prevalence of anal incontinence according to ageWomen of unreported ageKalantar 2002 • Men < 60 yrs: 0.8% 11.60 (8.68Okonkwo 2002 4.84 (4.2Perry 2002 2.70 (2.3Rizk 2001 • Women < 60 yrs: 1.6% 11.30 (8.73Roche 2001 6.46 (4.4MacLennan 2000 3.50 (2.6Mann 2000 • Men > 60 yrs: 5.1% 8.46 (4.79Soligo 2000 4.90 (2.13Lam 1999 5.60 (3.6Manning 1997• Women > 60 yrs: 6.2%9.12 (5.72Drossman 1993 0.90 (0.3• 1652 citations found• 79 suitable forevaluation• 29 articles used• Quality: 5/29 met highquality criteriaGender unreportedNakanishi 1997 15.30 (13.51Prosser 1997 9.30 (7.10Summary for men of all ages: 3.50 (2.3Summary for women of all ages: 4.50 (3.5Summary for age < 60 years 1.30 (0.8Summary for age > 60 years 6.20 (5.00 10 20Prevalence rates as % (linear scale)

Review of OASIS at BWH• To review subsequent mode of delivery and recurrent tearrates after obstetric anal sphincter injury.• All women delivered between May 2005 – December2010• Case note review of Women seen by a Specialist PerinealMidwife• Antenatal OASIS discussion clinic• To plan a mode of delivery• 8000 Del/year 120-150 OASIS/year

Number of women seen in OASIS Discussion ClinicN = 168n=38 (90%)3Bn=41 (84%)3CAnalysis by degree of previous OASI (N=168)n=42 n =44n=49UnspecifiedOASIn=4(10%)3A n=40 (91%)n=4(9%)n=8(16%)n =18n=13 (72%)n=5(28%)n=154 n=11 (73%)Asymptomaticat clinic visitn=143 (85%)Symptomaticat clinic visitn=25 (15%)Type of previous OASI

Analysis of symptomatic women by main complaintattending OASIS Discussion clinic n=25 (15%)FaecalIncontinencen=4(16%)22 = elective c/s – 22 advisedn=21(84%)3 = vaginal delivery – 1 requested / 2 advisedFaecal Urgency

Analysis of subsequent deliveryAnalysis of mode ofsubsequent deliveryN =168Analysis of perineal trauma from vaginal deliveriesn=97Degree of Perineal Trauman=71(41%)43C3Bn=1n=1n=97(59%)3A2 nd degree tearn=1n=491 st degree tearn=11Episiotomyn=21Intact Perineumn=14Caesarean SectionVaginal Delivery010 20 30 40 50 60% of womenRecurrent sphincter injury rate = 3% of vaginal deliveries

Analysis of subsequent deliveryAnal defects on USSBreakdown of Caesarean sectionsn=71n=3Analysis of mode ofsubsequent deliveryN =168Reason for Caesarean SectionEFW >90 th CentileFaecal IncontinenceFaecal Urgencyn=4n=3n=19n=71(41%)n=97(59%)Maternal request- traumatisedMaternal request- asymptomaticn=90 5 10 15 20 25 30 35 40 45% of womenn=33Caesarean SectionVaginal Delivery41% of elective caesarean sections were for clinical reasons54% if include traumatic first delivery

Our thoughts• Our series demonstrates a low risk of recurrent anal sphincterinjury (3%)– in keeping with our rate for primary injuries.– Asymptomatic women with 3a tears can be reassured that the risk offurther injury after a subsequent delivery appears to be low.– How much of this is our birth plans?• Our series is limited by the lack of data after subsequentdelivery to assess symptoms.– Changed our policy so that all women with a previous OASI will befollowed up to help guide future practice.

Managing prolapse• Greater awareness of problems• Joint colorectal clinic– New cohort of patients• Use of QoL– EPAQ• New views of old problems• Some new solutions

Cross sectional USS imaging

Quality of Life

BSUG database

BSUG analysis

BSUG analysis

Conclusions• Good planning helps achieve goodoutcomes after OASIS• Need greater awareness of symptoms andanatomical varients in prolapse• Newer imaging and surgical techniquesoffer appropriate management• All outcomes should be monitored

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