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Examining the Evidence


Another study links genital prolapse to incontinence

April 2003 · Vol. 15, No. 4

Objective

Researchers investigated the rate of anal incontinence in women who present with urinary incontinence and genital prolapse.

Method and results

In this study of almost 900 women, 20% of those with urinary incontinence and pelvic-organ prolapse also had anal incontinence. Subjects completed a bowel questionnaire and underwent a detailed exam. Researchers noted associations between anal incontinence and infant birth weights of 3,800 g or greater, rectocele greater than grade 2, urinary incontinence, hemorrhoidectomy, and irritable bowel syndrome.

Numerous studies report similar rates of anal incontinence associated with genital prolapse.1,2

Expert commentary

The social stigma of anal incontinence is not to be underestimated. Given the risk for anal incontinence from vaginal delivery and the inherent risks of elective cesarean section, which should we recommend for our patients? With the evidence before us, now is the time for a paradigm shift. While some academics and women’s rights groups dispute the utility and safety of elective cesarean delivery, investigations such as this one indicate that, in selected patients, it may be better.

Meschia and colleagues found a strong association between anal incontinence and urinary incontinence and genital prolapse, noting that this evidence is “consistent with the theory of a common pathogen mechanism for anal and genuine stress incontinence.” But do we really need more studies telling us that women who deliver large babies have more pelvic-floor dysfunction? As any pelvic reconstructive surgeon can attest, pelvic prolapse, urinary and fecal incontinence, and pelvic-floor dysfunction are epidemic. In a recent survey of obstetricians, many indicated that, given the choice, they would opt for elective cesarean section for themselves or family members.3

Many doctors resist when a patient asks for a specific mode of delivery. These physicians may feel such a request undermines their authority and somehow implies that a layperson knows best. When the evidence yields a clear message, however, it should be heeded: Cesarean delivery has a protective effect on the pelvis.

As O’Boyle outlines in an excellent opinion paper,4 we can set policy based on antiquated concepts, or we can conduct open, informed discussions with patients in the spirit of a true partnership and mutual decision-making.

Bottom line

Doctors don’t cause pelvic dysfunction during delivery, nature does. By communicating this concept we can help our patients make choices—and limit our already-catastrophic exposure to litigation.

REFERENCES

1. McArthur C, Bick D, Keighley M. Faecal incontinence after childbirth. Br J Obstet Gynaecol. 1997;104:46-50.

2. Sultan AH, Kamn MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905-1911.

3. Land R, Parry A, Rane A, Wilson D. Personal preferences of obstetricians towards childbirth. Aust N Z J Obstet Gynaecol. 2001;41:249-252.

4. O’Boyle AL, Davis GD, Calhoun BC. Informed consent and birth: Protecting the pelvic floor and ourselves. Am J Obstet Gynecol. 2002;187:981-983.

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