A 28-year-old woman, gravida 1 para 1, comes to the office for evaluation of fecal incontinence. Last week, the patient underwent spontaneous vaginal delivery of a 5-kg (11-lb) infant that was complicated by a third-degree perineal laceration. Since delivery, the patient has had episodes of fecal and flatal incontinence throughout the day. She also has had 1-2 soft bowel movements per day with no diarrhea or hematochezia. The patient has no chronic medical conditions and did not have incontinence during her pregnancy. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 76/min. On examination, the perineum appears edematous, but there is no induration or erythema. The laceration repair appears intact. Anal sphincter tone is weak and has asymmetric contraction. There is a moderate amount of stool in the rectal vault. On speculum examination, there is normal lochia from the cervix with no abnormal or malodorous discharge. Vaginal walls are intact with no lacerations or defects. Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman, gravida 1 para 1, comes to the office for evaluation of fecal incontinence.  Last week, the patient underwent spontaneous vaginal delivery of a 5-kg (11-lb) infant that was complicated by a third-degree perineal laceration.  Since delivery, the patient has had episodes of fecal and flatal incontinence throughout the day.  She also has had 1-2 soft bowel movements per day with no diarrhea or hematochezia.  The patient has no chronic medical conditions and did not have incontinence during her pregnancy.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 76/min.  On examination, the perineum appears edematous, but there is no induration or erythema.  The laceration repair appears intact.  Anal sphincter tone is weak and has asymmetric contraction.  There is a moderate amount of stool in the rectal vault.  On speculum examination, there is normal lochia from the cervix with no abnormal or malodorous discharge.  Vaginal walls are intact with no lacerations or defects.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da2b_4bec_bc81_5b7aab15de1a_MD0003_00 Obstetric anal sphincter injury is relatively common with vaginal delivery. It typically occurs in association with a third-degree perineal laceration, which tears the external anal sphincter (EAS), or a fourth-degree perineal laceration (ie, EAS and rectal mucosa tear). Risk factors include fetal macrosomia (as in this case), prolonged second stage of labor, and operative vaginal delivery (eg, forceps). perineal laceration Obstetric anal sphincter injuries are usually identified and repaired immediately after delivery. However, anal incontinence (ie, involuntary loss of fecal material and/or flatus) may still occur in the first few weeks after delivery due to labor-related stretching of the pudendal nerve and pelvic floor muscles (both of which normally help maintain continence). Therefore, patients with postpartum anal incontinence require evaluation to determine if symptoms are due to a benign cause (eg, pelvic floor stretching) or from breakdown of the EAS: Obstetric anal sphincter injuries In patients with a normal physical examination (eg, normal anal sphincter tone), symptoms will likely resolve as the pelvic floor recovers. For these patients, reassurance and observation are appropriate. In contrast, patients with weakened anal sphincter tone and asymmetric contraction (such as this patient) or a palpable defect are likely to have an anal sphincter muscle defect that requires additional management. For these patients, the best next step is endoanal ultrasonography, which can locate and assess the extent of the defect to guide treatment (eg, repeat surgical repair) and decrease the risk of chronic anal incontinence. (Choice A) A barium enema is administered for defecography (ie, dynamic anorectal x-ray) to assess anorectal anatomy. However, it is more invasive than endoanal ultrasonography and therefore typically reserved for patients with refractory fecal incontinence. (Choice B) CT scan of the abdomen and pelvis can evaluate for intraabdominal pathology (eg, diverticulosis) but is inferior to endoanal ultrasonography for visualization of the anal sphincter and perineum. (Choice C) Patients with fecal incontinence due to chronic constipation (ie, leakage of liquid stool around a solid impaction) may improve with dietary fiber and stool softeners. This patient has 1-2 daily bowel movements, making the diagnosis of constipation unlikely. Stool softeners would likely cause diarrhea and worsen her fecal incontinence. Educational objective: Postpartum fecal or flatal incontinence can occur due to external anal sphincter injury associated with a third- or fourth-degree obstetric perineal laceration. Patients typically have weakened anal sphincter tone, asymmetric sphincter contraction, or a palpable defect on examination. Evaluation is with endoanal ultrasonography. References: Use of endoanal ultrasound for reducing the risk of complications related to anal sphincter injury after vaginal birth. (http://www.ncbi.nlm.nih.gov/pubmed/26513224) Obstetrics and fecal incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/25320570)

A 28-Year-Old Woman, Gravida 1 Para 1, Comes to the Office