International Urogynecology Journal

https://doi.org/10.1007/s00192-020-04631-8

REVIEW ARTICLE

Establishing a peripartum perineal trauma clinic: a narrative review

Aurore Fehlmann 1,2 & Barbara Reichetzer 1 & Stéphane Ouellet 1 & Catherine Tremblay 1 & Marie-Eve Clermont 1

Received: 27 September 2020 / Accepted: 30 November 2020

# The International Urogynecological Association 2021

Abstract
Introduction and hypothesis Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially
severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI.
Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review
are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the
mode of delivery for subsequent pregnancies after an OASI.
Methods This narrative review covers information from patients’ questionnaires specific to anal incontinence, anal physiology
assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI.
Results This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national
professional organizations and experienced perineal clinics.
Conclusion This review summarizes the different choices in developing a perineal clinic to facilitate their development in
promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for
obstetrician-gynaecologists, family doctors, and residents.

Keywords Anal physiology . Obstetric anal sphincter injury . Pelvic ultrasound . Perineal clinic

Introduction first evaluation [2]. The consequences of such lesions are

multiple and potentially severe, including perineal pain, ab-
The incidence of obstetric anal sphincter injury (OASI) is scess formation, wound breakdown, rectovaginal fistula, anal
estimated to be within 4–6.6% [1]. However, these numbers incontinence, and other anorectal symptoms [1, 3, 4]. Anal
may be underestimated, as 28–87% of OASIs are missed at sphincter injury is the most established risk factor for anal
incontinence in otherwise healthy women, with the prevalence
of long-term anal incontinence after a primary repair of an
* Aurore Fehlmann
OASI estimated to be between 35 and 60% [5, 6].
aurore.fehlmann@hcuge.ch
Moreover, 30–50% of patients correctly diagnosed and su-
Barbara Reichetzer tured would still have a significant residual defect of the anal
barbara.reichetzer.1@umontreal.ca sphincter [7–9].
Stéphane Ouellet
In this context, obstetrician-gynaecologists established per-
doc.ouellet@me.com ineal clinics to assess women who suffered from third- or
fourth-degree tears in the National Maternity Hospital in
Catherine Tremblay
tremcath@gmail.com Ireland in 1995 [10–12]. The goals of these clinics were the
following: to assess women’s sphincter integrity, to evaluate
Marie-Eve Clermont
marie-eve.clermont@umontreal.ca
and treat women with an underreported disease like faecal
incontinence, to provide an opportunity to debrief after a trau-
1
Department of Obstetrics and Gynaecology, Université de Montréal matic delivery, and to counsel women on their next delivery
and Centre Hospitalier de l’Université de Montréal (CHUM), [11].
Montréal, Canada In the UK, the Royal College of Obstetricians and
2
Department of Paediatrics, Gynaecology and Obstetrics, Geneva Gynaecologists (RCOG) recommends an evaluation of all
University Hospitals and Faculty of Medecine, Geneva, Switzerland women with an OASI at 6–12 weeks postpartum and, ideally,
an assessment of the sphincter integrity for women suffering

from anal incontinence or perineal pain by a specialist with
endoanal ultrasound and anal manometry [13]. Despite this
recommendation, less than one-third of hospitals in the UK
had a dedicated perineal trauma clinic in 2009 [14]. In
Canada, a survey showed that obstetrician-gynaecologists rec-
ommend a follow-up visit at 6–12 weeks following an OASI
with an obstetrician-gynaecologist rather than with the pa-
tient’s family doctor. In the case of faecal incontinence, they
would refer the patient to a colorectal or general surgeon, a
urogynaecologist or a physiotherapist [15]. The 2015
Canadian recommendation about OASIs advised counselling
pregnant women about the routes of subsequent delivery fol-
lowing an OASI and discussed their risks and benefits. They
also suggested using anal function testing in antenatal evalu-
ation in guiding the choice of mode of delivery [1].
Nevertheless, perineal clinics are still very underdeveloped.
In this context, the development of perineal trauma clinics is
essential in response to national and international
recommendations.
Therefore, this narrative review aims to summarize the dif-
ferent options on developing a perineal clinic using informa-
tion from patients’ questionnaires, anal physiology assess-
ments, and pelvic floor and anal sphincter imaging. We also
discuss factors to consider in selecting the mode of subsequent
delivery in pregnant women following an OASI.
Methods
We first defined the topics covered in this review, including
the choice of patients’ questionnaires on anal incontinence,
the choice of imaging, the choice of anal function tests, and
the factors to consider in counselling a mode of delivery after
an OASI.
Studies of interest, written in English or French, without
any restriction regarding the years of publication, were
searched in MEDLINE, using the following keywords: “per-
ineal clinic”, “delivery after OASI”, “perineal ultrasound”,
“anal physiology”, and/or “anal incontinence”. Reference lists
of eligible articles were also searched, and relevant studies
identified through these lists were also included in this review
if they were judged to provide further relevant information.
Results
Organization of perineal clinics
A perineal clinic is a multidisciplinary clinic with various
specialities depending on the country and organization. It is
most often composed of urogynaecologists or obstetricians
who are in close cooperation with colorectal surgeons, psy-
chosexual counsellors, physiotherapists, radiologists, and
Int Urogynecol J
clinical neurophysiologists [10, 11, 16]. Some institutions pro-
pose a 1-day perineal clinic, where a patient can have a com-
plete evaluation and counselling about a subsequent delivery
or management [17].
The indication to refer a patient to a perineal clinic is not
universal. In some countries, all patients suffering from an
OASI are seen in these clinics, irrespective of symptom pre-
sentation [18]. Some institutions will not see asymptomatic
patients with a 3a perineal tear, while others examine birth-
precipitated anal incontinence, regardless of the degree of per-
ineal tear [19, 20]. Perineal clinics can see women during the
first 2 weeks following the delivery (to assess early complica-
tions such as wound infection or dehiscence), around 6–
12 weeks later (as recommended by RCOG), or up to
12 months after the end of the pregnancy [13, 20–23].
Follow-up consultations can be organized regularly (i.e. every
6 weeks to 6 months) or based on the evolution of symptoms
[11]. Assessment of anal integrity and functionality is essen-
tial prior to discussing the mode of delivery following an
OASI and should be done before the pregnancy or around
the end of the second trimester of the current pregnancy [18,
20, 21, 24, 25].
Perineal clinic report template
A standardized report template for a perineal clinic should be
established to facilitate standardized data collection and pro-
vide standardized care. Currently, no study presents such a
template. Some clinics have developed their own template,
based mostly on their needs [16]. Nonetheless, all templates
should include the usual information such as medical and
surgical history, previous and current pregnancy history, and
results from various previously mentioned examinations (i.e.
questionnaire, ultrasonography, manometry).
Symptoms questionnaires
Currently, the International Consultation on Incontinence
(ICI) and the International Urogynecology Association
(IUGA) recommend using the Cleveland Clinic Score (or
Wexner score) and the St Marks incontinence score (or
Vaizey score) (grade C recommendation) (Tables 1 and 2)
[26–28]. Other validated symptom scores exist in the litera-
ture, including the Pescatori score or the faecal incontinence
severity index. However, these scores only include the type
and frequency of faecal incontinence [29, 30]. The Wexner
score takes into account the use of protective pads and chang-
es in the quality of life [26]. Finally, the St Marks incontinence
score (SMIS) is a revision of the Wexner score with the addi-
tion of urgency symptoms and the use of anti-diarrhoeal treat-
ment [27]. Also, as the SMIS is based on the 4 previous
weeks, it is more appropriate for monitoring a patient’s symp-
toms over time. It groups patients in three categories based on
Int Urogynecol J

Table 1 The Jorge-Wexner incontinence score (or Cleveland clinic than life-threatening [37]. For assessing the quality of life in
score)
patients with faecal incontinence, there are at least 12 different
Type of incontinence Frequency scales [38]. The Faecal Incontinence Quality of Life (FIQL)
scale, the Gastrointestinal Quality-of-Life (GIQoL) Index, and
Never Rarely Sometimes Usually Always the International Consultation on Incontinence Modular
Solid 0 1 2 3 4
Questionnaire-Bowels (ICIQ-B) appear to have the highest
degree of validity [38]. Recently, IUGA has suggested using
Liquid 0 1 2 3 4
the FIQL scale for research and, optionally, as a clinical tool
Gas 0 1 2 3 4
[28] .The American Society of Colon and Rectal Surgeons
Wears Pad 0 1 2 3 4
(ASCRS) also strongly recommends using the FIQL scale as
Lifestyle alteration 0 1 2 3 4
part of clinical assessment because of its impact on the choice
Never, 0; rarely, < 1/month; sometimes, < 1/week, ≥ 1/month; usually, < of treatment (grade of recommendation: strong recommenda-
1/day, ≥ 1/week; always, ≥ 1/day tion based on moderate quality evidence) [39]. FIQL is a
0, perfect continence; 20, complete incontinence widely used quality of life questionnaire with 29 items,
Adapted from Jorge JM, Wexner SD. [26] subdivided into 4 scales (lifestyle, coping, depression/self-per-
ception, and embarrassment) [38, 40]. This scale has been
the severity of symptoms: low (0–4), medium (5–8), and high translated and validated in multiple languages [41]. Finally,
(> 8) [22, 31, 32]. Although the SMIS is an interview-based the FIQL scale has demonstrated a wide range of validity
questionnaire, it can also be used as a self-reported question- testing and a moderate correlation with increasing severity
naire [27, 33]. This score has been shown to have a good of faecal incontinence, explaining its use as a complementary
correlation with clinical assessment, demonstrating the best tool to symptoms questionnaires [38, 42].
test-retest reliability and the best correlation with symptoms
before or after surgery [27]. Therefore, it is considered appro-
Imaging of the anal sphincter
priate for the assessment of faecal incontinence severity and
outcome of treatment [34]. For patients with an OASI, the
The gold standard for anal sphincter imaging in the case of
SMIS also has good correlations with quality of life question-
faecal incontinence is endoanal ultrasound (EAUS), which is
naires [31]. Finally, this score is widely used in perineal clinics
recommended by the IUGA/ICS Working Group on Female
in the UK and Europe as well as in the research field [20, 22,
Anorectal Terminology (Grade II) [28, 43]. Endoanal imaging
24, 32, 35, 36].
is conducted with a specific rigid endocavitary 360° probe
with high frequency to assess the integrity of the anal sphinc-
Quality of life questionnaire ter. This technique is the best tool to assess external anal
sphincter (EAS) defects, with 100% accuracy compared to
Quality of life questionnaires are valuable tools to evaluate the histological examination [44]. Since then, EAUS has been
repercussions of disease on different aspects of life, especially widely used to assess anal sphincter integrity. However, its
when the concerned disease is more functional and chronic invasiveness and equipment availability limit its utilization.

Table 2 St Mark’s score (or Vaizey score)

Never Rarely Sometimes Weekly Daily

Incontinence for solid stool 0 1 2 3 4

Incontinence for liquid stool 0 1 2 3 4
Incontinence for gas 0 1 2 3 4
Alteration in lifestyle 0 1 2 3 4
No Yes
Need to wear a pad or plug 0 2
Taking constipating medicines 0 2
Lack of ability to defer defecation for 15 min 0 4

Never, no episodes in the past 4 weeks; rarely, 1 episode in the past 4 weeks; sometimes, > 1 episode in the past 4 weeks but < 1 a week; weekly, 1 or
more episodes a week but < 1 a day; daily, 1 or more episodes a day
Add one score from each row
Minimum score is 0 = perfect continence; maximum score is 24 = totally incontinent
Adapted from Vaizey et al. [27]

Indeed, the rotating probe is inserted into the rectum at 6 cm
and progressively withdrawn to examine the puborectalis
muscle, deep EAS (proximal), superficial EAS (mid), and
subcutaneous EAS (distal) [43]. Confirmation of a significant
defect requires two visualizations of the defect on the three
levels [45, 46]. However, this rigorous process is not system-
atically mentioned or used [18, 47, 48]. When three-
dimensional endoanal ultrasound (3D-EAUS) is used, the
length of the defect can be estimated. A widely accepted
cut-off for the total length of the anal sphincter is around
50%, similar to the cut-offs used in the endoanal ultrasound
score of Norderval or the Starck score [49–51]. Regarding the
radial defect, the most commonly used cut-off is a 30° radius
(equivalent to 1 h on a 12-h clock).17 However, some authors
have used a limit of a 90° radius, which is equivalent to one
quadrant [25]. As can be seen, there is currently no universally
accepted consensus regarding EAUS. Nevertheless, the utility
of anal sphincter imaging has been sufficiently proved to be
widely accepted. For example, a persistent residual sphincter
defect of more than a quadrant after a primary repair of an
OASI was associated with a higher risk of de novo anal symp-
toms after a subsequent vaginal delivery [52]. Recently, a
meta-analysis also demonstrated a relative risk of 2.8 for anal
incontinence after a primary repair of an OASI in patients with
persistent residual sphincter defects compared to patients
without residual sphincter defects [53].
Another method for assessing anal sphincter integrity is
transperineal ultrasound (TPUS). Due to a lack of research
and ongoing studies, the IUGA decided not to recommend
its use in 2017 [28]. Three-dimensional transperineal ultra-
sound (3D-TPUS) was first described in 2006 by Yagel and
Valsky as a tool for assessing anal sphincter integrity [54, 55].
Since then, some publications have demonstrated a good cor-
relation between 3D-TPUS and EAUS in the diagnosis of anal
sphincter defects. Oom et al. demonstrated good agreement
between 3D-TPUS and 2D-EAUS in detecting anal sphincter
injury with excellent interobserver agreement [56]. Strong
agreement between 3D-TPUS and 3D-EAUS in detecting anal
sphincter injury was found 6 months after OASI repair, and
better agreements were obtained when patients were
contracting the pelvic floor muscle [57]. Ros et al. showed
that, compared to 2D-TPUS and three-dimensional
endovaginal ultrasound (3D-EVUS), the 3D-TPUS had the
best sensitivity and specificity for the EAS defect, using the
3D-EAUS as the gold standard [58].
Guzman et al. described a standardized technique to assess
the anal sphincter by tomographic imaging with 3D-TPUS
[35]. The advantages of this method include no deformation
of the anal canal, a higher level of patient acceptance and
comfort, and the capability to assess the pelvic floor integrity
and functionality simultaneously [43, 56, 59]. The anal
sphincter is first delimited by placing one slice cranial to the
EAS at the puborectalis level and one slice caudal to the
Int Urogynecol J
internal sphincter anal (IAS). Then, six slices are taken be-
tween these two limits to analyse the anal sphincter. A defect
should be seen at two-thirds of the length of the anal sphincter;
thus, a minimum of four slices is required for a defect to be
considered positive [46]. Using this cut-off, patients with an
EAS defect have been shown to have an 18-fold increased risk
of anal incontinence, supporting a correlation between tomo-
graphic imaging and symptoms [35]. This procedure has been
shown to have good inter- and intra-observer reliability [35,
60]. More recently, Taithongchai et al. compared tomographic
imaging of 3D-TPUS with 3D-EAUS [59]. They defined the
optimal cut-off of slices for the best diagnostics of external or
internal sphincter defects on 3D-TPUS: three or more slices
for EAS (sensitivity 0.70 and specificity 0.69) and two or
more slices for IAS (sensitivity 0.43 and specificity 0.97).
Because of its high negative predictive value, 3D-TPUS is
able to accurately identify patients without an anal sphincter
defect. These cut-offs appear to be more adapted to young
women, early after an OASI, and when symptoms are less
frequent than later in life [59]. Although 3D-TPUS seems
more practical and readily available for obstetrician-
gynaecologists, 3D-EAUS shows a better correlation with
anal incontinence symptoms in patients around 2 years after
OASIs [61]. As well, there is a correlation among faecal ur-
gency, solid or liquid anal incontinence, and evidence of an
EAS defect on 3D-EAUS and also between flatal incontinence
and IAS defects on 3D-EAUS [61].
In particular, some physicians place an endovaginal probe
transperineally (or more specifically introitally) to possibly
obtain higher frequencies of ultrasound, but this modality is
not fully considered as a transperineal image [36, 43, 58].
Moreover, introital ultrasound cannot discriminate symptom-
atic from asymptomatic patients after an OASI and produces
images of lower resolution and quality compared to 3D-TPUS
[61, 62].
Currently, EAUS remains the gold standard, but 3D-TPUS
shows sufficiently encouraging results to be an alternative to
EAUS in case of unfeasibility to acquire or use EAUS.
Imaging of the pelvic floor
Pelvic floor functionality was originally assessed by digital
palpation with a modified Oxford score (MOS). However, this
method was judged to have insufficient reproducibility, sensi-
tivity, and validity for evaluating pelvic floor muscle strength
for scientific purposes [63–65]. Pelvic imaging could be a
better option to evaluate the contraction of the puborectalis
sling through the reduction of the anteroposterior hiatal dis-
tance (2D- or 3D-TPUS) or the hiatus area (3D-TPUS). Both
have a good correlation with digital palpation MOS but also
with more precise measurements such as perineometry
[66–68]. On 3D-TPUS, puborectalis sling contraction is de-
scribed as absent for a proportional change in the
Int Urogynecol J
anteroposterior diameter of the hiatus that is < 7% (MOS
equivalent of 0); weak for a proportional change of 7–18%
(MOS equivalent of 0.5–2); normal for a change of 18–35%
(MOS equivalent of 2.5–4); and strong for a change > 35%
(MOS equivalent of 4.5–5) [68]. For the 2D-TPUS, the cut-off
for each category is slightly different, respectively, < 1%, 2–
14%, 15–29%, and > 30% [69].
Pelvic floor integrity can then be assessed with 3D-TPUS
by examining for a hiatal ballooning or a puborectalis avul-
sion, as described by Dietz et al. [70]. The role of puborectalis
avulsion in faecal incontinence is still uncertain [71, 72].
However, data supporting the role of levator ani function on
faecal continence are growing [73]. A few years after an
OASI, women with puborectalis avulsion diagnosed by 3D-
TPUS are more likely to face severe faecal incontinence of
solid and liquid stools compared to women without avulsion
with or without proven residual anal sphincter defect [32, 74].
Similar results have been found in older patients [75].
A 3D-TPUS assessment of the integrity of the anal sphinc-
ter and levator ani muscle after OASIs can be used to recom-
mend the mode of delivery in subsequent pregnancies [32]. In
the case of a major injury to the levator ani muscle or anal
sphincter, regardless of anal symptoms, or in the case of anal
incontinence, a caesarean section could be suggested [32].
In summary, 3D-TPUS seems to be an excellent way to
assess the anal sphincter and levator ani muscle in the same
examination, and it allows for a global evaluation of anatom-
ical integrity and functionality. As discussed, the use of 3D-
TPUS on the anal sphincter has been shown to have a high
negative predictive value and can be safely used to permit a
vaginal delivery in the case of an intact anal sphincter.
Moreover, the anal sphincter integrity assessment should be
completed by an evaluation of its function with anorectal
manometry.
Anal physiology
Anal physiology allows us to analyse the functionality of the
anorectal complex from continence to evacuation. A system-
atic procedure was recently described [76]. Anal manometry
measures the pressure of anal resting and anal squeezing and
determines the functional length of the anal canal. Mean anal
resting pressure usually ranged around 50–60 mmHg,
reflecting 50–85% of the IAS, 25–30% of the EAS, and
15% of the anal cushions [77]. Maximal anal squeeze pressure
(MSP) reflects the maximal voluntary contraction of the stri-
ated external sphincter and can generally reach two to three
times the basal pressure (100–180 mmHg) [78]. These values
are similar during the third trimester and up to 12 weeks post-
partum of the first delivery, with a normal range of 29–
90 mmHg and 27–98 mmHg for anal resting pressure and
50–163 mmHg and 43–156 mmHg for anal squeezing pres-
sure [79]. Anal manometry is an essential tool to assess the
functionality of the anal sphincter besides the anal sphincter
imaging, even when there is no anal sphincter injury such as
pudendal neuropathy or other neurologic injuries [77]. Some
publications have demonstrated a correlation between low
anal manometry variables and faecal incontinence in women
with anal sphincter defects [80–82]. However, the literature is
generally inconsistent regarding the relationship among anal
sphincter repair, manometry, and symptoms. Although some
studies demonstrated a correlation between anal incontinence
symptoms and MSP after overlapping sphincteroplasty, other
studies did not find any manometry improvement, despite a
successful anal sphincter repair in terms of symptoms
[83–85].
On a practical aspect, Roos et al. determined a set of cut-off
values of anal manometry with high sensitivity and high neg-
ative predictive values for residual sphincter defects after an
OASI [86]. With a cut-off at 54 mmHg for the resting pressure
and 95 mmHg for the squeeze pressure, the sensitivity and
specificity values were 97.5% and 39% with a negative pre-
dictive value of 98%. Based on these results, anal manometry
would be an excellent test to reject an anal sphincter defect
diagnosis but would be inaccurate for confirming a diagnosis.
However, the most commonly used measure for anal manom-
etry is the incremental anal squeeze pressure, with a widely
accepted cut-off value at 20 mmHg (Table 3) [18, 19, 24].
Both an anal sphincter defect of more than one quadrant and
an incremental squeeze pressure < 20 mmHg are associated
with a significant aggravation of faecal incontinence [52].
Mean resting pressure could also be used with a cut-off at
40 mmHg [10, 18, 25].
Mode of delivery after an OASI
An evaluation of mode of delivery after an OASI may predict
the risk of deterioration of anal sphincter function following a
subsequent vaginal delivery. It is suggested to conduct this
evaluation with patients and to discuss the predicted risk [1,
61]. More specifically, the objective of this evaluation is to
predict the risk of deterioration of the anal sphincter function
following a subsequent vaginal delivery. In addition, the dis-
cussion should also include information on risk factors of
recurrent OASIs and the potential protective effect of episiot-
omy [87, 88].
There is no international consensus regarding the mode of
delivery after an OASI. Some professional societies recom-
mend a vaginal delivery or a caesarean depending on the sit-
uation. In Germany, a cesarean is the initial choice for the case
of persistent fecal incontinence, suspected fetal macrosomia or
reduced anal sphincter function [89]. In the UK, the RCOG
suggests a caesarean after an OASI in the presence of anal
incontinence symptoms or abnormal endoanal ultrasonogra-
phy and/or manometry [13]. In Australia, the indication for a
caesarean is quite large, including current symptoms of anal
Table 3 Summary of different clinics’ protocols

Perineal clinic Definition of Definition of Definition of Cases recommended for vaginal delivery Cases recommended for caesarean Comments
abnormal abnormal ultrasound significant
manometry symptoms

St Mary’s Hospital Mean resting EAUS: EAS or IAS, Most of the time No symptoms AND normal manometry AND Symptoms OR abnormal manometry OR Women’s preferences were considered
UK, Karmarkar pressure < 40 defect or all the time normal EAUS abnormal EAUS for final decision of mode of delivery.
et al., 2015. [18] mmHg OR mean if >30° for faecal
incremental urgency or
pressure < 20 faecal
mmHg incontinence
Croydon University Incremental EAUS: EAS defect Unspecified Midly symptomatic or asymptomatic with Mildly symptomatic OR asymptomatic No equivocal cases
Hospital UK, pressure < 20 if > 30° (SMIS) normal manometry AND normal EAUS with abnormal manometry AND
Jordan et al., mmHg Severely symptomatic with abnormal EAUS abnormal EAUS
2018. [24] AND abnormal manometry
Norfolk and Incremental EAUS: EAS defect Presence of any Asymptomatic women with only one Asymptomatic women with both Excluding women with asymptomatic 3a
Norwich pressure < 20 m- if >30° anal abnormal investigation (AM or EAUS) OR abnormal manometry AND abnormal tear
University mHg incontinence symptomatic without abnormal EAUS OR symptomatic women with
Hospital UK, (Pescatori investigation only one abnormal investigation
Cassis et al., score) (abnormal manometry or abnormal
2018. [19] EAUS)
National Maternity In equivocal cases: EAUS: EAS or IAS Modified Wexner scale < 5 AND normal EAUS Wexner ≥ 5 AND abnormal EAUS Asymptomatic with abnormal EAUS or
Hospital of Mean resting defect Jorge-Wexner symptomatic with less than one
Dublin IE, pressure < 40 if > 90° Scale ≥ 5 quadrant defect are defined as
Fitzpatrick et al., mmHg OR mean equivocal cases and needed other
2016. [25] squeeze determinants (rectal examination,
pressure < 60 manometry)
mmHg
Birmingham Not applicable EAUS: EAS or IAS Unspecified Asymptomatic AND normal EAUS Symptoms OR abnormal EAUS
Women’s and defect (Manchester
Children’s NHS if > 30° Health
Foundation Trust Questionnaire)
UK, Webb et al.,
2020. [47]
Albert Schweitzer Not applicable 3D-TPUS: IAS or Unspecified Asymptomatic without severe anatomical Severe anatomical residual damage of the
Hospital NL, EAS discontinuity residual damage of the LAM or anal LAM OR anal sphincter OR
Van der Vlist et al., or LAM sphincter, with or without preconditions symptoms
2020. [32] discontinuity of depending on factors (foetal macrosomia,
puborectal part at an occiput posterior presentation or an
the pubic bone eventual instrumental delivery for a
subsequent birth)

EAUS, endoanal ultrasound; EAS, external anal sphincter; IAS, internal anal sphincter; SMIS, St Mark incontinence score; AM, anal manometry; LAM, levator ani muscle
Int Urogynecol J
Int Urogynecol J
incontinence, psychological and/or sexual dysfunction, sono-
graphic evidence of anal sphincter defect (> 30°), low
anorectal manometric pressures (e.g. incremental squeeze
pressure < 20 mmHg), previous fourth-degree tear or by a
woman’s request [90]. Contrarily, France does not recom-
mend a caesarean to prevent anal incontinence but suggests
only a discussion about the mode of delivery [91]. Finally, the
Society of Obstetricians and Gynaecologists of Canada does
not provide any recommendations about the mode of delivery
after an OASI but suggests counselling women about delivery
plans based on the statement that the risk of recurrence is 4–
8% and that 2.3 caesareans would be required to prevent one
case of anal incontinence in a woman with a prior OASI [1].
Some published algorithms from different perineal clinics
are available [18, 19, 24, 25, 32, 47, 92]. These protocols are
mostly based on anal incontinence symptoms, anal ultra-
sound, and/or anal manometry [18, 19, 24]. Although most
of the protocols agree on the conditions recommended to sug-
gest a vaginal delivery for patients without any consequences
(i.e. absence of anal symptoms, normal manometry, integrity
of sphincter) and a caesarean for patients with high severity
damage (i.e. symptomatic patients with abnormal manometry
and abnormal ultrasound), they tend to disagree for patients
with a mixed presentation. Moreover, some authors consider a
vaginal delivery possible even in severe cases, with the plan to
perform a secondary sphincteroplasty after the patient’s deci-
sion to cease having further children [24].
Discussion and conclusion
This review summarized the different choices to consider
when developing a perineal clinic. There is substantial varia-
tion in the organization and availability of equipment in per-
ineal clinics and the protocol used to advise the mode of de-
livery for subsequent pregnancies. This heterogeneity is not
entirely surprising, as the development of a perineal clinic will
depend on its specific setting. However, there are many rea-
sons why we would encourage the development of those
clinics. First, dedicated perineal clinics could help women
suffering from OASI finding multisource support such as:
physiotherapy, psychology, and sexology. It is also an oppor-
tunity to review the previous delivery events and discuss po-
tentially distressful experiences. Those clinics provide a com-
plete evaluation of their perineal function and determine the
best management for each woman, tailored to their conditions
and needs. Second, perineal clinics can contribute to medical
students, midwives, residents, and doctors, especially about
the long-term consequences of delivery, and adjust their man-
agement in obstetric clinics and delivery rooms. Finally, more
information and publications in this field are needed to stan-
dardize evaluation and guideline development.
This narrative review, by definition, presents some limita-
tions in its methodology. We used only one database,
Medline, with terms without variation or MESH term.
However, we conducted an extensive search, using several
combinations of keywords, and filtering all the reference lists
for eligible articles. We also included textbook chapters when
precise information was not reported in peer-review articles
(i.e. perineal clinic report template). This review is part of the
exhaustive work of research we have done to establish our
perineal clinic, and we hope it will facilitate the journey for
other teams in developing their own.
From a patient’s perspective, although more challenging to
set up, a 1-day clinic would be the best option to assess pa-
tients living in both surrounding and remote areas, especially
in a vast country like Canada.
From a research and clinical practice point of view, it
would be valuable to improve our knowledge in this field in
order to standardize different practices.
Finally, we hope that this review will help
urogynaecologists establish dedicated perineal clinics, pro-
mote peripartum women’s health care, and educate obstetri-
cian-gynaecologists, family doctors, and residents on the per-
ineal consequences of delivery.
Acknowledgements The authors thank Mengting Xu for proofreading
this manuscript.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
References
1. Harvey MA, Pierce M, Alter JE, Chou Q, Diamond P, Epp A, et al.
Obstetrical anal sphincter injuries (OASIS): prevention, recogni-
tion, and repair. J Obstet Gynaecol Can. 2015;37(12):1131–48.
2. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter
injuries—myth or reality? BJOG. 2006;113(2):195–200. https://
doi.org/10.1111/j.1471-0528.2006.00799.x.
3. Stock L, Basham E, Gossett DR, Lewicky-Gaupp C. Factors asso-
ciated with wound complications in women with obstetric anal
sphincter injuries (OASIS). Am J Obstet Gynecol. 2013;208(4):
327 e321–6. https://doi.org/10.1016/j.ajog.2012.12.025.
4. Das B, Snyder M. Rectovaginal fistulae. Clin Colon Rectal Surg.
2016;29(1):50–6. https://doi.org/10.1055/s-0035-1570393.
5. Oberwalder M, Connor J, Wexner SD. Meta-analysis to determine
the incidence of obstetric anal sphincter damage. Br J Surg.
2003;90(11):1333–7. https://doi.org/10.1002/bjs.4369.
6. Thubert T, Cardaillac C, Fritel X, Winer N, Dochez V. Definition,
epidemiology and risk factors of obstetric anal sphincter injuries:
CNGOF perineal prevention and protection in obstetrics guidelines.
Gynecol Obstet Fertil Senol. 2018;46(12):913–21. https://doi.org/
10.1016/j.gofs.2018.10.028.
7. Shek KL, Guzman-Rojas R, Dietz HP. Residual defects of the ex-
ternal anal sphincter following primary repair: an observational

study using transperineal ultrasound. Ultrasound Obstet Gynecol.
2014;44(6):704–9. https://doi.org/10.1002/uog.13368.
8. Turel FD, Langer S, Shek KL, Dietz HP. Medium- to long-term
follow-up of obstetric anal sphincter injury. Dis Colon Rectum.
2019;62(3):348–56. https://doi.org/10.1097/DCR.
0000000000001297.
9. Thomas GP, Gould LE, Casunuran F, Kumar DA. A retrospective
review of 1495 patients with obstetric anal sphincter injuries re-
ferred for assessment of function and endoanal ultrasonography.
Int J Color Dis. 2017;32(9):1321–5. https://doi.org/10.1007/
s00384-017-2851-3.
10. Fitzpatrick M, Cassidy M, O’Connell PR, O’Herlihy C. Experience
with an obstetric perineal clinic. Eur J Obstet Gynecol Reprod Biol.
2002;100(2):199–203. https://doi.org/10.1016/s0301-2115(01)
00427-4.
11. Fowler G, Williams A, Murphy G, Taylor K, Wood C, Adams E.
How to set up a perineal clinic. Obstet Gynaecolt. 2009;11(2):129–
32. https://doi.org/10.1576/toag.11.2.129.27487.
12. Sultan AH, Thakar R. Lower genital tract and anal sphincter trau-
ma. Best Pract Res Clin Obstet Gynaecol. 2002;16(1):99–115.
https://doi.org/10.1053/beog.2002.0258.
13. RCOG. Royal College of Obstetricians and Gynaecologists: Green-
top Guideline No. 29: The Management of Third- and Fourth-
Degree Perineal Tears. 2015. London: Royal College of
Obstetricians and Gynaecologists. https://www.rcog.org.uk/
globalassets/documents/guidelines/gtg-29.pdf Accessed 1
May 2020.
14. Ismail SI. The management of obstetric anal sphincter injuries
(OASIS): a national postal questionnaire survey in hospitals in the
U. K J Obstet Gynaecol. 2015;35(3):229–34. https://doi.org/10.
3109/01443615.2014.954098.
15. Best C, Drutz HP, Alarab M. Obstetric anal sphincter injuries: a
survey of clinical practice among Canadian obstetricians. J Obstet
Gynaecol Can. 2012;34(8):747–54. https://doi.org/10.1016/S1701-
2163(16)35338-5.
16. Futaba KRS, Webb S, Parsons M. Management of Perineal Trauma
Complications: the role of the MDT. In: K I, editor. Perineal trauma
at childbirth. Cham: Springer; 2016. https://doi.org/10.1007/978-3-
319-14860-1_10.
17. Scheer I, Thakar R, Sultan AH. Mode of delivery after previous
obstetric anal sphincter injuries (OASIS)—a reappraisal? Int
Urogynecol J Pelvic Floor Dysfunct. 2009;20(9):1095–101.
https://doi.org/10.1007/s00192-009-0908-8.
18. Karmarkar R, Bhide A, Digesu A, Khullar V, Fernando R. Mode of
delivery after obstetric anal sphincter injury. Eur J Obstet Gynecol
Reprod Biol. 2015;194:7–10. https://doi.org/10.1016/j.ejogrb.
2015.07.019.
19. Cassis C, Giarenis I, Mukhopadhyay S, Morris E. Mode of delivery
following an OASIS and caesarean section rates. Eur J Obstet
Gynecol Reprod Biol. 2018;230:28–31. https://doi.org/10.1016/j.
ejogrb.2018.09.020.
20. Pretlove S, Thompson PJ, Toozs-Hobson PM, Radley S. The first
18 months of a new perineal trauma clinic. J Obstet Gynaecol.
2004;24(4):399–402. https://doi.org/10.1080/
01443610410001685538.
21. Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, Kenton K,
Gossett DR. Wound complications after obstetric anal sphincter
injuries. Obstet Gynecol. 2015;125(5):1088–93. https://doi.org/10.
1097/AOG.0000000000000833.
22. Anglim B, Kelly L, Fitzpatrick M. Risk factors and outcome of
repair of obstetric anal sphincter injuries as followed up in a dedi-
cated perineal clinic. Int Urogynecol J. 2019;30(10):1649–55.
https://doi.org/10.1007/s00192-019-03960-7.
23. Brincat C, Crosby E, McLeod A, Fenner DE. Experiences during
the first four years of a postpartum perineal clinic in the USA. Int J
Int Urogynecol J
Gynaecol Obstet. 2015;128(1):68–71. https://doi.org/10.1016/j.
ijgo.2014.07.026.
24. Jordan PA, Naidu M, Thakar R, Sultan AH. Effect of subsequent
vaginal delivery on bowel symptoms and anorectal function in
women who sustained a previous obstetric anal sphincter injury.
Int Urogynecol J. 2018;29(11):1579–88. https://doi.org/10.1007/
s00192-018-3601-y.
25. Fitzpatrick M, Cassidy M, Barassaud ML, Hehir MP, Hanly AM,
O’Connell PR, et al. Does anal sphincter injury preclude subsequent
vaginal delivery? Eur J Obstet Gynecol Reprod Biol. 2016;198:30–
4. https://doi.org/10.1016/j.ejogrb.2015.12.004.
26. Jorge JM, Wexner SD. Etiology and management of fecal inconti-
nence. Dis Colon Rectum. 1993;36(1):77–97. https://doi.org/10.
1007/BF02050307.
27. Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective compar-
ison of faecal incontinence grading systems. Gut. 1999;44(1):77–
80. https://doi.org/10.1136/gut.44.1.77.
28. Sultan AH, Monga A, Lee J, Emmanuel A, Norton C, Santoro G,
et al. An International Urogynecological Association (IUGA)/
International Continence Society (ICS) joint report on the terminol-
ogy for female anorectal dysfunction. Int Urogynecol J. 2017;28(1):
5–31. https://doi.org/10.1007/s00192-016-3140-3.
29. Pescatori M, Anastasio G, Bottini C, Mentasti A. New grading and
scoring for anal incontinence. Evaluation of 335 patients. Dis Colon
Rectum. 1992;35(5):482–7. https://doi.org/10.1007/BF02049407.
30. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis
C, Thorson AG, et al. Patient and surgeon ranking of the severity of
symptoms associated with fecal incontinence: the fecal inconti-
nence severity index. Dis Colon Rectum. 1999;42(12):1525–32.
https://doi.org/10.1007/BF02236199.
31. Roos AM, Sultan AH, Thakar R. St. Mark’s incontinence score for
assessment of anal incontinence following obstetric anal sphincter
injuries (OASIS). Int Urogynecol J Pelvic Floor Dysfunct.
2009;20(4):407–10. https://doi.org/10.1007/s00192-008-0784-7.
32. van der Vlist M, Oom D, van Rosmalen J, van Ovost A,
Hogewoning C. Parturition mode recommendation and symptoms
of pelvic floor disorders after obstetric anal sphincter injuries. Int
Urogynecol J. 2020. https://doi.org/10.1007/s00192-020-04241-4.
33. Johannessen HH, Norderval S, Stordahl A, Falk RS, Wibe A.
Interview-based versus self-reported anal incontinence using St
Mark’s incontinence score. Int Urogynecol J. 2018;29(5):667–71.
https://doi.org/10.1007/s00192-017-3363-y.
34. Maeda Y, Pares D, Norton C, Vaizey CJ, Kamm MA. Does the St.
Mark’s incontinence score reflect patients’ perceptions? A review
of 390 patients. Dis Colon Rectum. 2008;51(4):436–42. https://doi.
org/10.1007/s10350-007-9157-4.
35. Guzman Rojas RA, Kamisan Atan I, Shek KL, Dietz HP. Anal
sphincter trauma and anal incontinence in urogynecological pa-
tients. Ultrasound Obstet Gynecol. 2015;46(3):363–6. https://doi.
org/10.1002/uog.14845.
36. Valsky DV, Cohen SM, Lipschuetz M, Hochner-Celnikier D,
Yagel S. Three-dimensional transperineal ultrasound findings asso-
ciated with anal incontinence after intrapartum sphincter tears in
primiparous women. Ultrasound Obstet Gynecol. 2012;39(1):83–
90. https://doi.org/10.1002/uog.10072.
37. Bonniaud V, Guyatt G, Bonniaud P, Perennou D, Parratte B.
Choosing a quality-of-life questionnaire. Presse Med. 2006;35(2
Pt 2):281–6. https://doi.org/10.1016/s0755-4982(06)74571-7.
38. Lee JT, Madoff RD, Rockwood TH. Quality-of-life measures in
fecal incontinence: is validation valid? Dis Colon Rectum.
2015;58(3):352–7. https://doi.org/10.1097/DCR.
0000000000000290.
39. Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The
American Society of Colon and Rectal Surgeons’ clinical practice
guideline for the treatment of fecal incontinence. Dis Colon
Int Urogynecol J
Rectum. 2015;58(7):623–36. https://doi.org/10.1097/DCR.
0000000000000397.
40. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis
C, Thorson AG, et al. Fecal incontinence quality of life scale: qual-
ity of life instrument for patients with fecal incontinence. Dis Colon
Rectum. 2000;43(1):9–16; discussion 16-17. https://doi.org/10.
1007/bf02237236.
41. Rullier E, Zerbib F, Marrel A, Amouretti M, Lehur PA. Validation
of the French version of the fecal incontinence quality-of-life
(FIQL) scale. Gastroenterol Clin Biol. 2004;28(6-7 Pt 1):562–8.
https://doi.org/10.1016/s0399-8320(04)95012-9.
42. Bordeianou L, Rockwood T, Baxter N, Lowry A, Mellgren A,
Parker S. Does incontinence severity correlate with quality of life?
Prospective analysis of 502 consecutive patients. Color Dis.
2008;10(3):273–9. https://doi.org/10.1111/j.1463-1318.2007.
01288.x.
43. Abdool Z, Sultan AH, Thakar R. Ultrasound imaging of the anal
sphincter complex: a review. Br J Radiol. 2012;85(1015):865–75.
https://doi.org/10.1259/bjr/27314678.
44. Sultan AH, Kamm MA, Talbot IC, Nicholls RJ, Bartram CI. Anal
endosonography for identifying external sphincter defects con-
firmed histologically. Br J Surg. 1994;81(3):463–5. https://doi.
org/10.1002/bjs.1800810349.
45. Gurland B, Hull T. Transrectal ultrasound, manometry, and puden-
dal nerve terminal latency studies in the evaluation of sphincter
injuries. Clin Colon Rectal Surg. 2008;21(3):157–66. https://doi.
org/10.1055/s-2008-1080995.
46. Roos AM, Thakar R, Sultan AH. Outcome of primary repair of
obstetric anal sphincter injuries (OASIS): does the grade of tear
matter? Ultrasound Obstet Gynecol. 2010;36(3):368–74. https://
doi.org/10.1002/uog.7512.
47. Webb SS, Sitch A, MacArthur C. The impact of mode of subse-
quent birth after obstetric anal sphincter injury on bowel function
and related quality of life: a cohort study. Int Urogynecol J. 2020.
https://doi.org/10.1007/s00192-020-04234-3.
48. Belmonte-Montes C, Hagerman G, Vega-Yepez PA, Hernandez-
de-Anda E, Fonseca-Morales V. Anal sphincter injury after vaginal
delivery in primiparous females. Dis Colon Rectum. 2001;44(9):
1244–8. https://doi.org/10.1007/BF02234778.
49. Norderval S, Rossaak K, Markskog A, Vonen B. Incontinence after
primary repair of obstetric anal sphincter tears is related to relative
length of reconstructed external sphincter: a case-control study.
Ultrasound Obstet Gynecol. 2012;40(2):207–14. https://doi.org/
10.1002/uog.10154.
50. Norderval S, Markskog A, Rossaak K, Vonen B. Correlation be-
tween anal sphincter defects and anal incontinence following ob-
stetric sphincter tears: assessment using scoring systems for sono-
graphic classification of defects. Ultrasound Obstet Gynecol.
2008;31(1):78–84. https://doi.org/10.1002/uog.5155.
51. Starck M, Bohe M, Valentin L. The extent of endosonographic anal
sphincter defects after primary repair of obstetric sphincter tears
increases over time and is related to anal incontinence. Ultrasound
Obstet Gynecol. 2006;27(2):188–97. https://doi.org/10.1002/uog.
2630.
52. Fynes M, Donnelly V, Behan M, O’Connell PR, O’Herlihy C.
Effect of second vaginal delivery on anorectal physiology and fae-
cal continence: a prospective study. Lancet. 1999;354(9183):983–
6. https://doi.org/10.1016/S0140-6736(98)11205-9.
53. Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D,
Zamora J, Jha S, et al. Risk of obstetric anal sphincter injuries
(OASIS) and anal incontinence: a meta-analysis. Eur J Obstet
Gynecol Reprod Biol. 2020;252:303–12. https://doi.org/10.1016/
j.ejogrb.2020.06.048.
54. Yagel S, Valsky DV. Three-dimensional transperineal ultrasonog-
raphy for evaluation of the anal sphincter complex: another dimen-
sion in understanding peripartum sphincter trauma. Ultrasound
Obstet Gynecol. 2006;27(2):119–23. https://doi.org/10.1002/uog.
2714.
55. Valsky DV, Messing B, Petkova R, Savchev S, Rosenak D,
Hochner-Celnikier D, et al. Postpartum evaluation of the anal
sphincter by transperineal three-dimensional ultrasound in primip-
arous women after vaginal delivery and following surgical repair of
third-degree tears by the overlapping technique. Ultrasound Obstet
Gynecol. 2007;29(2):195–204. https://doi.org/10.1002/uog.3923.
56. Oom DM, West RL, Schouten WR, Steensma AB. Detection of
anal sphincter defects in female patients with fecal incontinence: a
comparison of 3-dimensional transperineal ultrasound and 2-
dimensional endoanal ultrasound. Dis Colon Rectum. 2012;55(6):
646–52. https://doi.org/10.1097/DCR.0b013e318251dca1.
57. Stuart A, Ignell C, Orno AK. Comparison of transperineal and
endoanal ultrasound in detecting residual obstetric anal sphincter
injury. Acta Obstet Gynecol Scand. 2019;98(12):1624–31. https://
doi.org/10.1111/aogs.13701.
58. Ros C, Martinez-Franco E, Wozniak MM, Cassado J, Santoro GA,
Elias N, et al. Postpartum two- and three-dimensional ultrasound
evaluation of anal sphincter complex in women with obstetric anal
sphincter injury. Ultrasound Obstet Gynecol. 2017;49(4):508–14.
https://doi.org/10.1002/uog.15924.
59. Taithongchai A, van Gruting IMA, Volloyhaug I, Arendsen LP,
Sultan AH, Thakar R. Comparing the diagnostic accuracy of 3
ultrasound modalities for diagnosing obstetric anal sphincter inju-
ries. Am J Obstet Gynecol. 2019;221(2):134 e131–9. https://doi.
org/10.1016/j.ajog.2019.04.009.
60. Turel Fatakia F, Subramaniam N, Bienkiewicz J, Friedman T, Dietz
HP. How repeatable is assessment of external anal sphincter trauma
by exoanal 4D ultrasound? Ultrasound Obstet Gynecol.
2019;53(6):836–40. https://doi.org/10.1002/uog.20175.
61. Volloyhaug I, Taithongchai A, Arendsen L, van Gruting I, Sultan
AH, Thakar R. Is endoanal, introital or transperineal ultrasound
diagnosis of sphincter defects more strongly associated with anal
incontinence? Int Urogynecol J. 2020;31(7):1471–8. https://doi.
org/10.1007/s00192-020-04274-9.
62. Cattani L, Van Schoubroeck D, Housmans S, Callewaert G,
Werbrouck E, Verbakel JY, et al. Exo-anal imaging of the anal
sphincter: a comparison between introital and transperineal image
acquisition. Int Urogynecol J. 2020;31(6):1107–13. https://doi.org/
10.1007/s00192-019-04122-5.
63. Bo K, Finckenhagen HB. Vaginal palpation of pelvic floor muscle
strength: inter-test reproducibility and comparison between palpa-
tion and vaginal squeeze pressure. Acta Obstet Gynecol Scand.
2001;80(10):883–7. https://doi.org/10.1034/j.1600-0412.2001.
801003.x.
64. Navarro Brazalez B, Torres Lacomba M, de la Villa P, Sanchez
Sanchez B, Prieto Gomez V, Asunsolo Del Barco A, et al. The
evaluation of pelvic floor muscle strength in women with pelvic
floor dysfunction: a reliability and correlation study. Neurourol
Urodyn. 2018;37(1):269–77. https://doi.org/10.1002/nau.23287.
65. Ferreira CH, Barbosa PB, de Oliveira Souza F, Antonio FI, Franco
MM, Bo K. Inter-rater reliability study of the modified Oxford
grading scale and the Peritron manometer. Physiotherapy.
2011;97(2):132–8. https://doi.org/10.1016/j.physio.2010.06.007.
66. van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility:
digital assessment vs transperineal ultrasound. Ultrasound Obstet
Gynecol. 2015;45(2):217–22. https://doi.org/10.1002/uog.13456.
67. Albrich S, Steetskamp J, Knoechel SL, Porta S, Hoffmann G, Skala
C. Assessment of pelvic floor muscle contractility: digital palpation
versus 2D and 3D perineal ultrasound. Arch Gynecol Obstet.
2016;293(4):839–43. https://doi.org/10.1007/s00404-015-3897-5.
68. Volloyhaug I, Morkved S, Salvesen O, Salvesen KA. Assessment
of pelvic floor muscle contraction with palpation, perineometry and
transperineal ultrasound: a cross-sectional study. Ultrasound Obstet
Gynecol. 2016;47(6):768–73. https://doi.org/10.1002/uog.15731.

69. Nyhus MO, Oversand SH, Salvesen O, Salvesen KA, Mathew S,
Volloyhaug I. Ultrasound assessment of pelvic floor muscle con-
traction: reliability and development of an ultrasound-based con-
traction scale. Ultrasound Obstet Gynecol. 2020;55(1):125–31.
https://doi.org/10.1002/uog.20382.
70. Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the
diagnosis of avulsion of the puborectalis muscle by tomographic
ultrasound. Int Urogynecol J. 2011;22(6):699–704. https://doi.org/
10.1007/s00192-010-1329-4.
71. Chantarasorn V, Shek KL, Dietz HP. Sonographic detection of
puborectalis muscle avulsion is not associated with anal inconti-
nence. Aust N Z J Obstet Gynaecol. 2011;51(2):130–5. https://
doi.org/10.1111/j.1479-828X.2010.01273.x.
72. Murad-Regadas SM, da SFGO, Regadas FS, Rodrigues LV, Filho
FS, Dealcanfreitas ID, et al. Usefulness of anorectal and
endovaginal 3D ultrasound in the evaluation of sphincter and
pubovisceral muscle defects using a new scoring system in women
with fecal incontinence after vaginal delivery. Int J Color Dis.
2017;32(4):499–507. https://doi.org/10.1007/s00384-016-2750-z.
73. Heilbrun ME, Nygaard IE, Lockhart ME, Richter HE, Brown MB,
Kenton KS, et al. Correlation between levator ani muscle injuries on
magnetic resonance imaging and fecal incontinence, pelvic organ
prolapse, and urinary incontinence in primiparous women. Am J
Obstet Gynecol. 2010;202(5):488 e481–6. https://doi.org/10.1016/
j.ajog.2010.01.002.
74. Martinez Franco E, Lopez Negre JL, Pares D, Ros Cerro C, Amat
Tardiu L, Cuadras D, et al. Anatomic and functional evaluation of
the levator ani muscle after an obstetric anal sphincter injury. Arch
Gynecol Obstet. 2019;299(4):1001–6. https://doi.org/10.1007/
s00404-019-05070-7.
75. Lewicky-Gaupp C, Brincat C, Yousuf A, Patel DA, Delancey JO,
Fenner DE. Fecal incontinence in older women: are levator ani
defects a factor? Am J Obstet Gynecol. 2010;202(5):491 e491–6.
https://doi.org/10.1016/j.ajog.2010.01.020.
76. Carrington EV, Heinrich H, Knowles CH, Fox M, Rao S, Altomare
DF, et al. The international anorectal physiology working group
(IAPWG) recommendations: standardized testing protocol and the
London classification for disorders of anorectal function.
Neurogastroenterol Motil. 2020;32(1):e13679. https://doi.org/10.
1111/nmo.13679.
77. Brusciano LDSC, Lucido F, Del Genio A. Manometry, rectoanal
inhibition and compliance assessment in proctologic practice: ap-
proaches in the reoperative case. In: Reconstructive surgery of the
rectum, anus and perineum. London: Springer; 2013. https://doi.
org/10.1007/978-1-84882-413-3_6.
78. Papaconstantinou HT. Evaluation of anal incontinence: minimal
approach, maximal effectiveness. Clin Colon Rectal Surg.
2005;18(1):9–16. https://doi.org/10.1055/s-2005-864076.
79. Chaliha C, Sultan AH, Emmanuel AV. Normal ranges for anorectal
manometry and sensation in women of reproductive age. Color Dis.
2007;9(9):839–44. https://doi.org/10.1111/j.1463-1318.2007.
01212.x.
80. Nazir M, Carlsen E, Jacobsen AF, Nesheim BI. Is there any corre-
lation between objective anal testing, rupture grade, and bowel
symptoms after primary repair of obstetric anal sphincter rupture?:
Int Urogynecol J
an observational cohort study. Dis Colon Rectum. 2002;45(10):
1325–31. https://doi.org/10.1007/s10350-004-6419-2.
81. de Leeuw JW, Vierhout ME, Struijk PC, Auwerda HJ, Bac DJ,
Wallenburg HC. Anal sphincter damage after vaginal delivery: re-
lationship of anal endosonography and manometry to anorectal
complaints. Dis Colon Rectum. 2002;45(8):1004–10. https://doi.
org/10.1007/s10350-004-6351-5.
82. Parangama C, Anu E, Sukria N. Endoanal ultrasound assessment of
sphincter defects and thinning–correlation with anal manometry.
Arab J Gastroenterol. 2014;15(1):27–31. https://doi.org/10.1016/j.
ajg.2014.01.006.
83. Ha HT, Fleshman JW, Smith M, Read TE, Kodner IJ, Birnbaum
EH. Manometric squeeze pressure difference parallels functional
outcome after overlapping sphincter reconstruction. Dis Colon
Rectum. 2001;44(5):655–60. https://doi.org/10.1007/BF02234561.
84. Elton C, Stoodley BJ. Anterior anal sphincter repair: results in a
district general hospital. Ann R Coll Surg Engl. 2002;84(5):321–4.
https://doi.org/10.1308/003588402760452420.
85. Zutshi M, Salcedo L, Hammel J, Hull T. Anal physiology testing in
fecal incontinence: is it of any value? Int J Color Dis. 2010;25(2):
277–82. https://doi.org/10.1007/s00384-009-0830-z.
86. Roos AM, Abdool Z, Thakar R, Sultan AH. Predicting anal sphinc-
ter defects: the value of clinical examination and manometry. Int
Urogynecol J. 2012;23(6):755–63. https://doi.org/10.1007/s00192-
011-1609-7.
87. Jha S, Parker V. Risk factors for recurrent obstetric anal sphincter
injury (rOASI): a systematic review and meta-analysis. Int
Urogynecol J. 2016;27(6):849–57. https://doi.org/10.1007/
s00192-015-2893-4.
88. D’Souza JC, Monga A, Tincello DG, Sultan AH, Thakar R, Hillard
TC, et al. Maternal outcomes in subsequent delivery after previous
obstetric anal sphincter injury (OASI): a multi-centre retrospective
cohort study. Int Urogynecol J. 2020;31(3):627–33. https://doi.org/
10.1007/s00192-019-03983-0.
89. Aigmueller T, Bader W, Beilecke K, Elenskaia K, Frudinger A,
Hanzal E, et al. Management of 3rd and 4th degree perineal tears
after vaginal birth. German guideline of the German Society of
Gynecology and Obstetrics (AWMF registry no. 015/079,
October 2014). Geburtshilfe Frauenheilkd. 2015;75(2):137–44.
https://doi.org/10.1055/s-0034-1396323.
90. Queensland Clinical Guidelines (2018) Maternity and neonatal
clnical gudeline -perneal care. https://wwwhealthqldgovau/__data/
assets/pdf_file/0022/142384/g-pericarepdf. Accessed 23 April
2020.
91. Gachon B. Cesarean section and perineal protection: CNGOF per-
ineal prevention and protection in obstetrics Guidelines. Gynecol
Obstet Fertil Senol. 2018;46(12):968–85. https://doi.org/10.1016/j.
gofs.2018.10.030.
92. Taithongchai A, Thakar R, Sultan AH. Management of subsequent
pregnancies following fourth-degree obstetric anal sphincter inju-
ries (OASIS). Eur J Obstet Gynecol Reprod Biol. 2020;250:80–5.
https://doi.org/10.1016/j.ejogrb.2020.04.063.
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