Obstetric Anal Sphincter Injury (OASIS)

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Obstetric anal sphincter injury (OASIS)

Authors: Milena M Weinstein, MD, FACOG, Helai Hesham, MD, FACOG
Section Editors: Linda Brubaker, MD, FACOG, Martin Weiser, MD
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2022. | This topic last updated: Oct 06, 2021.
INTRODUCTION
Obstetric anal sphincter injuries (OASIS) are complications that occur during vaginal delivery.
Also referred to as third- and fourth-degree perineal lacerations, these injuries involve the anal
sphincter complex and, in more severe cases, anal mucosa. In addition to contributing to short-
term morbidity, such as wound breakdown and perineal pain, OASIS is a leading risk factor for
subsequent loss of bowel control in women.
This topic will discuss the epidemiology, clinical presentation, diagnosis, treatment, and
prognosis of OASIS. Related topics on repair and management of obstetric lacerations and the
effect of pregnancy and childbirth on anal sphincter function are presented separately:
● (See "Repair of perineal and other lacerations associated with childbirth".)
● (See "Postpartum perineal care and management of complications".)
● (See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling,
evaluation, and management".)
ANORECTAL ANATOMY AND LACERATION
Continence of feces and gas is maintained by the anorectal complex, which consists of the anal
canal and rectum ( figure 1). The anal canal starts below the anorectal junction that is formed
by the puborectalis muscle. The major muscular components of the anal canal are the internal
and external anal sphincters.
https://www.uptodate.com/contents/obstetric-anal-sphincter-injury-oasis/print 1/39
● The internal anal sphincter is the terminal thickened portion of the smooth circular muscle
of the gastrointestinal tract. The internal anal sphincter is under autonomic control and
contributes up to 85 percent of resting pressure of the anal canal and is critical to
maintaining continence [1]. Internal anal sphincter damage is associated with passive
soiling or flatal incontinence [2]. (See 'Loss of bowel control' below.)
● The external anal sphincter is a striated muscle that provides most of the squeeze
pressure important in maintaining anal continence. The external anal sphincter is
innervated by the pudendal nerve. Damage to the external anal sphincter is associated
with fecal incontinence [3]. (See 'Loss of bowel control' below.)
Obstetric perineal lacerations are classified into degrees based on the depth of tissue
disruption ( table 1) [4,5]. (See 'Occult (delayed) OASIS' below.)
EPIDEMIOLOGY AND RISK FACTORS
● Incidence – A meta-analysis of eight observational studies that included over 99,000

women reported the following [6]:
• Overall OASIS risk: 6.3 percent

• Risk of OASIS in the first delivery: 5.7 percent
• Risk in parous women with no previous OASIS: 1.5 percent
In a retrospective study of over 700 women with twin pregnancies, OASIS occurred in 2.8
percent of women undergoing vaginal delivery of both twins [7].
In evaluating the prevalence of OASIS, the delivery record appears to be a more accurate
source of information than patient recollection because of recall bias. As an example, one
study of over 1000 women reported that women with pelvic floor symptoms were more
likely to recall a history of OASIS regardless of whether such a laceration was documented
[8].
● Risk factors – Risk factors for OASIS include vaginal delivery, obstetric factors, operative
vaginal delivery, episiotomy, fetal macrosomia, prolonged second stage, fetal occiput
posterior presentation, and increasing maternal age [9-12]. Obesity does not appear to be
a risk factor [13].
• Obstetric factors – Prolonged second stage of labor and episiotomy have been
consistently associated with increased risk of OASIS. Additional risk factors likely
include primiparity, large birth weight, and vaginal birth after cesarean delivery. A
computer-generated model has been created to help predict the risk of OASIS for
individuals considering a trial of labor after cesarean delivery [14]. (See "Choosing the
route of delivery after cesarean birth", section on 'Risks/benefits of TOLAC versus
PRCB'.)
Supporting data include:
- Obstetric factors US population – In a retrospective cohort study of over 22,000

women undergoing term vaginal delivery in the Kaiser Permanente Northern
California health system, second-stage of labor ≥3 hours, midline episiotomy, and
vaginal birth after cesarean delivery were associated with an approximately
threefold increased risk of OASIS [15]. An approximate doubling of OASIS risk was
reported for being primiparous or of Asian ancestry.
- Obstetric factors Indian population – A case-control study of over 28,000 births

in India similarly reported an increased risk of OASIS with prolonged second stage
of labor and episiotomy [16]. Additional OASIS risk factors in the adjusted analysis
included primiparity, gestational age ≥41 weeks, epidural analgesia, shoulder
dystocia, and birth weight ≥4000 g.
- Birth weight and fetal head circumference – A population-based study of over

284,000 women reported a 1.5-fold increase in the odds of OASIS with each 500 g
increase in fetal birth weight over 2000 g [17]. A retrospective cohort study
comparing 455 births with OASIS with nearly 150,000 births without OASIS
reported increasing OASIS risk with birth weight ≥90th percentile and combined
birth weight and head circumference ≥90th percentile [18].
- Shoulder dystocia – Retrospective analysis of over 67,000 birth reported an OASIS

rate of 9 percent for women with shoulder dystocia [19].
• Operative vaginal delivery – The risk of OASIS, and subsequent fecal incontinence, is
increased with operative vaginal delivery (both vacuum-assisted and forceps) [12]. In
the above study from the Kaiser Permanente health system, OASIS occurred in 24
percent of vacuum-assisted deliveries compared with 4 percent of spontaneous
deliveries [15]. The body of evidence suggests that forceps delivery is associated with a
greater risk of OASIS than vacuum delivery, but the data are conflicting [20-26]. In a
study of over 100,000 spontaneous vaginal deliveries, OASIS occurred in 8.6 percent of
forceps assisted deliveries, 3.7 percent of vacuum assisted vaginal deliveries, and 1.3
percent of spontaneous vaginal deliveries [21]. In addition, small cohort studies have
reported the diagnosis of delayed OASIS in over 80 percent of women with forceps-
assisted deliveries [27,28].
Thus, operative vaginal delivery should only be used for obstetric indications given the
increased risk of OASIS. (See "Operative vaginal delivery", section on 'Indications'.)
• Episiotomy – Routine use of episiotomy is no longer recommended because of

insufficient objective, evidence-based data demonstrating benefit or defining the
criterion for its use [5,29,30]. One consequence of episiotomy is extension of the
incision into or through the anal sphincter complex, particularly for median (midline)
episiotomy [31]. In the above Kaiser Permanente study, median episiotomy was
associated with an approximate threefold increased risk of OASIS compared with an
approximate doubling of risk for mediolateral episiotomy [15]. A meta-analysis of over
700,000 pregnant patients found that mediolateral episiotomy neither increased nor
protected against perineal lacerations (relative risk 1.55, 95% CI 0.95-2.53) [12]. When
episiotomy is deemed necessary, we recommend mediolateral episiotomy to reduce
the risk of OASIS, although rarely mediolateral incisions may still extend into an anal
sphincter laceration [32]. (See "Approach to episiotomy".)
• Prior OASIS – Women with prior OASIS are at increased risk of repeat OASIS in a
subsequent delivery. Repeat OASIS rates of 3 to 6 percent have been reported;
variation comes in part from number of prior OASIS events.
- (See 'Prognosis' below.)

- (See 'Approach to future delivery' below.)
CLINICAL SIGNIFICANCE
Clinical issues related to OASIS include an increased risk for loss of bowel control, optimal mode
of delivery for future pregnancy, and routine screening at the time of vaginal delivery.
Loss of bowel control — OASIS increases the risk of subsequent loss of bowel control. Studies
have reported postpartum fecal incontinence (involuntary loss of stool) rates of 0 to 28 percent
in women with OASIS, compared with rates of 1 to 10 percent for women delivered without
OASIS [20,33-44]. Rates vary by definitions used and duration of follow-up. At least one study
has reported that fourth-degree lacerations are associated with higher long-term risk of bowel
incontinence compared with third-degree lacerations [45]. The physiology of defecation and
fecal incontinence is reviewed in detail separately. (See "Fecal incontinence in adults: Etiology
and evaluation", section on 'Physiology of defecation'.)
Loss of bowel control can be further divided into flatal, fecal, and anal incontinence [3]. Various
terminologies exist for medical professionals; affected patients prefer the term "accidental
bowel leakage" [46].
● Flatal incontinence – The involuntary loss of flatus only

● Fecal incontinence – The involuntary loss of solid or liquid feces
● Anal incontinence – The involuntary loss of solid or liquid feces or flatus
Approach to future delivery — For women with a prior OASIS, there are insufficient high-
quality data to make recommendations regarding delivery mode in a subsequent pregnancy
[47]. While we take the approach below, the ultimate decision regarding delivery route is made
by the patient.
Based on the available literature and our clinical experience, we do the following:
● For asymptomatic women with one prior OASIS, we believe vaginal delivery can be
reasonably offered after careful counseling regarding the risks of a second OASIS (and
subsequent fecal incontinence) compared with the risks of cesarean delivery. We would
advise use of operative delivery and episiotomy only as obstetrically indicated. For women
with primary OASIS, the risk of repeat OASIS is approximately 3 to 5 percent [48,49]. It is
estimated that 2.3 cesarean deliveries would be needed in women with prior OASIS to
prevent one new case of anal incontinence [50]. In addition, it is not clear that subsequent
vaginal delivery negatively impacts measurable anal sphincter function [51].
● For asymptomatic women with two or more prior OASIS or symptomatic women with any
prior OASIS, we offer a planned cesarean delivery in future pregnancies [4]. Women with
two prior OASIS have an approximately 10-fold increased risk for sphincter injury with the
next delivery [52]. Women with transient anal incontinence symptoms following an initial
delivery have a one in six chance of developing permanent symptoms following a
subsequent vaginal delivery [50,53]. Of note, while it appears that vaginal delivery
increases the short-term risk of persistent fecal incontinence in women with previous
OASIS [54-56], an elevated risk of fecal incontinence is not noted when women are
followed for five or more years [57-59]. In counseling symptomatic women with a history
of OASIS, it is important to explain the uncertainties regarding risk of recurrent or
persistent anal incontinence as well as operative risks associated with cesarean delivery.
In a retrospective study of 153 women with a prior OASIS, approximately 30 percent elected to
have a cesarean delivery at the time of subsequent pregnancy [60]. Selection of cesarean
delivery was associated with White ethnicity and severity of endoanal ultrasound results,
although study numbers were small. In another retrospective study of 233 patients with prior
OASIS, endoanal ultrasound and anorectal manometry were performed on all the patients and
then test results were applied to different decision algorithms regarding route of delivery [61].
When the strictest protocol was applied, which included cesarean delivery when only one
investigation was abnormal or for all women with anal incontinence, more than 80 percent of
women would be advised to have a cesarean delivery in subsequent pregnancy. When the
algorithm was changed to require symptomatic women to have one abnormal investigation
and asymptomatic women to have abnormalities of both tests, the advised cesarean delivery
rate dropped to 40 percent.
Screening at time of vaginal delivery — There is no consensus as to whether or not

postpartum women should be routinely screened for OASIS in the delivery room or postpartum
period. Persistent pelvic floor issues in a postpartum patient, particularly fecal urgency or
incontinence, should raise suspicion for possible pelvic floor injury, including OASIS. (See
'Evaluation and management' below.)
PREVENTION
While the risk of OASIS during vaginal delivery cannot be eliminated, some techniques appear
to reduce the incidence of OASIS. However, a reduction in OASIS is not clearly associated with
reduced long-term loss of bowel control.
● Cesarean delivery – While primary cesarean delivery does prevent OASIS, cesarean
delivery has not been associated with decreased long-term rates of fecal incontinence and
thus is not routinely advised for this indication [62]. However, for women who have had a
previous anal sphincter injury or have symptomatic fecal incontinence, planned cesarean
delivery, after counseling regarding risks and benefits, is a reasonable approach to
decrease the chances of permanent symptoms. (See 'Approach to future delivery' above.)
The impact of cesarean delivery on pelvic floor function is reviewed further in a related
topic. (See "Fecal and anal incontinence associated with pregnancy and childbirth:
Counseling, evaluation, and management", section on 'Approach to delivery'.)
● Perineal massage – Perineal massage, either antepartum or during the second stage of
labor, has shown to decrease muscular resistance and reduce the likelihood of laceration
for patients [63,64]. However, while perineal massage may reduce the incidence of
perineal laceration, it does not appear to decrease postpartum fecal incontinence [65].
● Maternal birth position – Population studies have reported increased rates of anal
sphincter injury for women who deliver in standing, squatting, or lithotomy positions
compared with supine, semirecumbent, or lateral recumbent positions [66,67]. It is not

known if the standing, squatting, or lithotomy birth positions are associated with
increased long-term rates of loss of bowel control or if the other positions reduce the
long-term rates of involuntary loss of bowel control.
● Obstetric provider training – Training programs have been created to improve clinician
understanding of perineal anatomy, improve recognition of obstetric lacerations, and
reduce OASIS [68-72]. While at least one study has reported decreased OASIS rates [69],
the long-term impact of such programs on loss of bowel control is not known. That said,
the risks associated with improved provider education are likely to be low.
CLINICAL PRESENTATION
While there are no universal standards for defining OASIS subtypes by the time frame in which
the patient presents, we find the following subgroups clinically useful as the management
differs among them. These time frames are general parameters and not strict guidelines.
● Immediate – The majority of women with OASIS have an obvious perineal laceration
following vaginal delivery. The diagnosis is confirmed by physical examination, including
anorectal examination. (See 'Immediate OASIS' below.)
● Postpartum – Postpartum OASIS refers to anal sphincter injury that is identified during
the postpartum period, typically within six to eight weeks after delivery, but not
recognized at the time of delivery. These women may present with symptoms of perineal
pain or discomfort, perineal bleeding or discharge, and/or loss of bowel control. (See
'Postpartum OASIS' below.)
Women with postpartum OASIS can have either:
• A recognized laceration that was repaired at the time of delivery but presents with a
complication, such as wound separation or infection, during the postpartum period.
This group represents the most common cause of postpartum presentation.
• OASIS that may or may not have been recognized at the time of delivery but requires
repair in the postpartum period. This group can include women who have unattended
deliveries or who are unable to access obstetric services immediately after delivery.
● Delayed – Delayed OASIS, also known as occult OASIS, refers to an anal sphincter
laceration that is diagnosed beyond the postpartum period, generally remote from
delivery. These women typically present with symptoms of loss of bowel control and/or
fecal urgency years following delivery. (See 'Occult (delayed) OASIS' below.)
EVALUATION AND MANAGEMENT
Immediate OASIS — Immediate OASIS is one that is recognized and repaired at the time of
delivery. (See 'Clinical presentation' above.)
Diagnostic evaluation — Patient history and physical examination are the main components
of the diagnostic evaluation in women suspected to have OASIS immediately after vaginal
delivery. Imaging is performed in some research settings.
● History – The history includes information about the patient's delivery, medical and
surgical problems, and assessment of behavioral changes ( table 2). For women who are
being evaluated immediately postpartum, the obstetric events that preceded the delivery
are most relevant.
● Physical examination – The physical examination is adjusted based on the timing of the
examination in relation to vaginal delivery and the presenting symptoms. Immediately
following vaginal delivery, all women are presumed to be at risk for OASIS. The clinician
should examine the perineum for evidence of disrupted anal sphincter complex. A digital
anorectal examination is performed to assess for possible sphincter and/or anal mucosal
injury. Examination of obstetric lacerations, the perineum, and rectum requires adequate
tissue exposure and lighting [4]. Analgesia or anesthesia to improve patient comfort can
aid evaluation.
● Imaging – Endoanal ultrasound is not routinely performed prior to perineal repair due to
limited availability of equipment and clinician training [73] as well as sparse outcome data.
In a trial that randomly assigned 752 primiparous women with a second-degree perineal
laceration to either ultrasound or routine clinical examination of the anal sphincter,
women who received ultrasound evaluation were less likely to have severe fecal
incontinence at 3 months (3.3 versus 8.7 percent) and 12 months (3.2 versus 6.7 percent)
postpartum [74]. The women in the ultrasound group were more likely to report severe
perineal pain at three months compared with control women (5.2 versus 0.9 percent).
Ultrasound would have to be performed in 29 women to prevent one case of severe fecal
incontinence at one year following delivery.
Treatment
Surgical repair — If OASIS is diagnosed following vaginal delivery, immediate surgical

repair is the mainstay of treatment. The approach to surgical repair ( figure 2) and discussion
of overlapping ( figure 3) versus end-to-end ( figure 4) techniques are presented in detail
separately. (See "Repair of perineal and other lacerations associated with childbirth", section on
'Third- and fourth-degree tears'.)
When resources for immediate repair of known OASIS following vaginal delivery are not
available, OASIS repair may be delayed for up to 12 hours without apparent detrimental effect
[68]. Factors that can preclude immediate repair include lack of anesthesia services, lack of
operating room and/or staff, and inadequate training of the obstetric provider. In a trial that
randomly assigned women with OASIS to immediate repair or repair after an 8 to 12 hour delay,
there were no differences in anal incontinence or pelvic floor symptoms between the groups at
one year of follow-up [75].
Adjunct treatments — In addition to surgical repair, we advise the following adjunct

treatments for all women with OASIS to help reduce symptoms and improve function:
● Behavioral changes – Behavior changes to avoid constipation are generally advised for all
patients with defecatory symptoms. A detailed discussion of these approaches is
presented separately. (See "Management of chronic constipation in adults".)
Such interventions can include:
• Education regarding fluid intake (at least 48 to 64 oz of fluid a day, mostly water; this
volume is increased as needed for lactating women) and dietary adjustments (high-
fiber diet with at least 30 grams of fiber per day).
• Increase in fiber intake [76] with the goal of avoidance of loose stools.
• Establish predictable patterns of bowel evacuation (ie, bowel training).
• Use proper posture during defecation (examples of proper toilet positions can be
found online).
● Medical therapy to prevent constipation – Stool-bulking agents, softeners, osmotic

agents, and stimulant laxatives are prescribed, in that order, as needed to prevent
constipation ( table 3). For women with symptomatic fecal incontinence, loperamide can
be used in conjunction with stool bulking agents, such as methylcellulose (commercial
name Citrucel) or psyllium (commercial name Metamucil) [77].
● Physical therapy and pelvic floor muscle training – Many clinicians advise women to
begin pelvic floor physical therapy with pelvic floor muscle training after appropriate
healing of their sphincter injury. Several trials have reported improvement in anal and
fecal incontinence symptoms with such physical therapy [78-82]. While pelvic floor physical
therapy is typically begun six to eight weeks from repair, at least one study has reported
improved outcomes with initiating therapy four weeks from repair [83]. Pelvic floor
physical therapy is performed by physical therapists with specialty training. For women
with fecal incontinence, training in fecal urge suppression techniques can also be helpful.
(See "Myofascial pelvic pain syndrome in females: Treatment", section on 'Pelvic floor
physical therapy' and "Myofascial pelvic pain syndrome in females: Pelvic floor physical
therapy for management".)
● Biofeedback – Biofeedback is a physiotherapy technique that uses external equipment to

provide visual or auditory biofeedback during muscle training. One trial reported similar
short-term outcomes for women with OASIS assigned to either biofeedback or traditional
pelvic floor training [84]. However, in adults with fecal incontinence, biofeedback is often
used as an adjunct to pelvic floor exercises, as combination treatment appears to be more
effective than pelvic floor physical therapy alone [85]. It is not yet known if adding
biofeedback will improve long-term outcomes for women with OASIS. (See "Fecal
incontinence in adults: Management", section on 'Biofeedback'.)
Post-repair care — Care of OASIS injuries does not end in the delivery suite. Appropriate
postpartum perineal care is important to decrease the risk of postpartum complications,
including wound separation and infection. Routine postpartum perineal care is presented in
detail separately. (See "Postpartum perineal care and management of complications", section
on 'Initial approach'.)
Postpartum OASIS
Presentation and history — Women with postpartum OASIS typically present with symptoms
of fecal urgency, fecal or anal incontinence, perineal pain or discomfort, perineal bleeding,
and/or discharge. Symptoms can either persist or worsen following delivery. Key elements of
the history include the details of the delivery and events that deviate from routine postpartum
recovery ( table 2). For example, some women with wound separation report feeling a
"popping" sensation when their sutures separated. Additional risk factors include instrumented
vaginal delivery, known higher-order perineal laceration, and episiotomy.
Physical examination findings — For women who present in the postpartum period, the
examiner needs to consider the following possibilities when performing the physical
examination:
● Recent repair with possible complications – These are women who underwent repair of
the anorectal sphincter and perineal structures but present during the postpartum period
with complications of the repair. The clinician evaluates for evidence of normal healing as
well as disrupted sutures, wound separation, hematoma and/or seroma, and infection
(with or without abscess). Rectovaginal examination is crucial to assess healing of perineal
structures and anorectal complex. In a retrospective review of over 900 women with
OASIS, 7 percent experienced wound complications, including infection, separation,
packing, operative intervention, and secondary repair [86]. Women suspected of having
either problem are typically evaluated in the operating room, where adequate analgesia,
visualization, and wound debridement can occur.
If wound separation is noted, the examiner next determines if superficial or deep

structures are affected. If infection or abscess is suspected, the examiner may need to
remove any remaining sutures to assess the extent of tissue involvement ( picture 1).
(See 'Management' below.)
● Disrupted perineum with OASIS – OASIS is present but was not repaired in the
immediate postpartum period. This perineum may appear as a cloaca or with partial
integrity of the rectovaginal septum, perineal structures, or perineal skin.
● Intact perineum with underlying OASIS – Some women have what appears to be a
visually intact perineum, yet a partial or full disruption of the anal sphincter complex is
detected on digital anorectal examination ( picture 2) or with imaging (eg, office
endoanal ultrasound ( image 1)). Digital anorectal examination involves circumferential
palpation of muscular and connective structures. When a defect is suspected, the
asymmetry can often be felt by the palpating finger. Use of an additional examination
finger inside the vagina or on the perineum can aid in detecting tissue asymmetry and
making the diagnosis. Anorectal squeeze assessment during examination may also reveal
asymmetry in the normally circumferential muscle contraction (ie, absence or decrease of
contraction of the anterior portion of the anal sphincter), which further supports the
diagnosis.
Management
Separation (breakdown) — Wound separation of a previously repaired OASIS typically

occurs within days or weeks of the initial repair. In our experience, these women generally
present with perineal pain, bleeding, and/or foul-smelling discharge. Some women have
diagnosed the perineal disruption on self-examination, yet some may be asymptomatic. On
physical examination, the wound is noted to be disrupted, although suture material may still be
present. Removal of suture material may be necessary to understand the extent of the
separation ( picture 1). The depth of separation needs to be determined because subsequent
management decisions will be based on the level of tissue integrity.
For women with isolated wound separation (ie, no infection), the repair technique is similar to
primary repair. In our practice, we advise using interrupted sutures as much as possible
throughout the repeat repair. The rationale is that if one suture breaks or erodes, the remaining
sutures will remain in place. All necrotic tissue must be debrided prior to performing the repeat
repair. The debridement technique depends on the amount and location of necrotic tissue as
well as patient characteristics. The goal of debridement is to remove the fibrinous and necrotic
tissue to expose healthy, pink, and vascular tissue. Superficial debridement can be performed in
the office. However, if extensive debridement is needed, this is typically done with local
anesthesia or sedation. Debridement can be done both sharply and bluntly. Sharp debridement
uses scalpel or scissors in cases of extensive debridement or excessive necrotic tissue. Blunt
debridement can be done using a sponge or plastic brush (we use prep brushes or
Cytobrushes). There is currently no conclusive evidence whether repair should be delayed,
although historical practice has been to delay the repair for up to three months. In our practice,
the timing of repeat repair is individualized and based on patient tissue quality, extent of the
breakdown, and the patient's symptoms and preference. In a case series, 18 individuals with
OASIS underwent repair a median of 19.5 days from diagnosis of wound separation, with no
recurrences at three months postoperatively [87]. (See "Postpartum perineal care and
management of complications", section on 'Separation'.)
If the tissue integrity is found to be poor, closure of the wound should be delayed and possible
infection should be suspected. Separate from symptoms and signs of systemic infection, signs
of perineal wound infection can include presence of pus or heavy discharge with suture
breakdown and tissue discoloration. In these cases, we use similar debridement technique as
above: remove loose sutures and consider systemic antibiotic treatment (for women with
confirmed or likely infection) while frequently monitoring the wound (at least weekly). Delayed
repair is considered once infection is cleared and tissue quality is improved.
● (See "Cellulitis and skin abscess in adults: Treatment".)
● (See "Delayed surgical management of the disrupted anal sphincter".)
Infection — When infection is suspected, the clinician needs to determine if infection is

superficial or deep and if an abscess is present. If deep infection surrounds intact suture
material, the suture material should be removed. If wound infection is diagnosed, wound
closure is delayed until the infection has cleared. These women require surgical debridement of
the necrotic tissue, incision and drainage of any abscesses, and antibiotic therapy. After
debridement, the wound is loosely packed with surgical gauze. The patient is then followed at
least weekly and sharp debridement is repeated as necessary. Once the wound is no longer
infected, plans can be made for a delayed closure three to six months from time of initial
debridement. The evaluation and management of women with infected perineal wounds and
delayed wound closure are reviewed in detail separately. (See "Postpartum perineal care and
management of complications", section on 'Infection' and "Delayed surgical management of
the disrupted anal sphincter".)
Interval OASIS repair — Women with OASIS who are diagnosed during the postpartum
period, but not at the time of delivery, are managed similarly to women with a wound
separation above. (See 'Separation (breakdown)' above.)
OASIS repair with intact perineum — The timing of OASIS repair in women with an
intact perineum depends on many factors, including the patient's symptoms, desire for future
child-bearing, and patient preferences. We only consider postpartum OASIS repair in the setting
of an intact perineum in women with symptoms of fecal incontinence. Approach to repair of
OASIS with intact perineum is similar to any anal sphincteroplasty. The patient's position
depends on training and provider preference: Most gynecologic surgeons prefer the lithotomy
position, whereas colorectal surgeons prefer jack-knife. The repair often includes an inverted-U
incision of an intact perineum and dissection of the perineal structures and anal sphincters.
(See "Delayed surgical management of the disrupted anal sphincter", section on 'Surgery'.)
Occult (delayed) OASIS — Occult OASIS, also known as delayed OASIS, refers to an anal
sphincter laceration that is diagnosed beyond the postpartum period, typically years later.
Mechanism — Anal sphincter injury may not be recognized on examination after vaginal

delivery, and thus be unrepaired, or may be recognized and repaired, but with continued
sphincter defect. Up to 35 percent of women with a recognized and repaired OASIS will have
persistent sonographic defects of the anal sphincter complex 6 to 12 months postpartum [88].
Women with fourth-degree lacerations appear to be at increased risk for residual sphincter
defects compared with women with third-degree perineal lacerations [88]. (See 'Anorectal
anatomy and laceration' above.)
History, examination, and imaging — Women with occult OASIS may present for evaluation
of anal incontinence. History elements that are particularly important include risk factors for
OASIS (eg, operative vaginal delivery or episiotomy) or a prior diagnosis of OASIS ( table 2).
Occult OASIS is suggested by the dovetail sign on physical examination ( picture 2) and
confirmed by imaging, typically endoanal ultrasound, that demonstrates a torn anal sphincter
complex ( image 1) [89]. Endoanal ultrasound evaluates the entire anal sphincter complex,
including both internal anal sphincter (IAS) and external anal sphincter (EAS) ( image 2).
Ultrasound imaging can also identify the posterior portion of the puborectalis muscle.
Disruptions can be identified at the level of the IAS and EAS ( image 1). (See "Delayed surgical
management of the disrupted anal sphincter", section on 'Preoperative management'.)
Normal anatomic variations that are visualized with endoanal ultrasound include:
● Normally, at the level of puborectalis muscle, the EAS is not visualized anteriorly, as this is
proximal to the normal EAS position.
● Normal IAS ends more proximally than EAS.
Other imaging modalities that can be helpful include perineal or introital ultrasound or
magnetic resonance imaging (MRI) [90]. In situations where endoanal ultrasound is not
available, MRI may be helpful in making the diagnosis, particularly if there is concern for fistula.
There is no consensus as to which women benefit from additional imaging; imaging decisions
are based on provider preference and equipment availability. (See "Ultrasound examination of
the female pelvic floor".)
Women with suspected occult OASIS based on history and symptoms may undergo anorectal
manometry, which is the gold standard for assessing anal sphincter function [89]. Absent or
impaired anal sphincter function can indicate prior OASIS, but such findings are not exclusive to
OASIS. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Anorectal
manometry' and "Delayed surgical management of the disrupted anal sphincter", section on
'Anorectal physiology tests'.)
Treatment — Decision to repair occult OASIS depends on patients' presenting symptoms and

preferences. There are several techniques for surgical dissection and repair. (See "Delayed
surgical management of the disrupted anal sphincter", section on 'Surgery'.)
PROGNOSIS
● Primary OASIS – For women with primary OASIS, the risk of repeat OASIS in a future
vaginal delivery is approximately 3 to 5 percent [48,49]. Women with one OASIS are at
increased risk of anal incontinence and fecal urgency compared with women without
OASIS (47 versus 13 percent) [20]. Of women with OASIS, those with internal anal
sphincter involvement are at increased risk for wound infection and dehiscence, perineal
pain, and rectovaginal fistula compared with women who have only external anal
sphincter injury [86].
● Repeat OASIS – In a 2016 meta-analysis of eight studies including over 99,000 women,
repeat OASIS occurred in 6.3 percent of women with a prior OASIS [6]. However, women
with two prior OASIS have been reported to have a 10-fold increased risk for sphincter
injury in next pregnancy [52].
Beyond having had a primary OASIS, additional risk factors for recurrent anal sphincter
injury include [6,11]:
• Operative vaginal delivery

• Median episiotomy
• Large for gestational age fetus
• Shoulder dystocia
Women who sustain a second OASIS appear to have an increased risk of long-term anal
and fecal incontinence. In a secondary analysis of data from a questionnaire survey,
women with a second OASIS had a nearly 70 percent increased risk of anal incontinence
and nearly double the risk of fecal incontinence [91]. The study adjusted for type of OASIS,
maternal age, infant birth weights, years since delivery, and presence of anal incontinence
before the second pregnancy, and the women were followed for five years or more.
● Long-term complications – Long-term sequelae of OASIS (primary or repeat) include

[9,92-94]:
• Fecal and anal incontinence

• Perineal pain
• Dyspareunia
• Defecatory dysfunction
• Urinary incontinence
SUMMARY AND RECOMMENDATIONS
● Continence of feces and gas is maintained by the anorectal complex, which consists of the
anal canal and rectum ( figure 1). The internal anal sphincter is the terminal thickened
portion of the smooth circular muscle of the gastrointestinal tract that provides most of
the resting anal pressure. The external anal sphincter is a striated muscle that provides
most of the squeeze pressure important in maintaining anal continence. (See 'Anorectal
anatomy and laceration' above.)
● Clinical issues related to obstetric anal sphincter injuries (OASIS) include an increased risk
of loss of bowel control, optimal mode of delivery for future pregnancy, and routine
screening at the time of vaginal delivery. (See 'Clinical significance' above.)
● The overall risk of OASIS is approximately 6 percent. Risk factors include vaginal delivery,
obstetric factors, operative vaginal delivery, episiotomy, fetal macrosomia, longer second
stage, and increasing maternal age. (See 'Epidemiology and risk factors' above.)
● While the risk of OASIS during vaginal delivery cannot be eliminated, factors that appear
to reduce the incidence of OASIS include avoidance of episiotomy, perineal massage,
maternal birth position, and training of obstetric providers. However, despite a reduction
in OASIS, reduced long-term loss of bowel control is not certain. (See 'Prevention' above.)
● While there are no universal standards for defining OASIS subtypes by the time frame in
which the patient presents, we find the subgroups of immediate, postpartum, and delayed
clinically useful as the management differs among them. These time frames are general
parameters and not strict guidelines. (See 'Clinical presentation' above.)
• Immediate OASIS is one that is recognized and repaired at the time of delivery. For
women diagnosed with OASIS at the time of vaginal delivery, immediate surgical repair
is the mainstay of treatment. (See 'Immediate OASIS' above.)
• Postpartum OASIS refers to lacerations that are diagnosed in the postpartum period
(six to eight weeks postpartum) but not at the time of delivery. These women typically
present with symptoms of fecal urgency, fecal or anal incontinence, perineal pain or
discomfort, perineal bleeding, and/or discharge, yet they may also be asymptomatic.
These women may have had an OASIS repair and subsequent complications, an OASIS
that was not repaired, or an intact perineum with underlying OASIS. (See 'Postpartum
OASIS' above.)
• Occult OASIS, also known as delayed OASIS, refers to an anal sphincter laceration that
is diagnosed beyond the postpartum period, typically years later. Women with occult
OASIS may present for evaluation of anal incontinence. These women may undergo
delayed surgical dissection and repair if symptoms warrant intervention. (See 'Occult
(delayed) OASIS' above.)
● For women with primary OASIS, the risk of repeat OASIS in a future vaginal delivery is
approximately 3 to 5 percent. Women who sustain a second OASIS appear to have an
increased risk of long-term anal and fecal incontinence. (See 'Prognosis' above.)
Use of UpToDate is subject to the Terms of Use.
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Topic 114776 Version 21.0
GRAPHICS
Anatomy of the anus and rectum
The anal canal is 2.5 to 4.0 cm long and begins superiorly where the rectal ampulla is
narrowed by the anorectal ring. This palpable muscular ring is formed by fusion of the
puborectalis muscle (part of the levator ani muscle complex) with the more inferior
internal and external anal canal sphincters.
The external anal canal sphincter ends just distally to the internal anal canal sphincter; the
intersphincteric groove is the palpable plane that can be palpated between the
termination of the two sphincters. The presence of the intersphincteric groove coincides
roughly with the anal verge, which marks the distal portion of the anal canal. The perianus
or anal margin extends 5 cm laterally from the anal verge and is characterized by the
presence of hair follicles and glands.
The interior of the anal canal can be divided into proximal and distal portions by an
irregular line formed by the anal valves called the dentate (or pectinate) line (colored
purple in the diagram). The portions of the anal canal proximal and distal to the dentate
line have different origins of arterial supply, nerve innervation, and venous lymphatic
drainage. The squamo-columnar junction (SCJ) lies within the proximal portion of the anal
canal and marks the transition between rectal columnar epithelium to anal squamous
epithelium. The exact position of the SCJ changes with time due to replacement of
columnar epithelium with squamous epithelium in a process known as squamous
metaplasia. The anal transformation zone (ATZ) is the zone where all aspects of squamous
metaplasia are currently found and/or have occurred. The ATZ is marked by the SCJ
proximally and extends distally to approximately the level of the dentate line.
Graphic 62539 Version 16.0
Classification of obstetric lacerations[1]
First degree
Injury to perineal skin only
Second degree
Injury to perineum involving perineal muscles but not involving anal sphincter
Third degree
Injury to perineum involving anal sphincter complex
3a: Less than 50% of external anal sphincter thickness torn
3b: More than 50% external anal sphincter thickness torn
3c: Both external anal sphincter and internal anal sphincter torn
Fourth degree
Injury to perineum involving anal sphincter complex (external anal sphincter and internal anal
sphincter) and anal epithelium
Reference:
1. reVITALize Obstetric Data Definitions. American College of Obstetricians and Gynecologists. Available at:
https://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-
Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf?dmc=1&ts=20190103T1910133780 (Accessed on January 3,
2019).
History components for women with suspected obstetric anal sphincter injury
(OASIS)
Obstetric components – Immediately following delivery
Duration of second stage of labor
Infant birth weight
Obstetric laceration and degree, if known
Use of episiotomy and extension, if known
Use of forceps or vacuum
Additional obstetric questions for women remote from vaginal delivery
All routine obstetric questions above
Did the patient have an obstetric laceration repaired?
Did the patient have problems with perineal healing?
Did the patient have a wound separation or infection? If so, what treatment did she receive?
Surgical history
Prior pelvic surgery: Reconstructive pelvic surgery
Prior rectal surgery (eg, hemorrhoidectomy, perianal abscess, anal fissures)
Gastrointestinal
Known bowel disorders:
Irritable bowel syndrome
Inflammatory bowel disorders (eg, Crohn disease, ulcerative colitis)
Bowel function history:
Frequency of bowel movements
Need to strain to defecate
Difficulty with evacuation
Regular stool consistency
Chronic diarrhea
Fecal urgency
Passage of stool/gas per vagina
Incontinence:
Flatus
Mucus
Liquid stool
Solid stool
Medication
All regularly used medication
Use of additional:
Fiber supplements
Stool softeners
Laxative
Behavior
Use of protective pads or similar (tissue paper, rags) or clothing changes secondary to fecal
incontinence
Avoidance of activities (eg, sex or exercise)
Courtesy of Milena M Weinstein, MD, FACOG, FPMRS, and Helai Hesham, MD.
Repair of a fourth-degree obstetric laceration
(A) Fourth-degree laceration.
(B) The torn anal mucosa is repaired using a running stitch, but

interrupted stitches are also acceptable.
(C) The internal anal sphincter should be properly identified and

repaired as a separate layer.
(D) The external sphincter is then identified and repaired. The repair
consists of either end-to-end or overlapping plication of the
disrupted external anal sphincter and capsule using interrupted or
figure-of-eight sutures.
Anal sphincter repair: Overlap approach
Anal sphincter repair: Incision and end-to-end approach
Medications for treatment of constipation
Onset of
Medication Usual adult dose Side effects
action
Bulk-forming laxatives*
Psyllium Up to 1 tablespoon (≅3.5 grams 12 to 72 h Impaction above

fiber) 3 times per day strictures, fluid
overload, gas and
Methylcellulose Up to 1 tablespoon (≅2 grams 12 to 72 h
bloating
fiber) or 4 caplets (500 mg fiber per
caplet) 3 times per day
Polycarbophil 2 to 4 tabs (500 mg fiber per tab) 24 to 48 h

per day
Wheat dextrin¶ 1 to 3 caplets (1 gram fiber per 24 to 48 h

caplet) or 2 teaspoonsful (1.5 gram
fiber per teaspoon) up to 3 times
per daily
Surfactants (softeners)
Docusate sodium 100 mg 2 times per day 24 to 72 Well tolerated, but less
hours effective than other
agents. Use lower dose
if administered with
Docusate calcium 240 mg 1 time per day 24 to 72 another laxative.
hours Contact dermatitis
reported.
Osmotic agents
Polyethylene glycol 8.5 to 34 grams in 240 mL (8 1 to 4 days Nausea, bloating,

(macrogol) ounces) liquids cramping
Lactulose 10 to 20 grams (15 to 30 mL) every 24 to 48 Abdominal bloating,

other day. May increase up to 2 hours flatulence
times per day.
Sorbitol 30 grams (120 mL of 25% solution) 24 to 48 Abdominal bloating,

1 time per day hours flatulence
Glycerin (glycerol) One suppository (2 or 3 grams) per 15 to 60 Rectal irritation

rectum for 15 minutes 1 time per minutes
day
Magnesium sulfate 2 to 4 level teaspoons 0.5 to 3 Watery stools and

(approximately 10 to 20 grams) of hours urgency; caution in
granules dissolved in 8 ounces (240 renal insufficiency
mL) of water; may repeat in 4 (magnesium toxicity)
hours. Do not exceed 2 doses per

day.
Magnesium citrate 200 mL (11.6 grams) 1 time per day 0.5 to 3

hours
Stimulant laxatives
Bisacodyl 10 to 30 mg as enteric coated tabs 6 to 10 hours Gastric irritation

1 time per day
10 mg suppository per rectum 1 15 to 60 Rectal irritation

time per day minutes
Senna 2 to 4 tabs (8.6 mg sennosides per 6 to 12 hours Melanosis coli

tab) or 1 to 2 tabs (15 mg
sennosides per tab) as a single
daily dose or divided twice daily
Other
Lubiprostone 24 micrograms 2 times per day 24 to 48 Nausea, diarrhea

hours
Linaclotide 145 micrograms 1 time per day 12 to 24 Diarrhea, bloating

hours
Plecanatide 3 mg 1 time per day 12 to 24 Diarrhea

hours
Prucalopride 2 mg per day 6 to 12 hours Nausea, headache,

diarrhea
All doses shown are for oral administration unless otherwise noted. Phosphate containing laxatives are
not recommended. Mineral oil (enema and oral liquid) laxatives are not generally recommended except
as enema following disimpaction (refer to UpToDate content).
* Initiate at one-half or less of dose shown and gradually increase as needed to minimize gas and
bloating. Administer with 180 to 360 mL (6 to 12 ounces) water or fruit juice. Do not administer within 1
hour of other medications. Fiber content per dose may vary. Consult individual product label.

¶ US trade name Benefiber.
Courtesy of Arnold Wald, MD. Additional data from: Lexicomp Online. Copyright © 1978-2022 Lexicomp, Inc. All Rights Reserved.
OASIS wound separation before and after surgical inspection
(A) This patient presented 4 weeks postpartum after noting that her perineum was still separated; she was fou
to have an anal sphincter separation without infection. Note the presence of sutures overlying the wound
separation.
(B) This image show the same patient after the sutures have been removed in the operating room. No infectio
was present, and the separation (breakdown of prior repair) was repaired.
Dovetail sign suggesting underlying anal sphincter laceration
Note the absence of anal folds along the perineal aspect of the sphincter, which
suggests that the external anal sphincter at least partially separated.
3D endoanal ultrasound image of disrupted anal sphincter
3D EAUS axial view of a disrupted anal sphincter. The double asterisks demarcate the torn ends of the externa
anal sphincter.
3D: three-dimensional; EAUS: endoanal ultrasound; EAS: external anal sphincter; A: anterior; P: posterior; PD:
perineal defect; R: right; L: left; PS: pubic symphysis; T: transducer.
Reproduced with permission from Seyed Abbas Shobeiri, MD, FACS, FACOG.
Endoanal ultrasound image of intact anal sphincter complex
Endoanal ultrasound image: The thin arrows identify the IAS, which is hypoechoic (dark);
the thick arrows identify the mixed echogenicity that is the EAS.
IAS: internal anal sphincter; EAS: external anal sphincter.
Contributor Disclosures
Milena M Weinstein, MD, FACOG Grant/Research/Clinical Trial Support: Renovia Inc [Pelvic floor
exercises/urinary incontinence]. All of the relevant financial relationships listed have been mitigated. Helai
Hesham, MD, FACOG No relevant financial relationship(s) with ineligible companies to disclose. Linda
Brubaker, MD, FACOG Grant/Research/Clinical Trial Support: National Institutes of Health [Prevention of
lower urinary symptoms]. Other Financial Interest: Journal of the American Medical Association [Women's
health]; Female Pelvic Medicine and Reconstructive Surgery [Female pelvic medicine and reconstructive
surgery]. All of the relevant financial relationships listed have been mitigated. Martin Weiser,
MD Consultant/Advisory Boards: PrecisCa [Gastrointestinal surgical oncology]. All of the relevant financial
relationships listed have been mitigated. Kristen Eckler, MD, FACOG No relevant financial relationship(s)
with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Obstetric Anal Sphincter Injury (OASIS) - UpToDate

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Obstetric Anal Sphincter Injury (OASIS) - UpToDate

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8/4/22, 19:34 Obstetric anal sphincter injury (OASIS) - UpToDate

Official reprint from UpToDate®

● (See "Repair of perineal and other lacerations associated with childbirth".)

● (See "Postpartum perineal care and management of complications".)

ANORECTAL ANATOMY AND LACERATION

EPIDEMIOLOGY AND RISK FACTORS

● Incidence – A meta-analysis of eight observational studies that included over 99,000

• Overall OASIS risk: 6.3 percent

Supporting data include:

- Obstetric factors US population – In a retrospective cohort study of over 22,000

- Obstetric factors Indian population – A case-control study of over 28,000 births

- Birth weight and fetal head circumference – A population-based study of over

- Shoulder dystocia – Retrospective analysis of over 67,000 birth reported an OASIS

• Episiotomy – Routine use of episiotomy is no longer recommended because of

- (See 'Prognosis' below.)

● Flatal incontinence – The involuntary loss of flatus only

Screening at time of vaginal delivery — There is no consensus as to whether or not

compared with supine, semirecumbent, or lateral recumbent positions [66,67]. It is not

Women with postpartum OASIS can have either:

EVALUATION AND MANAGEMENT

Surgical repair — If OASIS is diagnosed following vaginal delivery, immediate surgical

Adjunct treatments — In addition to surgical repair, we advise the following adjunct

Such interventions can include:

• Establish predictable patterns of bowel evacuation (ie, bowel training).

● Medical therapy to prevent constipation – Stool-bulking agents, softeners, osmotic

● Biofeedback – Biofeedback is a physiotherapy technique that uses external equipment to

If wound separation is noted, the examiner next determines if superficial or deep

Separation (breakdown) — Wound separation of a previously repaired OASIS typically

● (See "Cellulitis and skin abscess in adults: Treatment".)

● (See "Delayed surgical management of the disrupted anal sphincter".)

Infection — When infection is suspected, the clinician needs to determine if infection is

Mechanism — Anal sphincter injury may not be recognized on examination after vaginal

● Normal IAS ends more proximally than EAS.

Treatment — Decision to repair occult OASIS depends on patients' presenting symptoms and

• Operative vaginal delivery

● Long-term complications – Long-term sequelae of OASIS (primary or repeat) include

• Fecal and anal incontinence

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Terms of Use.

Anatomy of the anus and rectum

Graphic 62539 Version 16.0

Classification of obstetric lacerations[1]

3a: Less than 50% of external anal sphincter thickness torn

3b: More than 50% external anal sphincter thickness torn

Graphic 116249 Version 3.0

Obstetric components – Immediately following delivery

Duration of second stage of labor

Infant birth weight

Obstetric laceration and degree, if known

Use of episiotomy and extension, if known

Use of forceps or vacuum

Additional obstetric questions for women remote from vaginal delivery

All routine obstetric questions above

Did the patient have an obstetric laceration repaired?

Did the patient have problems with perineal healing?

Prior pelvic surgery: Reconstructive pelvic surgery

Prior rectal surgery (eg, hemorrhoidectomy, perianal abscess, anal fissures)

Known bowel disorders:

Irritable bowel syndrome

Inflammatory bowel disorders (eg, Crohn disease, ulcerative colitis)

Bowel function history:

Frequency of bowel movements