Fenner Dee E, Genberg Becky, Brahma Pavna, Marek Lorri, DeLancey John O L
Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
Am J Obstet Gynecol. 2003 Dec;189(6):1543-9; discussion 1549-50. doi: 10.1016/j.ajog.2003.09.030.
The purpose of this study was to estimate the incidence of urinary and bowel incontinence in relation to anal sphincter laceration in primiparous women and to identify factors that are associated with anal sphincter laceration in a unit that uses primarily midline episiotomy.
From January 1, 1997, to March 30, 2000, 2941 questionnaires concerning pelvic floor function 6 months after delivery were mailed to primiparous women who were delivered vaginally at the University of Michigan Medical Center. Charts were reviewed for 2858 deliveries to assess the use of episiotomy and the degree of perineal trauma, along with demographic and pertinent delivery variables. There were 943 women who completed the urinary function questionnaire and 831 women who completed the bowel function questionnaire. Univariate analysis was performed on all covariates. Multiple logistic regression was used for the analysis of the presence of third- or fourth-degree lacerations as the outcome.
Nineteen percent of the women who completed the survey had sustained third- or fourth-degree lacerations during childbirth. The women in the sphincter laceration group were more likely (23.0%) to have bowel incontinence than the women in the control group (13.4%) (P<.05). The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%) compared with women with third-degree lacerations (3.6%, P<.001). Macrosomia (odds ratio, 2.19; 95% CI, 1.61, 2.99), forceps-assisted delivery (odds ratio, 4.75; 95% CI, 3.43, 6.57), and vacuum-assisted delivery (odds ratio, 3.51; 95% CI, 2.64, 4.66) were associated with higher risks of third- and fourth-degree lacerations. Midline episiotomy (odds ratio, 2.24; 95% CI, 1.81, 2.77), but not mediolateral (odds ratio, 0.66; 95% CI, 0.375, 1.19), episiotomy was associated with anal sphincter lacerations. More than one half of the women had new onset of urinary incontinence after delivery and reported several lifestyle modifications to prevent leakage.
Women with third- and fourth-degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Fourth-degree lacerations appear to affect anal continence greater than third-degree lacerations.
本研究旨在评估初产妇中与肛门括约肌撕裂相关的尿失禁和大便失禁的发生率，并确定在主要采用会阴正中切开术的科室中与肛门括约肌撕裂相关的因素。
从1997年1月1日至2000年3月30日，向在密歇根大学医学中心经阴道分娩的初产妇邮寄了2941份关于产后6个月盆底功能的问卷。查阅了2858例分娩的病历，以评估会阴切开术的使用情况和会阴创伤程度，以及人口统计学和相关分娩变量。有943名妇女完成了尿功能问卷，831名妇女完成了肠功能问卷。对所有协变量进行单因素分析。采用多因素logistic回归分析以三度或四度撕裂伤的存在作为结局。
完成调查的妇女中有19%在分娩期间发生了三度或四度撕裂伤。括约肌撕裂伤组的妇女发生大便失禁的可能性（23.0%）高于对照组妇女（13.4%）（P<0.05）。四度撕裂伤的妇女（30.8%）大便控制较差的发生率比三度撕裂伤的妇女（3.6%，P<0.001）高出近10倍。巨大儿（比值比，2.19；95%可信区间，1.61，2.99）、产钳助产（比值比，4.75；95%可信区间，3.43，6.57）和真空辅助分娩（比值比，3.51；95%可信区间，2.64，4.66）与三度和四度撕裂伤的较高风险相关。会阴正中切开术（比值比，2.24；95%可信区间，1.81，2.77），而非会阴侧切术（比值比，0.66；95%可信区间，0.375，1.19）与肛门括约肌撕裂伤相关。超过一半的妇女在产后出现了新发尿失禁，并报告了几种预防漏尿的生活方式改变。
三度和四度撕裂伤的妇女比无肛门括约肌撕裂伤的妇女更易发生大便失禁。四度撕裂伤似乎比三度撕裂伤对肛门节制的影响更大。
