Care pathways and anorectal evaluation for obstetric anal sphincter injury‐related incontinence: A UK survey of obstetricians

TL;DR

This UK survey shows inconsistent care for women with childbirth-related anal injuries, highlighting the need for standardized treatment pathways.

Contribution

The study identifies variability in clinical practices for managing obstetric anal sphincter injury-related incontinence among UK obstetricians.

Findings

Most clinicians perform clinical and rectal exams but rarely use objective incontinence screening tools.

Endoanal ultrasound is the preferred diagnostic method, and asymptomatic patients are often discharged quickly.

Referral for physiotherapy is common, but follow-up specialty varies widely.

Abstract

To report on national clinical practice in relation to the post‐partum management of patients with obstetric anal sphincter injury (OASI)‐related incontinence in the UK.

This was a cross‐sectional, observational study of maternity units in the National Health Service (NHS). Data were collected using a survey that was distributed, via the British Society of Urogynaecologists (BSUG), Royal College of Obstetricians & Gynaecologists (RCOG) and the NHS England email directory, to consultant obstetricians and urogynaecologists involved in the post‐partum care of patients with OASI. A descriptive, thematic analysis of the data was performed.

One hundred and twenty‐six responses were included in the final analysis (estimated response rate~2.5%). The majority of respondents routinely conducted clinical and rectal examinations at the post‐partum clinic visit (81.7% and 57.6%, respectively) but they were less likely to use an objective screening tool for incontinence (36.5%). Respondents were more likely to refer patients for anorectal studies if they were symptomatic (72.6%) rather than asymptomatic (34.2%); the diagnostic modality of choice was endoanal ultrasound (70%) rather than manometry (0%). Almost 80% of respondents discharged asymptomatic patients within 3 months. All respondents referred symptomatic patients for physiotherapy; 87% were seen within 6 weeks. Although 70% would discuss complicated cases at a multidisciplinary team meeting (MDT), there was a wide variation in which speciality would follow up the patient.

This study demonstrates variability in clinical practice that does not entirely appear to be evidence driven. A nationally endorsed pathway, embedded within Perinatal Pelvic Health Services, could standardize access to expertise and enable benchmarking. A prospective multicentre audit is recommended to compare maternal functional outcomes in units that use these standardized pathways versus those that do not.

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