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\begin{document}

\title{Irritable bowel syndrome worsens faecal incontinence after primary
repair of major obstetric anal sphincter injuries (OASIS): a prospective
cohort study}



\author[1]{Mina Sarofim}%
\author[2]{Annelie  Slaar}%
\author[2]{Sylvia  Dermout}%
\author[2]{Frank den Boer}%
\author[1]{Alexander Engel}%
\affil[1]{University of Sydney}%
\affil[2]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objective: Obstetric anal sphincter injuries (OASIS) occur in
approximately 3-6\% of vaginal deliveries and are the leading risk
factor for late onset faecal incontinence. We aimed to assess the effect
of irritable bowel syndrome (IBS) on severity of faecal incontinence
after immediate primary repair of major OASIS (Grade IIIb-IV). Design:
Prospective cohort study Setting: Zaans Medisch Centrum, Zaandam, The
Netherlands Population: Women who underwent a primary repair of major
OASIS over a 2-year period (Group A), a control group consisting of
primigravid women (Group B), and another control group who underwent
elective Caesarean section (Group C). Methods: Participants were
assessed with ultrasonography within 12 weeks, then a follow-up
questionnaire after at least 12 months. Main outcome: Wexner faecal
incontinence scores and presence of IBS based on Rome IV criteria.
Results: There were 211 total patients included, and mean follow-up time
was 26 months after sphincter repair. Ultrasonographic sphincter defects
were detected in 37\% but did not affect faecal incontinence score
(p=0.16). Patients with IBS had significantly worse faecal incontinence
(p\textless{}0.001), and interestingly in women with OASIS those without
IBS had comparable symptoms to the control groups. Inability to defer
defaecation for 15 minutes was also associated with worse faecal
incontinence (p=0.003). Conclusion: After OASIS repair faecal
incontinence was significantly worsened by the presence of IBS, or in
women with an inability to defer defaecation. Presence of
ultrasonographic sphincter defects did not correlate to a clinical
difference in faecal incontinence scores. Funding: Nil. Keywords: OASIS,
sphincter, irritable bowel syndrome, incontinence%
\end{abstract}%



\sloppy


\textbf{Title:} Irritable bowel syndrome worsens faecal incontinence
after primary repair of major obstetric anal sphincter injuries (OASIS):
a prospective cohort study

\textbf{Authors}

Mina Sarofim \textsuperscript{1, 2}

Annelie Slaar \textsuperscript{3}

Sylvia Dermout \textsuperscript{4}

Frank den Boer \textsuperscript{5}

Alexander Engel \textsuperscript{1, 2}

\textbf{Affiliations}

\begin{enumerate}
\tightlist
\item
  Department of Colorectal Surgery, Royal North Shore Hospital Sydney
  Australia
\item
  School of Medicine, University of Sydney, NSW Australia
\item
  Department of Radiology Dirksland Ziekenhuis, Hoorn, The Netherlands
\item
  Department of Gynaecology \& Obstetrics, Zaans Medisch Centrum,
  Zaandam, The Netherlands
\item
  Department of Surgery, Zaans Medisch Centrum, Zaandam, The Netherlands
\end{enumerate}

\textbf{Corresponding Author}

Dr Mina Sarofim. Colorectal Surgery, Royal North Shore Hospital, Reserve
Rd, St Leonards NSW 2065

Email: drsarofim@gmail.com

\textbf{Shortened running title:} IBS worsens faecal incontinence after
primary repair of OASIS

\textbf{Conflict of Interest:} None to declare

\textbf{Contribution to authorship:} All co-authors were involved in the
planning, carrying, analysing, and writing of this manuscript and accept
responsibility for this study



\textbf{ABSTRACT}

\textbf{Objective:} Obstetric anal sphincter injuries (OASIS) occur in
approximately 3-6\% of vaginal deliveries and are the leading risk
factor for late onset faecal incontinence. We aimed to assess the effect
of irritable bowel syndrome (IBS) on severity of faecal incontinence
after immediate primary repair of major OASIS (Grade IIIb-IV).

\textbf{Design:} Prospective cohort study

\textbf{Setting:} Zaans Medisch Centrum, Zaandam, The Netherlands

\textbf{Population:} Women who underwent a primary repair of major OASIS
over a 2-year period (Group A), a control group consisting of
primigravid women (Group B), and another control group who underwent
elective Caesarean section (Group C).

\textbf{Methods:} Participants were assessed with ultrasonography within
12 weeks, then a follow-up questionnaire after at least 12 months.

\textbf{Main outcome:} Wexner faecal incontinence scores and presence of
IBS based on Rome IV criteria.

\textbf{Results:} There were 211 total patients included, and mean
follow-up time was 26 months after sphincter repair. Ultrasonographic
sphincter defects were detected in 37\% but did not affect faecal
incontinence score (p=0.16). Patients with IBS had significantly worse
faecal incontinence (p\textless{}0.001), and interestingly in women with
OASIS those without IBS had comparable symptoms to the control groups.
Inability to defer defaecation for 15 minutes was also associated with
worse faecal incontinence (p=0.003).

\textbf{Conclusion:} After OASIS repair faecal incontinence was
significantly worsened by the presence of IBS, or in women with an
inability to defer defaecation. Presence of ultrasonographic sphincter
defects did not correlate to a clinical difference in faecal
incontinence scores.

\textbf{Funding:} Nil. \textbf{Keywords:} OASIS, sphincter injury,
irritable bowel syndrome, incontinence

\textbf{FUNDING}

Nil

\textbf{INTRODUCTION}

Obstetric anal sphincter injuries (OASIS) occur in approximately 3-6\%
of vaginal deliveries and are considered a significant risk factor for
late onset faecal incontinence. {[}1{]} Continence is a complex
multi-factorial mechanism which relies crucially on intact anal
sphincters, as well as rectal compliance, rectal sensation, stool
consistency and neural coordination. Primiparity, large birth weight,
instrumental deliveries, parietal or vertex presentation, and a
prolonged second stage of labour (which may lead to denervation of the
pelvic floor) are obstetric factors which increase the risk of a
sphincter injury, graded as third or fourth degree perineal tears in the
widely accepted standardised classification. {[}2-4{]}

Late post-partum faecal incontinence is an underdiagnosed pathology
which affects almost one in three women following OASIS and dramatically
reduces quality of life. {[}5{]} Impaired sphincter and neurological
function after OASIS repair is a likely contributor, in combination with
a diminishing trophic effect of oestrogen on pelvic floor function as
patients age and menopause approaches. In recent years, irritable bowel
syndrome (IBS) which affects 10-15\% of the population has been shown to
double the risk of faecal incontinence after OASIS in the early
post-partum period. {[}6, 7{]} In this population however, it is not
known how repair of OASIS, remaining sphincter defects and IBS interact.

The aim of this study therefore is to investigate the effect of IBS on
severity of faecal incontinence symptoms after primary repair of OASIS.

\textbf{METHODS}

All patients with major OASIS (defined as Grade IIIb, IIIc or IV by the
Sultan classification {[}4{]}) in a single birthing unit over a two year
period underwent endoanal ultrasonography (B\&K, Denmark) at 6-12 weeks
post-surgical repair (Group A). Surgical repair was performed by a
specialist consultant under anaesthesia (general or spinal) using an
overlapping technique if possible, otherwise an approximation technique
was used. Any ultrasonographic gap or discontinuity for any vertical
length, or horizontal width, in the anal sphincters was scored as a
defect. The defect was scored separately for internal anal sphincter
(IAS) or external anal sphincter (EAS). The endosonographic assessment
was blinded to the ultimate faecal incontinence scores obtained at a
later date.

At 1-3 years after the obstetric event these patients were sent a
questionnaire designed to allow extraction and calculation of the Wexner
faecal incontinence score (Figure 1). We defined Wexner score of [?] 9 as
significantly affecting quality of life. {[}8{]} The Vaizey score was
not used because of the integral use of ability to defer defaecation in
this score, which would introduce considerable overlap with the presence
of IBS complaints. However, the ability to defer defaecation longer than
15 minutes was included as an item in our questionnaire. The
questionnaire also allowed us to calculate the presence and type of IBS
based on the Rome IV criteria (Figure 2). Other variables that were
collected were age, parity and mode of delivery, body mass index (BMI).

Two control groups were included, and these were aimed to be of equal
size to Group A. The first control group consisted of primigravid women
(Group B) who filled out a questionnaire at their first consultation of
a midwife or obstetrician in the first trimester of their pregnancy. The
second control group were women who underwent an elective Caesarean
section (Group C) who filled out a questionnaire at a minimum of 12
months post-partum. Exclusion criteria were previous anal surgery,
previous obstetric sphincter injury, inflammatory bowel disease and
coeliac disease.

Statistical analysis was done with SPSS version 24 (IBM, USA). For
comparison of binary variables Chi quare test was used, for intra-group
comparison of mean (SD) Wexner scores a t-test was used and for
inter-group comparison of mean (SD) Wexner scores ANOVA was used. Format
of data presentation was deliberately chosen to suit subsequent clinical
usefulness. The study protocol obtained ethical approval from the local
health district.

\textbf{RESULTS}

A total of 82 women had surgical repair of major OASIS. Of these, 73
women (89\%) returned the questionnaire at a mean 26 months post
sphincter repair and these women formed Group A. Groups B and C
consisted of 55 and 83 patients respectively recruited during the same
period. Patient characteristics are presented in Table 1. Of note,
patients in Group C were significantly younger than those in Groups A
and B. The overall prevalence of IBS in our cohort was 12.8\%

The inability to defer defecation for more than 15 minutes occurred more
commonly in Group A patients (46.6\%) versus Group B (21.8\%) and Group
C (27.7\%) and this was statistically significant (p=0.009).

In Group A, 46 patients (63\%) had no residual sphincter defect, 10
patients (13.7\%) had an isolated internal anal sphincter (IAS) defect,
5 patients (6.9\%) had an isolated external anal sphincter defect (EAS),
and 12 patients (16.4\%) had a defect in both IAS and EAS. There was no
significant difference in Wexner score in relation to localisation or
combination of sphincter defects and there was no difference in Wexner
score between those patients that had any sphincter defect versus those
that did not (Table 2). Group A patients had significantly higher mean
Wexner scores than Group B and C patients. Perfect continence (Wexner
score 0) was significantly less present in Group A (21.9\%) patients
compared with Group B (50.9\%) and Group C (45.8\%) (Table 3). There was
no difference between Groups in number of patients with Wexner scores of
9 and above.

When the presence of IBS was taken into account, Wexner scores were
significantly higher in patients with IBS and this was observed
separately in all three patient groups. Inter-group comparison showed
that when IBS was present, Group A patients had significantly higher
Wexner scores than Group B and C patients. Interestingly when IBS was
absent there was no significant difference between Wexner scores in
inter-group comparison of all three groups (Table 4).

Wexner scores were also found to be significantly higher on intra-group
comparison in all three groups based on those that could not defer
defaecation longer than 15 minutes (Table 5). Inter-group comparison
showed that Group A patients maintained significantly higher Wexner
irrespective of whether they were able to defer defaecation for 15
minutes. Furthermore, the inability to defer defaecation for more than
15 minutes was not significantly related to an isolated IAS defect (7/34
vs 5/39, p=0.37), isolated EAS defect (1/34 vs 4/39, p=0.22), both IAS
and EAS defect (8/34 vs 2/39, p=0.79) or any sphincter defect (14/34 vs
13/39, p=0.49).

For the total group, IBS presence in combination with inability to defer
defaecation for 15 minutes was associated with the highest Wexner score
(Table 6). Backwards stepwise linear regression including the following
variables: age, IAS and or EAS ultrasonographic sphincter defect
(isolated or in combination), parity, presence of IBS, inability to
defer defaecation more than 15 minutes and BMI was performed. In the
final model (adjusted R-square .241, F=.7.68, p=0.002) presence of IBS
(Beta=3.48, p=0.002) and inability to defer defaecation for more than 15
minutes (Beta=2.17, p=0.044) were the significant independent factors
predicting increasing Wexner scores in Group A patients.

\textbf{DISCUSSION}

IBS is chronic functional gastrointestinal tract disorder which causes
abdominal pain and alteration to bowel habit in 10-15\% of the
population, which is in keeping with the results of our study. There is
also a greater preponderance toward women, with some estimates
suggesting more than half are without a formal diagnosis. {[}9{]} Our
findings demonstrate that patients with IBS have significantly worse
faecal incontinence after primary OASIS repair. Women without IBS did
not show significant difference in faecal incontinence after primary
OASIS repair compared to controls. Uniquely we have also shown that the
presence of IBS in post caesarean section in primigravid patients -- in
whom there were no sphincter injuries -- also demonstrated higher faecal
incontinence scores albeit more modestly. Lastly we have shown that
persistent sphincter defects after primary OASIS repair did not
correlate to worse faecal incontinence scores. {[}10{]}

OASIS causes both short and long-term complications after childbirth
such as perineal pain, dyspareunia, faecal and urinary incontinence; in
addition to emotional and psychological effects. {[}11, 12{]} Immediate
surgical repair by experienced obstetricians or colorectal surgeons
trained in sphincter tissue recognition within 12 hours is considered
the gold standard, either using an overlapping or end-to-end technique.
{[}13, 14{]} The exact incidence of faecal incontinence after OASIS is
likely under-reported as some patients feel unable to discuss their
symptoms with a medical professional. {[}15{]}

OASIS are classified within the spectrum of perineal tears. The
internationally accepted classification of obstetric perineal trauma is
as follows {[}4{]}: first degree -- laceration of vaginal epithelium or
perineal skin, second degree -- involvement of perineal muscles, third
degree -- disruption of \textless{}50\% external sphincter (IIIa),
\textgreater{}50\% external sphincter (IIIb), or both external and
internal sphincter (IIIc), and most severe fourth degree -- disruption
of anal epithelium. Previous studies have suggested that grading of
obstetric sphincter injuries can help prognosticate quality of life and
manometry outcomes. {[}16, 17{]} The risk of sphincter defects following
vaginal delivery may be as high as 26\% and up to half of these are
missed on routine physical examination immediately post-partum, however
women with IBS are at no increased risk of obstetric sphincter injury.
{[}10, 18{]}

When assessing women with different grades of sphincter defect on
ultrasound, our findings reveal no significant difference in mean Wexner
scores compared to women without sphincter defects. Roos et al {[}17{]}
report comparable rates of incontinence and sphincter defects to our
population, however they found that a combined IAS and EAS defect
resulted in worse faecal incontinence after a mean follow up of 9 weeks.
Our study used more liberal criteria to define ultrasonographic residual
sphincter defects in the absence of standardised and clinically
validated residual defect definitions. Our study confirms claims of
other studies that ultrasonographic sphincter defects may not reliably
correlate with increased severity of faecal incontinence after the
initial post-partum period {[}19, 20{]}. Our findings provide evidence
that after OASIS repair, screening for presence of IBS may be more
valuable than ultrasonography in predicting those at risk of worse
long-term faecal incontinence which could facilitate more targeted
behavioural, dietary, or pharmacological intervention.

We found that women who are unable to delay defaecation experience more
severe faecal incontinence. Faecal urgency occurs due to unexpected
contractions within the rectum and subsequent relaxation of the anal
canal. A population-based study by Bharucha et al {[}19{]} support our
findings, identifying urgency as a significant risk factor for
post-partum faecal incontinence. In a healthy rectum, intraluminal
pressure beyond 300 millilitres results in a feeling of urgency.
{[}21{]} Although not extensively studied, the effects of hormonal
changes intra- and post-partum are also believed to influence
gastrointestinal tract function in women with IBS. For example,
oestrogen influences the gut-brain axis which upregulates visceral
hypersensitivity and mucosal immune activation. {[}22{]} Manometry
reveals increased mucosal sensitivity to electrical stimulation of the
upper anal canal compared to parous women without IBS. {[}10{]} These
factors may therefore lower the threshold required for urgency to occur
and synergistically increase the risk of faecal incontinence following
OASIS repair.

A major strength of this study was the dual versatility of the
questionnaire which allowed standardisation of subjective symptoms by
calculation of a Wexner score, and also diagnosing IBS based on Rome IV
criteria. This ensured that patients who may not have a formal diagnosis
of IBS (which as stated earlier is not infrequent) were appropriately
categorised to increase accuracy of our results. An additional strength
of the study was the mean follow up interval of over two years, which
facilitated assessment of symptoms beyond the commonly studied early
post-partum period.

A limitation to the present study was the predominance of younger
patients in the control groups, as it is known that the risk of faecal
incontinence increases with age {[}3{]}. Mean Wexner scores were
significantly higher in the older Group A, but linear regression
analysis allowed control for this variable and age did not significantly
alter faecal incontinence scores in our cohort. Another limitation is
the single centre design which may be improved by future research
utilising a multi-centre design and recruiting a larger sample size.

\textbf{CONCLUSION}

After primary repair of major OASIS, patients are less likely to retain
perfect continence compared to control groups. Ultrasonographic mostly
partial sphincter defects were detected in 37\% of patients on follow
up, but this did not correlate to a clinical difference in faecal
incontinence scores. Faecal incontinence was significantly worsened by
the presence of IBS, or the inability to defer defaecation for 15
minutes. Women who did not have IBS had similar or minor incontinence
scores across the study groups of major OASIS repair, primigravid or
post-caesarean section.

We propose that the presence of IBS interacts with the complex
neuro-physiological coordination required for continence, which may be
exacerbated by Grade III/IV perineal trauma. Screening for presence of
IBS is therefore a useful tool to prognosticate the risk of faecal
incontinence after major OASIS, but also to assess future faecal
incontinence risk, if patients are known to be at high risk for OASIS,
in order to advise on optimal birthing options.

\textbf{ACKNOWLEDGEMENTS}

N/A

\textbf{FIGURES \& TABLES CAPTIONS}

Figure 1. Wexner faecal incontinence score

Figure 2. Rome IV criteria for diagnosis of irritable bowel syndrome

Table 1. Patient characteristics

Table 2. Mean Wexner scores based on location and presence of
ultrasonographic sphincter defect

Table 3. Wexner score distribution among cohort

Table 4. Mean Wexner scores based on presence of IBS among groups

Table 5. Mean Wexner scores based on ability to defer defaecation
\textgreater{} 15 minutes

Table 6. Mean Wexner scores based on urge symptoms (inability to defer
defaecation for \textgreater{} 15 minutes) in combination with IBS

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