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Title: Prevalence and risk factors associated with anal incontinence among nulliparous parturients with vaginal delivery in a Nigerian hospital
Running title: Anal incontinence and nulliparous parturients 
Authors:
Aduloju Olusola Peter MBBS, MPH, FWACS
Department of Obstetrics and Gynecology,
Ekiti State University, 
Ado-Ekiti, Nigeria.
Ajayi Oladimeji Akande MBBS, FWACP
Department of Medicine,
Ekiti State University, 
Ado-Ekiti, Nigeria.
Aduloju Tolulope RN, RM, B Ed, MSW 
Department of Medical Social Services,
Ekiti State University Teaching Hospital, 
Ado-Ekiti, Nigeria.
Grants or financial support: The authors did not receive any grants or financial support for this study.
Corresponding Author:
	Dr Aduloju Olusola Peter
Department of Obstetrics and Gynecology,
Ekiti State University,
Ado-Ekiti, Nigeria.
Phone no: +2348033900908
e mail:  HYPERLINK "mailto:olusola.aduloju@eksu.com" olusola.aduloju@eksu.com;  HYPERLINK "mailto:peter.aduloju@yahoo.com" peter.aduloju@yahoo.com 




















Abstract
Objectives: Anal incontinence may complicate childbirth and this has been grossly under-reported. This study aimed at determining the prevalence and risk factors associated with anal incontinence among nulliparous women undergoing vaginal delivery at a tertiary healthcare center in Nigeria.
Methods: A longitudinal study carried out among 293 nulliparous women delivered vaginally at Ekiti State University Teaching Hospital, Ado-Ekiti between January and March, 2012. Questionnaires were administered at index delivery, nine months and five years assessing for socio-demographic data, subsequent deliveries and anorectal symptoms. Women with sphincter tear at first delivery were compared with women without such injury while risk factors associated with anal incontinence were determined.
Results: A total of 186 women were analysed and prevalence of anal incontinence increased significantly over the study period. Among women with sphincter tear at index delivery, 27.3% and 36.4% of them had anal incontinence at 9 months and 5 years respectively, p = 0.002 and among those without sphincter injury, 8.6% and 16.6% of them reported symptoms of anal incontinence at 9 months and 5 years respectively, p = 0.037. Maternal age, sphincter tear at index delivery and subsequent vaginal delivery were associated with anal incontinence at 5 years, p < 0.05. Majority of women with symptoms had flatus incontinence while faecal incontinence was rare.
Conclusion: Though not routinely screened for, anal incontinence does occur among our parturients after the index delivery. It can get worsened with subsequent vaginal deliveries especially if complicated by anal sphincter injury. 

Key words: Prevalence; Flatus incontinence; Faecal incontinence; Sphincter tear; Parturients; Nigerian hospital
 




















Introduction 
Faecal and flatus incontinence occurring after childbirth constitutes a potentially debilitating condition. This has been grossly under-reported due to non-disclosure and reluctance to seek medical treatment by the women affected by it [1, 2]. Anal incontinence is often associated with adverse effects on quality of life, with wide implications on everyday function including social interactions, personal hygiene, sexuality, and self-esteem [3, 4]. The prevalence of anal incontinence ranges between 24% and 44% in population-based studies and it occurs in all age strata of the adult female population [3, 5]. Previous studies have reported that about 6-10% of women experience new defaecatory symptoms postpartum and 10-13% experience loss of control of flatus [6, 7]. Identified risk factors for anal incontinence in the general population include ageing, vaginal childbirth, pelvic surgery, neurological and degenerative disorders [8, 9].
Vaginal childbirth has been shown to be associated with anal incontinence. This has been attributed to trauma to the pelvic floor, which may give rise to either a sphincter laceration, injury to the pudendal nerves, or both [10]. Studies on predictors of anal incontinence after childbirth also identified obstetric instrumentation (forceps and vacuum) and that episiotomy (surgical incision of the perineum) may increase the risk of sphincter injury [3]. Advocates of routine episiotomy during childbirth claimed that it helps to avoid relaxation of the pelvic floor muscles and prevent perineal trauma (third and fourth degree perineal lacerations). However, there are now evidences that have shown that episiotomy does not prevent trauma to the perineum [10-12].
Most of the studies on childbirth and anal incontinence were done in developed countries. To the best of our knowledge, there is paucity of studies on the prevalence of anal incontinence among parturients in sub-Saharan Africa including Nigeria. Therefore, this study was carried out to determine the prevalence of anal incontinence and the associated risk factors among parturients in a Nigerian hospital. 



.

















Method and Materials
This longitudinal study was carried out among nulliparous women, who delivered in the Labour Ward of the Department of Obstetrics and Gynecology, Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, Nigeria over 3 months starting on 1st January, 2012 and were followed up to 5years after ending on 30th April, 2017. EKSUTH is a tertiary healthcare institution and it serves as a referral centre for primary and secondary healthcare facilities located in State. There are also referrals from the neighboring states of Ondo, Osun, Kwara and Kogi. The Department of Obstetrics and Gynecology has eight consultants divided equally into two firms. The Department runs Antenatal and Postnatal Clinics on Wednesdays and Fridays and a Booking Clinic on Tuesdays. About 150 women register for antenatal care monthly in this centre with a monthly delivery rate of 130-155 deliveries, out of which about 30-35 are unbooked.
We included all nulliparous women who had antenatal care and vaginal deliveries in the hospital and consented to participate in the study while those parturients who had multiple deliveries, cesarean deliveries and did not attend antenatal care in the hospital or give their consent to participate in the study were excluded. Adhering to the inclusion criteria, 293 women were eligible to participate. 
Definition of terms: 
Anal incontinence may include both unintentional loss of flatus (gas) and feces.
Fecal incontinence refers to the involuntary loss of solid or liquid stool.
Sphincter lacerations and perineal tears conform to the standards set by the World Health Organization (International Classification of Diseases 9 and 10, Geneva, Switzerland, 1992).
A pretested questionnaire was administered to all participating women immediately after delivery by the trained Specialist Registrars and follow up was done at six weeks, nine months and five years postpartum by the Specialist Registrars and Nursing Staff of the Postnatal Clinic of the hospital. Text messages were sent to these women using phone to remind them of their return visits to the clinic at six weeks, nine months and five years after first delivery. Second and third reminder text messages were sent immediately to those who did not honor the first one. Women who did not return to the clinic after the third reminding text message were considered non-responders.
The questionnaire was adapted from a previously validated bowel function questionnaire recommended by the Swedish Society of Colorectal Surgeons [13, 14]. The questionnaire was divided into three sections: the first section elicited information about socio-demographic and obstetric characteristics of the women like age, parity, gestational age at delivery; the second section inquired about the events of labour and delivery like duration of second stage of labour, use of obstetric instruments (forceps or vacuum), episiotomy, lacerations, infant birth weight while the third section asked about questions anal incontinence which are: �Did you have sphincter tear in your first pregnancy?�; �Do you pass flatus/gas when you don�t want to?�; Do you experience passage of stools when you don�t want to?� and �Do you leak fluid around the anal opening when you don�t want to?�. Ordinal response alternatives were used to categorize the frequency of their symptoms as: no; less than once per week; more than once per week and daily. In this study, women reporting involuntary loss of flatus >1/week or daily, or loss of feces (with any frequency) were considered having severe anal incontinence whereas involuntary loss of flatus <1/week was considered as mild incontinence. The first and third sections were obtained directly from the women while the third section was extracted from their case records.
The data obtained were analyzed using Statistical Package for Social Sciences version 20 (IBM, Amonk, NY, USA). Continuous variables were analyzed using mean, standard deviation and student t test while categorical variables were analyzed using frequency, percentages and Fischer exact test. Logistic regression analysis was done to determine factors associated with anal incontinence using Odd ratio and 95% confidence interval. Statistical test of significance was set at p < 0.05.
Ethical approval was obtained from the Ethics and Research Committee of EKSUTH, Ado-Ekiti and verbal consent was obtained from the women who participated in the study having been duly informed of the objectives of the study. The questionnaires were made anonymous and the women were at liberty to withdraw or refrain from participating in the study without any consequence on their care. 














Results 
Out of the 293 women that were recruited into the study at delivery, 213 women completed the study at 5 year follow up giving a response rate of 72.7%. Thirty-seven (17.4%) of the 213 women had no subsequent delivery, 149 (69.9%) reported having had subsequent vaginal deliveries only and 27 (12.7%) were excluded from the study due to caesarean section prior to the completion of the five year follow up period. Therefore, 186 women with vaginal deliveries were eligible for final analysis at the five year follow up period.
Table 1 showed that there was no significant difference in the mean age of the women at index delivery, maternal weight, parity and gestational age at delivery among the women involved in this study. Other obstetric characteristics of the women are as shown in the table 1.
Table 2 showed that three of the 11 women with a sphincter tear at the first delivery (27.3%) had no additional childbirth during the study period. Of these 3 women, no one reported anal incontinence symptoms at 9 months postpartum, while 1 (33.3%) woman had symptoms at the 5-year follow up, p = 0.325. Eight of the 11 women (72.7%) with a sphincter tear at the first delivery had 1 or more subsequent childbirths and of these 8 women, 3 (37.5%) reported anal incontinence symptoms at the 9 months and 4 (50%) at the 5-year follow-up, p = 002.
Thirty-four (19.4%) of the 175 women without a sphincter tear at the first delivery had no additional childbirth during the study period. Of these 34 women, 6 (17.6%) reported symptoms of anal incontinence at the 9-month follow-up and 8 (23.5%) at the 5-year follow-up, p = 0.420.
One hundred and forty one (80.6%) of the 175 women without a sphincter tear at their first delivery had 1 or more subsequent childbirths during the study period and of these 141 women, 15 (10.6%) reported anal incontinence symptoms at 9 months postpartum and 18 (12.8%) at the 5-year follow-up, p = 0.034.
Among the 186 women, 11 (5.9%) women had sphincter tear at index delivery and none reported anal incontinence prior to delivery. Three (27.3%) of the eleven women who sustained sphincter tear at index delivery had some degree of anal incontinence at nine months follow up while at five year follow up, 5 (45.5%) of them were incontinent. Of the 175 women without sphincter tear, 15 (8.6%) of these women had symptoms of anal incontinence at nine months while 29 (16.6%) of them had anal incontinence at five years follow up. (Table 3)
Table 4 showed that maternal age, sphincter tear at the first delivery and subsequent childbirth were independent risk factors associated with anal incontinence 5 years postpartum. In women without symptoms of anal incontinence before their first pregnancy, anal incontinence at 9 months postpartum (OR 4.3; 95% CI 2.2-8.2) was a significant risk factor for persistent symptoms at 5-year follow-up. 












Discussion
This study was particularly done on primiparous women to assess the long term effect of vaginal birth on anal incontinence. Previous study had documented that primiparous women are at a low risk of anal incontinence and this risk is increased in multiparous women. However, primiparous women have a higher risk of sustaining sphincter tear compared to multiparous women [15]. This study revealed that about 28% of women who sustained sphincter tear at delivery developed anal incontinence at 9 months and this increased to about 50% at 5 years follow up. This result is comparable to findings from previous studies [16, 17] and it was opined that this result might be due to inadequate surgical techniques or insufficient healing of the primary repair. This was corroborated by a study by Sultan et al [18] that examined women with endoanal ultrasonography at follow up after primary repair of sphincter injuries and found out that about 85% of them had persisted morphologic sphincter defects.
Anal incontinence was found among women who did not report sphincter injury during the index delivery and this was similarly reported in previous studies by Nordenstam et al [10] and Pollack et al [17]. Both studies suggested that this might due to undetected occult sphincter injury at delivery or presence of other known risk factors such as subsequent births, pelvic surgeries, neurologic or gastrointestinal disease. A study by Sultan et al [2] described a strong association between anal incontinence and occult sphincter injuries and this was affirmed by findings from other studies [15, 19]. The prevalence of anal incontinence among these women increased over the period of study from time of delivery up to the 5 year follow up. This was noticed in similar studies [17, 20] and most of these women had also had subsequent deliveries aside the index deliveries. However, this was in contrast to the finding of Nordenstam et al [10] that reported a reduction in anal incontinence at the end of their observation period even without treatment. They suggested that this might be due to dietary and lifestyle changes as well as slow neural regeneration over the period of study [21].
Subsequent deliveries were significantly associated with occurrence of anal incontinence in this study and this was in conformity with the findings from previous studies [20, 22]. Fynes et al [22] found a deterioration of symptoms in women with persistent anal incontinence after second delivery while Ryhammer et al [20] reported an increase in symptoms of incontinence after third vaginal delivery among women studied. Most published data support the finding that additional deliveries may increase the risk for anal incontinence. A study by Faltin et al [23] found an increased prevalence of anal incontinence after previous sphincter tear and subsequent delivery, and Payne et al [24] reported an increased risk for a recurrent sphincter injury at subsequent vaginal deliveries. However, Hojberg et al [25] did not find any association between subsequent deliveries and anal incontinence.
In this study, it was found that increasing maternal age was associated with anal incontinence after child birth. Older age groups were at a higher risk of having anal incontinence and this was consistent with findings from previous studies [10, 15, 17]. This might due to the fact maternal age at first delivery has continued to be on the increase [26] and in our environment; this might be as a result of late marriage, delayed childbearing, education or career progression. Also, previous sphincter tear and subsequent vaginal deliveries were associated with persistence of symptoms of anal incontinence at five years. Since subsequent vaginal deliveries worsen anal incontinence in women with previous sphincter injuries, therefore, such women can be counseled against exposing the anal sphincter mechanism to the risk of functional impairment through vaginal deliveries [17]. 
The high response rates among the women involved in this study and the use of previously validated questionnaires with standardized answers were the strengths of the study. The use of validated questionnaires and standardized answers prevented erroneous and varied interpretation of the questions that might distort the answers provided. Caesarean delivery may have effect on development of anal incontinence while anal incontinence may also affect the quality of life in women affected. These are areas that could be considered for further research in the future. 
The findings from this study are in agreement with previous long term studies done at five and ten years after index delivery to assess prevalence of anal incontinence in which women with sphincter tears were at higher risk compared to women without sphincteric tear [10, 17]. The consistency of these long-term studies strengthens the assumption that a thorough evaluation of anal continence function may be used in obstetrical decision making when guiding patients� choice of delivery mode.











Acknowledgement 
The authors acknowledged all the parturients that participated in this study, the Specialist Registrars and the Nursing staff that helped in the collation of the data.




















Conflicts of interest disclosure
The authors declare that they have no conflict of interests.





















References
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Table 1 Obstetric characteristics of women involved in the study
Variables No sphincter tear
n = 175Sphincter tear 
n = 11p valueAge at index delivery (years)29.23 � 6.5030.14 � 4.220.230Gestational age at delivery (weeks)40.10 � 1.1039.30 � 1.700.072Maternal weight at delivery (kgs)74.30 � 10.4073.10 � 12.300.113Duration of first stage of labour (hours)8.55 � 2.309.59 � 4.200.025*Duration of 2nd stage of labour (hours)1.25 � 0.431.34 � 0.330.015*Episiotomy 53 (30.3%)4 (36.4%)0.042*Vacuum delivery15 (8.6%)2 (18.2%)0.032*Birth weight (kgs)3.35 � 0.213.53 � 0.120.204Obstetric tears    No tear127 (72.6%)5 (45.5%)0.014*    1st degree tear33 (18.9%)2 (18.2%)0.362    2nd degree tear15 (8.6%)1 (9.1%)0.324    3rd degree tear02 (18.2%)-    4th degree tear01 (9.1%)-Subsequent delivery   None34 (19.4%)3 (27.3%)0.058   Subsequent vaginal delivery       1 106 (60.6%)5 (45.5%)0.035*        > 1 29 (16.6%)2 (18.2%)0.027*   Subsequent vacuum delivery6 (3.4%)1 (9.1)0.418* Statistically significant

Table 2 Subsequent childbirth and anal incontinence during the study period
VariablesAnal incontinence with no Sphincter tearSubsequent delivery                 n = 175 (%)9 months5 yearsp valueNo delivery34 (19.4%)6 (17.6%)8 (23.5%)0.420e" 1 delivery141 (80.6%)15 (10.6%)18 (12.8%)0.034*VariablesAnal incontinence with Sphincter tearSubsequent deliveryn = 11 (%)9 months 5 yearsp valueNo delivery 3 (27.3%) 01 (33.3%)0.325e" 1 delivery8 (72.7%)3 (37.5%)4 (50.0%)0.002** Statistically significant















Table 3 Prevalence of anal incontinence compared to index delivery
Variables No Sphincter tear n = 175Index delivery9 months5 yearsp valueNo incontinence 175 (100%)160 (91.4%)146 (83.4%)0.006*Involuntary flatus   d" 1/ week03 (1.7%)8 (9.6%)0.032*   > 1/ week 06 (3.4%)11 (6.3%)0.021*   Daily 05 (2.9%)7 (4.0%)0.320Faecal incontinence   d" 1/ week01 (0.6%)3 (1.7%)0.043*   > 1/ week0000   Daily 0000Anal incontinence015 (8.6%)29 (16.6%)0.037*Severe anal incontinence012 (6.9%)21 (12.0%)0.021** Statistically significant
Variables Sphincter tear n = 11Index delivery9 months5 yearsp valueNo incontinence 11 (100%)8 (72.3%) 7 (63.6%)0.020*Involuntary flatus   d" 1/ week01 (9.1%)1 (9.1%)1   > 1/ week 01 (9.1%)1 (9.1%)1   Daily 00 1 (9.1%)0.024*Faecal incontinence   d" 1/ week01 (9.1%)1 (9.1)1   > 1/ week000-   Daily 000-Anal incontinence03 (27.3%)4 (36.4%)0.002*Severe anal incontinence02 (18.2%)3 (27.3%)0.029** Statistically significant





















Table 4 Factors associated with anal incontinence after five years of index delivery
VariablesOdd Ratio (95% Confidence Interval)p valueMaternal age (years)2.1 (1.6 � 2.7)0.012*Sphincter tear2.9 (2.1 - 3.4)0.042*Subsequent child delivery2.4 (1.9 � 3.0)0.035* * Statistically significant















Department of Obstetrics and Gynecology,
Ekiti State University Teaching Hospital,
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la�p�������yt�H�woxo�o�o�o�o�o�o�o�o^VVVVVVVV$a$gd9M�kd�.$$If�l��F��2
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t��0�������6������������������4�4�
la�p�������yt�H�	�o�o�o�o�o�o�o�o�o�o�o,,3,\,v,�,�,@-�-..G.p.�.�����������������������$d��a$gdR�$a$gdR�gdR���^��gdR�����^��`��gdR�$a$gd9MAdo-Ekiti.
3rd January, 2017.
The Editor-in-Chief,
Journal of Genital System and Disorders,
United States of America.
Dear Sir,
Re: Cover letter
Anal incontinence may complicate previous vaginal delivery associated with anal sphincter injury. It is worsened with increased maternal age and subsequent vaginal delivery. 
The authors of this manuscript who are responsible for the intellectual content have agreed to publish the manuscript in your highly reputable journal. The total number of tables is 4.
The address of the corresponding author is as below:
Dr Aduloju Olusola Peter
Department of Obstetrics and Gynecology,
Ekiti State University, Ado-Ekiti, Nigeria.
Phone no: +2348033900908
e mail:  HYPERLINK "mailto:olusola.aduloju@eksu.com" olusola.aduloju@eksu.com;  HYPERLINK "mailto:peter.aduloju@yahoo.com" peter.aduloju@yahoo.com 
We look forward to your prompt review and publication in your journal.
Yours faithfully,
Aduloju Olusola Peter
Ajayi Akande Oladimeji
Aduloju Tolulope 








 PAGE   \* MERGEFORMAT 25




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