AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | Outcomes of Primary Sphincteroplasty for Obstetric Anal Sphincter Injuries in a Resource-limited Setting : A Prospective Case Series ABSTRACT Introduction: OASI is the most severe form of perineal trauma that occurs during vaginal delivery and has devastating effects on a patient’s quality of life. Objective: This study assessed the outcomes and management strategies of patients attending the Perineal Clinic at Tygerberg Hospital after primary OASI repair. Methods: This was a prospective, descriptive case series of all patients with OASI attending the Perineal Clinic who met criteria and provided consent. Symptomatology, clinical findings, and ultrasound findings are described, and the correlation between these aspects are examined. Management of each type of presentation is reported, with outcomes. Results: A total of 74 patients were scheduled for the Perineal Clinic; 28 attended. 23 patients consented to participate in the study. Of those who consented, 72.73% (n=16) reported symptoms, while 27.27% were asymptomatic. Symptom distribution included bowel-related complaints in 18.18%, bladder issues in 22.7%, vaginal symptoms in 50%, and sexual dysfunction in 31.82%. Notably, ultrasound imaging revealed defects in 63.6% (n=14) of all participants. Conclusion: We analysed the outcomes and management of obstetric anal sphincter injuries (OASI) within a low- to middle-income country (LMIC) setting and compared our findings with international literature. Despite the study’s limited sample size and the inherent challenges associated with LMIC healthcare environments, our results were largely consistent with global data. Furthermore, the management strategies employed reflected a standard of care comparable to that observed in higher-resource settings. Keywords: AI: Anal incontinence, EAS: External anal sphincter, IAS: Internal anal sphincter, LMIC; Low-to-middle income country, OASI: Obstetric anal sphincter injury, PFMC: Pelvic floor muscle contraction, TPUS: Transperineal ultrasound, UI: Urinary incontinence INTRODUCTION Obstetric anal sphincter injury (OASI), comprising third- and fourth-degree perineal tears, is a severe form of perineal trauma sustained during childbirth (1) . Comprehensively described by Sultan (2) , and recognised by the Royal College of Obstetricians and Gynaecologists (RCOG) (1) , third-degree perineal tears involve injuries to the perineum extending to the anal sphincter complex and are further subdivided into 3 categories; whereas fourth-degree tears involve injury to both the anal sphincter complex and anal epithelium. OASI affects 5.4% to 18% of vaginal births (3–5) , with incidence rising globally. Well-resourced settings report higher rates due to increased diagnostic awareness (6,7) while data from resource-limited settings remain scarce (5,8,9) . Low-income nations report prevalence rates ranging from 0.1% to 15% in Asia and 0.6% to 7.2% in Africa (5) . OASI represents the most significant modifiable risk factor for anal incontinence (AI) in women (10) , and women with previous OASI are at risk for recurrent injury (11,12) . The long-term consequences of inadequately managed OASI — including persistent pain, AI, and impaired sexual function — can significantly diminish quality of life (13–19) . In LMICs, these sequelae further strain overburdened healthcare systems and exacerbate social challenges. The resulting morbidities can negatively impact marital relationships, reduce economic productivity, and contribute to social isolation. In South Africa’s public healthcare context, barriers to specialist care and rehabilitation highlight the need for improved prevention, intervention and management strategies to enhance patient outcomes. OBJECTIVE To assess the management of patients and outcomes of repair of patients attending the Perineal Clinic after primary OASI repair in a resource-limited setting. METHODS This was a prospective, descriptive case series conducted between October 2023 and July 2024 at Tygerberg Hospital’s Urogynaecology Perineal Clinic - a subspecialist service conducted once-monthly. All patients referred to the Perineal Clinic after primary OASI repair were included. Patients were excluded if they had: • buttonhole injuries • coincidental OASI defects detected on examination/ TPUS (transperineal ultrasound) • non-obstetric sphincter trauma. Ethical approval was obtained from the Health Research Ethics Committee of Stellenbosch University (Ethics Reference No: S23/04/068). Permission from Tygerberg Hospital was also obtained. All eligible patients were provided with an information leaflet in their preferred language — English, Afrikaans, or isiXhosa. Informed R Peters, KT Jere, D Masimila Department of Obstetrics and Gynaecology, Tygerberg Hospital and Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. CORRESPONDENCE: R Peters | Email: rafeeqahpeters@sun.ac.za Outcomes of Primary Sphincteroplasty for Obstetric Anal Sphincter Injuries in a Resource-limited Setting : A Prospective Case Series African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 10