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 consent, in the patient’s language of choice, included discussion of the study’s purpose, voluntary participation as well as detail regarding examinations and procedures performed. Time was allocated for questions and assurances were made that participation would not affect the quality or nature of their medical care. Those who consented to participate subsequently signed an informed consent form. A comprehensive clinical assessment was conducted including a detailed obstetric and gynaecological history, patient demographics, delivery and repair details, injury severity, and the presence of functional and psychological symptoms. Information regarding delivery and subsequent repair was corroborated through hospital records and referral letters. AI severity was quantified using the St Marks incontinence score (SMIS), which ranges from 0 (no symptoms) to 24 (severe incontinence). While no validated scoring system exists for UI or sexual dysfunction specific to OASI patients, associated symptoms—including urgency, voiding dysfunction, perineal pain, dyspareunia, and psychological impact — were documented alongside lifestyle alterations and pad use. All patients underwent a vaginal examination assessing for visible defects, wound integrity, perineal body length, perianal sensation, trigger points, pelvic floor muscle contraction (PFMC) and the presence of pelvic organ prolapse (using the POP-Q system). Perineal body length was measured during maximal Valsalva. PFMC was graded using the modified Oxford scale, and neurological assessment included testing perianal sensation in the dermatomal areas, as well as eliciting the anal wink and bulbocavernosus reflex. A rectal examination was performed to evaluate anal sphincter tone at rest and during voluntary contraction. All investigations performed were part of routine clinical practice. All women presenting to the Perineal Clinic with a history of OASI, irrespective of symptoms or grade of OASI, were investigated with TPUS - a non-invasive, patient- acceptable form of investigating the anal sphincter that allows analysis of the anal sphincter's undisturbed state (20–23) . All patients underwent a 2D TPUS using either a GE Voluson E6 50/60Hz 1000VA 220/240V (GE Medical System, Kretctechnik GmbH, Tiefenbach 15, Austria), or a Sonoscape P10 50/60Hz 2.0-0.8A 100-240V (Sonoscape Medical Corp, Guangdong, China) machine and a curvilinear transabdominal transducer. TPUS was performed at rest and on maximum pelvic PFMC with the patient in the supine position. The entire length of the anal sphincter was assessed from the puborectalis to the subcutaneous level of the external anal sphincter (EAS). An anal sphincter defect was defined as a disruption of the external or internal anal sphincter (IAS) involving more than 1 hour on the clock face (more than 30 degrees). A significant EAS or IAS defect was defined as the presence of a defect in 2/3 the length of the EAS or IAS. During the period of the study, the primary investigator – trained and supervised by the urogynaecology consultant - conducted most TPUSs. AI, UI, perineal pain, dyspareunia and psychological symptoms were managed according to best practice protocols – including NICE and RCOG Guidelines. Data was collated, and statistical analysis performed using STATISTICA version 17 (StatSoft Inc., 2021). Demographic variables, obstetric outcomes, rates of OASI morbidity and outcomes, and their subcomponents were descriptively analysed and presented as measures of location (median and mean), spread (standard deviation and percentiles for continuous data), and as frequencies (count and percentage) for categorical data. Figure 1: Transducer placement for TPUS in midsagittal plane (photo), and corresponding ultrasound image expected on screen (illustration) Figure 2: Transducer placement for visualization and imaging of anal canal (photo) and corresponding ultrasound image (labelled illustration and photo) RESULTS A total of 74 patients were booked for the Perineal Clinic for the period of the study. Of these, 28 attended (37.8%). Among those, 26 met study criteria, and 23 consented to participate (88.5%), with 1 patient later withdrawing (see Figure 3). The mean follow-up interval from repair until the Perineal Clinic appointment was 18 weeks (range 7 – 38 weeks). Baseline demographic characteristics and major risk factors The mean maternal age was 25.05 years, with 72.73% of participants being primigravida. The average BMI was 25.66 with 41% classified as being overweight. Smoking and HIV prevalence were 9% and 4.55%, respectively. Identifiable OASI risk factors were present in 59% - most common being elevated BMI, followed by ventouse-assisted delivery (14%). Spontaneous labour occurred in 72.73%. Episiotomy was performed in 31.82% of cases. The mean birth weight was 3345g (range 2380g – 4600g). Labour- related complications occurred in 19% of cases, with African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 11