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 sexual dysfunction (31.82%) and psychological symptoms (4.55%) – see Table 2. 50% of symptomatic patients reported symptoms in more than 1 domain, and 45.45% were sexually active at the time of review. Of the four patients with bowel symptoms, AI of solid stool was reported on a daily basis in 25% and on a weekly basis in 25%. AI of liquid stool on a daily basis was reported by 1 patient, and another on a weekly basis, while the remaining 2 patients reported no incontinence of liquid stool. Furthermore, flatal incontinence was reported on an occasional basis in one patient and weekly by another patient. The use of pads or plugs were required by 75% of symptomatic patients and 50% reported a change in their lifestyle - 1 patient was unable to defer defecation for 15 minutes. Two of the patients also reported coital incontinence. The overall cohort had a mean SMIS score of 1.77 (SD 4.42, range 0 – 18). However, symptomatic AI patients had an average SMIS score of 7.8 (range 2 to 18). Urinary incontinence was reported in 13.64% of patients, followed by nocturia (9.09%), urgency, hesitancy and incomplete voiding (each 4.55%). Bothersome symptoms were reported in 18.18%. Of the 4 patients reporting AI symptoms, 2 of them also had concurrent urinary symptoms. Vaginal symptoms affected 50% – namely, dyspareunia 31.82%, perineal pain 36.36% and wound dehiscence 9.09% – additionally 31.82% reported sexual dysfunction. Clinical Findings With clinical examination, a visible defect was apparent in 27.27% of patients. Average perineal body length was 2.64cm. All patients had intact sensation and reflexes. The average PFMC on the Oxford scale was 3.7 (SD 0.96, range 2 – 5). The average PFMC for patients with AI was 2.75. Sphincter tone at rest was strong in 27.27% of cases, while 31.82% demonstrated poor tonus. Notably, all four patients exhibiting AI symptoms demonstrated poor sphincter tone at rest. Among these, 3 patients had poor anal sphincter tone during squeezing, while 1 patient had no demonstrable sphincter tone with squeezing. Imaging Findings On TPUS 63.6% of all patients (n = 14/22) showed a significant sphincter defect. Combined IAS and EAS defects were detected in 36.4%, while isolated IAS or EAS defects were present in 55%. Among symptomatic patients (for any domain), 75% exhibited a significant visible defect and half had both IAS and EAS defects. All four patients with AI symptoms had significant TPUS defects - two patients having defects of both the IAS and EAS sphincter. Of the patient with no AI but symptoms in other domains – 66.7% (n = 8/12) had a defect on TPUS. 50% (n = 6/12) had a combined IAS and EAS defect. There were 6 patients who reported no symptoms in any domain; of these, 66.7% (n = 4/6) had a defect on TPUS. The 2 patients with no defect on TPUS also had a normal PFMC and sphincter tone. The strongest risk factors for TPUS defects were first vaginal birth, sustaining a 4th-degree tear and an increased BMI. EAS and IAS defects were comparably prevalent. All 3a tears and 3c tears exhibited significant TPUS defects. Among 3b tears only 2 patients (14%) had TPUS defects, while 64% of 4th-degree tears had defects. In 4th-degree tears, the EAS was disproportionately affected, with all 9 cases showing EAS defects compared to IAS defects in 6 out of 9 cases. Management Strategies Recommended mode of delivery after the initial visit was advised as vaginal delivery in 45.45%, caesarean section in 27.27%, and the remainder, the mode of delivery decision remained guarded. All patients were offered and referred for pelvic floor physiotherapy. Of the entire cohort of patients, 13.6% were discharged after initial consultation, 1 booked for sphincteroplasty, and the remainder scheduled for follow-up at 3 months (72%) and 6 months (28%). Unfortunately 54.55% of patients defaulted follow-up (Figure 3). Of the patients with AI symptoms, 1 was booked for sphincteroplasty after initial consultation, 2 received bowel training and 3 referred for pelvic floor muscle training. Other than the patient booked for sphincteroplasty, 3 patients had follow-up at a 3-month interval – 1 of whom had ongoing bowel symptoms despite physiotherapy and bowel training. For both patients PFMC remained unchanged and anal sphincter tone remained poor (unchanged). The symptomatic patient opted for sphincteroplasty after consultation. Urinary symptoms were addressed through a multidisciplinary approach comprising of bladder retraining, fluid intake education and pelvic floor muscle training. No patients required pharmacological intervention. Vaginal symptoms were managed according to underlying pathology. Granulation tissue was treated with silver nitrate application, while persistent perineal scar tenderness was treated with local lidocaine (Remicaine) massage. In patients with concomitant dyspareunia, guidance was provided to apply Remicaine 30 minutes prior to intercourse and topical oestrogen prescribed where indicated. In cases of levator ani spasm patients underwent targeted pelvic floor physiotherapy, including myofascial release and desensitisation techniques facilitated by a dedicated pelvic floor physiotherapist. Follow Up Outcomes At follow-up 33% of patients attended. No new bowel symptoms developed among those previously asymptomatic. New symptoms included UI, urinary hesitancy, new-onset dyspareunia and perineal pain. One patient that initially reported UI had symptomatic improvement and resolution of nocturia at follow-up. Of 3 patients with initial vaginal symptoms - all of whom reported perineal pain, 2 with dyspareunia and 1 with associated sexual dysfunction - dyspareunia and sexual dysfunction resolved in all. Ongoing perineal pain was reported by one patient and was managed conservatively. African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 13