The assessment of suspected sexual child abuse demands teamwork where the paediatrician plays a central role. From a juridical point of view, the task of the paediatrician is to evaluate the anatomic, microbiologic and forensic medical findings. In 1995, in order to improve the quality of this work, Norwegian paediatricians established a peer review group which meets on a regular basis. Based on available literature and the experience of the individual members, a classification system for anogenital findings has been developed. The findings are divided into five classes. Class one comprises findings frequently seen in children who have not been abused. Class two comprises findings not considered to be normal, but for which there could be many different causes. Classes three, four and five represent findings which are increasingly predictive with respect to injury penetration or attempted penetration. Since our knowledge of anogenital anatomy in children who have not been abused is limited, our classification system should be updated regularly.
Comment In: Tidsskr Nor Laegeforen. 1998 May 10;118(12):19109638062
Cancer treatment during childhood may lead to late adverse effects, such as reduced musculoskeletal development or vascular, endocrine and pulmonary dysfunction, which in turn may have an adverse effect on later pregnancy and childbirth. The aim of the present study was to investigate pregnancy and obstetric outcomes as well as the offspring's health among childhood and adolescent female cancer survivors.
This register-based study included all women born between 1973 and 1977 diagnosed with cancer in childhood or adolescence (age
OBJECTIVE: To assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence and to identify factors to predict women at risk. DESIGN: An observational study. SETTINGS: Departments of Obstetrics and Gynaecology and of Surgery D, Glostrup County University Hospital, Denmark. PARTICIPANTS: Ninety-four consecutive women who had sustained an obstetric anal sphincter rupture. INTERVENTIONS: Assessment of history, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months postpartum A questionnaire regarding anal and urinary incontinence was sent two to four years postpartum. MAIN OUTCOME MEASURES: The frequency of anal and urinary incontinence and risk factors for the development of incontinence. RESULTS: Thirty of 72 women (42%) who responded had anal incontinence two to four years postpartum; 23 (32%) had urinary incontinence and 13 (18%) had both urinary and anal incontinence. Overall, 40 of 72 women (56%) had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies of more than 2.0 ms, and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Seventeen women had subsequently undergone a vaginal delivery in relation to which four (24%) had aggravation of anal incontinence, and three (18%) had aggravation of urinary incontinence. Of the women with incontinence, 38% wanted treatment but only a few had sought medical advice. CONCLUSIONS: Obstetric anal sphincter rupture is associated with a risk of approximately 50% for developing either anal or urinary incontinence or both. The prediction of women at risk is difficult. Information and routine follow up of all women with obstetric anal sphincter rupture is mandatory.
BACKGROUND: Anal sphincter tears during vaginal delivery are a major cause of anal incontinence. We wanted to assess the incidence in a Norwegian county where primary repairs are performed in four hospitals using similar per- and postoperative protocol for the treatment of such injuries. METHODS: A postal questionnaire was distributed to all women who underwent primary repair of obstetric sphincter tears in the years 1999 and 2000 in the county of Möre and Romsdal. Symptoms of incontinence and fecal urgency were recorded. Incontinence was assessed using the Pescatori score system. RESULTS: Clinically detected sphincter tears occurred in 180 of 5123 vaginal deliveries (3.5%). The questionnaire was returned by 156 women (87%). Six women were excluded. Median follow-up was 25 months (range 4-39). Incontinence was reported by 88 women (59%), restricted to flatus incontinence in 53 cases (35%). Fecal urgency without incontinence was reported by 14 women (9%). Sixty-three women (42%) reported de novo moderate to severe symptoms. There was no difference in outcome whether the sphincter injury was partial or complete. Mean Pescatori score was 3.7 in women who felt disabled compared with 2.9 in women who did not feel disabled by their incontinence (P
OBJECTIVE: To investigate the incidence and degree of anal incontinence after vaginal delivery among primiparous women and to define associated risk factors. DESIGN: Prospective observational study. SETTING: Karolinska Institutet, Danderyd Hospital, Sweden, a university hospital. PARTICIPANTS: Three hundred and forty-nine primiparous women. METHODS: Questionnaires distributed within the first days after delivery and re-distributed five and nine months postpartum. Analysis of delivery records. RESULTS: Eighty percent of the women answered all questionnaires. At five months postpartum, 2% of the women had symptoms of faecal incontinence and 25% had symptoms of involuntary flatus. At nine months postpartum, 1% of the women had symptoms of faecal incontinence and 26% had symptoms of involuntary flatus. The majority of the women had infrequent symptoms and a decrease in severity was noted at nine months. Symptoms of incontinence were more common in women who sustained a sphincter tear at delivery. Risk factors for incontinence at five months included maternal age, duration of the second stage of labour, instrumental vaginal delivery, and clinically diagnosed sphincter tear at delivery. Development of incontinence at nine months was associated with maternal age and clinically diagnosed sphincter tear at delivery. CONCLUSIONS: The present study demonstrates that infrequent involuntary flatus is a common symptom after vaginal delivery in primiparous women. These symptoms of involuntary flatus frequently improved and only a few women suffered from frank faecal incontinence. Factors associated with an increased risk of anal incontinence and sphincter tears should be considered during delivery.
BACKGROUND: Rupture of the anal sphincter during childbirth is a major cause of faecal incontinence among women, a condition with considerable psychosocial consequences. The reported incidences show large variations, from 0.36% to 24%. Definitions and classifications vary as much. Also, reports on the persisting subjective problems of the women afflicted demonstrate diversity. MATERIAL AND METHODS: Over a 2(1/2) year period from January 2000, all women with partial or total rupture of the anal sphincter during delivery were invited to a follow up consultation after 6 months and interviewed about their subjective discomfort. RESULTS: Over the period in question we registered 147 ruptures of the anal sphincter among 6124 vaginal deliveries (2.4%); 109 (1.7%) were partial ruptures, 38 (0.7%) total ruptures. Among the 137 women who came in for a consultation 6 months after delivery, 92 (67%) had no complaints at all. Five women (4%) had some degree of leakage for liquid stools. None of them had incontinence for solid stools. INTERPRETATION: The reported incidence is in keeping with most of the previous registrations in the Nordic countries, but not with those giving the lowest figures. Improved delivery technique might reduce the incidence. The incidence of discomfort and complaints we found at 6 months was lower than expected on the basis of previous reports.
Comment In: Tidsskr Nor Laegeforen. 2005 Jun 2;125(11):153815940336
OBJECTIVE: To analyze circumstances relating to severe anal sphincter tears occurring at spontaneous delivery, in view of reported differences in practice regarding manual perineal protection during delivery. DESIGN: Cohort study of midwife-conducted non-operative vaginal deliveries. SETTING: Five Norwegian hospitals with 12,438 consecutive deliveries during a 12-month period. METHODS: Data from 357 women sustaining third and fourth grade anal sphincter tears (2.9%) were analyzed. MAIN OUTCOME MEASURES: Different incidence of major perineal tears. RESULTS: Sphincter tear incidence varied significantly between the five hospitals, from 1.3 to 4.7% (p
OBJECTIVE: To evaluate intrapartum risk factors for anal sphincter tear. DESIGN: A prospective observational study. SETTING: Delivery unit at the University Hospital in Göteborg, Sweden. PARTICIPANTS: 2883 consecutive women delivered vaginally during the period between 1995 and 1997. Information was obtained, from patient records and from especially designed protocols which were completed during and after childbirth. MAIN OUTCOME MEASURES: Anal sphincter (third and fourth degree) tear. RESULTS: Anal sphincter tear occurred in 95 of 2883 women (3.3%). Univariate analysis demonstrated that the risk of anal sphincter tear was increased by nulliparity, high infant weight, lack of manual perineal protection, deficient visualisation of perineum, severe perineal oedema, long duration of delivery and especially protracted second phase and bear down, use of oxytocin, episiotomy, vacuum extraction and epidural anaesthesia. After analysis with stepwise logistic regression, reported as odds ratio, 95% confidence interval, the following factors remained independently associated with anal sphincter tear: slight perineal oedema (0.40, 0.26-0.64); manual perineal protection (0.49, 0.28-0.86); short duration of bear down (0.47, 0.24-0.91); no visualisation of perineum (2.77, 1.36-5.63); parity (0.59, 0.40-0.89); and high infant weight (2.02, 1.30-3.16). Analysis of variance showed that manual perineal protection had a stronger influence on lowering the frequency, and lack of visualisation of perineum and infant weight had a stronger influence on raising the frequency, of anal sphincter tears in nulliparous compared with parous women. CONCLUSIONS: Perineal oedema, poor ocular surveillance of perineum, deficient perineal protection during delivery, protracted final phase of the second stage, parity and high infant weight all constitute independent risk factors for anal sphincter tear. Such information is essential in order to reduce perineal trauma during childbirth.