Postpartum Anal and Urinary Continence Assessment

The analysis of anal continence was based on the Vaizey score [22 (link)] (Appendix A). Data differs in the literature to assess which Vaizey value significantly defines incontinence [23 (link)]. In the EPIC study, based on this literature and on expert opinion, a score ≥5 defined AI [8 (link),24 (link)]. Our population being inhomogeneous regarding continence before D2, we selected as the primary endpoint worsening of the Vaizey score after D2, defined as an increase ≥2 points in the score between the two proctological examinations. Comparable definitions were used in previous proctologic studies [25 (link)].
Because transient AI (lasting less than 2 months) is common in the immediate postpartum period [26 (link),27 (link)], the assessment 6 months after D2 was used to measure persistent continence deterioration.
EAS was performed by a single trained operator, using a rotating rectal probe (7–10 MHz, Brüel and Kjaer). Upper, middle and lower anal canal were studied. A sphincter lesion was identified as a loss of continuity visible by a change in echogenicity within the sphincter ring [28 (link)]. Severity was assessed based on the Starck score (Appendix B). A score ≥9 was used to define a severe sphincter rupture [29 (link),30 (link)]. The clinical description of perineal lesions was based on the Royal College of Obstetricians and Gynecologists classification, where the anal sphincter is considered impaired in grades III and IV (Appendix C). We defined a “hidden sphincter rupture” as a tear undiagnosed in the delivery room (or under-diagnosed as a grade I or II) but observed by EAS. After D2, ruptures were considered “de novo” if no EAS defect was visible after D1.
The analysis of urinary continence was based on the MHU score (Appendix D) [31 (link)], treated as a continuous variable ranging from 0 to 28 points. Macrosomia was defined by birthweight >4 kg [32 (link)]. Birthweight was not collected in D2 in the case of CS. Instrumental delivery referred to the use of all types of forceps or vacuum but the type of forceps was not specified. Details of the episiotomy were not collected. We defined “abnormal transit” as the presence of diarrhea, constipation or dyschesia. We asked the patients whether or not they had undergone perineal rehabilitation, but the modalities were not collected (number of sessions or technique used).