•What is currently known about this topic: pediatric patients presenting with accidental genital injury historically were taken for examination under anesthesia (EUA); more recent literature suggests ...reduced need for EUA and associated cost savings.•What new information is contained in this article: physical exam findings indicating likely need for operative intervention include active bleeding, laceration or hematoma > 2 cm, and GIS ≥ II.•What new information is contained in this article: a proposed pathway is presented to help reduce the number of patients who go to the operating room for an EUA unnecessarily.
The indications for operative management of pediatric perineal injuries are debated. We aimed to investigate our institution's experience with perineal injuries in girls and identify factors for which patients require examination under anesthesia (EUA).
All female pediatric patients presenting to our institution June 2015–2021 with an isolated perineal injury were reviewed. Demographics, symptoms, exam findings, Genitourinary Injury Score (GIS), and management strategy were recorded and analyzed. Patients were divided based on level of intervention – bedside examination without sedation, Emergency Department (ED) exam with sedation, or EUA.
In total, 202 patients with a median age of 6 years were analyzed. Bleeding was reported most frequently by patients and families (90.1%), but only 27.2% of patients had bleeding noted on ED exam. Over half of patients (n = 110, 54.5%) were managed nonoperatively; the remaining 92 (45.5%) underwent EUA. The majority of patients (n = 150, 74.3%) had a GIS of I. EUA patients had a higher estimated median total injury size (2.5 (1.5–3.5) cm vs 1.0 (0.5–1.5) cm, p < 0.001), higher percentage of active bleeding (53.3% vs. 4.8%), and higher GIS (≥ II). No one discharged from the ED required operative intervention at a later time.
Although further prospective evaluation is required, our investigation suggests the majority of patients presenting with perineal injuries can be managed in the emergency department, but operative intervention should be considered for patients presenting with active bleeding on physical exam, laceration or hematoma > 2 cm, or GIS ≥ II.
Background: Obstetric perineal injury is a major contributor to women’s reproductive health problems. More than 60% of women suffer varying degrees of obstetric perineal injuries during vaginal ...delivery requiring repair. This study determined the risk factorsassociated with perineal injury. Method: Prospective observational study of 356 women who had singleton term vaginal delivery between 1stApril and 31stMay, 2018 at the KBTH. Sociodemographic and clinical data of participants were collected and analysed to determine association betweenvariables. A p-value of <0.05 was considered statistically significant.Results: Two hundred and thirty-six women (66.29%) had vaginal deliveries with no perineal injuries comprising 81 primiparous and 155 multiparous women. Perineal injury among the study participants were 120/356 (33.71%) while perineal injury for first degree, second degree, third degree and fourth degree were 75/356 (21.07%), 41/356 (11.52%), 2/356 (0.56%), 2/356 (0.56%) respectively. A total of 948 vaginal deliveries was conducted during the study period. The odds of developing a perineal injury was 8 times higher among participants with previous surgery on genital tract (OR, 8.29 95% CI 2.69- 25.6; p<0.001) and 18 times higher among participants with previous postpartum complication (OR, 18.00 95% CI 4.06-79.71, p<0.001). Babies with birth weights ≥2.5kg had 4.11 increased odds of developing perineal injury when compared to those with birth weights <2.5kg (OR, 4.11 95% CI, 1.70-9.98 p=0.001). Vacuum delivery was strongly associated with a 4.81 odds perineal injury (OR, 4.81 95% CI, 1.22-18.9 p<0.014).Conclusion: The incidence of perineal injury among women who had vaginal delivery at the KBTH maternity during the study period of (12.66%) was high compared to other studies from the West African Subregion. Risk factors such as previous postpartum complication, episiotomy, and gestational age at delivery, head circumference of the baby, asthma, hypertension and past genital tract surgery weresignificantly associated with perineal injury. Early identification of women at risk of perineal injury could help with interventions to reduce the incidence of this complication during childbirth.
Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in ...low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT.
•Risk factors for OASIS often become apparent late in labour.•Antenatal and intrapartum risk factors should be identified, and precautions taken.•Outcomes following primary repair of OASIS are difficult to establish as they vary with respect to repair techniques.•Perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching.•Episiotomies should be done judiciously with the correct technique when indicated.•Systematic repair of the anal sphincter complex should be performed by a trained caregiver with good postoperative care.
Abstract Background Interference with activities of daily living can negatively impact maternal practices both physically and psychologically. This study aimed to explore the patterns of interference ...with activities of daily living and perineal pain among Japanese women until 1 month postpartum. Furthermore, we aimed to describe how both perineal pain and delivery-related factors were associated with interference with activities of daily living. Methods This study was part of a larger prospective longitudinal study conducted at five maternity hospitals in Japan. The participants were 293 women who had full-term vaginal deliveries and singleton infants. Participants self-evaluated their perineal pain and interference with activities of daily living using a 100 mm visual analogue scale and ‘behaviour that interferes with daily life scale’ at day 1, day 5, and 1 month postpartum. We used a linear mixed model to calculate the fixed-effects parameter estimates and their 95% confidence intervals. Interference with activities of daily living, which included difficulty sitting, difficulty moving, and difficulties with excretion and cleanliness, were set as the dependent variables. Results The final analysis included 184 participants with a mean age of 31.5±4.5 years. Perineal pain and the three sub-scales of interference with activities of daily living reduced from day 1 to 5 postpartum, and further from day 5 to 1 month postpartum (perineal pain, p <0.01, p <0.01; difficulty sitting, p <0.01, p <0.01; difficulty moving, p <0.01, p <0.01; difficulties with excretion and cleanliness, p <0.01, p <0.01). These tendencies did not change, even adjusted for independent variables using a mixed model. In the mixed model for follow-up data, perineal pain was a significantly and positively associated with three sub-scales of interference with activities of daily living, even after adjusted for perineal injury and episiotomy. Conclusions Positive relationships were observed between perineal pain and interference with activities of daily living until 1 month postpartum, although both reduced. To promote maternal role attainment through child-rearing since early postpartum, midwives should pay additional attention to mothers’ perineal pain as it could negatively affect their daily life and child-rearing.
•Obstetric anal sphincter injuries (OASIS) are rising internationally due to increasing global birth rates and rising interventions in birth, impacted also by more accurate classification of OASIS ...and increased pre-existing co morbidities amongst affected women.•Significant physical and psychosocial morbidity is associated with OASIS injuries which can have short and long term implications.•This literature review highlights the psychological consequences of OASIS, the role of the midwife and other health care professionals in the care and follow up of women with OASIS and implications for future pregnancies.
Perineal injury during childbirth is a very common event which affect women during childbirth. Significant morbidities are associated with third-and-fourth degree perineal tears in particular, also referred to as obstetric anal sphincter injuries (OASIS). With an increasing global birth rate and rising interventions in birth, the incidence of perineal trauma following vaginal birth is increasing on an international scale, impacted also by more accurate classification and definitions of OASIS and increased pre-existing co morbidities amongst affected women. The consequences of OASIS can be physically and psychologically distressing for affected women and have significant impact on quality of life.
The aim of this integrative review was to examine women's experience of OASIS following childbirth using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A number of academic electronic databases were systematically searched and results are presented and analysed. Results of the complete search are presented in PRISMA format. Eight papers, which were assessed for quality using an appropriate appraisal tool, are included in the review and thematic analysis used to identify themes.
The themes identified were; psychological consequences, the role of the health care professionals and implications for future pregnancies. Psychological consequences included anxiety, loneliness, isolation, shame, fear, many of which were associated with physical ramifications of OASIS and how these feelings affect activities of daily living. The importance of access to and support from health care professionals was highlighted. The impact the experience of OASIS had on women's decisions about future pregnancies was also evident.
The association between OASIS and maternal quality of life following childbirth can be substantial as evidenced by this literature review. The review identifies the need for improvement in the care and management of these women to alleviate the physical and psychological consequences of OASIS, including decisions in relation to future pregnancies and childbirth. Health care professionals caring for women in pregnancy and childbirth need to be educated and informed on the sequelae of OASIS, to ensure appropriate information and support is provided to these women and their families. Such knowledge may enable health care professionals to alleviate symptoms associated with OASIS and help women make sense and cope with their experiences.
Traumatic injuries from jet ski-related accidents have increased in incidence over the past few decades. Anorectal injuries are uncommon but typically arise from high-speed jet ski accidents. We ...present a case of a severe anorectal injury from a fall off the back of an accelerating jet ski.
This case reports on the presentation, operative findings and management of a 22-year-old female with major internal and external anal sphincter disruption sustained via an unusual traumatic mechanism. Operative findings identified a complete internal and external anal sphincter disruption at the 1 and 7 O'clock positions and extra-peritoneal rectal perforation. Washout, suture repair and an end-colostomy were performed.
Understanding the potential severity of injury from the insult mechanism is paramount to triaging and managing trauma patients. Although this case describes an inconspicuous mechanism, the resulting trauma is significant and should prompt consideration in future cases. In addition, the article describes an approach to the repair of such injuries and the difficult decision relating to the role and type of defunctioning colostomy to protect any possible missed injuries in a complex traumatic environment, and in the protection of the anorectal repair.
Literature characterizing pediatric perineal trauma is sparse and generally limited to females. The purpose of this study was to characterize pediatric perineal injuries with specific focus on ...patient demographics, mechanisms of injury, and care patterns at a regional level 1 pediatric trauma center.
Retrospective review of children aged younger than 18 years evaluated at a level 1 pediatric trauma center from 2006 to 2017. Patients were identified by International Classification of Diseases-9 and 10 codes. Extracted data included demographics, injury mechanism, diagnostic studies, hospital course, and structures injured. The χ 2 and t tests were used to examine differences between subgroups. Machine learning was used to predict variable importance in determining the need for operative interventions.
One hundred ninety-seven patients met inclusion criteria. Mean age was 8.5 years. A total of 50.8% were girls. Blunt trauma accounted for 83.8% of injuries. Motor vehicle collisions and foreign bodies were more common in patients aged 12 years and older, whereas falls and bicycle-related injuries were more common in those younger than 12 years ( P < 0.01). Patients younger than 12 years were more likely to sustain blunt trauma with isolated external genital injuries ( P < 0.01). Patients aged 12 and older had a higher incidence of pelvic fractures, bladder/urethral injuries, and colorectal injuries, suggesting more severe injury patterns ( P < 0.01). Half of patients required operative intervention. Children aged 3 years or younger and older than 12 years had longer mean hospital stays compared with children aged 4 to 11 years ( P < 0.01). Mechanism of injury and age constituted more than 75% of the variable importance in predicting operative intervention.
Perineal trauma in children varies by age, sex, and mechanism. Blunt mechanisms are the most common, with patients frequently requiring surgical intervention. Mechanism of injury and age may be important in deciding which patients will require operative intervention. This study describes injury patterns in pediatric perineal trauma that can be used to guide future practice and inform injury prevention efforts.
Background. According to various researchers, obstetric perineal injury is the most commOn complication in childbirth, the frequency of which can vary from 13 to 85%. Currently, vaginal delivery and ...birth trauma are recognized as the leading risk factors for the development of pelvic, urodynamic and sexual dysfunctions. Urinary and fecal incontinence, pelvic organ prolapse, sexual health disorders, chronic pelvic pain and the presence of cosmetic defects in the perineum are the reasons for a significant decrease in the quality of life of women after delivery. Recently, there has been a tendency to "rejuvenate" dysfunctions of the ligamentous apparatus and muscles of the pelvic floor, which support the pelvic organs in a normal position in women after the first birth. In the absence of timely diagnosis and treatment, anatomical changes and clinical symptoms will rapidly progress, forming persistent dysfunctions of the pelvic organs.
Aim. To evaluate pelvic and urodynamic dysfunctions in women after per vias naturales delivery with concomitant perineal trauma.
Materials and methods. A prospective cohort comparative study was conducted, which included 55 women of reproductive age after delivery per vias naturales of the fetus in cephalic presentation. The main group consisted of 30 women who had a perineal injury during childbirth, the control group included 25 women with uncomplicated straining period. All patients 34 months after delivery underwent a gynecological examination with perineometry, ultrasound examination of the pelvic organs, as well as a comprehensive urodynamic study.
Results. Women with a perineal injury during childbirth were significantly more likely to complain of frequent urination and urinary incontinence during physical exertion than women in the control group 70.0% versus 40.0% and 76.7% versus 40.0% of cases respectively (p0.05). According to the ultrasound data, the patients of the main group had a significantly more pronounced deviation of the angle and the angle during straining in comparison with the control group 4.672.6 versus 2.651.1 and 11.937.1 versus 7.104.7 respectively (p0.05). Statistically significant differences were also obtained when measuring the strength of the pelvic floor muscles in patients with perineal injury in comparison with the control group 68.175.8 mmHg versus 76.805.3 mmHg (p0.05). According to urofluometry, the patients of the main group showed a statistically significant decrease in the rate of average and maximum urine flow than in the women of the control group 11.693.8 ml/sec versus 17.902.1 ml/sec and 20.617.0 ml/s versus 25.223.1 ml/s respectively (p0.05).
Conclusion. The results obtained indicate the occurrence of urodynamic and pelvic disorders in women during the first 4 months after childbirth, complicated by perineal trauma. In women who have experienced birth trauma, such pelvic and urodynamic dysfunctions as hypermobility of the urethrovesical segment in 86% of cases, a decrease in the strength of the pelvic floor muscles in 54% of cases, and a decrease in the average urine flow rate in 25% of cases were revealed. These disorders can be diagnosed using available non-invasive instrumental examination methods, such as ultrasound, perineometry and uroflowmetry. Thus, there is a need for early detection of pelvic floor dysfunctions for the purpose of subsequent treatment after childbirth, which in turn will help prevent the progression of genital prolapse and urinary incontinence, prevent their severe forms, reduce the need for surgical interventions and preserve the quality of life of women.
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