Lower genital tract and anal sphincter trauma

Anal incontinence occurs more frequently in women but its incidence is grossly underestimated because of under-reporting. Obstetric trauma is a major cause of anal incontinence but it is only recently that attention has been focused on this subject. Episiotomy and choice of instrument at assisted delivery have been subjected to randomized trials but some issues, such as the benefit of episiotomy in instrumental delivery, have not been addressed. The management of acute anal sphincter rupture is inconsistent and, although studies report on the sub-optimal outcome, evidence-based guidelines are currently awaiting publication. Training in perineal anatomy and repair is poorly taught, and there is wide variation in classification of perineal tears. Consequently anal sphincter tears are being missed at delivery and/or inappropriately managed. This chapter aims to highlight these issues based on previous and current teaching and to recommend a protocol based on the best available evidence.