Care pathways and anorectal evaluation for obstetric anal sphincter injury-related incontinence: A UK survey of obstetricians.

Abstract

To report on national clinical practice in relation to the post-partum management of patients with obstetric anal sphincter injury (OASI)-related incontinence in the UK. This was a cross-sectional, observational study of maternity units in the National Health Service (NHS). Data were collected using a survey that was distributed, via the British Society of Urogynaecologists (BSUG), Royal College of Obstetricians & Gynaecologists (RCOG) and the NHS England email directory, to consultant obstetricians and urogynaecologists involved in the post-partum care of patients with OASI. A descriptive, thematic analysis of the data was performed. One hundred and twenty-six responses were included in the final analysis (estimated response rate~2.5%). The majority of respondents routinely conducted clinical and rectal examinations at the post-partum clinic visit (81.7% and 57.6%, respectively) but they were less likely to use an objective screening tool for incontinence (36.5%). Respondents were more likely to refer patients for anorectal studies if they were symptomatic (72.6%) rather than asymptomatic (34.2%); the diagnostic modality of choice was endoanal ultrasound (70%) rather than manometry (0%). Almost 80% of respondents discharged asymptomatic patients within 3 months. All respondents referred symptomatic patients for physiotherapy; 87% were seen within 6 weeks. Although 70% would discuss complicated cases at a multidisciplinary team meeting (MDT), there was a wide variation in which speciality would follow up the patient. This study demonstrates variability in clinical practice that does not entirely appear to be evidence driven. A nationally endorsed pathway, embedded within Perinatal Pelvic Health Services, could standardize access to expertise and enable benchmarking. A prospective multicentre audit is recommended to compare maternal functional outcomes in units that use these standardized pathways versus those that do not.