PERINEAL EXAMINATION AS A PREDICTOR OF UNDERLYING EXTERNAL ANAL-SPHINCTER DAMAGE

Objective To assess the relation between perineal inspection and sphin cter integrity in parous women. Design Prospective observational study . Setting District general hospital. Population Fifty-seven consecutiv e parous women attending a gynaecology clinic for problems unrelated t o the pelvic floor. Methods A detailed history of bowel function and m ode of delivery obtained; the perineum inspected to determine the pres ence and position of scarring, and anal endosonography performed. Resu lts In 19 women with an intact perineum on inspection, endosonography showed perineal scarring in five, with both perineal and sphincter sca rring in three. Four had urge faecal incontinence. Three patients had a perineal tear only on inspection, but this group was too small for a nalysis and was discounted. Nine had an episiotomy scar only. Endosono graphy demonstrated perineal scarring in four, and combined perineal a nd sphincter scarring in two; one woman in this group had urge faecal incontinence. Twenty-six women had episiotomy and perineal tears on in spection. Endosonography revealed underlying perineal scarring in five women, with combined perineal and sphincter scarring in 14; six women in this group had urge faecal incontinence and one passive incontinen ce for flatus. Sonographically the scarring was anterior and circumfer ential rather than radial, and mostly left-sided, whereas on inspectio n episiotomy and perineal scarring were right sided. Conclusions A nor mal perineum on clinical examination does not exclude underlying sphin cter damage. The incidence of sphincter damage increases significantly when an episiotomy scar is associated with a perineal tear.