Episiotomy and the Development of Postpartum Dyspareunia and Anal Incontinence in Nulliparous Females Epizyotomi, Nullipar Kadınlarda Postpartum Disparoni Ve Anal İnkontinansa Sebep Olabilir Mi?

Objective: The impacts of an episiotomy on a woman's sex life and ability to relax the pelvic musculature remain largely unknown. The aim of the present study was to assess the impact of an episiotomy on the development of postpartum dyspareunia and anal incontinence. Materials and Methods: A total of 200 patients participated in the present study. The patients were grouped as follows: vaginal delivery with episiotomy (Group 1, N=100) and Caesarian section (Group 2, N=100). An interview, which asked about the presence of dyspareu-nia or anal incontinence, was conducted with the participants at 12 weeks postpartum. Results: The mean age (years) of Group 1 was 22.6±4.4, and the mean age of Group 2 was 24.1±4.6. Anal incontinence was detected in 4 patients (4%) in Group 1 and 2 patients (2%) in Group 2. Dyspareunia was present in 21 patients (21%) in Group 1 and 8 patients (8%) in Group 2. No significant differences were detected in the severity of anal incontinence between the two groups. The amount of time to the first coitus following delivery and the total amount of intercourse was compared between the two groups. Conclusion: It appears that episiotomies do not lead to anal incontinence. However, episiotomies may cause dyspareunia, a condition that may negatively affect a women's sex life. Therefore, routine episi-otomies are not suggested. Sonuç: Epizyotomiler anal inkontinansa yol açmamaktadır, ancak epizyotomiler disparoniye sebep olabilir ve disparoni kadınların cin-sel yaşamlarını olumsuz yönde etkileyebilir. Bu sebeple rutin epizyo-tomi uygulaması önerilmemektedir.


Introduction
Episiotomies are one of the most common surgical procedures conducted among females [1].Although not evidencebased, one of the most common clinical indications for episiotomy is increased risk of anal sphincter trauma, e.g., short perineal body length; a long perineum; a rigid, firm, inelastic, or edematous perineum; and complications during previous episiotomies.However, data concerning the indications for episiotomy are not included in register-based studies are not available in register-based studies [2].Indeed, whether episiotomies reduce the risk of obstetric anal sphincter injuries remains controversial [3].The use of episiotomy varies greatly worldwide.A study from Iran reported an episiotomy rate of approximately 39% in primiparous women [4], while data from Turkey on this topic are quite limited.In one Turkish report, nearly 90% of primigravid women underwent an episiotomy, while a reduction in the incidence of episiotomy was noted with increased parity [5].The impacts of an episiotomy on a female's sex life and pelvic relaxation are largely unknown.One report suggested that women who underwent an episiotomy during delivery displayed delayed sexual activity and had more severe dyspareunia at 3 months postpartum [6].
The aim of the present study was to assess the impacts of episiotomy on the development of postpartum dyspareunia and anal incontinence.

Materials and Methods
The medical records of patients who gave birth at Etlik Zübeyde Hanım Maternity and Women's Health Education and Research Hospital, Department of Obstetrics and Gynecology, from March 2008 to September 2008 were evaluated.A total of 200 patients participated in the present study.Participants were divided into groups based on the type of delivery (i.e., Caesarian section or vaginal delivery with episiotomy).The patients were grouped as follows: vaginal delivery with episiotomy (Group 1, N=100) and Caesarian section (Group 2, N = 100).Women who experienced 3 rd or 4 th grade lacerations during vaginal delivery were excluded from the study.Age, gravidity, labor duration, type of induction, and birth weight were recorded.In addition to episiotomy, 1 st and 2 nd degree lacerations were recorded.
Women who suffered from dyspareunia or incontinence prior to pregnancy, patients with a previous history of surgery in the anal region, and patients with colorectal disorders or neurological disorders were excluded from the present study.Moreover, patients who did not provide written informed consent were excluded.This prospective study was conducted at Etlik Zubeyde Hanim Maternity and Women's Health Education and Research Hospital (Ankara, Turkey).This study was approved by the ethics board at our hospital.
In the present study, an episiotomy was defined as a 3-4 cm incision over the medial lateral line of the perineum from the introitus, which included the skin, subcutaneous cellular tissue, superficial fascia, and perineal muscle, and a 4-cm incision of the vaginal mucosa.This procedure was conducted under local anesthesia using lidocaine.
An interview concerning the presence of dyspareunia or anal incontinence was conducted with all participants at 12 weeks postpartum.The questionnaire was used to evaluate the degree and severity of anal incontinence and dyspareunia.The Pescatori scoring system was used to evaluate anal incontinence [7].Anal incontinence was categorized in the following manner: A, flat/mucus; B, liquid feces; and C, solid feces incontinence.A total of 1 point was given for A, 2 points for B, and 3 points for C. The frequency of incontinence was scored as follows: less than once a week, 1 point; at least once a week, 2 points; and daily, 3 points.The incontinence state and frequency values were combined and recorded as an incontinence score.To determine the severity of dyspareunia, a Visual Analog Scale (VAS), which rates pain from nonexistent to very severe, was used on the follow-up form.On the follow-up form, participants were also asked to assess the severity, timing, type, and impact of dyspareunia on their sex drive.

Statistical Analysis
The Statistical Package for the Social Sciences, version 13.0, was used to evaluate the collected data (SPSS Inc., Chicago, IL, USA).The Kolmogorov-Smirnov test was used to determine whether the distribution of the quantitative data was normally distributed.Those data that were normally distributed were expressed as the arithmetic mean±standard deviation and compared using Student's t-test.Those data that were not normally distributed were expressed as median values (minimum-maximum) and compared using the Mann-Whitney U test.To compare categorical data, Pearson's chisquare and Fisher's exact chi-square tests were conducted.An assessment of the relationship between different variables was completed using Pearson's simple correlation coefficient and Spearman's correlation coefficient.P<0.05 was considered significant.

Results
Of the 200 patients who participated in the present study, 100 were included in Group 1 (vaginal delivery with episiotomy) and 100 were included in Group 2 (Caesarian section).All of the participants were primigravid.The mean age (years) of Group 1 was 22.6±4.4,and the mean age of Group 2 was 24.1±4.6.The mean birth weight in Group 1 was 3268.0±346.6 g compared to 3373.5±498.7 g in Group 2. The mean duration of labor was 360 min (85-1260) in Group 1 and 205 min (0-1140) in Group 2. The characteristics of the groups are summarized in Table 1.
Participants were evaluated during the 12 th week postpartum for anal incontinence and dyspareunia.Anal incontinence was detected in 4 patients (4%) in Group 1 and 2 patients (2%) in Group 2. Incontinence scores were calculated according to the Pescatori scoring system.The average incontinence scores were 3.2 for Group 1 and 3.0 for Group 2. No significant differences were detected in the severity of anal incontinence between the two groups.The frequency of dyspareunia was compared between the two groups.Dyspareunia was present in 21 patients (21%) in Group 1 and 8 patients (8%) in Group 2 (Table 2).A significant increase in the frequency of dyspareunia was noted in those patients who had a vaginal delivery.
The amount of time to the first coitus following delivery and the total amount of intercourse were compared between the two groups.No significant differences were noted in the amount of time to the first coitus.A significant difference was observed in the total amount of intercourse.The average time to the first coitus was 41 days in Group 1 and 42 days in Group 2. During the first 12 weeks postpartum, the total amount of intercourse for Group 1 was less than that for Group 2.

Discussion
In modern obstetrical practice, episiotomy is a widely performed surgical procedure [8].However, there has been a recent reduction in its use during delivery because patients who undergo episiotomies display more frequent blood loss, perineal damage, postpartum dyspareunia, and anal incontinence due to anal sphincter damage.Episiotomies are still recommended in association with fetal distress, operative vaginal delivery, and shoulder dystocia.
In the present study, the impact of episiotomy on anal incontinence and the development of dyspareunia were investigated.Previous studies have reported that episiotomies cause 3 rd and 4 th degree perineal lacerations.This situation occurs less frequently with medial lateral episiotomies [9,10].In 9-26% of patients with median episiotomies, 3 rd and 4 th degree lacerations have been observed.However, there are no data for the prevalence of medial lateral episiotomies.Interestingly, studies suggest that medial lateral episiotomies may prevent the occurrence of perineal lacerations [11].Previous studies have shown that the incidence of anal incontinence has increased in patients who have had 3 rd or 4 th degree perineal lacerations.We compared patients who had a Caesarian section and patients who had a vaginal delivery with episiotomy.No significant differences were noted between the two groups.Anal incontinence was found in 6 patients, fecal incontinence was noted in 2 patients (1 patient in Group 1 and 1 patient in Group 2), and flatus incontinence was noted in 4 patients (3 patients in Group 1 and 1 patient in Group 2).
In two randomized prospective studies, the development of anal incontinence was compared in females who had vaginal deliveries and Caesarian sections.Eason et al. [12].conducted a study of 949 women.Three months after delivery, fecal incontinence was detected in 29 women, while gas incontinence was noted in 242 women.Their results suggested that postpartum anal incontinence is related to the force of vaginal delivery and anal sphincter lacerations.The authors also stated that anal incontinence was unrelated to vaginal delivery with vacuum extraction, vaginal delivery with episiotomy and Caesarian section delivery.A total of 2,008 randomly selected women with a single vaginal or Caesarian section delivery and normal presentation were included in a multi-center study called the Term Breech Trial.These women were asked to complete  questionnaires about birth and health issues, including anal incontinence.No significant differences were noted between the groups.However, the authors did not mention whether vaginal deliveries were associated with episiotomies [13].Another study reported that obstetric variables (e.g., type of delivery, episiotomy, birth weight, and 3 rd or 4 th degree perineal lacerations) were not related to the development of future anal incontinence [14].Moreover, a study that compared patients who had an episiotomy and an intact perineum reported no significant differences in anal incontinence [15].Postpartum dyspareunia, the amount of time prior to the initiation of an active sex life, and the regaining of obstetric functioning must also be considered with respect to episiotomies.The present study examined the differences between patients who had a vaginal delivery with episiotomy and patients who had a Caesarian section.The amount of time to the return of sexual functioning and dyspareunia were investigated.The severity of dyspareunia was determined based on a VAS.Significant differences were noted in both the occurrence and severity of dyspareunia.However, no significant difference was noted in the amount of time to becoming sexually active.In the present study, all of the participants regained an active sex life approximately 7 weeks postpartum.With respect to the total amount of intercourse, significant differences were noted among women who had a Caesarian section when compared to a vaginal delivery.In a study by Byrd et al. [16], women who had a Caesarian section delivery were more interested in sexual intercourse and became sexually active in less time when compared with women who had a vaginal delivery.In the present study, no differences were found between the time to the first coitus after delivery among groups.However, similar to the study by Byrd, women who had a vaginal delivery with episiotomy also reported reduced sexual intercourse.In a study by Buhling et al. [17], 665 patients who had a Caesarian section, vaginal delivery with episiotomy, or operative vaginal delivery were questioned for the presence dyspareunia and the amount of time until the first coitus.Women with an intact perineum who had a Caesarian section displayed less dyspareunia when compared with the other two groups.No differences were noted in the amount of time to the first coitus.For all of the groups, the time at first coitus was approximately 8 weeks.Moreover, dyspareunia was more commonly associated with increased age and was unrelated to birth weight.In the present study, there was no relationship between age and dyspareunia in the Caesarian section group.However, we found an increase in the frequency of dyspareunia with decreasing age.No relationship was noted between birth weight and dyspareunia in either group.
A study by Andrews et al. [18] compared women who had a vaginal delivery and either an intact perineum or perineal trauma (including anal sphincter damage) due to spontaneous or episiotomy-assisted delivery.A VAS was used to assess pain.No significant differences were noted in rates of dyspareunia among these groups, with the exception of patients who suffered anal sphincter damage.These results are not consistent with those observed in the present study.Furthermore, there was no increase in the frequency of dyspareunia among patients noted in our study.In general, dyspareunia is more common in patients with perineal lacerations, especially among patients who have dyspareunia as a result of an episiotomy.One study showed that patients who complain of dyspareunia during sexual intercourse at 3 months postpartum have typically had an episiotomy during delivery [19].The results of our study are consistent with this finding.
The clinical benefits and complications of episiotomy are still under debate.The aim of the present study was to examine patients with dyspareunia and anal incontinence following a vaginal delivery with episiotomy.Patients were evaluated 3 months postpartum.Anal incontinence was noted more frequently in women with 3 rd and 4 th degree lacerations and an episiotomy.However, we did not find support for an increase in the frequency of anal incontinence in patients who did not have anal sphincter damage.Dyspareunia following a vaginal delivery and episiotomy is more frequent when compared with other types of delivery.This may be due to an intact perineum.The results of our study are consistent with this hypothesis.While some patients who have had a Caesarian section have an active sex life earlier than patients who have had a vaginal delivery, we did not find this in our study.However, the total amount of sexual intercourse was higher in women with a Caesarian section.We believe that this result may be due to dyspareunia.
In conclusion, future studies should focus on perineal damage associated with episiotomy, the prevention of

Table 1 . Demographic Characteristics of the Participants
*: The indicated values are the mean±standard deviation.**: The indicated values are the median (minimum-maximum).

Table 3 . Amount of time to the first coitus and the total amount of intercourse
prolapse due to episiotomy, and the development of anal incontinence following an episiotomy.It appears that episiotomies do not lead to anal incontinence.However, episiotomies may cause dyspareunia, a condition that may negatively impact a woman's sex life.Therefore, routine episiotomies are not suggested.