Anorektale Inkontinenz als Folge der vaginalen Geburt

 

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Zusammenfassung

Die traumatische Schädigung des Beckenbodens durch die Geburt ist die häufigste Ursache für eine Stuhlinkontinenz, die aus Scham häufig weder dem Partner noch dem behandelnden Arzt gegenüber offenbart wird. Verschiedene Untersuchungen haben gezeigt, dass es unter der Geburt zu Verletzungen des analen Schließmuskels und zu Nervenschäden durch Überdehnung des Beckenbodens kommen kann. Durch die anale Sonographie konnte bei 30 % der Erstgebärenden ein okkulter Sphinkterschaden nachgewiesen werden. Ein Drittel dieser Patientinnen entwickelt nach der Entbindung eine Stuhl- oder Urgeinkontinenz; die tatsächliche klinische Bedeutung dieser Defekte kann erst durch Langzeitbeobachtungen beurteilt werden. 19 - 58 % der Frauen mit Dammrissen III° oder IV°, die sich bei 0,4 - 7 % der Geburt ereignen, leiden bis zu sechs Monate postpartal unter einer Stuhlinkontinenz, die noch Jahre später bei bis zu 30 % der Frauen persistiert. Durch eine erneute vaginale Geburt erhöht sich bei diesen Frauen das Risiko für eine anale Inkontinenz. Lässt sich sonographisch ein persistierender Schaden darstellen oder liegt bereits eine Stuhlinkontinenz vor, sollte der elektive Kaiserschnitt diskutiert werden. Nach Sectio caesarea konnten keine klinisch relevanten Beckenbodenschäden nachgewiesen werden. Eine Reduzierung schwerer Sphinkterschäden ist durch eine restriktive Indikationsstellung zur Episiotomie und die vorzugsweise Verwendung der Vakuumglocke gegenüber der Zange zu erreichen. Frauenärzte und Ärzte anderer Fachrichtungen müssen sich über die Bedeutung der analen Dysfunktion als Folge der vaginalen Geburt bewusst sein und sind aufgefordert, aktiv zur Prävention und Früherkennung einer Stuhlinkontinenz beizutragen.

Summary

Obstetric trauma is the most common cause of anal incontinence in women. Incontinence is usually for gas, but some women are incontinent of solid or liquid stool. Women are frequently too embarrassed by anal incontinence to raise the issue with a physician. Vaginal delivery can result in direct muscular injury to the anal sphincter and indirect neurologic injury to the pelvic floor. Anal endosonography has shown a 30 % rate of occult sphincter defects in women after their first vaginal delivery. About a third of these women develop anal incontinence or urgency, but the long-term clinical significance of these findings is unclear. Routine mediolateral episiotomy does not protect against anal sphincter trauma and midline episiotomy is associated with an increased rate of sphincter tears. Overall, anal sphincter tears occur at 0.4 % to 7 % of deliveries. About 19 % to 58 % of these women are incontinent at 6 months and symptoms can persist in up to 30 %. Subsequent vaginal deliveries after an anal sphincter tear increase the risk of anal incontinence. Elective cesarean delivery should be discussed with women with a persistent sphincter defect or transient fecal incontinence. Cesarean delivery is not associated with clinically significant long-term pelvic floor morbidity. Methods to prevent perineal trauma during vaginal delivery include restricting episiotomy and using vacuum extraction instead of forceps delivery. Obstetricians should be aware of the prevalence of and risk factors for the development of fecal incontinence and ask patients specifically about urinary and anal incontinence.

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Ltd. Oberarzt der Frauenklinik Dr. med. Andree Faridi

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