# Improving the quality of information after an obstetrical anal sphincter injury improves the quality of life for women experiencing anal incontinence

Aurélien Venara, Emeline Rebmann, Candice Helbert, Florine Lemasson, Guillaume Legendre, Jean-François Hamel

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## ► To cite this version:

Aurélien Venara, Emeline Rebmann, Candice Helbert, Florine Lemasson, Guillaume Legendre, et al. Improving the quality of information after an obstetrical anal sphincter injury improves the quality of life for women experiencing anal incontinence. European Journal of Obstetrics & Gynecology and Reproductive Biology, 2025, 310, pp.113989. 10.1016/j.ejogrb.2025.113989. hal-05066096

HAL Id: hal-05066096

https://hal.science/hal-05066096v1

Submitted on 13 May 2025

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Full length article

# Improving the quality of information after an obstetrical anal sphincter injury improves the quality of life for women experiencing anal incontinence

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Venara Aurélien<sup>a,b,c,d,*</sup>, Rebmann Emeline<sup>a,b</sup>, Helbert Candice<sup>a</sup>, Lemasson Florine<sup>a</sup>, Legendre Guillaume<sup>a,e</sup>, Hamel Jean-François<sup>a,f,g</sup>

## ARTICLE INFO

### Keywords:

Obstetrical anal sphincter injury

Anal incontinence

Quality of life

Risk factors

## ABSTRACT

**Background:** To compare the information remembered by women about the potential risk of obstetrical anal sphincter injury (OASIS) according to the occurrence of anal incontinence and the time elapsed since the OASIS.

**Methods:** This prospective and observational monocentric cohort study included all the 227 women who had OASIS during a 15-years period. Information was collected using the Fecal Incontinence Quality of Life (FIQL) questionnaire, sent to participants by post, and by a phone interview about women's memories of the information given.

**Results:** 80 patients had at least one episode of anal incontinence (AI) (35.2 %). Patients remembered having received information about the risk of AI in 28.2 % (n = 64) and about the risk of urinary incontinence (UI) in 34.4 % (n = 78). 82.2 % (n = 188) stated that they would be interested in having information about AI and 84.6 % wanted information about UI.

Patients who received the information ≤ 5 years ago were more able to remember information about AI and UI than other patients. Being able to remember information about the risk of AI was significantly associated with a better quality of life.

**Conclusion:** Patients who had received information ≤ 5 years ago were able to remember more of it. This coincides with the implementation of a specific post-OASIS consultation and therefore advocates for such consultations becoming common practice.

## Introduction

Anal incontinence (AI) occurs in 20 % of patients in the four years following an obstetrical anal sphincter injury (OASIS) [1], up to 33.6 % after in 11 years [2,3], and up to 61 % after 15 to 25 years [4,5]. Given that 0.1 to 4.8 % of deliveries are complicated by OASIS [6] and that up to 13 % of deliveries lead to occult sphincter tears [7], AI in young parturient women might be expected to represent a burden to both women and society as a whole.

Only 10 % of patients with AI, however, talk about it at the primary

care visit [8]. Moureau et al. [9] report that avoidance, fear, and discouragement are the most common barriers for women seeking care. Additionally, Parsons J et al. [10] report that the lack of information and awareness, both amongst women and healthcare professionals, contributes to delays in both accurate diagnosis and appropriate treatment.

To our knowledge, the best information and means of delivering it to women following OASIS have not been defined. In the case of elective surgery, for example, patients tend not to remember the majority of the information given by the surgeon during a dedicated consultation [11]. It is therefore probable that during delivery, when women are busy

<footnote><sup>a</sup> Faculty of Health, Angers, France</footnote>

<footnote><sup>b</sup> Department of Visceral Surgery, CHU Angers, 4 rue Larrey, 49933 Angers, France</footnote>

<footnote><sup>c</sup> IHFIH, UPRES EA 3859, University of Angers, Angers, France</footnote>

<footnote><sup>d</sup> The Enteric Nervous System in Gut and Brain Disorders, Université de Nantes, INSERM, TENS, IMAD, F-44000 Nantes, France</footnote>

<footnote><sup>e</sup> Department of Gynecology-Obstetrics, CHU Angers, 4 rue Larrey, 49933 Angers, France</footnote>

<footnote><sup>f</sup> Department of Biostatistics, CHU Angers, 4 rue Larrey, 49933 Angers, France</footnote>

<footnote><sup>g</sup> Ester|Irset Inserm UMR 1085, Angers, France</footnote>

<footnote>* Corresponding author at: Department of Visceral Surgery, CHU Angers (Angers University Hospital), 4 rue Larrey, 49933 Angers CEDEX 09, France.</footnote>

<footnote>E-mail address: auvenara@chu-angers.fr (A. Venara).</footnote>
learning about maternity, they do not take in information about possible complications many years following the OASIS. This study hypothesizes that restating information about the mid- and long-term risks of OASIS to patients after three to six months may improve the amount of information that patients remember.

Our primary aim was to compare the information women remembered about the potential risk of OASIS according to both the occurrence of AI and the time elapsed since the OASIS. Our second aim was to assess how the actual information remembered by women experiencing AI impacted their quality of life.

## Materials and methods

This was a prospective, observational, monocentric study including all female patients who had experienced an OASIS between January 2005 and December 2019. We detail our recruitment of the patients in a previous report, 383 women were identified and 227 were included (59.3 %) [3].

The study protocol was approved by the Committee for the Protection of Persons (CPP, registration number 2021-A01128-33) and the French Data Protection Authority (CNIL, registration number: ar21-0150v0).

## Design

Women identified as having a diagnosis of OASIS during delivery within the period of inclusion were contacted by phone to confirm their agreement to participating in the study. After the woman gave her consent to participate the study, a short interview was conducted. During this interview, women were asked two questions about the information they received when discharged from hospital following delivery:

- What information can you remember receiving after the OASIS (risk of anal incontinence, risk of urinary incontinence, risk of postoperative abscess, risk of wound disruption)?

- What information would you have been interested in receiving after the OASIS (risk of anal incontinence, risk of urinary incontinence, risk of postoperative abscess, risk of wound disruption)?

Together with an informative letter, the Fecal Incontinence Quality of Life (FIQL) questionnaire [12] was sent to patients prior to the phone interview.

## Management of the information

Before 2018, the information was given orally to all women who experienced OASIS. This information explained the common risk of perineal wounds as well as the risk of AI within a few months or years.

After 2018, the information was given orally to all women who experienced OASIS. This was undertaken in a specific oral consultation with a colorectal surgeon, which was scheduled three months after delivery, in which schemas were provided and specific examinations were undertaken if the women had certain symptoms [13].

## Statistical analysis

Categorical data were described using percentages and compared using chi-squared tests. Continuous data were described using means and standard deviations and compared using t-tests.

The statistical analyses were performed using SAS 9.4 Software and $p \ge 0.05$ was considered significant.

## Results

Among the 227 patients included, 80 had at least one episode of anal incontinence (35.2 %).

The mean of age of patients was 28.4 (+/-4.6) and the mean BMI was 24.6 (+/-5.2) [3]. The median patient follow-up presenting no event was 8.9 years (min: 2.2; max: 31). The patients stated that they remembered having received information about the risk of AI in 28.2 % (n = 64), that they were at risk of developing a perineal abscess in 26.9 % (n = 61), that they were at risk of scar disruption in 28.2 %, and that were at risk of urinary incontinence (UI) in 34.4 % (n = 78) (Table 1). Two women stated that they remembered being given further information: “perineal physiotherapy will improve your functional outcomes”; and “you cannot have another vaginal birth”. Interestingly, the patients noted that they would have been interested in receiving information about AI in 82.2 % (n = 188), about the risk of perineal abscess in 79.7 % (n = 181), about the risk of scar disruption in 80.6 % (n = 183), and about the risk of UI in 84.6 % (n = 192) (Table 1).

## Women with at least one episode of anal incontinence versus women with no episode of anal incontinence

At baseline, there was no difference between the two groups of women, except for the medical history of Crohn disease that was more common in the group of women with AI (3). The information content remembered was not significantly different between the group of patients who experienced at least one episode of AI and group of women who did not experience AI (Table 1). Those patients who experienced at least one episode of AI were more interested in receiving information about AI and UI than women without incontinence ($p = 0.09$ and $p = 0.05$, respectively) (Table 1).

## Recall of information according to time elapsed since delivery

Women who had delivered $\le 5$ years ago were more able to remember information about the risk of AI (42 %) than women who had

<caption>Table 1</caption>

Remembers and information the women would have received according to the occurrence of anal incontinence.

<table><thead><tr><th></th><th>No anal incontinence (n = 147)</th><th>Anal incontinence (n = 80)</th><th>Total (n = 227)</th><th>p</th></tr></thead><tbody><tr><td><strong>Remembers:</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Risk of anal incontinence</td><td>39 (26.53 %)</td><td>25 (31.25 %)</td><td>64 (28.19 %)</td><td>0.54</td></tr><tr><td>Risk of abscess</td><td>41 (27.89 %)</td><td>20 (25.00 %)</td><td>61 (26.87 %)</td><td>0.75</td></tr><tr><td>Risk of scar disruption</td><td>43 (29.25 %)</td><td>21 (26.25 %)</td><td>64 (28.19 %)</td><td>0.76</td></tr><tr><td>Risk of urinary incontinence</td><td>52 (35.37 %)</td><td>26 (32.50 %)</td><td>78 (34.36 %)</td><td>0.77</td></tr><tr><td>Other memories</td><td>1 (0.68 %)</td><td>1 (1.25 %)</td><td>2 (0.88 %)</td><td>1</td></tr><tr><td><strong>Information the women would have received:</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Risk of anal incontinence</td><td>117 (79.59 %)</td><td>71 (88.75 %)</td><td>188 (82.82 %)</td><td>0.10</td></tr><tr><td>Risk of abscess</td><td>115 (78.23 %)</td><td>66 (82.50 %)</td><td>181 (79.74 %)</td><td>0.49</td></tr><tr><td>Risk of scar disruption</td><td>116 (78.91 %)</td><td>67 (83.75 %)</td><td>183 (80.62 %)</td><td>0.48</td></tr><tr><td>Risk of urinary incontinence</td><td>119 (80.95 %)</td><td>73 (91.25 %)</td><td>192 (84.58 %)</td><td>0.05</td></tr></tbody></table>
delivered 5–10 years ago (29.8 %) and > 10 years ago (19.3 %) (p = 0.02). The same difference was observed regarding the risk of UI (52 %, 33.3 %, and 25.8 %, respectively; p = 0.008) (Table 2). By contrast, there was no significant difference regarding the information the women would have been interested in having.

### Impact of the information recall on quality of life

Among the women experiencing AI, the group of women who had remembered information regarding the risk of AI scored higher quality of life scores for behavior and embarrassment (p = 0.02 and p = 0.02, respectively) (Table 3).

### Discussion

Among the 227 patients included, 80 had experienced at least one episode of AI (35.2 %). Patients stated that they remembered having received information about the risk of AI in 28.2 % of cases and about the risk of UI in 34.4 %; 82.2 % of the patients stated, however, that they would have been interested in receiving information about AI, with 84.6 % making the same claim about the risk of UI. The content of the information that could be remembered was not significantly different between the group of patients who experienced at least one episode of AI, on the one hand, and those patients who did not experience AI. Women who experienced at least one episode of AI were more interested in receiving information about AI and UI than women without AI (p = 0.09 and p = 0.05, respectively). Women who had received the information ≤ 5 years ago were better able to recall information about AI and UI than other patients.

The findings of our study accord with recent research reporting that, after two months, patients who gave their consent to participate to clinical trials remember 35 to 50 % of the information [14] against 12 to 14 % in everyday clinical practice [15]. When it comes to pregnancy and labor, Ayling L et al. [16] highlight that information given during labor or early after birth is less likely to be understood or retained than information given at 36 weeks following labor. Information about potential risks arising from OASIS should therefore be given at another opportunity, rather than immediately after labor or immediately prior to discharge from hospital.

Research to date presents some new strategies for informing patients about pathologies. In the context of parotid surgery, Mohler et al. [17] show that additional audiovisual information improves memorization of

<caption>**Table 2**</caption>

Remembers and information the women would have received according to the time from the delivery.

<table><caption>**Table 3**</caption><thead><tr><th></th><th>&lt; 5 years<br>(n = 50)</th><th>5-10 years<br>(n = 84)</th><th>&gt; 10 years<br>(n = 93)</th><th>p</th></tr></thead><tbody><tr><td><strong>Remembers:</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Risk of anal incontinence</td><td><strong>21 (42.00)</strong><br>(%)</td><td><strong>25 (29.76)</strong><br>(%)</td><td><strong>18 (19.35)</strong><br>(%)</td><td><strong>0.016</strong></td></tr><tr><td>Risk of abscess</td><td>17 (34.00)<br>(%)</td><td>24 (28.57)<br>(%)</td><td>20 (21.51)<br>(%)</td><td>0.24</td></tr><tr><td>Risk of scar disruption</td><td>17 (34.00)<br>(%)</td><td>27 (32.14)<br>(%)</td><td>20 (21.51)<br>(%)</td><td>0.16</td></tr><tr><td>Risk of urinary<br>incontinence</td><td><strong>26 (52.00)</strong><br>(%)</td><td><strong>28 (33.33)</strong><br>(%)</td><td><strong>24 (25.81)</strong><br>(%)</td><td><strong>0.008</strong></td></tr><tr><td>Other memories</td><td>0 (0.00 %)</td><td>0 (0.00 %)</td><td>2 (2.15 %)</td><td>0.51</td></tr><tr><td><strong>Information the women<br>would have received:</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Risk of anal incontinence</td><td>40 (80.00)<br>(%)</td><td>70 (83.33)<br>(%)</td><td>78 (83.87)<br>(%)</td><td>0.83</td></tr><tr><td>Risk of abscess</td><td>39 (78.00)<br>(%)</td><td>71 (84.52)<br>(%)</td><td>71 (76.34)<br>(%)</td><td>0.36</td></tr><tr><td>Risk of scar disruption</td><td>40 (80.00)<br>(%)</td><td>72 (85.71)<br>(%)</td><td>71 (76.34)<br>(%)</td><td>0.29</td></tr><tr><td>Risk of urinary<br>incontinence</td><td>41 (82.00)<br>(%)</td><td>73 (86.90)<br>(%)</td><td>78 (83.87)<br>(%)</td><td>0.71</td></tr></tbody></table>

Comparison of the quality of life of women according to the remembers of the information given after the delivery.

<table><thead><tr><th></th><th>No remembers</th><th>Remembers</th><th>p</th></tr></thead><tbody><tr><td><strong>Risk of anal incontinence</strong></td><td>n = 55</td><td>n = 25</td><td></td></tr><tr><td>Lifestyle</td><td>38.14 + -4.36</td><td>39.48 + -1.16</td><td>0.22</td></tr><tr><td>Coping/behavior</td><td><strong>31.26 + -6.50</strong></td><td><strong>34.44 + -3.14</strong></td><td><strong>0.017</strong></td></tr><tr><td>Depression/ Self-perception</td><td>27.90 + -3.35</td><td>29.12 + -1.83</td><td>0.12</td></tr><tr><td>Embarrassment</td><td><strong>10.58 + -2.44</strong></td><td><strong>11.68 + -0.99</strong></td><td><strong>0.019</strong></td></tr><tr><td><strong>Risk of abscess</strong></td><td>n = 60</td><td>n = 20</td><td>p</td></tr><tr><td>Lifestyle</td><td>38.49 + -4.18</td><td>38.85 + -1.57</td><td>0.18</td></tr><tr><td>Coping/behavior</td><td>32.24 + -6.09</td><td>32.55 + -4.98</td><td>0.60</td></tr><tr><td>Depression/ Self-perception</td><td>28.25 + -3.20</td><td>28.45 + -2.33</td><td>0.73</td></tr><tr><td>Embarrassment</td><td>10.82 + -2.33</td><td>11.30 + -1.45</td><td>0.82</td></tr><tr><td><strong>Risk of scar disruption</strong></td><td>n = 59</td><td>n = 21</td><td>p</td></tr><tr><td>Lifestyle</td><td><strong>38.54 + -4.23</strong></td><td><strong>38.71 + -1.52</strong></td><td><strong>0.03</strong></td></tr><tr><td>Coping/behavior</td><td>32.26 + -6.14</td><td>32.48 + -4.86</td><td>0.46</td></tr><tr><td>Depression/ Self-perception</td><td>28.37 + -3.21</td><td>28.14 + -2.35</td><td>0.24</td></tr><tr><td>Embarrassment</td><td>10.85 + -2.33</td><td>11.19 + -1.50</td><td>0.87</td></tr><tr><td><strong>Risk of urinary incontinence</strong></td><td>n = 54</td><td>n = 26</td><td>p</td></tr><tr><td>Lifestyle</td><td>38.16 + -4.40</td><td>39.38 + -1.24</td><td>0.41</td></tr><tr><td>Coping/behavior</td><td>31.35 + -6.56</td><td>34.15 + -3.31</td><td>0.12</td></tr><tr><td>Depression/ Self-perception</td><td>27.98 + -3.41</td><td>28.92 + -1.81</td><td>0.48</td></tr><tr><td>Embarrassment</td><td>10.63 + -2.43</td><td>11.54 + -1.24</td><td>0.11</td></tr></tbody></table>

the information. And in the context of allogenic stem cell transplantation, Herrmann A et al. [18] report that patients are better placed to remember the information given in two short consultations as opposed to one long consultation. Interestingly, if we extrapolate these findings to the context of labor and OASIS, a second consultation at some distance from delivery would seem to be recommended. Our results also support the need for this second consultation, because women who have delivered ≤ 5 years previously are better able to remember the information provided following delivery. At first sight, we might suppose that the simple fact that the information has been delivered more recently leads to better recall among patients. Then again, the literature reported above highlights that after two months less than 50 % of the information can be recalled [11,14,15]. Forgetting information happens early on in our study, with 40 to 50 % of the information being remembered within the first five years. During those last five years of the inclusion period, women received a specific consultation three months after the OASIS [13]. The patients appreciated this consultation, which beyond presenting the same information to the women again, enabled the early diagnosis of AI or dyschezia which could be then be treated, thus limiting the risk of it becoming chronic [13].

Finally, the women who remembered the information had a better quality of life. This points to the importance of the quality of the information, quite independently of whether the women to whom it is delivered are in hospital at the time. Hegelson VS [19] reports that the more social support an individual receives, the better their quality of life, regardless of their level of stress. Moreover, patients may see a positive effect from spending more time with healthcare professionals [20]. As the unknown is stressful, women who do not remember information about AI may turn to the internet in order to find information and reassure themselves. Unfortunately, unlike UI [21], the readily available information about AI varies and key components are often missing [22].

The present study does, however, have some limitations that arise from its design. As the study was initially designed to assess the prevalence of AI and the quality of life for patients after OASIS, we did not consider the current management of potential AI or UI. Also, we did not collect information about the sexual function despite it is probably associated with gastrointestinal functions disorders. Furthermore, during the last five years of the inclusion period, information was specifically given to women about AI at a dedicated consultation with a colorectal surgeon. This makes it difficult to distinguish whether they remembered the information from the delivery or from that consultation. On top of this, the study protocol did not ask the women whether
they were seeking treatment. Knowing this might help us to understand the role of the postpartum consultation in directing women toward specialist care.

## Conclusion

Women who had received the information ≤ 5 years ago were more able to remember it. This coincides with the implementation of a specific post-OASIS consultation. Being able to remember information about the risk of AI significantly improves the quality of life for women who experience FI. This makes a strong case for expanding the delivery of specific post-OASIS consultations or, at least, for improving how such information is delivered to patients following an OASIS.

## Details of Ethics Approval

The protocol was approved by the Committee for the Protection of Persons (CPP, registration no.: 2021-A01128-33) and the French Data Protection Authority (CNIL, registration no.: ar21-0150v0).

## Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

## Declaration of generative AI

None.

## CRediT authorship contribution statement

**Venara Aurélien:** Writing – review & editing, Supervision, Methodology, Data curation.
**Rebmann Emeline:** Writing – original draft, Formal analysis, Data curation, Conceptualization.
**Helbert Candice:** Writing – review & editing, Data curation.
**Lemasson Florine:** Writing – review & editing, Data curation.
**Legendre Guillaume:** Writing – review & editing, Data curation.
**Hamel Jean-François:** Writing – original draft, Methodology, Formal analysis, Conceptualization.

## Informed consent

All the patients gave their consent to participate.

## Funding

None.

## Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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