Anal sphincter injuries are missed when the perineum is inspected but not examined. Standard practice is a systematic assessment after every vaginal birth with perineal trauma: inspect, then perform a rectal examination to feel for a defect in the external and internal sphincter before any repair begins. Classify the tear fully and document it. A sphincter injury found at the time and repaired by an experienced operator does better than one discovered months later with incontinence.
- Perform a rectal examination after every vaginal birth with perineal trauma, before suturing.
- Classify the tear by degree and sub-type, and document it.
- Call a senior or experienced operator for any third- or fourth-degree tear.
- Arrange follow-up for women with sphincter injury, including questions about continence.
Why it matters
Sphincter injuries are common enough in high-risk groups, such as women with lichen sclerosus, that inspection alone will miss some.
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