Sphincterolevatoroplasty for post-traumatic anal incontinence in women

Anal incontinence (AI) is one of the most socially disabling manifestations of pelvic floor dysfunction. It is associated with a substantial reduction in quality of life, limitations in daily activities, sexual and psychological dysfunction, and considerable socioeconomic burden [1].

The prevalence of AI is 8.6% at 6 weeks after vaginal delivery [2] and 21.8% at 9–12 months postpartum among primiparous women who underwent vacuum-assisted vaginal delivery [3]. AI has been reported in 15.6% of women within 10 years of their first childbirth [4]. Among patients with severe perineal tears, the prevalence of AI is 59% [5]. Missed obstetric perineal injuries represent a major clinical concern, with one in four missed cases subsequently requiring surgical intervention (relative risk [RR] 4.1, 95% confidence interval [CI] 1.0–16.3) [6].

Third- and fourth-degree perineal tears sustained during childbirth are among the leading causes of structural anal incontinence (AI) in women. A network meta-analysis demonstrated that the prevalence of AI was significantly higher among patients with third-degree (OR 1.79, 95% CI 1.09–2.94) and fourth-degree tears (OR 2.37, 95% CI 1.40–4.02) than among those with less severe obstetric injuries [7]. According to a 2024 systematic review, 3.8% of spontaneous vaginal deliveries worldwide are complicated by third- or fourth-degree perineal tears, which are associated with an extremely high risk of subsequent AI [8]. Risk factors for obstetric anal sphincter injuries include primiparity, operative vaginal delivery, fetal macrosomia, prolonged second stage of labor, persistent occiput posterior position, midline episiotomy, and obesity [9,10].

Post-traumatic AI resulting from obstetric anal sphincter injuries is particularly important in obstetric and gynecological practice because the presence of a structural defect frequently determines the indication for reconstructive surgery.

Overlapping sphincteroplasty (reconstruction by overlapping the ends of the injured sphincter muscle) remains the principal surgical treatment for AI associated with defects of the sphincter muscle ring, with good or excellent outcomes reported in 93% of patients after a mean follow-up of 3.5 years [11]. Favorable outcomes are associated with younger age (<50 years), shorter interval since injury (<5 years), absence of severe denervation, preserved puborectalis muscle function, and feasibility of complete reconstruction of the perineal body [12]. Conversely, neuropathy, extensive scar formation, and long-standing defects are associated with poorer outcomes [12,13]. Thus, surgical success depends not only on the anatomical characteristics of the sphincter injury but also on the quality of the remaining pelvic floor and perineal tissue.

Although sphincteroplasty effectively restores anatomy in the short term, its long-term efficacy is limited by progressive muscle atrophy, fibrotic scarring, and functional deterioration over time, leading many investigators to question whether it is the optimal treatment strategy [14,15]. Sacral neuromodulation has emerged as an alternative approach that focuses on the functional modulation of neural signaling. A systematic review and meta-analysis demonstrated superior outcomes with sacral neuromodulation compared to sphincteroplasty (RR 1.68, 95% CI 1.16–2.44; p=0.006) [15].

Because continence depends on the coordinated function of the internal and external anal sphincters, levator ani muscle, intact rectal sensation, and preserved neuromuscular conduction, isolated reconstruction of the sphincter ring does not always achieve durable functional recovery, particularly in patients with a combined external anal sphincter defect and perineal body deficiency [14–20]. Surgical procedures combining sphincteroplasty, levatoroplasty, and perineal reconstruction have demonstrated favorable functional outcomes in 92.9% of patients [21,22].

In Russian surgical terminology, this combined procedure is referred to as sphincterolevatoroplasty (SLP), emphasizing the integrated restoration of the pelvic floor muscular framework and anal continence mechanism. However, under the current official Russian procedural nomenclature (Ministry of Health Order No. 804n, October 13, 2017), these procedures are coded separately: A16.19.015 for sphincteroplasty and A16.20.030 for vulvar and perineal reconstruction.

According to current evidence, combined reconstructive surgery reduces incontinence severity scores by approximately four- to fivefold, with approximately 93% of patients rating the outcome as good or excellent when appropriate postoperative rehabilitation is provided. Continence is maintained in 84% of patients during long-term follow-up (mean follow-up, 5 years) [12]. Although short-term success rates are high, studies have emphasized the importance of postoperative biofeedback training because continence may gradually decline over 5–10 years due to age-related tissue changes.

Both Russian clinical practice guidelines and international literature consider pelvic floor muscle training, biofeedback therapy, and anal sphincter electrical stimulation as first-line components of conservative treatment. The choice between reconstructive surgery, sacral neuromodulation, and other interventions is determined by the anatomical characteristics of the defect, interval since injury, and residual tissue reserve of the pelvic floor and perineum [23, 24]. However, despite the widespread use of neuromodulation, conservative treatment, and regenerative therapies, the available evidence does not support these approaches as universal alternatives to reconstructive surgery in patients with anatomically confirmed anterior external anal sphincter defects [15, 25, 26]. Therefore, the development and evaluation of comprehensive surgical strategies that combine anal sphincter complex reconstruction with pelvic floor reconstruction remain of substantial clinical importance.

This study aimed to evaluate the effectiveness of sphincterolevatoroplasty in treating anal incontinence in women with posttraumatic external anal sphincter insufficiency.

Materials and methods

An uncontrolled, quasi-experimental clinical study was conducted on patients who underwent surgery between 2019 and 2025 at the Center for Restorative Gynecology "Women's Clinic" and Coloproctology Department of City Clinical Hospital No. 40 Yekaterinburg, Russia. This study adhered to the principles of the World Medical Association Declaration of Helsinki, Good Clinical Practice guidelines, and current regulations of the Russian Federation. All patients provided written, informed consent to participate in the study.

The study included 43 women diagnosed with pelvic organ prolapse, rectocele, anal sphincter insufficiency, or anal incontinence (N81.6, N81.8, K62.8, R15). Follow-up data were available for these patients from 1 year to 3–6 years after surgical treatment.

The inclusion criteria were a history of vaginal delivery, symptoms of AI and/or identification of a defect or thinning of the anterior semicircumference of the EAS, and written informed consent to participate in the study.

The exclusion criteria were no history of vaginal delivery, defects associated with previous surgery on the anal canal, malignant neoplasms, and acute exacerbation of chronic diseases.

The assessment included the collection of complaints and medical history, as well as general clinical, gynecological, and rectal examinations. Medical records were reviewed, and in-person, telephone, and remote follow-up surveys were performed.

The severity of AI was assessed using a three-stage clinical classification: grade I (flatus incontinence), grade II (incontinence of flatus and liquid stool), and grade III (incontinence of flatus, liquid, and solid stool). Changes in the EAS were classified by morphological type (defect or thinning) and circumferential extent of sphincter involvement. Patients were categorized by type of pelvic organ prolapse (POP) as having cystocele, rectocele, or a combination, and severity was assessed using the Baden–Walker classification. Clinical symptoms were evaluated using the Cleveland Clinic Incontinence Score (Wexner score).

The anal sphincter was evaluated using ultrasonography (US; Samsung MEDISON V6-RUS and GE Voluson E8, South Korea) before surgery, on postoperative day 7, and three months after surgery. Sphincterometry was performed using a Gastro Scan-SF device (Istok-Sistema, Russia) before and 3 months after surgery. The results were interpreted with reference to the normative values for women: mean resting pressure, 37.1±15.3 mmHg; maximum resting pressure, 43.8±15.5 mmHg; mean voluntary contraction pressure, 75.1±29.5 mmHg; and maximum voluntary contraction pressure, 99.1±39.7 mmHg [28].

Patient satisfaction with the treatment was assessed using a Likert scale.

Surgical correction of EAS defects was performed in combination with reconstruction of the rectovaginal fascia and restoration of the levator ani muscle anatomy using our previously developed combined levatoroplasty technique [28].

SLP technique

The surgery was performed using a transvaginal approach. Following preliminary hydrodissection of the posterior vaginal wall with 0.9% sodium chloride solution containing epinephrine at a dilution of 1:500, the perineal skin and posterior vaginal mucosa were sharply incised at the junction of the middle and upper thirds of the vagina. The margins of the external anal sphincter defect were sharply dissected from the scar tissue without mobilization. Three stay sutures of multifilament absorbable suture material (USP 0) were placed at the margins of the injured EAS (Fig. 1.1).

The anterior rectal wall was then dissected in the suprafascial plane to the margins of the intact rectovaginal fascia, exposing the internal surfaces of the puborectalis and pubococcygeus muscles, unilaterally or bilaterally. The exposed anatomical structures were treated with an argon plasma beam in the "Fulgur" mode (ONYX-A electrosurgical unit, FOTEK; power output, 60 W). A levator plate defect, defined as diastasis between the puborectalis and pubococcygeus muscles, was identified both visually and by palpation. When present, interrupted sutures of multifilament absorbable material (USP 0) were placed in the muscle bellies to correct diastasis. This procedure, termed lateral levatoroplasty, aims to restore the levator ani anatomy and consequently improve the contractile function of the anorectal continence mechanism, thereby improving surgical outcomes.

The rectovaginal fascia defect was subsequently repaired using interrupted or continuous absorbable sutures (USP 0 size). The medial portions of the puborectalis muscles were approximated in the lower third of the vagina using multifilament absorbable suture material (medial levatoroplasty) (Fig. 1.2). If an internal anal sphincter defect was identified before the rectovaginal septum was reconstructed, it was repaired using interrupted absorbable sutures.

The margins of the EAS defect were treated with an argon plasma beam, after which the previously placed sutures were tied to restore EAS continuity. The reconstructed anal sphincter was buried with interrupted sutures to create a second layer of sutures over the EAS. The procedure was concluded with reconstruction of the vaginal mucosa and perineoplasty. The perineal body was reconstructed using the medial portions of the puborectalis muscles to cover the anal sphincter’s sutures (Fig. 1.3). The perineal skin was repaired with interrupted absorbable multifilament sutures (USP 3–0), and a high-viscosity skin adhesive was applied. The vagina was treated with an aqueous antiseptic solution and tightly packed with gauze impregnated with iodopyrone solution; the packing was removed after 18–24 h. Patients were mobilized 12 h after sphincteroplasty.

During the postoperative period, patients received a course of antibacterial therapy and analgesia with nonsteroidal anti-inflammatory drugs. To prevent purulent complications of the surgical wound and promote tissue repair, the vaginal mucosa and perineal skin sutures were treated twice daily with a cavitated antiseptic solution (0.05% aqueous chlorhexidine solution; ACTITON-A device, FOTEK) [29]. Patients were discharged after the restoration of spontaneous defecation, usually on postoperative days 3–4. Treatment with the cavitated antiseptic solution continued on an outpatient basis for up to 6 days after the procedure.

Treatment effectiveness was evaluated based on the criterion of "recovery," defined as the absence of symptoms of anal and urinary incontinence and symptomatic rectocele, as well as patients' subjective satisfaction with the surgical outcome, assessed on postoperative day 7 and at 12 months postoperatively. Follow-up data were available for 3–6 years after the surgery.

Statistical analysis

Statistical analysis was performed using Microsoft Excel 2010. Continuous data are presented as mean (M) and standard deviation (SD) or median (Me) and interquartile range (Q1–Q3). Categorical variables are presented as absolute frequencies (n) and percentages (%). Paired samples were compared using the Wilcoxon signed-rank test. McNemar's test was used to analyze qualitative (nominal) data in two paired samples. The absolute risk reduction was calculated as a percentage with 95% confidence intervals (CIs). Statistical significance was set at p=0.05.

Results

The mean (SD) age of the patients was 43.8 (10.6) years. The mean number of spontaneous vaginal deliveries was 1.9 (0.8). Obstetric trauma was documented in 83.7% (36/43) of patients. The interval since delivery ranged from 1 to 15 years (mean interval, 5.5 years). The overall clinical characteristics of the patients are shown in Table 1.

The patients underwent SLP and perineoplasty (reconstruction of the posterior compartment of the pelvic floor and perineum) in 46.5% (20/43) of cases, cystocele and rectocele repair in 39.5% (17/43), and placement of a suburethral sling combined with posterior pelvic floor reconstruction in 14.0% (6/43). In one additional patient, the sling was placed as a second-stage procedure 3 months later. The indication for urethropexy in these cases was concomitant severe urinary incontinence. One patient with a 40% EAS defect underwent simultaneous laparoscopic-assisted loop sigmoid colostomy.

Changes in clinical symptoms/signs and summary measures of treatment efficacy are shown in Table 2.

As shown in Table 2, the absolute risk of AI decreased by 79.1% after surgery, primarily owing to a reduction in patients with moderate AI, in whom the risk decreased by 48.8%. The risks of urinary incontinence and sexual dysfunction decreased by 39.5% and 51.2%, respectively (all p<0.001). Dyspareunia was reported by 14.0% of women before surgery and by 11.6% after the intervention (the reduction was not statistically significant). Among patients with preoperative dyspareunia, the symptom resolved, whereas newly developed pain was associated with increased tone of the puborectalis muscles caused by high levatorplasty. Subsequently, dyspareunia resolved spontaneously or was alleviated by restoring pelvic floor muscle function using biofeedback therapy.

According to the final assessment, the efficacy of surgery, defined as “cure,” on postoperative day 7 was 79.1%: symptoms were completely resolved in 34/43 patients with preoperative AI. Overall satisfaction with the intervention was 90.7%, reflecting a positive perception of the procedure among 39/43 study participants.

Three patients developed postoperative complications, including perineal wound infection and partial wound dehiscence. No other complications, including fistula formation, were observed.

The sphincterometry findings 3 months after surgical treatment and rehabilitation are presented in Table 3.

The mean resting anal canal pressure increased by 14.6 mm Hg (+41.4%), whereas the maximum anal canal pressure during voluntary contraction increased by 34.05 mm Hg (+38.3%). Thus, the patients demonstrated a substantial increase in anal sphincter “squeeze strength.” This capacity enables an individual to retain intestinal contents when the urge to defecate occurs or during physical exertion. An increase of 38.3 mmHg in the maximum anal canal pressure during voluntary contraction represents a favorable clinical outcome, indicating improved voluntary control of defecation.

At 12 months after surgery (n=33; 76.7%), efficacy was 100% (all patients maintained continence for stool and flatus), and satisfaction was 90.9% (30/33).

During follow-up from 1 to 3 years after surgery (n=30; 69.8%), the efficacy and satisfaction rates were 93.3% (28/30) and 90% (27/30), respectively. Long-term outcomes 3 to 6 years after surgery were assessed in one-third of the patients (n=14; 32.6%); the treatment effect was maintained in 64.3% (9/14), whereas satisfaction was reported by 92.9% (13/14).

Clinical case

Patient A., aged 38 years, was admitted for elective surgical treatment.

Complaints: fecal and flatus incontinence and a sensation of a foreign body in the vagina that intensified with straining.

Medical history. The family history was unremarkable. Allergy history: intolerance to B vitamins (urticaria). The patient denied any chronic medical conditions. Childhood infections: varicella. She denied smoking, alcohol consumption, and other harmful habits. Previous surgery: appendectomy.

Obstetric and gynecologic history. Menarche occurred at the age of 13 years. Her menstrual cycle was regular, 28 days in length, with 5 days of menstruation, and was not associated with pain. She had been sexually active since the age of 18 years. She had one pregnancy and one term of spontaneous vaginal delivery. She denied any history of gynecological diseases or sexually transmitted infections.

History of the present illness. She considered herself symptomatic for more than 3 years. She attributed the onset of symptoms to her first spontaneous vaginal delivery at the age of 35 years, which was complicated by a grade IIIa perineal tear; the infant weighed 4100 g.

Physical examination. Her general condition was satisfactory. The skin was of normal color and clear in appearance. Breath sounds were vesicular with no wheezing or crackling. The body temperature was 36.7°C. The blood pressure was 120/70 mmHg, and the pulse was 72 beats/min with adequate volume. The abdomen was symmetrical, non-distended, soft, and nontender. Bowel sounds were present and active; flatus was passed, and the stools were formed. Urination was spontaneous, painless, and with adequate urine output.

Gynecological examination. Examination revealed an “absent” perineum, gaping vaginal introitus, and grade II rectocele (Fig. 2A). Vaginal examination revealed bilateral avulsion of the puborectalis muscles from the perineal body, lateralization of the muscle bundles, and diastasis of up to 2 cm between the pubococcygeus and puborectalis muscles. Digital rectal examination revealed an external anal sphincter (EAS) defect extending from the 10 to the 1 o’clock positions on the conventional clock face, with reduced sphincter tone and voluntary squeeze strength.

Functional assessment. Digital perineometry demonstrated a peak contraction of 3 units, and the contraction strength was 1 point on the modified Oxford scale. Pelvic floor ultrasonography revealed a rectocele, complete bilateral avulsion of the puborectalis muscles from the perineal body, and a 15-mm EAS defect (Fig. 2B), with an intact internal anal sphincter. Manometric findings were consistent with grade II anal sphincter insufficiency: the mean resting anal canal pressure was 27.8 mmHg, and the maximum pressure during voluntary contraction was 102.5 mmHg.

Diagnosis: Grade II pelvic organ prolapse (POP). Grade II rectocele. Levator insufficiency. Absent perineum. Grade II anal sphincter insufficiency. Moderate fecal incontinence.

Surgical procedure. The patient underwent rectocele repair, bilateral lateral levatorplasty, SLP, and perineoplasty (Fig. 3A).

The postoperative course was uneventful. On postoperative day 7, follow-up ultrasonography confirmed the formation of a neoperineum and neo-sphincter without evidence of hematoma (Fig. 3B).

The patient underwent a rehabilitation course consisting of pelvic floor biofeedback therapy (seven sessions).

Three months after surgery, the patient reported no symptoms, and there were no signs of POP. Pelvic floor ultrasonography revealed an intact EAS without defects (Figure 4). Manometric findings were within the normal range: the mean resting pressure was 47 mmHg, and the maximum pressure during voluntary contraction was 125.1 mmHg.

Follow-up. Three years after surgery, the patient remained continent, was sexually active, and completely satisfied with the treatment outcome. Clinical examination revealed preservation of the levator plateau, and the EAS was palpable throughout the entire circumference, corresponding to the conventional clock-face positions.

Discussion

Our experience with SLP for the treatment of AI has demonstrated high clinical effectiveness and patient satisfaction in most women. We achieved anatomically sound reconstruction of the sphincter complex and perineal body in all operated patients, with an acceptable rate of postoperative complications in all patients. These findings align with reports from case series of overlapping SLP and anterior levatorplasty, which also showed good or excellent short-term functional outcomes in most patients [12, 22].

A key advantage of SLP is its ability to address not only EAS defects but also associated perineal instability, anterior anal canal deformation, and levator muscle insufficiency [11, 12, 21, 22]. This combined correction of the anal sphincter, rectovaginal fascia, and pelvic floor muscles is what leads to favorable functional outcomes in patients with multicomponent postpartum trauma. However, it is important to note that the effectiveness of reconstructive procedures tends to diminish over longer follow-up periods. This phenomenon is attributed to progressive denervation, muscle atrophy, and cicatricial-fibrous tissue remodeling [11–13]. Therefore, the critical factors for success include proper patient selection, thorough imaging of the defect, functional assessment of the anorectal region, and consideration of the neuromuscular component of the disease.

We wish to highlight several important features of our surgical technique. We avoided mobilizing the edges of the EAS defect to prevent disruption of innervation and blood supply. To prevent excessive tension on the sphincter sutures, we perform complete dissection of the puborectalis muscles from scar adhesions and mobilize them at their attachment sites to the EAS. This is followed by levatorplasty, which creates a second layer of sutures over the reconstructed sphincter. We also place considerable importance on the intraoperative use of argon plasma and postoperative treatment of the surgical wound with cavitated antiseptic solutions.

Limitations.The primary limitation of this study is the absence of a control group. Nevertheless, our findings accurately reflect real-world clinical practice in the reconstructive treatment of women with combined defects of the sphincter complex and pelvic floor. Rehabilitation after SLP may improve the long-term outcomes. According to a randomized study and clinical series, biofeedback therapy after sphincteroplasty contributes to better functional outcomes. In cases of marked hypotonia, its effect may be enhanced by electromyostimulation, highlighting the directions for further research.

Conclusion

AI in women after vaginal delivery results from a combined injury to the EAS, perineal body, and levator apparatus. A comprehensive diagnostic and therapeutic approach for women with post-traumatic defects of the sphincter complex and AI, including SLP, facilitates clinical recovery in 79.1% of patients and high treatment satisfaction in 90.7%.

Video of a surgical procedure (SLP) performed to treat sphincter insufficiency associated with AI.