In a first for Paper of the Month, we have selected a pelvic floor paper.

Cesarean delivery to prevent anal incontinence: a systematic review and meta‑analysis
Nelson et al
Techniques in Coloproctology 2019. 23 (9) 809-820

This well conducted systematic review and meta-analysis was published in Techniques in Coloproctology in September 2019. One of the challenges a colorectal surgeon faces is the treatment of faecal incontinence in the parous women. Whether incontinence can be prevented by caesarean section will have crossed the mind of many.

The paper assessed for various measures of incontinence comparing vaginal delivery to caesarean section in an average risk pregnancy cohort. It does not show a statistically significant difference in the rates of gas or faecal incontinence, nor of combined anal incontinence. The study includes assessments of Caesarean section prior to onset of labour, and stratifies for age and parity. There was some heterogeneity in the analyses, and bias assessments found studies satisfactory in the most part.
The authors suggest that these findings challenge thinking on mechanisms of incontinence after vaginal delivery. Whilst it is undeniable that obstetric sphincter injury is a significant problem, this direct trauma may not offer the entire explanation for incontinence. The lack of difference in outcomes between caesarean section and vaginal delivery also suggests that nerve related injury may not be the entire story either.

Whilst the paper may not directly affect clinical care, it does stimulate thought about mechanisms of faecal incontinence in parous women. If we dig deeper into this problem we might be able to identify new treatment or prevention strategies