IUGA International Guidelines on Obstetric Anal Sphincter Injuries

IUGA · 2026 · international

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Authors: A H Sultan, N A Okeahialam, J De Leeuw et al.
Title: IUGA International Guidelines on Obstetric Anal Sphincter Injuries
Journal: International Urogynecology Journal, 2026
DOI: 10.1007/s00192-026-06642-3
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13486146

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Low- and Middle-Income Countries

Data from low- to middle-income countries (LMICs) are limited. A systematic review that evaluated the rates of perineal trauma in low- and middle-income countries found a paucity of data for most countries. The Philippines has the highest reported OASI rate (15%), whereas Cambodia has the lowest (0.1%) [29]. A case–control study within a retrospective cohort of vaginal births at a tertiary care facility in South India (2008–2012) reported an OASI incidence of 2.1% after vaginal births. Major-degree (grade 3c- and fourth-degree) anal sphincter injuries constituted 20.9% of tears [30]. After adjusted analysis, significant predictors included primiparity, birth at or beyond 41 weeks of gestation, epidural analgesia, OVB, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against OASIs, particularly in OVBs. Shoulder dystocia was significantly associated with major-degree tears, whereas episiotomy appeared to be protective. Retrospective cohort studies demonstrate that in Brazil, OASI rates range between 0.9% and 2.7% [31–34]. However, it is important to take into account that all prevalence data were collected prior to training in the detection of OASIs, meaning that these rates may be incorrect owing to underdiagnosis.

Which Techniques Should Be Used to Accomplish Repair of Obstetric Anal Sphincter Injuries?

When the EAS is only partially torn (grade 3a and some grade 3b), then an end-to-end repair should be performed using two or three mattress sutures (D).

External Anal Sphincter

An overlap repair allows for a greater surface area of contact between the muscle ends, meaning that if further retraction of the overlapped muscle ends were to occur, muscle continuity is likely to be maintained. With an end-to-end repair, as the full length of the EAS may not be identified, this may lead to incomplete apposition, a shorter anal canal length, and increased risk of developing fecal urgency and incontinence [63]. A prospective study of 74 women followed up an average of 27 months following primary repair found that the resulting anal sphincter length following repair was significantly associated with anal incontinence [91]. However, an overlap technique can only be performed when the full thickness of the EAS is involved and the full length of the EAS is free. This means that an overlap repair is not possible with a grade 3a tear or a partial thickness grade 3b tear; an end-to-end repair should be performed for all partial-thickness EAS tears (grade 3a and some grade 3b) [63]. As “figure-of-eight” sutures are hemostatic and can cause strangulation of tissue, they should never be used to repair the anorectal epithelium or the sphinctersEvidence level 2+

Contents of the original publication

The section headings of the original.

Summary
Section 1: Introduction
Scope and objectives
Background and Epidemiology
Anal Sphincter Anatomy and Physiology of Anal Continence
Scope of the Literature Search
Methodology
Levels of Evidence and Grades of Recommendation
Section 2: Classification and Diagnosis
Principles in clinical diagnosis
Physical examination, digital rectal examination technique
Section 3: OASI Repair and Short-Term Management
Consent
Repair Techniques
Perioperative Management
Short- and Long-Term Outcome of Primary Repair
Early and Late Complications
Assessment and Investigation Tools After Obstetric Anal Sphincter Injuries
Section 4: Long-Term Management of Patients with Obstetric Anal Sphincter Injuries
Section 5: Risk Factors, Prediction, and Prevention
Can Obstetric Anal Sphincter Injuries Be Prevented?
What Risk Factors Are Associated with Obstetric Anal Sphincter Injuries?
Section 6: Management of Subsequent Pregnancies
What Is the Risk of Recurrent Obstetric Anal Sphincter Injury in a Subsequent Birth?
What are the risk factors and protective factors for rOASI?
What Is the Risk of Development of Anorectal Symptoms After Subsequent Birth Post-Obstetric Anal Sphincter Injury?
Do Women Regret Their Mode of Subsequent Birth?
Section 7: Medicolegal, Education, and Resources
Governance, Risk, and Litigation
Provider Education and Training and Competency Tools
Patient Education and Counselling
Patient Information Leaflets, Links, Apps, Support Groups
Information Resources for Health Providers
Audits of Management and Outcome
Section 8: Concluding Sections
Summary
Areas for Future Research
Conclusions
Appendix 1
Appendix 2

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