Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy

Objective  To compare two policies for episiotomy: restrictive and systematic. Design  Quasi-randomised comparative study. Setting  Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. Population  Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37–41 weeks. Methods  A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures  Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. Results  We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05–3.22). Conclusions  A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.