By Chiara Ghetti, MD
Associate Professor of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
Although there has been increased awareness of pelvic floor disorders in recent years, fecal incontinence (FI), likely the most devastating of the pelvic floor disorders, remains a silent epidemic. FI is defined by the unintentional loss of solid or liquid stool, and anal incontinence (AI) includes leakage of gas and/or FI.1 Together these are also called accidental bowel leakage (ABL), a term that may be more acceptable to patients. The Rome III criteria define FI as “recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 3 years over the last 3 months.”2 The International Continence Society defines AI as “any involuntary loss of faecal material and/or flatus.”3
FI is common and is thought to affect 7-15% of non-institutionalized community-dwelling men and women, although estimates range between 2-24%.4,5 Unfortunately, patients often under-report symptoms and providers seldom screen for FI. Several documents were published in 2015 regarding accidental bowel leakage, including the proceedings of a National Institutes of Health-sponsored conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of FI and to identify topics for future clinical research.6-9 In this feature I hope to briefly review the prevalence of FI and its impact on quality of life, as well as the basic evaluation and available management options.
PREVALENCE
Studies evaluating the prevalence of FI are limited by selected populations, varied definitions of FI, outcome measures, and subject numbers. Based on a dozen large population-based epidemiologic studies, FI is common in women, with a prevalence ranging from 7-15% in non-institutionalized community-dwelling women. A similar prevalence has been found in men.1 FI is more prevalent with increasing age and in care-seeking populations, including adults in home-care and long-term care settings.1 The prevalence ranges from 20-70% in these care settings.1
INCIDENCE/RISK FACTORS
The incidence of FI has been examined in few studies. In two studies, the incidence rate of FI ranged from 7.0% in 10 years in a population of community-dwelling adults and 17% in 4 years in community-dwelling women. Risk factors for the development of FI in these studies were white race, depression, chronic diarrhea, urinary incontinence, self-reported diarrhea, incomplete evacuation, and pelvic radiation.10-11 In community surveys, diarrhea, rectal urgency, chronic illness, and history of cholecystectomy are the most significant independent risk factors for fecal incontinence.1 A history of smoking and obesity also appear to be possibly modifiable risk factors.1 Other conditions associated with FI include advanced age, anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity.1
QUALITY OF LIFE
As one might imagine, the inability to control the loss of flatus or stool can have an overwhelming effect on a person’s life. It can lead to shame, loss of confidence, social stigma, depression, and anxiety.1,9 In a study looking at the impact of FI on quality of life using the Pelvic Floor Impact Questionnaire, 40% of women with FI noted a severe impact on quality of life in one or more of seven Pelvic Floor Impact Questionnaire domains.12 More frequent FI episodes, fecal urgency, nocturnal bowel movements, FI without warning, stress FI, weekly urinary incontinence, and underlying bowel disorder were all associated with severe impact on quality of life. FI greatly affected quality of life through its effect on emotional health and participation in social activities. FI has been found to be associated with depressive and anxiety symptoms.13
HEALTH SEEKING BEHAVIOR
To manage symptoms and support patients with this socially debilitating problem, it is imperative that FI be recognized. Unfortunately, FI is dramatically under-recognized. This likely occurs for two reasons: 1) Patients are hesitant to disclose their symptoms, and 2) Providers are not routinely screening for FI. Several studies have shown that less than one-third of patients with FI had sought care, discussed their symptoms, or were asked about symptoms by a healthcare provider, including studies of women presenting for annual gynecologic care.14,15,16
Factors that have been associated with those who seek care for FI are: 1) having a primary care physician, 2) knowledge of fecal incontinence, 3) frequency and severity of FI symptoms, and 4) longer duration of symptoms.1 Barriers to patients seeking care are a lack of knowledge about fecal incontinence, including the belief that it is a normal part of aging and that there are no treatment options, embarrassment, and other medical comorbidities.1
PHYSIOLOGY
A combination of several components, including anatomic factors, sensation, and rectal compliance, allow for fecal continence. The internal anal sphincter, a circular smooth muscle, contributes to the majority (70%) of resting anal tone. The remaining 30% of resting tone is contributed by the external anal sphincter, which is composed of striated muscle and can be voluntarily contracted.17 In addition, the pelvic floor muscles, and in particular the puborectalis muscle, contribute to rectal continence and maintain the recto anal angle at rest. The pelvic floor muscles can be voluntarily contracted to further contribute to continence. Disturbances in any of these components of rectal continence, as well as bowel disturbances such as diarrhea, can lead to FI. In patients with FI, frequently more than one component can be affected.
EVALUATION
The evaluation of a patient with FI begins with a thorough history and physical examination. Approaching a detailed history for FI may seem unfamiliar and intimidating for providers; however, it is essentially no different from other types of history taking. It should include questions regarding duration, frequency, urgency symptoms, timing (is FI always associated with urgency or does it happen without notice?), quality of leakage, use of pads, problems with constipation, and impact of FI on quality of life. Every patient has a different understanding of the word constipation; hence, inquiring specifically about stool consistency is important. Assessing for presence of diarrhea and frequency of bowel movements can provide more specific information. As with other delicate subjects we broach with our patients, our own ability to openly discuss FI-related issues could enable patients to feel more comfortable discussing such a sensitive topic.
Additionally, the provider should obtain a history of obstetric, medical, and surgical conditions, including back injuries, previous anorectal or abdominal surgeries, cholecystectomy, irradiation history, diabetes, multiple sclerosis, and scleroderma. Medications, food intolerance, and activity restrictions may also add information.
PHYSICAL EXAMINATION
A thorough pelvic and digital rectal examination with evaluation of the anocutaneous reflex and perineal sensation, vaginal prolapse, anal anatomy and tone, presence of hemorrhoids, fistulae or scarring, as well as thorough examination of the pelvic floor musculature are paramount in the evaluation of a woman with FI.
TREATMENTS
Anal continence is preserved by multiple physiologic mechanisms, and as a corollary, FI can result from deficits in any of these mechanisms. Treatments are often multimodal and aim to approach several mechanisms. Treatments can be divided in non-invasive and invasive therapies. Non-invasive therapies include fiber supplementation and antidiarrheal drugs for diarrhea-associated FI; laxatives, enemas, or suppositories for constipation-associated FI; pelvic floor exercises; biofeedback; and electrical stimulation of anal mucosa.6 Biofeedback involves the use of electronic or mechanical devices to increase patients’ awareness of physiological responses and muscle contractions to facilitate neuromuscular retraining. Biofeedback is the non-invasive treatment with the best evidence and success rate. It is currently recommended for the treatment of FI by the American College of Gastroenterology and the American Gastroenterological Association.6 Invasive treatments include sacral nerve stimulation (Interstim®), injectable bulking agents, sphincteroplasty, artificial sphincter, and colostomy. Of these, sacral nerve stimulation and injection of bulking agents have the best evidence and success rates as measured by either reduction in the frequency of FI or a patient report of “satisfactory relief.” Colostomy is considered a procedure of last resort and its effect on fecal incontinence must be weighed against its effect on other aspects of quality of life.
BRIEF COMMENTARY ON THE ROLE OF CHOLECYSTECTOMY
Many of our patients have previously undergone cholecystectomy for symptomatic gallbladder disease. More than one-third of patients are thought to have post-cholecystectomy syndrome and describe gastrointestinal symptoms including abdominal pain and cramping, flatulence, dyspepsia, as well as diarrhea, increased stool frequency, and urgency.18,19 These changes in bowel habits can aggravate bowel leakage symptoms, and post-cholecystectomy syndrome is an important consideration in the evaluation of women with fecal incontinence. Changes in bowel habits following cholecystectomy are thought to be related, in part, to bile acid malabsorption. The use of cholestyramine has been associated with improvements in diarrhea-associated FI.
In summary, FI is a common and often devastating disorder. Although additional rigorous research is needed to better identify barriers to care and effective therapies, small changes in clinical practice can aid women affected by FI. Employing a regular screening question may help women discuss this sensitive topic. In addition, providing patient education, counseling women on bowel management to decrease diarrhea and constipation, and providing biofeedback in the setting of pelvic floor physical therapy are first-line management options for women with FI.
REFERENCES
- Bharucha AE, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: State of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol 2015;110:127-136.
- Bharucha AE, et al. Functional anorectal disorders. Gastroenterology 2006;130:1510-1518.
- Abrams P, et al. 4th International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse and Faecal Incontinence. 2009.
- Nelson R, et al. Community-based prevalence of anal incontinence. JAMA 1995;274:559-561.
- Varma MG, et al. Fecal incontinence in females older than aged 40 years: Who is at risk? Dis Colon Rectum 2006;49:841-851.
- Whitehead WE, et al. Treatment of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterol 2015;110:138-146.
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Ng KS, et al. Fecal incontinence: Community prevalence and associated factors — A systematic review. Dis Colon Rectum 2015;58:
1194-1209. - Thaha MA, et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev 2015;8:CD004464.
- Dunivan GC, et al. Fecal incontinence in primary care: Prevalence, diagnosis, and health care utilization. Am J Obstet Gynecol 2010;202:493.e1-6.
- Markland AD, et al. Incidence and risk factors for fecal incontinence in black and white older adults: A population-based study. J Am Geriatr Soc 2010;58:1341-1346.
- Rey E, et al. Onset and risk factors for fecal incontinence in a US community. Am J Gastroenterol 2010;105:412-419.
- Brown HW, et al. Quality of life impact in women with accidental bowel leakage. Int J Clin Pract 2012;66:1109-1116.
- Koloski NA, et al. Psychological impact and risk factors associated with new onset fecal incontinence. J Psychosom Res 2012;73:464-468.
- Johanson JF, Lafferty J. Epidemiology of fecal incontinence: The silent affliction. Am J Gastroenterol 1996;91:33-36.
- Boreham MK, et al. Anal incontinence in women presenting for gynecologic care: Prevalence, risk factors, and impact upon quality of life. Am J Obstet Gynecol 2005;192:1637-1642.
- Brown HW, et al. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg 2013;19:66-71.
- Mark D, et al. Urogynecology and Reconstructive Pelvic Surgery. 4th Ed, Philadephia, PA: Elsevier; 2015.
- Sauter GH, et al. Bowel habits and bile acid malabsorption in the months after cholecystectomy. Am J Gastroenterol 2002;97:1732-1735.
- Walters JR, et al. A new mechanism for bile acid diarrhea: defective feedback inhibition of bile acid biosynthesis. Clin Gastroenterol Hepatol 2009;7:1189-1194.
Although there has been increased awareness of pelvic floor disorders in recent years, fecal incontinence, defined by the unintentional loss of solid or liquid stool, remains a silent epidemic.
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