Fecal Incontinence in Women: Causes and Treatment

Ashima Makol; Madhusudan Grover; William E Whitehead

Women's Health. 2008;4(5):517-528.

Prevalence

Prior to the year 2000, there were almost no published data on the prevalence of FI. Since then, there have been a number of reports from population-based samples^[9,14,15] as well as clinical samples,^[16,17] and there are now systematic reviews^[2,18,19] and a meta-analysis.^[6] Nevertheless, the reported prevalence estimates still vary in a wide range. Factors contributing to this variability include differences in case definition (anal incontinence vs FI), differences in the population studied, especially the age of the sample,^[20] and whether nursing home residents are included. Reports of the prevalence of FI from population-based studies of community-dwelling adults range from 3 to 17%^[14,15] depending on the age of the cohort, with prevalence in women increasing from 6% in those younger than 40 years to 15% in women older than 65 years.^[5] The female:male ratio is estimated to be 3:2.^[9]

The prevalence of FI may be underestimated – less than a third of people who identify themselves as having FI in surveys say they have reported this to their doctor^[16] and, therefore, it is possible that some people might be reluctant to report FI in surveys as well.

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Sidebar: Executive Summary

Fecal Incontinence (FI) is a common medical condition affecting up to 15% of women.

It significantly impairs the lifestyle of women and has a tremendous negative impact on social interactions and self-image, resulting in poor quality of life, work absenteeism and self-imposed isolation and depression.

The physiological mechanisms that maintain continence are adequate strength in the pelvic floor muscles to hold back a bowel movement, adequate compliance of the rectum to be able to store stool between bowel movements, ability to sense rectal filling and normal stool consistency. Deficits in any of these may contribute to FI and, in any given patient, the etiology may be multifactorial.

Risk factors that are unique to women include obstetric trauma (instrumental vaginal delivery, prolonged second stage of labor, large neonatal birthweight and occipito-posterior presentation) and hysterectomy. Other risk factors common to both men and women include chronic diarrhea or urgency, obesity and older age. Systemic diseases that increase the risk of FI are irritable bowel syndrome and diabetes, and many neurological disorders increase the risk of FI. Urinary incontinence is a frequently associated condition.

Primary prevention strategies include reducing the incidence of diarrheal diseases through public health measures, discouraging routine use of episiotomies and internal anal sphincter myectomies, encouraging the use of pelvic floor exercises immediately after childbirth and decreasing obesity. Secondary prevention hinges on increasing the willingness of patients to consult their doctors about FI and the willingness of physicians to screen for FI. Conservative treatment measures that are effective are already available.

The role of elective cesarean section to prevent FI is controversial.

Treatments range from education and conservative medical management to biofeedback and surgery. Conservative treatment emphasizes normalization of stool consistency with antidiarrheal drugs or laxatives and encouragement of pelvic floor exercises. Biofeedback aims to strengthen pelvic floor muscles and improve perception of rectal sensations. The most common surgical options are sphincteroplasty, injection of bulking agents to improve resting pressure in the anal canal and colostomy. Sacral nerve stimulation is an experimental approach that appears promising.

It is important to sensitize general practitioners to this under-recognized condition with a high prevalence. Since effective therapies are available, clinicians who care for postpartum and elderly women should routinely screen for FI and offer evaluation and treatment to women with FI.

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