Fecal Incontinence in Women: Causes and Treatment

Abstract and Introduction

Fecal incontinence is a common problem in women, which often enforces life changes owing to embarrassment and social stigma. It is frequently not reported or diagnosed. Age, obstetric trauma, pelvic surgery, chronic diarrhea, obesity and other medical conditions, such as diabetes and stroke, increase the risk of fecal incontinence. Preventive strategies include avoiding diarrheal triggers, discouraging the routine use of episiotomies, early recognition and management of obstetric injuries and possibly pelvic floor muscle exercises after childbirth. Treatment options are available and should be discussed with the patient. These, in order of progression, are education and medications for diarrhea or constipation, supportive care, biofeedback training and surgery.

Fecal incontinence (FI) is a very common complaint; it affects up to 15% of community-living women^[1,2] and approximately half of the women in nursing homes.^[3,4] It is widely believed to be more common in women than in men,^[5] as women are exposed to a unique set of risk factors during pregnancy and childbirth. However, population-based studies that include subjects of all ages fail to find a significant difference between women and men.^[6] The most likely explanation for this disparity is that FI has multiple causes and, when all ages are included, the contribution of obstetrical injuries is diluted. Reproductive hormones do not appear to have a direct impact on FI since age-related increases in the prevalence of FI are observed in both men and women.^[6]

This article will focus on FI in community-dwelling women because the risk factors associated with FI and the approaches to its prevention and management are very different from those in institutional settings. We will review the definition and prevalence of FI, its impact on quality of life (QOL), the physiological mechanisms that are responsible for maintaining continence, risk factors (especially those that differentially affect women), approaches for prevention and treatment options. This is not a comprehensive systematic review or a meta-analysis; however, it is an overview that reflects the opinions of the authors. We sought to make this overview understandable to patients and healthcare providers from a variety of disciplines.

This is an opportune time to review FI in women because there has been an explosion of new research findings on FI in the past 5 years, and there is a new emphasis on prevention reflected in the sponsorship by the NIH of the State of the Science Conference on the prevention of FI and urinary incontinence (UI) in December 2007.^[5]

No writing assistance was utilized in the production of this manuscript.

Cite this: Fecal Incontinence in Women: Causes and Treatment - Medscape - Sep 01, 2008.

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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