Fecal Incontinence in Women: Causes and Treatment

Prevention

Preventive measures can be categorized into primary and secondary prevention, as depicted in Box 1 . Primary prevention refers to eliminating or ameliorating risk factors before FI develops in order to delay or prevent its occurrence. Secondary prevention refers to screening and detection of disease at an early stage, when FI is more amenable to treatment and before progression to a point that has severe adverse effects on health and QOL. Both primary and secondary prevention are important goals in FI.

Modifiable risk factors for FI include diarrhea, obesity and surgical/obstetrical practices. The prevention and treatment of diarrhea and obesity are established societal goals independent of their association with FI, and there is a large body of literature devoted to the management of both. However, obstetrical and surgical practices are areas in which improvements can be made.

In the past, episiotomy was routinely carried out at delivery, based on the belief that this would control and, therefore, minimize sphincter tears. However, recent evidence demonstrates that episiotomy does not prevent sphincter laceration but, instead, tends to make it worse.^[57] The use of routine episiotomy can cause morbidity in women who would have otherwise had an intact perineum.^[58] In fact, the risk of anal sphincter injury from a nonextending midline episiotomy is triple that compared with a spontaneous laceration.^[57] On the strength of this evidence, many obstetricians have abandoned episiotomy, and this decrease in the use of episiotomy has been associated with a substantial reduction in the incidence of sphincter lacerations.^[51] Nevertheless, some obstetricians continue to employ episiotomy. Practice guidelines now recommend that the routine use of episiotomy should be avoided.^[5]

There is some evidence that cesarean delivery may protect against sphincter lacerations during childbirth,^[52] although studies are inconclusive.^[53,54] This has sparked debate about offering elective cesarean delivery to all women or at least to women judged to be at high risk for sphincter lacerations, as a means of reducing the risk of obstetrical injury and possible FI.^[5] Although it is difficult to predict anal sphincter injury before delivery or identify the women at risk, certain parameters, such as estimated neonatal birthweight of above 4 kg, occipito-posterior presentation, prolonged second stage of labor, previous history of sphincter trauma and connective tissue disease and obesity,^[82] are known to increase the propensity to sustain perineal injury and poor wound healing and, thus, increase the likelihood of subsequent FI.^[83] However, cesarean delivery does not completely protect the pelvic floor, and rates of FI are noted to be higher among women who have undergone elective cesarean deliveries when compared with nulliparous controls.^[54] Current guidelines recommend that elective cesarean delivery be considered only in those at high risk of sphincter trauma from vaginal delivery and in those who have had previous FI symptoms or evidence of anal sphincter injury.^[84–86] Although the evidence for a protective effect is disputed, the worldwide incidence of cesarean delivery is increasing; it accounts for 29% of all deliveries in the USA.^[201]

There is some evidence that pelvic floor muscle training (also known as Kegel exercises) are effective in preventing and reversing childbirth-related FI for the first year after delivery, and that these exercises have short-term effectiveness in preventing and reversing FI in older women.^[87] One study demonstrated that when younger subjects were instructed in pelvic floor muscle exercises 3 months postnatally, they reported less frequent FI at 12-month follow-up.^[88] However, further studies are needed before any conclusive recommendation can be made.

The greatest challenge to secondary prevention, specifically, preventing the progression of FI, is that most physicians do not screen for it. Surveys repeatedly demonstrate that fewer than 25% of patients with FI have discussed this with their physician.^[67,89,90] There may be barriers, such as embarrassment and social stigma, which prevent patients from seeking medical help for this condition, but there is also a need for physicians to incorporate questions on FI into their routine review of symptoms. "If you don't ask, they won't tell".^[91] Increasing awareness of what can be done to treat FI may encourage more screening.

Early endoanal ultrasound can help detect missed sphincter defects in those suspected to have a second-degree tear during delivery.^[41] The presence of other risk factors should also alert the physician to screen for FI. These include diarrhea, urgency, IBS, DM and any neurological disorders.

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.

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

My Alerts