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. The use of routine episiotomy can cause morbidity in women who would have otherwise had an intact perineum. In fact, the risk of anal sphincter injury from a nonextending midline episiotomy is triple that compared with a spontaneous laceration. 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. Nevertheless, some obstetricians continue to employ episiotomy. Practice guidelines now recommend that the routine use of episiotomy should be avoided.
There is some evidence that cesarean delivery may protect against sphincter lacerations during childbirth, 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. 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, are known to increase the propensity to sustain perineal injury and poor wound healing and, thus, increase the likelihood of subsequent FI. 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. 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.
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. 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. 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". 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. 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.
Women's Health. 2008;4(5):517-528. © 2008 Future Medicine Ltd.
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Cite this: Fecal Incontinence in Women: Causes and Treatment - Medscape - Sep 01, 2008.