Prevalence of anal incontinence in 409 patients investigated for stress urinary incontinence

Faecal incontinence: a life-course approach

Faecal incontinence is under-reported and under-diagnosed. It is associated with negative social and psychological sequelae and reduced quality of life. Timely intervention potentially reduces its adverse impact throughout the life-course as most cases are potentially treatable. This review provides a summary of pre-disposing factors. It offers an overview of preventative and treatment options within the community setting, with signposting to further reading and a call to further research into this area of women's health.

Factors associated with fecal incontinence in women with lower urinary tract symptoms

AIM

The aim of this study was to identify the factors associated with fecal incontinence in female patients with lower urinary tract symptoms.

MATERIAL AND METHODS

  Data regarding clinical and urodynamic parameters and history of fecal incontinence of 1334 women with lower urinary tract symptoms who had previously undergone urodynamic evaluation were collected and subjected to univariate, multivariate, and receiver-operator characteristic curve analysis to identify significant associations between these parameters and fecal incontinence.

RESULTS

  Multivariate analysis identified age (odds ratio [OR]=1.03, 95% confidence interval [CI]=1.01-1.05, P=0.005), presence of diabetes (OR=2.10, 95%CI=1.22-3.61, P=0.007), presence of urodynamic stress incontinence (OR=1.90, 95%CI=1.24-2.91, P=0.003), pad weight (OR=1.01, 95%CI=1.00-1.01, P=0.04), and detrusor pressure at maximum flow (OR=1.02, 95%CI=1.01-1.03, P=0.003) as independent risk factors for fecal incontinence. Receiver-operator characteristic curve analysis identified age≥55years, detrusor pressure at maximum flow≥35 cmH(2) O, and pad weight≥15g as having positive predictive values of 11.4%, 11.5%, and 12.4%, respectively, thus indicating that they are the most predictive values in concomitant fecal incontinence.

CONCLUSIONS

  Detrusor pressure at maximum flow and pad weight may be associated with fecal incontinence in female patients with lower urinary tract symptoms, but require confirmation as indicators by further study before their use as screening tools.

[Results of sacral neuromodulation on the urinary and fecal incontinence and sexuality in 20 women suffering from a double incontinence]

CONTEXT

Urinary and faecal incontinence (defining double incontinence) are common conditions, which are frequently associated and can altered sexuality. The effectiveness of the sacral nerve modulation (NMS) in the treatment of the urge urinary incontinence, faecal incontinence and double incontinence was shown.

OBJECTIVE

The present article aims to determine the impact of SNM on female sexual function in twenty women suffering from a double incontinence.

METHODS

All patients who received sacral neuromodulation for urge urinary and/or faecal incontinence between 2005 and 2010 and who still had the implant were included. Only 20 sexually active patients suffering from double incontinence were considered eligible. They completed a questionnaire on follow-up examinations.

RESULTS

The initial indication of NMS was the urge urinary incontinence for 15 patients and the faecal incontinence for five patients. Ten patients (50%) were improved on two incontinence. All patients preserved sexual activity after the treatment of NMS. NMS improves the quality of sexual activity in 45% patients. The numbers of urinary and faecal episodes of incontinence are decreased respectively for 50% and 15% patients during sexual activity. The quality of sexual's life and orgasm score are significantly increased in the group of patients improved on the DI.

CONCLUSION

This study confirms the effectiveness of NMS in the treatment of double incontinence which half patients are improved on the two incontinence. This study shows that improvement of urinary or faecal incontinence could have a positive impact on sexuality of these patients, especially for patients improved double incontinence. It is difficult to know if these results are related to its direct action on the neurological ways of sexual function or on its benefit on the continence.

[The sacral neuromodulation in double incontinence treatment: a review]

Urinary and fecal incontinence are common conditions which are frequently associated and defining double incontinence. When conservative treatments fail, sacral nerve modulation (SNM) is considered to be a first-line treatment for patients with urge urinary incontinence and for patients with fecal incontinence. The present article aims to determine the effect of SNM on the treatment of double incontinence. A medline search for clinical studies with SNM and double incontinence was carried out, extracted data were reviewed and analysed. The results of SNM in patients with double incontinence has been reported in seven studies (120 patients). The percentage of patients suffering from double incontinence improved on the urinary and fecal incontinence varied between 32% to 75%. This review reports the effectiveness of the SNM on the urinary and fecal incontinence in this population of double incontinence patients. Its main advantage would be to treat two incontinence by a single treatment. The search of predictive factors of success must be given.

Clinical characteristics and quality of life in a cohort of 621 patients with faecal incontinence

AIM

The aim of this study was to study a cohort of patients with faecal incontinence (FI) to gain a better insight into the clinical and epidemiological characteristics of this pathology and its repercussions on quality of life (QL).

MATERIALS AND METHODS

Consecutive patients with FI seen at tertiary centres filled in a self-questionnaire. The severity of FI, constipation and urinary incontinence (UI) was evaluated, respectively, by the Jorge and Wexner score, the Knowles-Eccersley-Scott Symptom score and the Urological Distress Inventory score. ROME II criteria were used to assess the existence of an associated irritable bowel syndrome. The repercussion on QL was evaluated by the Gastrointestinal Quality of Life index score and the Ditrovie score. The psychological status was assessed by the Hospital Anxiety and Depression scale.

RESULTS

Six hundred twenty-one patients (114 men), mean age 58 +/- 15 years (range: 20-92), with FI, filled in the questionnaire. The mean Jorge and Wexner score was 11 +/- 4. Twenty-seven presented with an irritable bowel syndrome. Thirty-eight percent had an associated constipation. A UI was associated in 48% women and 25% men. QL was significantly altered, and anxiety and depression were frequent.

CONCLUSIONS

FI symptoms are frequently severe, QL very altered and anxiety and depression common. FI is frequently associated with other digestive and perineal symptoms, which argue in favour of a multi-disciplinary management of FI.

Colonosphincteric electromyographic responses to sacral root stimulation: evidence for a somatosympathetic reflex

The aim of the present study was to determine the effects of selectively stimulating the afferent fibres running in the dorsal sacral roots (S1, S2, S3) and the somatic (radial and sciatic) nerves on colonic and internal anal sphincter (IAS) electromyographic (EMG) activity in anaesthetized cats to try to understand how sacral nerve stimulation can improve fecal continence in human. Electrically stimulating the afferent fibres present in the sacral dorsal roots and somatic nerves inhibited the colonic spike potential frequency (n = 97) and increased the slow variations in the sphincteric membrane potential (n = 76). These effects were found to have disappeared after administering an alpha-noradrenergic receptor blocker (n = 64) or sectioning the sympathetic efferent fibres innervating these organs (n = 69) suggesting the involvement of the sympathetic system in the effects observed. Moreover, no significant differences were observed between the effects of sacral dorsal root vs somatic nerve stimulation on colonic and sphincteric EMG activity. In conclusion, the data obtained here show that neurostimulation applied to the sacral spinal roots may improve fecal continence by inhibiting colonic activity and enhancing IAS activity via a somatosympathetic reflex.

Age effects on anorectal pressure in anal continent women with lower urinary tract dysfunction

The objective of this paper is to evaluate age and associated factors affecting anorectal pressure profilometry in anal-continent women with lower urinary tract symptoms. One hundred and ten anal-continent women (mean age, 47.7+/-12.8 years; range, 23-87 years) with lower urinary tract symptoms voluntarily participated in this study after undergoing a complete urogynecological evaluation including a multichannel urodynamic study. Anorectal pressure was evaluated by using a radial four-channel manometry with a water-filled catheter, which was placed 10 cm into the anorectum above the anal verge. We divided the anorectal pressure profile into five segments and four axes to clarify the axis-specific defect or site-specific damage in the sphincter profile. The aging process had a negative effect on the peak resting pressure from the 41 to 100th percentile of the anorectal pressure profile at 12 o'clock, 3 o'clock, and 6 o'clock (P<0.05). With voluntary squeezing, aging had negative effects on the peak squeeze pressure from the 41 to 100th percentile of the anorectal pressure profile at 3 o'clock, and 61 to 80 percentile at 12 o'clock (P<0.05). There is a trend where anorectal pressure reduces as a woman ages, especially at the anal sphincter area in women with lower urinary tract symptoms. The anterior and left sides of the anorectal sphincter seem to be the most vulnerable in the aging process.

Pelvic floor dysfunction after Burch colposuspension - a comprehensive study. Part II

OBJECTIVE

To evaluate the prevalence of pelvic floor dysfunction (PFD) concerning bowel function at long-term follow-up after Burch colposuspension (Bc) in relation to the bowel function in an age-matched sample of women in the general population.

METHODS AND MATERIAL

This is a follow-up study of a cohort of 190 patients who underwent Bc in 1980-1988 and 305 age-matched control women without urinary anti-incontinence surgery, randomly selected from the general population. The participants answered a postal questionnaire with detailed questions about the pelvic floor function in 1998. Univariate and multivariate analyses were performed.

RESULTS

The patients showed considerable signs of bowel dysfunction compared with the general population in the following aspects: they used the fingers to help emptying the bowel [odds ratio (OR) 3.25 (1.35-7.86)]; had feeling of incomplete emptying of the bowel [OR 2.29 (1.11-4.73)]; felt no warning before passing a motion [OR 3.04 (1.20-7.71)]; had gas incontinence [OR 1.98 (1.17-3.37); had loose stool incontinence [OR 3.67 (1.43-9.42)]; used protection against fecal leakage during daytime [OR 3.22 (1.30-7.95)]; and experienced that the bowel function affected the general well-being adversely [OR 2.15 (1.30-3.56)].

CONCLUSION

The patients who have undergone colposuspension for stress urinary incontinence have more symptoms of PFD concerning the bowel function than women without urinary anti-incontinence surgery in the general population. This affects the general well-being. A comprehensive concept of multidisciplinary assessment and treatment of PFD should be encouraged.

Combined urinary and faecal incontinence

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9-19% (urinary) and 5-10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.

Female Pelvic Floor Health

An often neglected but important area of women's health involves the pelvic floor. Pelvic floor health can be reviewed by examining phases of a woman's life. Because pelvic floor health is not readily discussed and few professionals are considered experts in this area, it is often overlooked in women's healthcare. In medicine, care of the pelvic area can become fragmented as it is divided among urologists, gynecologists, and colorectal surgeons. The specialty of urogynecology combines 2 of the areas, and some physical therapists and nurses choose to specialize in female pelvic floor health. The issues of pelvic floor health are often addressed only after symptoms have presented. However, healthy practices can enhance pelvic floor well-being and maintain quality of life as a woman ages. This article is a review of clinical, research, and editorial articles on female pelvic floor issues and a discussion of measures that can contribute to optimal pelvic floor health.

Combined fecal and urinary incontinence: an update

PURPOSE OF REVIEW

To review last year's literature on combined fecal and urinary incontinence, highlighting the most recent contributions on prevalence, physiopathology, evaluation, and treatment.

RECENT FINDINGS

Prevalence studies of double incontinence are rare but both conditions are frequently associated with pelvic organ prolapse. Vaginal delivery and chronic straining are risk factors for double incontinence, and pudendal neuropathy may be responsible for deterioration of continence. Electrophysiological studies in patients with combined fecal and urinary incontinence are necessary to confirm this hypothesis. Patients with double incontinence should be evaluated by a multidisciplinary group of specialists. A complete evaluation including urodynamics, anal manometry, anal ultrasound and electrophysiologic tests is recommended in most cases. Conservative therapy including pelvic floor exercises combined with bladder training and biofeedback has been demonstrated to be effective. Surgery is indicated in very few selected patients and may be performed simultaneously for both fecal and urinary incontinence. New studies are necessary that focus on identification of other risk factors and preventive strategies before deterioration of continence occurs.

SUMMARY

Combined fecal and urinary incontinence is not uncommon and its pathophysiology involves multiple factors. These patients should be evaluated by a multidisciplinary group of specialists and offered appropriate measures to improve their quality of life.

Prevalence and correlations of anal incontinence and constipation in Taiwanese women

Anal incontinence and constipation are not only physically and psychologically disabling symptoms but also a significant social and public health problem. The epidemiology of anal incontinence and constipation from community-bases remains largely unknown, especially in Asian women. This study is a continuation of a previous survey taken on the epidemiology of urinary incontinence and overactive bladder in Taiwanese women by using a second questionnaire (correlation coefficient for symptoms, r=0.87; P<0.05). We evaluated the prevalence and potential risk factors associated with anal incontinence and constipation in the general population. Of the 1,584 (2.92%) women sampled, 1,253 (79.1%) were successfully interviewed at home. The prevalence of fecal incontinence and flatus incontinence was 35 (2.8%) and 107 (8.6%), respectively. There were 306 (24.5%) participants who reported constipation. However, according to the current medical criteria for constipation, the prevalence of constipation was only 2.7%. The prevalence of anal incontinence did not increase after the age of 65 years (9.7%, including 3.5% of elderly women with fecal incontinence and 6.2% of elderly women with flatus incontinence). The prevalence of constipation significantly increased in the women aged 65 years and over (self-reported prevalence: 32.4%, fitted in medical criteria for constipation: 8.3%). Our results demonstrated that constipation shares some of the same risk factors, namely, symptoms of uterovaginal prolapse, prior gynecologic surgery, and overactive bladder that predispose women to the occurrence of anal incontinence. The questionnaire needs a higher discriminatory capacity, and a longitudinal study should be conducted to clarify this conflict further.

Double incontinence in urogynecologic practice: A new insight

OBJECTIVES

This study was undertaken to evaluate the prevalence of anal incontinence in an urogynecologic setting and to investigate the relationship between lower urinary tract dysfunction and anal incontinence.

STUDY DESIGN

The study included 504 women referred to our urogynecologic outpatient clinic who were prospectively investigated and asked specific questions on anal incontinence. Clinical and instrumental data were compared between women with urinary incontinence and with double incontinence, with further analysis for subgroups in the anal incontinent group of women (passive/urge). For continuous variables, the Wilcoxon rank sum test was used, and the Fisher exact test was applied to dicotomic variables. Logistic regression was used for categorical data. A level of P<.005 was considered significant.

RESULTS

Of the investigated women, 20.2% were also anally incontinent. Women with double incontinence showed higher scores for urinary urgency (P=.010), which reached the established level of significance only in the subgroup with urge anal incontinence (P=.003). In this group, a higher prevalence of detrusor overactivity was observed.

CONCLUSION

Anal incontinence is highly prevalent among women with lower urinary tract disorders. The existence of subgroups of patients having different kinds of anal and urinary disorders should be taken into consideration both for research purposes and for new treatment perspectives.

Clinical, urodynamic, and manometric findings in women with combined fecal and urinary incontinence

AIMS

To determine the prevalence of fecal incontinence in patients with urinary incontinence, who were referred for urodynamic evaluation, and to compare clinical and manometric findings between double incontinence and isolated fecal incontinence.

METHODS

Nine hundred women with urinary and/or fecal incontinence were prospectively investigated. Patients with double incontinence (group 1) were compared with 38 women with isolated fecal incontinence (group 2). Clinical data regarding obstetric and urogynecologic history, bowel habit, and type of fecal incontinence were collected. Urodynamics and anal manometry were performed.

RESULTS

Seventy-eight patients (8.7%) presented double incontinence. A history of vaginal delivery and chronic straining was more frequent in patients with double incontinence (P=0.043). No differences were found in the severity of fecal incontinence. Physical examination showed a greater prevalence of rectocele (54% vs. 12%) in group 1. On urodynamics, 80% of women with double incontinence had stress urinary incontinence. Rectal sensation testing revealed a significantly higher rate of hyposensitivity in group 2 (22% vs. 43%).

CONCLUSIONS

This study supports a close association between combined stress urinary and fecal incontinence, history of vaginal delivery, and chronic straining.

Anorectal dysfunction in women with urinary incontinence or lower urinary tract symptoms

OBJECTIVES

(1) To evaluate the prevalence of anorectal dysfunction among women with urinary storage or voiding symptoms; and (2) to investigate the risk factors associated with anorectal symptoms.

METHODS

A sample of 320 women who attended the urogynecology outpatient clinic for urodynamic evaluation were requested to complete a structured questionnaire. The information collected included the medical, surgical, gynecological, and obstetric histories of the patients. Anal incontinence was defined as involuntary leakage of solid or liquid feces or gas. Constipation was defined as less than three bowel movements per week. Prevalence was estimated for anal incontinence and for constipation. A chi-square test was used to compare risk factors between women with and without anal incontinence or constipation. We used a multi-variable logistic regression analysis to estimate the association between other variables.

RESULT

Forty-nine (15.9%) women reported having anal incontinence according to the above definition. Of those 49 women, 11 (3.6%) experienced leakage of liquid and/or solid feces and 38 (12.3%) had flatus incontinence. Constipation was reported by 100 (31.5%) of the women. A multiple logistic regression analysis revealed that the main risk factor associated with anal incontinence and constipation was the presence of uterovaginal prolapse (odds ratio=5.02; 95% CI=2.19-11.5 for anal incontinence; odds ratio=1.78; 95% CI=1.03-3.09 for constipation).

CONCLUSION

Our results demonstrate a relatively high prevalence of anal incontinence or constipation among women suffering from urinary dysfunction. Uterovaginal prolapse is the main risk factor associated with anorectal dysfunction.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females

PURPOSE

This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females.

METHODS

A representative sample of multiparous United Arab Emirates females aged 20 years or older (N = 450) were randomly selected from the community (n = 225) and health care centers (n = 225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire.

RESULTS

Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P < 0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent).

CONCLUSIONS

Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.

Effect of sacral nerve stimulation in patients with fecal and urinary incontinence

PURPOSE

Preliminary studies have shown improvement in fecal incontinence in several patients who received temporary or permanent stimulation. The purpose of this study was to report our experience in sacral nerve stimulation in the treatment of fecal incontinence and to target patients who would benefit most from stimulation.

METHODS

Patients with fecal incontinence were studied clinically and manometrically before, during, and after temporary nerve stimulation. If temporary nerve stimulation was clinically successful, the patient was implanted and followed up for six months.

RESULTS

Nine patients (6 female) with a mean age of 50.7 +/- 12.3 years underwent temporary nerve stimulation. Temporary nerve stimulation was successful in eight patients, six of whom were implanted. Of the patients who could be evaluated, three of five had improved at the six-month follow-up visit, particularly in relation to the number of urgency episodes and delay in postponing defecation. All implanted patients had urinary symptoms. Urinary urgency was also improved by stimulation. During temporary nerve stimulation, the maximal squeeze pressure amplitude increased. After implantation, only the duration of maximal squeeze pressure seemed to improve.

CONCLUSION

Sacral nerve stimulation can be used in the management of fecal incontinence, particularly in cases of urge fecal incontinence associated with urinary urgency. This study seems to confirm the effect of sacral nerve stimulation on striated sphincter function.