Fecal incontinence after high-risk delivery

Obstetric risk factors for anorectal dysfunction after delivery: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Pregnancy and childbirth are considered risk factors for pelvic floor dysfunction, including anorectal dysfunction. We aimed to assess the effect of obstetric events on anal incontinence and constipation after delivery.

METHODS

We systematically reviewed the literature by searching MEDLINE, Embase and CENTRAL. We included studies in women after childbirth examining the association between obstetric events and anorectal dysfunction assessed through validated questionnaires. We selected eligible studies and clustered the data according to the type of dysfunction, obstetric event and interval from delivery. We assessed risk of bias using the Newcastle Ottawa Scale and we performed a random-effects meta-analysis and reported the results as odds ratios (ORs) with their 95% confidence intervals. Heterogeneity across studies was assessed using I² statistics.

RESULTS

Anal sphincter injury (OR: 2.44 [1.92-3.09]) and operative delivery were risk factors for anal incontinence (forceps-OR :1.35 [1.12-1.63]; vacuum-OR: 1.17 [1.04-1.31]). Spontaneous vaginal delivery increased the risk of anal incontinence compared with caesarean section (OR: 1.27 [1.07-1.50]). Maternal obesity (OR:1.48 [1.28-1.72]) and advanced maternal age (OR: 1.56 [1.30-1.88]) were risk factors for anal incontinence. The evidence on incontinence is of low certainty owing to the observational nature of the studies. No evidence was retrieved regarding constipation after delivery because of a lack of standardised validated assessment tools.

CONCLUSIONS

Besides anal sphincter injury, forceps delivery, maternal obesity and advanced age were associated with higher odds of anal incontinence, whereas caesarean section is protective. We could not identify obstetric risk factors for postpartum constipation, as few prospective studies addressed this question and none used a standardised validated questionnaire.

Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type

Gastrointestinal involvement is a well known complication of Ehlers-Danlos syndromes (EDSs), mainly in form of abdominal emergencies due to intestinal/abdominal vessels rupture in vascular EDS. In the last decade, a growing number of works investigated the relationship between a wide spectrum of chronic gastrointestinal complaints and various EDS forms, among which the hypermobility type (a.k.a. joint hypermobility syndrome; JHS/EDS-HT) was the most studied. The emerging findings depict a major role for gastrointestinal involvement in the health status and, consequently, management of JHS/EDS-HT patients. Nevertheless, fragmentation of knowledge limits its impact on practice within the boundaries of highly specialized clinics. In this paper, literature review on gastrointestinal manifestations in JHS/EDS-HT was carried out and identified papers categorized as (i) case-control/cohort studies associating (apparently non-syndromic) joint hypermobility and gastrointestinal involvement, (ii) case-control/cohort studies associating JHS/EDS-HT and gastrointestinal involvement, (iii) case reports/series on various gastrointestinal complications in (presumed) JHS/EDS-HT, and (iv) studies reporting gastrointestinal features in heterogeneous EDS patients' cohorts. Gastrointestinal manifestations of JHS/EDS-HT were organized and discussed in two categories, including structural anomalies (i.e., abdominal/diaphragmatic hernias, internal organ/pelvic prolapses, intestinal intussusceptions) and functional features (i.e., dysphagia, gastro-esophageal reflux, dyspepsia, recurrent abdominal pain, constipation/diarrhea), with emphasis on practice and future implications. In the second part of this paper, a summary of possible nutritional interventions in JHS/EDS-HT was presented. Supplementation strategies were borrowed from data available for general population with minor modifications in the light of recent discoveries in the pathogenesis of selected JHS/EDS-HT features.

The epidemiology of anal incontinence and symptom severity scoring

For many patients, anal incontinence (AI) is a devastating condition that can lead to social isolation and loss of independence, contributing to a substantial economic health burden, not only for the individual but also for the allocation of healthcare resources. Its prevalence is underestimated because of poor patient reporting, with many unrecorded but symptomatic cases residing in nursing homes. Endosonography has improved our understanding of the incidence of post-obstetric sphincter tears that are potentially suitable for repair and those cases resulting from anorectal surgery, most notably after fistula and hemorrhoid operations. The clinical scoring systems assessing the severity of AI are discussed in this review, along with their limitations. Improvements in the standardization of these scales will advance our understanding of treatment response in an era where the therapeutic options have multiplied and will permit a better comparison between specific therapies.

Fecal incontinence in older patients

Fecal incontinence (FI), the involuntary passage of fecal material through the anus, is a common medical problem in older people, especially in frail older nursing home residents. FI is often associated with urinary incontinence. Severe constipation leading to fecal impaction, laxative abuse, diarrhea, cognitive impairment, senescence, and neuromuscular disorders including autonomic neuropathy, are among the leading causes of FI in older patients. FI affects patients' physical and psychological well-being, and is responsible for considerable morbidity and mortality in older patients. This results in significant healthcare costs. Comprehensive management of this disorder requires a systematic approach including thorough history, physical examination, and step-wise evaluation. This review in contrast to others published in last decade, focuses on management of FI in frail older nursing home patients, who require an individualized approach, which should be minimally invasive and cost-effective. In many cases of FI, treatment of the underlying condition; adequate control of diarrhea, constipation, or fecal impaction; adjustment of medications; and proper feeding may control or reduce FI. Advanced tests are often not necessary in this population.