Menopause and obstetric history as risk factors for fecal incontinence in women

Innovating Care for Postmenopausal Women Using a Digital Approach for Pelvic Floor Dysfunctions: Prospective Longitudinal Cohort Study

Background

The menopause transition is a significant life milestone that impacts quality of life and work performance. Among menopause-related conditions, pelvic floor dysfunctions (PFDs) affect ∼40%-50% of postmenopausal women, including urinary or fecal incontinence, genito-pelvic pain, and pelvic organ prolapse. While pelvic floor muscle training (PFMT) is the primary treatment, access barriers leave many untreated, advocating for new care delivery models.

Objective

This study aims to assess the outcomes of a digital pelvic program, combining PFMT and education, in postmenopausal women with PFDs.

Methods

This prospective, longitudinal study evaluated engagement, safety, and clinical outcomes of a remote digital pelvic program among postmenopausal women (n=3051) with PFDs. Education and real-time biofeedback PFMT sessions were delivered through a mobile app. The intervention was asynchronously monitored and tailored by a physical therapist specializing in pelvic health. Clinical measures assessed pelvic floor symptoms and their impact on daily life (Pelvic Floor Impact Questionnaire-short form 7, Urinary Impact Questionnaire-short form 7, Colorectal-Anal Impact Questionnaire-short form 7, and Pelvic Organ Prolapse Impact Questionnaire-short form 7), mental health, and work productivity and activity impairment. Structural equation modeling and minimal clinically important change response rates were used for analysis.

Results

The digital pelvic program had a high completion rate of 77.6% (2367/3051), as well as a high engagement and satisfaction level (8.6 out of 10). The safety of the intervention was supported by the low number of adverse events reported (21/3051, 0.69%). The overall impact of pelvic floor symptoms in participants' daily lives decreased significantly (-19.55 points, 95% CI -22.22 to -16.88; P<.001; response rate of 59.5%, 95% CI 54.9%-63.9%), regardless of condition. Notably, nonwork-related activities and productivity impairment were reduced by around half at the intervention-end (-18.09, 95% CI -19.99 to -16.20 and -15.08, 95% CI -17.52 to -12.64, respectively; P<.001). Mental health also improved, with 76.1% (95% CI 60.7%-84.9%; unadjusted: 97/149, 65.1%) and 54.1% (95% CI 39%-68.5%; unadjusted: 70/155, 45.2%) of participants with moderate to severe symptomatology achieving the minimal clinically important change for anxiety and depression, respectively. Recovery was generally not influenced by the higher baseline symptoms' burden in individuals with younger age, high BMI, social deprivation, and residence in urban areas, except for pelvic health symptoms where lower BMI levels (P=.02) and higher social deprivation (P=.04) were associated with a steeper recovery.

Conclusions

This study demonstrates the feasibility, safety, and positive clinical outcomes of a fully remote digital pelvic program to significantly improve PFD symptoms, mental health, and work productivity in postmenopausal women while enhancing equitable access to personalized interventions that empower women to manage their condition and improve their quality of life.

Diastasis recti abdominis and pelvic floor dysfunction in peri- and postmenopausal women: a cross-sectional study

Introduction: Diastasis recti abdominis (DRA) and pelvic floor dysfunction (PFD) occurs commonly with aging; however, little is known about what leads to these changes.Objective: We aimed to investigate and compare the presence or absence of DRA and PFD in peri- and postmenopausal women.Methods: This cross-sectional study involved 150 participants who answered questions on their sociodemographic and clinical profiles related to urinary and fecal incontinence and pelvic organ prolapse. Diastasis recti abdominis was diagnosed with a digital caliper.Results: Supra-umbilical diastasis occurred in 37.3% of cases, and 78.6% of participants with DRA had PFD. No significant differences existed between participants with and without DRA in terms of background and clinical variables. However, participants with DRA were 2.6 times more likely to have PFD than participants without DRA. Furthermore, the presence of DRA was significantly shown to be a risk factor for PFD on binary logistic regression analyses (p = .01, OR = 3.2).Conclusions: This cross-sectional study suggests that DRA is a predictive factor of PFD in women aged over 50 years.

Effect of oestrogen therapy on faecal incontinence in postmenopausal women: a systematic review

INTRODUCTION AND HYPOTHESIS

Faecal incontinence (FI) is prevalent in postmenopausal women. Oestrogen receptors have been identified in the anal sphincter and have been implicated in the pathogenesis and potential treatment. We sought to evaluate the literature regarding the impact of local and systemic oestrogen therapy on FI in postmenopausal women.

METHODS

A systematic review of all studies in postmenopausal women was performed to establish how oestrogen therapy affects FI. Eight articles were deemed eligible for inclusion following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Their quality was assessed using the Cochrane risk-of-bias tool (RoB-2) and Newcastle-Ottawa quality assessment scale.

RESULTS

One randomised controlled trial (RCT), two cohort studies, one observational and four cross-sectional studies were identified. The RCT showed an improvement in FI with anal oestrogen (p = 0.002), but this improvement was also observed in the placebo arm (p = 0.013) and no difference was seen between these groups. A prospective observational study demonstrated significant improvement with an oestrogen patch (p = 0.004), but had no control group. Conversely, a large prospective cohort study demonstrated an increased hazard ratio of FI with current (1.32; 95% CI, 1.20-1.45) and previous oestrogen use (1.26; 95% CI, 1.18-1.34) compared with non-users.

CONCLUSION

All studies had a high risk of bias and had conflicting views on the effects of oestrogen on FI in postmenopausal women. This review has identified the need for further research in this area by highlighting the paucity of good research for evidence-based practice. We believe that a further RCT of local oestrogen is mandated to draw a valid conclusion.

Secondary sphincter repair for anal incontinence following obstetric sphincter injury: functional outcome and quality of life at 18 years of follow-up

AIM

Secondary sphincter repair has been the conventional management of anal incontinence (AI) when a structural defect in the sphincter is recognized. However, disappointing long-term results have contributed to a tendency towards an increasing use of alternative treatment methods. This study aimed to assess the long-term functional outcomes following a secondary sphincter repair in women with AI after obstetric sphincter injury.

METHOD

This is a questionnaire study of women who underwent a secondary sphincter repair in Denmark between January 1990 and December 2005. Patients were identified through the Danish National Patient Registry. Functional outcomes were assessed by a self-administered questionnaire in 2010 and 2018. Primary outcomes were Wexner and St. Mark's scores. Impact on quality of life was assessed using the Fecal Incontinence Quality of Life Scale.

RESULTS

Functional outcome was assessed in 370 women in 2010 and 255 women in 2018. At 18.3 [interquartile range (IQR 15.0-22.0)] years of follow-up, the mean ± SD Wexner score was 8.8 ± 4.8 and the mean St. Mark's score was 11.7 ± 5.0. Flatus incontinence was the most frequent symptom, reported by 97%. Incontinence for liquid and solid stools was reported by 75% and 54%, respectively. There were no significant changes in incontinence frequencies over time. Women with a Wexner score of ≥ 9 had a significantly lower quality of life score in all domains than did women with a Wexner score of < 9 (P < 0.001).

CONCLUSION

At long-term follow-up, few patients are fully continent following a secondary sphincter repair. However, it appears that the functional results remain stable at very long-term follow-up.

Defective Conduction of Anorectal Afferents Is a Very Prevalent Pathophysiological Factor Associated to Fecal Incontinence in Women

Background/Aims

Fecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughly researched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women, specifically, the conduction through efferent/afferent neural pathways.

Methods

A cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study included anorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) and sensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42 and 38 patients, respectively.

Results

The main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39 ± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%, respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter (60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEP and RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. In contrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients.

Conclusions

Pathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to a lesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also very prevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.

Altered defaecatory behaviour and faecal incontinence in a video-tracked animal model of pudendal neuropathy

AIM

The aim was to develop a behavioural animal model of faecal continence and assess the effect of retro-uterine balloon inflation (RBI) injury. RBI in the rat causes pudendal neuropathy, a risk factor for obstetric related faecal incontinence in humans.

METHOD

Video-tracking of healthy rats (n = 12) in a cage containing a latrine box was used to monitor their defaecatory behaviour index (DBI) over 2 weeks. The DBI (range 0-1) was devised by dividing the defaecation rate (pellets per hour) outside the latrine by that of the whole cage. A score of 0 indicates all pellets were deposited in the latrine. Subsequently, the effects of RBI (n = 19), sham surgery (n = 4) and colostomy (n = 2) were determined by monitoring the DBI for 2 weeks preoperatively and 3 weeks postoperatively.

RESULTS

The DBI for healthy rats was 0.1 ± 0.03 with no significant change over 2 weeks (P = 0.71). In the RBI group, 13 of 19 rats (68%) showed no significant change in DBI postoperatively (0.08 ±  -0.05 vs 0.11 ±  -0.07) while in six rats the DBI increased from 0.16 ±  -0.09 to 0.46 ± 0.23. The negative control, sham surgery, did not significantly affect the DBI (0.09 ± 0.06 vs 0.08 ± 0.04, P = 0.14). The positive control, colostomy, increased the DBI from 0.26 ± 0.03 to 0.86 ± 0.08.

CONCLUSIONS

This is the first study showing a quantifiable change in defaecatory behaviour following injury in an animal model. This model of pudendal neuropathy affects continence in 32% of rats and provides a basis for research on interventions for incontinence.

Identifying factors associated with clinical success in patients treated with NASHA(®)/Dx injection for fecal incontinence

Purpose

Injection with the bulking agent consisting of non-animal stabilized hyaluronic acid/dextranomer (NASHA^®/Dx) is well tolerated and efficacious for the treatment of fecal incontinence (FI); however, the patient population that may derive maximum benefit has not been established. This post hoc responder analysis assessed demographic and baseline characteristics predictive of responsiveness to NASHA/Dx treatment.

Methods

Adults with a Cleveland Clinic Florida fecal incontinence score (CCFIS) ≥10 were randomized to receive NASHA/Dx or sham treatment. The primary end point was response to treatment (ie, decrease from baseline of ≥50% in number of FI episodes) at 6 months; a prespecified secondary end point was change in fecal incontinence quality of life (FIQL) score at 6 months. Post hoc subgroup analyses were performed for baseline and demographic characteristics and prior FI treatments.

Results

Overall, response to treatment was significantly greater with NASHA/Dx versus sham injection (52.7% vs 32.1%; P=0.0089). All subgroups analyzed demonstrated evidence of improvement, favoring NASHA/Dx versus sham treatment for both response to treatment and change in the FIQL coping/behavior subscale score. For the primary end point, a significantly greater percentage of patients with CCFIS ≤15, FI symptoms ≤5 years’ duration, or obstetric causes of FI responded to NASHA/Dx treatment versus patients receiving sham treatment (51.1% vs 28.3%, P=0.0169; 55.4% vs 25.7%, P=0.0026; and 53.6% vs 23.1%, P=0.0191, respectively). The mean change in the FIQL coping/behavior score significantly favored NASHA/Dx versus sham treatment for patients with CCFIS ≤15 (P=0.0371), FI symptoms ≤5 years’ duration (P=0.0289), or obstetric causes of FI (P=0.0384). Patients without a history of specific FI treatments (eg, antidiarrheal medications, biofeedback, surgery) were more likely to respond to NASHA/Dx versus sham treatment for both end points.

Conclusion

Although all subgroups analyzed showed evidence of quantitative and qualitative benefit from NASHA/Dx therapy, patients with characteristics indicative of mild-to-moderate FI may exhibit the greatest benefit.

Prevalence of Fecal Incontinence in Women During Pregnancy: A Large Cross-Sectional Study

BACKGROUND

Although some studies have analyzed the prevalence of urinary incontinence during pregnancy, there are scarce data on the frequency and characteristics of fecal incontinence during this period.

OBJECTIVE

The aim of this study was to determine the incidence and characteristics of women with fecal incontinence symptoms during early and late pregnancy, to evaluate its impact on quality of life, and to identify whether there is a specific clinical pattern that could identify patients at risk.

DESIGN

This was a cross-sectional observational study.

SETTINGS

The study was conducted at the maternity unit of a university tertiary care center.

PATIENTS

Pregnant women undergoing obstetric follow-up were included in the study.

MAIN OUTCOME MEASURES

A prospective study was conducted. All of the patients attending our maternity unit for obstetric ultrasound examination during the first and third trimesters were eligible for inclusion. Selected patients completed a self-reported questionnaire that included items on fecal incontinence, Wexner score, and stool consistency. Quality of life was assessed using the Medical Outcomes Study Short Form 36.

RESULTS

The study included 228 consecutive pregnant women. Ninety-three patients (40.8%) had some episode of fecal incontinence in the 4 weeks before the survey, 15 patients with solid stool, 6 patients with liquid stools, and 72 with flatus. In these patients, the mean Wexner score was 3.82 (range, 2.0-13.0). In patients with incontinence, quality of life was significantly affected in most subscales of Medical Outcomes Study Short Form 36. There were no significant differences in the following variables between patients with and without symptoms of fecal incontinence, including age (p = 0.090), BMI (p = 0.094), history of previous deliveries (p = 0.492), trimester of pregnancy (p = 0.361), and Bristol Stool Form Scale (p = 0.388).

LIMITATIONS

The cross-sectional design hampered identification of specific time at which the impact of pregnancy occurred.

CONCLUSIONS

The prevalence of fecal incontinence is high during pregnancy with a notable impact on quality of life. There was no specific clinical pattern during pregnancy that could define patients at risk for fecal incontinence during this period of life.

Current and emerging treatment options for fecal incontinence

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

Effect on anal pressure of percutaneous posterior tibial nerve stimulation for faecal incontinence

AIM

Previous studies on percutaneous posterior tibial nerve stimulation (PTNS) for faecal incontinence do not report anal pressure changes. In the present study the effect of percutaneous PTNS on anal manometry was determined.

METHOD

This was a prospective observational study of patients with faecal incontinence. They underwent one 30-min session of PTNS weekly for 12 consecutive weeks. Patients who showed improvement were given six more sessions at 2-weekly intervals. Anal manometry was performed before and after treatment. Clinical data including the Wexner score, psychological testing, quality of life using the Fecal Incontinence Quality of Life Score and the contents of a continence diary were recorded before and after the procedure.

RESULTS

Twenty-four patients were included in the study of whom 17 (70.83%) demonstrated some degree of clinical or manometric improvement at 3 months. Before treatment 18 patients had urgency of <1 min. At 3 and 6 months this had risen to 5 min in 62.5% and 70.83% (P < 0.001). The anal resting pressure increased from 21.7 to 37.6 mmHg (P = 0.021), the maximum squeeze pressure from 58.2 to 72.2 mmHg (P = 0.045) and the Wexner score fell from 15 to 10 (P = 0.018) at 6 months. Predictive factors for a response included fewer than three incontinent episodes per week (P = 0.027). Negative predictive factors included episiotomy and an initial Wexner score of > 12 (P = 0.035).

CONCLUSION

Percutaneous PTNS was effective in over 70% of patients in the present study with improvements in urgency, anal pressures and Wexner score.

What's New in the Toolbox for Constipation and Fecal Incontinence?

Constipation and fecal incontinence (FI) are common complaints predominantly affecting the elderly and women. They are associated with significant morbidity and high healthcare costs. The causes are often multi-factorial and overlapping. With the advent of new technologies, we have a better understanding of their underlying pathophysiology which may involve disruption at any levels along the gut-brain-microbiota axis. Initial approach to management should always be the exclusion of secondary causes. Mild symptoms can be approached with conservative measures that may include dietary modifications, exercise, and medications. New prokinetics (e.g., prucalopride) and secretagogues (e.g., lubiprostone and linaclotide) are effective and safe in constipation. Biofeedback is the treatment of choice for dyssynergic defecation. Refractory constipation may respond to neuromodulation therapy with colectomy as the last resort especially for slow-transit constipation of neuropathic origin. Likewise, in refractory FI, less invasive approach can be tried first before progressing to more invasive surgical approach. Injectable bulking agents, sacral nerve stimulation, and SECCA procedure have modest efficacy but safe and less invasive. Surgery has equivocal efficacy but there are promising new techniques including dynamic graciloplasty, artificial bowel sphincter, and magnetic anal sphincter. Despite being challenging, there are no short of alternatives in our toolbox for the management of constipation and FI.

Urogynecological effects of menopause

The menopause signifies a period after significant hormonal change that affects all estrogen-sensitive tissues. This change may result in symptoms affecting any part of the urogenital system. These changes can significantly affect women's health and quality of life. The menopause is associated with lower urinary tract symptoms, vulvovaginal symptoms and pelvic organ prolapse. In this article, we have aimed to describe the symptomatology along with pathophysiology of the effects of menopause on urogynecological problems affecting women's health. Other factors apart from menopause add to these symptoms, like parity, mode of delivery, obesity, smoking and poor psychological health.

Prevalence of anal incontinence among Norwegian women: a cross-sectional study

OBJECTIVE

Anal incontinence (AI) is a symptom associated with age, bowel symptoms and obstetric injuries. Primary aim of the study was to establish the prevalence of AI among women and secondarily to evaluate the impact on daily life and conditions associated with AI.

DESIGN

A cross-sectional study.

SETTING

Participants attended research stations located in different parts of Nord-Trøndelag county, Norway. Data were collected through interviews, questionnaires and clinical examinations.

PARTICIPANTS

In total, 40 955 community-dwelling women aged 30 years and older were invited. A total of 25 037 women participated, giving a participation rate of 61.1%.

PRIMARY AND SECONDARY OUTCOME MEASURES

Fecal incontinence and flatal incontinence was defined as involuntary loss of feces and flatus weekly or more, respectively. AI was defined as the involuntary loss of feces and/or flatus weekly or more. Urgency was defined as the inability to defer defecation for 15 min. Statistical methods included prevalence estimates and logistic regression analysis.

RESULTS

Questions about AI were completed by 20 391 (82.4%) women. Among the 20 391 women, AI was reported by 19.1% (95% CI 18.6% to 19.7%) and fecal incontinence was reported by 3.0% (95% CI 2.8% to 3.2%). Urgency was experienced by 2586 women (12.7%, 95% CI 12.2 to 13.1). Impact on daily life was stated by 794 (26.0%, 95% CI 24.4 to 27.5) women with AI. In bivariate age-adjusted analysis of AI, OR and CI for urgency (OR 3.19, 95% CI 2.92 to 3.49) and diarrhoea (OR 3.81, 95% CI 3.32 to 4.38) revealed strongest associations with AI.

CONCLUSIONS

AI affects one in five women older than 30 years. Strongest associated symptoms are urgency and diarrhoea.

TRIAL REGISTRATION NUMBER

The study was approved by the Regional Committee for Medical and Health Research Ethics (No. 2009/1214) and followed the Declaration of Helsinki.