Recently I was invited to participate in a panel on fecal incontinence (FI) for a series, Second Opinion, being recorded by PBS television station WXXI in Rochester, New York. The program, one of 13 in a series on a wide variety of health topics, featured Dr. Peter Salgo of New York Presbyterian Hospital in New York City as host and included two colon & rectal surgeons as well as a patient from Cleveland Clinic, along with me. It was the first time the series had addressed fecal incontinence as a topic.
There are various definitions of "fecal incontinence" which covers lack of bowel control. When flatus, or loss over gas, is included in the definition, it is referred to as "anal incontinence." Otherwise, FI refers to the loss of control over stool, whether solid or liquid. Staining one's brief or underwear is incontinence if it is not caused by insufficient wiping following a bowel movement. As true with urinary incontinence, there are degrees of severity that also include frequency of incontinent episodes, or events.
Published prevalence estimates for FI among community-dwelling adults vary widely. This is due only in part to variation in definitions and how individuals interpret severity of symptoms. Incidence is also impacted by the willingness of individuals to report such symptoms, whether anonymously in a survey or when prompted privately by a visit with a healthcare provider. Although in 2001, the NIH estimated its prevalence to be 5.5 - 6.5 million, just six years later the NIH went on record estimating prevalence in the community to range from 6% in those women younger than 40 years to 15% in older women. Among men living in the community, FI is less prevalent but still ranges from 6-10%, also increasing with age1. The Mayo Clinic estimates that prevalence in women ranges from 7% beginning in the third decade of life to 22% by the sixth decade and increasing steadily from there, with symptoms categorized as mild (45%), moderate (50%), or severe (5%)2. Consequently, more than one in 10 adult women in the population has FI, with prevalence up to 70% among the most dependent residents of nursing homes.
Women are more susceptible to FI than men, in part because of nerve damage that occurs during prolonged labor and childbirth but also because women are more prone to suffer from constipation. Thus, vaginal delivery and chronic straining are risk factors for not only FI but double incontinence. Pudendal nerve neuropathy, particularly in women, may be responsible for deterioration of continence over the years3. It should come as no surprise that routine episiotomy and forceps delivery are the most easily preventable precipitating factors for fecal incontinence. Much more research is needed to understand risk factors, particularly for double incontinence. Half of all women with fecal incontinence are estimated to experience urinary incontinence, strongly suggesting underlying pelvic floor disorders. And twenty percent of those with urinary incontinence also suffer from fecal incontinence, indicating more than just anal sphincter deficiencies or tears.
The symptoms are a burden to patient and caregiver alike and come at both a psychological and economic cost of enormous proportions. That's the bad news.
The good news is that increasing options are becoming available to individuals to help manage and even eliminate symptoms. Behaviorally, dietary changes can improve consistency and frequency of bowel movements. Calcium-rich foods slow transit time. Fiber is an important bulking agent, especially for people experiencing chronic bouts of diarrhea. Biofeedback can improve the function of the anal sphincter if it's slightly damaged. An artificial anal sphincter is now FDA approved, and recently published research highlights the efficacy of the Interstim® device using pacemaker technology in treating fecal urgency in at least half of all patients receiving the implant4. Injectibles are also being investigated and new medication is soon coming onto the market.
No one should hide in embarrassment. Get educated and open the discussion.
1NIH State-of-the-Science Conference Statement on Prevention of Fecal and Urinary Incontinence in Adults, Volume 24, Number 1, December 10-12, 2007, National Institutes of Health, Washington, DC.
2 Bharucha AE, Zinsmeister AR, Locke GR, Seide BM, McKeon K, Schleck CD, and Melton LJ. (2005). Prevalence and burden of fecal incontinence: a population-based study in women. Gastroenterology, 129 (1): 42- 49.
3Lacima G and Pera M (2003). Combined fecal and urinary incontinence: an update. Current Opinion in Obstetrics & Gynecology, 15 (5): 405- 410.
4Kim DH, Faruqui N, and Ghoniem GM (2010). Sacral neuromodulation outcomes in patients with urinary urge incontinence and concomitant urge fecal incontinence. Female Pelvic Medicine and Reconstructive Surgery, 16(3), 171-178.
Published On: June 30, 2010