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Medical News and Perspectives
March 22/29, 2006

Silence Masks Prevalence of Fecal Incontinence

JAMA. 2006;295(12):1362-1363. doi:10.1001/jama.295.12.1362

Fecal incontinence can have a devastating impact on a woman's life, yet few women with this problem seek help from their physicians. This silence makes it difficult for physicians to assess how common the problem is, and it prevents women from receiving treatment. Now, results from a pair of large, community-based studies may help lift this veil of secrecy and enable physicians to identify patients who need care.

One study—conducted by researchers from the University of Washington, Seattle; the University of Michigan, Ann Arbor; and the Group Health Cooperative of Puget Sound, a Seattle-based health insurer—found that about 7% of women experience fecal incontinence at least once a month and that the condition is even more common among older women (Melville JL et al. Am J Obstet Gynecol. 2005;193:2071-2076). A second study, by researchers from the Mayo Clinic College of Medicine and the Olmstead Medical Center, Rochester, Minn, found that more than 1 in 10 women have had fecal incontinence in the past year (Bharucha AE. Gastroenterology. 2005;129:42-49).

For the first study, the scientists mailed a survey to an age-stratified random sample of 6000 women, aged 30 to 90 years, enrolled in a health maintenance organization in Washington state. Of the 5531 who were deemed eligible to participate, 64% (3536) responded and about 7% of the responders reported having fecal incontinence at least once a month. But the prevalence in the general female population in the United States is likely to be closer to 8% when these statistics are adjusted for the overrepresentation of younger women in the study, said Dee E. Fenner, MD, a member of the research team and associate professor in the Department of Obstetrics and Gynecology of the University of Michigan Health System in Ann Arbor.

In the second study, a survey was sent to an age-stratified random sample of 5300 women in Olmstead County, Minnesota, using the Rochester Epidemiology Project System. Of those women surveyed, 2800 (53%) responded; of the responders, more than 1 in 10 had experienced fecal incontinence in the past year, and almost 1 in 15 had experienced moderate to severe fecal incontinence. Adil E. Bharucha, MD, lead author of the Minnesota study and associate professor of medicine at the Mayo Clinic College of Medicine, said the prevalence of fecal incontinence in both studies is consistent with previous research and that differences in prevalence between the studies are most likely due to differences in the populations surveyed or in the way the condition was defined.

In both studies, women who experienced loss of either liquid or solid fecal material reported important effects on their lives. In the Washington-based study, half the women reported that the condition affected their quality of life, requiring them to use pads or alter their lifestyle. In the Minnesota-based study, 34% reported using an aid such as a pad, and 23% reported that the condition had a moderate to severe impact on at least one of the following areas: activities at home, activities away from home, and ability to travel.

“Patients will report not only that they have to wear pads or diapers, but that they plan their lives around defecation, or they don't plan [activities] at all,” said Jennifer Christie, MD, director of the Mount Sinai Women's Gastrointestinal Health Center. “They can become reclusive and depressed.”

WOMEN AT RISK

While fecal incontinence is not uniquely a women's condition, women are at greatest risk, and the etiology of the disorder is different between the sexes. Even among women, the condition has various possible causes, including injury during childbirth, diseases such as irritable bowel syndrome or diabetes, or neurological impairment (Cooper ZR and Rose S. Mt Sinai J Med. 2000;67:96-105).

Older age is often associated with the disorder, but fecal incontinence is not a normal part of aging, said Fenner. Not all older women develop the problem, and young women also may have it. Among the women in the Minnesota study who reported having fecal incontinence, 31% first experienced it before age 40 years. Another 37% first noticed symptoms between the ages of 41 and 60 years, and 32% had their first symptoms between the ages of 61 and 80 years, Bharucha and his colleagues reported.

Fenner and colleagues identified several medical conditions or aspects of an individual's medical history that are associated with the disorder. In their study, fecal incontinence was strongly linked with major depression, urinary incontinence, comorbid medical illness, and a history of vaginal delivery involving forceps or vacuum-assisted devices. Older age, higher body mass index, higher number of deliveries, and previous hysterectomy were also associated with the condition.

The relationship with depression was somewhat surprising but “we can't determine cause and effect,” Fenner said. She explained that it makes sense that a woman may feel depressed because she cannot control her bowels, but it is also possible that the altered levels of neurotransmitters in patients with depression may influence bowel function.

POSING THE QUESTION

Patients often have a hard time talking to their physicians about fecal incontinence because it is so personal, said Nancy J. Norton, president and founder of the International Foundation for Functional Gastrointestinal Disorders (http://www.iffgd.org). In fact, in the Minnesota study, only 10% of the women with fecal incontinence had consulted a physician for the symptom in the past year.

Because patients may be reluctant to broach the topic, physicians need to take the lead. “It's very important that physicians ask patients about their bowel function and their ability to control their bowels,” Norton said. Fenner, Christie, and Bharucha agreed, noting that it is especially important for physicians to ask patients at greatest risk—those with irritable bowel syndrome, diabetes, urinary incontinence, or diarrhea.

Christie said patients with fecal incontinence may present with diarrhea. “If a patient comes to you reporting diarrhea, it's prudent to probe and really understand what they mean by diarrhea. . . . If you peel back the layers, what they may be telling you is that they have incontinence.”

Interventions are available to help improve patients' bowel control and quality of life. “We have a broad range of treatment modalities, depending on what we think the etiology of the woman's incontinence is,” Fenner said.

For women with diarrhea, treatments may include the use of diet or medication to try to make the stool more solid. For women with very frequent stooling, physicians may use diet or medication to slow gastrointestinal transit time and decrease frequency. Other treatments may include Kegel exercises to strengthen the pelvic floor muscles or biofeedback therapies to help restore control of the anal sphincter. Surgery remains an option for cases that are more extreme or do not respond to conservative treatments.

Risk Factors for Fecal Incontinence

  • Urinary incontinence

  • Irritable bowel syndrome

  • Diarrhea

  • Diabetes

  • Older age

  • Stroke/neurological disorders

  • High body mass index

  • Multiple vaginal deliveries

  • History of vaginal delivery with forceps or a vacuum-assisted device

  • Poor overall health

  • Previous hysterectomy

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