Incidence of fecal incontinence after childbirth

Outcomes of redo for failed colorectal or coloanal anastomoses: a systematic review and meta-analysis

PURPOSE

This study aimed to review the outcomes of redo procedures for failed colorectal or coloanal anastomoses.

METHODS

A systematic review was performed using the PubMed, Embase, Cochrane, and LILACS databases. The inclusion criteria were adult patients undergoing colectomy with primary colorectal or coloanal anastomosis and studies that assessed the postoperative results. The protocol is registered in PROSPERO (No. CRD42021267715).

RESULTS

Eleven articles met the eligibility criteria and were selected. The studied population size ranged from 7 to 78 patients. The overall mortality rate was 0% (95% confidence interval [CI], 0%-0.01%). The postoperative complication rate was 40% (95% CI, 40%-50%). The length of hospital stay was 13.68 days (95% CI, 11.3-16.06 days). After redo surgery, 82% of the patients were free of stoma (95% CI, 75%-90%), and 24% of patients (95% CI, 0%-39%) had fecal incontinence. Neoadjuvant chemoradiotherapy (P=0.002) was associated with a lower probability of being free of stoma in meta-regression.

CONCLUSION

Redo colorectal and coloanal anastomoses are strategies to restore colonic continuity. The decision to perform a redo operation should be based on a proper evaluation of the morbidity and mortality risks, the probability of remaining free of stoma, the quality of life, and a functional assessment.

Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas

OBJECTIVE

This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI.

STUDY DESIGN

This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations.

RESULTS

Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81).

CONCLUSION

Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI.

KEY POINTS

· Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..

3rd and 4th degree perineal tears that occurs during vaginal delivery

Objective: Perineal injuries are common in vaginal delivery. In this study, we aimed to investigate the factors affecting the degree of perineal injury and the effect of injury degree on incontinence. Methods: Fifteen patients, underwent sphincter repair by the general surgery unit, who had perineal tear during normal vaginal delivery between January 2018 and March 2019 in our hospital and were retrospectively evaluated. Those with grade 3a and 3b perineal tears were divided into 2 groups as group-1, and those with grade 3c and grade 4 perineal tears as group-2. Episiotomy type, fetal characteristics [head circumference and birth weight], early postoperative continence findings were compared in between groups. Results: The average age of the patients was 30 ± 8.7 years. When the groups were compared, there was no significant superiority of episiotomy in terms of perineal injury (p=0.07). 4 patients had 3a, 3 patients had 3b, 6 patients had 3c and 2 patients had fourth-degree perineal injuries. The average birth weight of the newborns was 3438 ± 492 g, and the head circumference was 34.33 ± 1.23 cm. There was no significant difference in incontinence between the groups (p=0.55). Conclusıon: The treatment of anorectal injuries is surgery. The method of treatment varies according to the time elapsed between injury and intervention, fecal contamination, degree of injury, general condition of the patient, presence of accompanying injury, experience and preference of surgeon. We think that sphincter damage during delivery can be looked after successfully with early diagnosis and intervention before tissue edema develops.

Prevalence of pelvic floor dysfunction: a Saudi national survey

BACKGROUND

Pelvic Floor Dysfunction (PFD) is a global health problem affecting millions of women worldwide and comprises a broad range of clinical dysfunctions such as urinary incontinence (UI), fecal incontinence (FI), pelvic organ prolapse (POP) vaginal laxity (VL), vaginal wind (VW), and overactive bladder (OAB). This study aims to estimate the prevalence of PFD among Saudi women attending primary health care centers (PHCCs) across 13 regions of Saudi Arabia and their characteristics along with associated factors.

METHODS

A cross-sectional study was conducted on 2,289 non-pregnant women. The probability population proportional sampling technique was employed followed by a convenient sampling technique to recruit eligible women. Types of PFD were assessed using a self-administered electronic questionnaire. Pelvic Floor Distress Index (PFDI-20) was used to assess the primary study outcomes (FI, VL, POP, VW, and OAB). A multivariate logistic regression model was used to identify independent associated factors for PFD.

RESULTS

The findings showed that 830 women (36.3%) had any type of UI. Stress UI affected726 (31.7%) women, whilst 525 women (22.9%) had urge UI. VL occurred in 505 women (22.1%), whilst POP occurred in 536 women (23.4%). VW occurred in 733 participants and (32%) 1238 women (54.1%) had OAB. The multivariate analysis suggested that region, location, parity, and assisted birth were significantly associated with UI, VL, FI and PFD (P < 0.001).

CONCLUSION

PFD is a common condition among Saudi women. UI, VL, VW, OAB, POP and FI increased consistently among urban women with increased age, greater parity, assisted birth, and post-menopausal status.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

OBJECTIVES

Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI.

METHODS

In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter.

RESULTS

In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001).

CONCLUSIONS

Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Group-based pelvic floor muscle training for all women during pregnancy is more cost-effective than postnatal training for women with urinary incontinence: cost-effectiveness analysis of a systematic review

QUESTION

What is the most cost-effective way of providing pelvic floor muscle training (PFMT) to prevent or treat postpartum incontinence?

DESIGN

Meta-analysis and cost-effectiveness analysis of models of care included in a recent Cochrane systematic review.

PARTICIPANTS

Pregnant and postnatal women.

INTERVENTION

Supervised PFMT for preventing or treating urinary and/or faecal incontinence.

OUTCOME MEASURES

Postpartum urinary or faecal incontinence.

ANALYSIS

We examined the comparative incremental cost effectiveness of different approaches to successfully prevent or cure one case of incontinence. Costs were valued in Australian dollars using publicly available market rates and enterprise agreements as of 2019. Comparisons involving group-based treatment approaches were subject to sensitivity analyses where the numbers of patients attending each group were varied to identify thresholds where recommendations change.

RESULTS

Seventeen trials were included for meta-analysis. Three models of care were clinically effective: individually supervised PFMT during pregnancy to prevent urinary incontinence (Model 1), group-based PFMT during pregnancy to prevent or treat urinary incontinence (Model 2) and individually supervised postnatal PFMT to treat urinary incontinence and prevent or treat faecal incontinence (Model 3). The health service costs per urinary incontinence case prevented or cured were $768 for Model 1, and $1,970 for Model 3. However, Model 2 generated a cost saving of $14 if there were eight participants per session, with greater savings if more participants attend. The health service cost per faecal incontinence case prevented or cured was $2,784 (Model 3).

CONCLUSION

Providing group-based PFMT for all women during pregnancy is likely more efficient than individual PFMT for incontinent women postnatally; however, providing PFMT for postnatal women with urinary incontinence should not be discounted because of the added known benefit for preventing and treating faecal incontinence.

ICS debate article-childbirth, modes of delivery, and pelvic floor dysfunction-challenges in educating women about modes of delivery and granting an informed decision process

The impact of the mode of birth on the mother and fetus has been a popular topic for a long-standing debate. Several morbidities have been associated with one mode of delivery or another. When this debate focuses specifically on the effects of vaginal birth or cesarean delivery on pelvic floor function and dysfunction, current research-based evidence fails to provide clear answers as many contributing and confounding factors, and other limitations inherent to the evidence itself blur the links between causes and outcomes. This debate article provides and overview of the biopsychosocial gaps on this subject and raises questions to the current state in patient counselling on labour and delivery.

INCREASED OASIS INCIDENCE - INDICATOR OF THE QUALITY OF OBSTETRIC CARE?

In the era of new molecular, epigenetic and proteomic discoveries, birth canal injuries seem like outdated discussion. A vast increase in the incidence of obstetric anal sphincter injuries (OASIS) has been recorded in the last two decades despite advantages in modern medicine and new obstetric methods. This increase might be attributed to the new classification of perineal injury but also to the new imaging methods, including endoanal sonography, which earlier identifies injuries that previously were considered to be occult and actually underwent unrecognized, and which should have been recognized immediately postpartum. OASIS are third and fourth degree perineal injuries that occur during delivery. The reported incidence of OASIS varies from 0.1% to 10.9%. It is well known that third and fourth degree perineal injuries occur more often in primiparae, and in cases of macrosomic newborn, dorsoposterior position of fetal head and shoulder dystocia. The protective role of episiotomy is controversial. Birth canal injury during delivery can happen to any parturient woman. It is important for obstetricians to have this in mind at every delivery. Repercussions of OASIS are serious and can persist for life. They include emotional, psychological, social, physical and sexual disturbances. Therefore, it is very important to recognize the risk factors, diagnose the injury on time and treat it properly by a multidisciplinary team. Accordingly, it can be concluded that the increased incidence of OASIS is a result of better recognition of the risk factors, reduced rates of unrecognized sphincter injuries, adoption of the new classification and better postpartum imagining methods for detection of occult injuries.

Non-surgical acute traumatic perianal injuries

Objectives

The diagnosis of fecal incontinence is challenging and complex. One of the most significant causes of fecal incontinence is trauma in the perianal area. The most important cause of such trauma is birth trauma. It is hard to evaluate patients and plan treatment. Surgical method is determined by the severity of sphincter damage and injuries formed in the organs in the perianal area. The aim of this study, therefore, was to analyze the cases of patients who had undergone sphincter repair because of acute injuries in the perianal area.

Material and Methods

The cases of 15 patients with perianal area injuries who had presented to Necmettin Erbakan University Meram Medical School's General Surgery Clinic between 2010 and 2015 were retrospectively analyzed. Data on age, sex, form of injury, severity of injury, time of first response, form of repair, injury problems, and post-operative complications of the patients were investigated. The patients' long-term results were analyzed.

Results

While 5 of the patients were male, 10 were female. 9 of the female patients had birth trauma, while one had injury during sexual intercourse. While all of the patients received sphincteroplasty, 10 had levatoroplasty. All the female patients received vaginoplasty.

Conclusion

We are of the opinion that it is significant to have surgical intervention before tissue edema develops.

Delivery mode, levator avulsion and obstetric anal sphincter injury: A cross-sectional study 20 years after childbirth

BACKGROUND

Levator ani muscle (LAM) and anal sphincter injuries are common after vaginal birth and are associated with pelvic organ prolapse and anal incontinence.

AIMS

Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.

METHODS

All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ² test and results are expressed as odds ratios (OR).

RESULTS

Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.

CONCLUSIONS

Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.

Fecal and Urinary Incontinence Associated with Pregnancy and Childbirth

Introduction:

Fecal incontinence (FI) and urinary incontinence (UI) are major problems faced by women worldwide, with pregnancy and delivery representing two major risk factors for these conditions. The prevalence of FI and UI varies across studies. In our region, only a few publications have addressed this topic.

Aim:

The aim of this study was to determine the prevalence of FI and UI in Saudi pregnant women, their characteristics, and a specific clinical pattern that could identify patients that are at a risk for incontinence.

Materials and Methods:

This was a questionnaire-based crosssectional study conducted over a 3 months period in 2017, among pregnant women attending King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

Results:

Our study included 393 pregnant women. FI was reported by 24 patients (6.1%), and fecal urgency was reported by 30.5%. UI was reported by 84 patients (21.4 %). When patients with no UI were compared with patients with UI, the only statistically significant factor was BMI (p = 0.043). There were no statistically significant differences when comparing patients with FI versus no-FI, and fecal urgency versus no-fecal urgency. However, laceration (OR: 1.696, p = 0.036), episiotomy (OR: 1.413, p = 0.029), constipation (OR: 1.944, p < 0.001), hypertension (OR: 1.993, p = 0.022), and Bristol stool scale score (p = 0.002) were statistically significant factors for determining fecal control.

Conclusion:

FI and UI are frequently associated with pregnancy and delivery, but their prevalence is underestimated. The role of the practitioner is crucial in preventing and treating these conditions, and in impeding their harmful effects on the postpregnancy quality of life of Saudi women.

Third and Fourth Degree Perineal Tear in Four-Year Period at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia

OBJECTIVES:

Obstetric anal sphincter injury (OASIS) includes the third and fourth degree of perineal injury. The risk for OASIS is about 1% of all vaginal deliveries. If not recognised and treated properly, obstetric anal sphincter injury can have serious consequences for reproductive age woman.

MATERIAL AND METHODS:

We have retrospectively gathered and analysed data on obstetric anal sphincter injury in a four-year period at our department. The control group in this study included vaginal deliveries in 2012.

RESULTS:

We recorded 0.34% third and fourth degree of perineal injury in all vaginal deliveries, and 87.9% of those patients were primiparae. Episiotomy was performed in 57.6% of all women with obstetric anal sphincter injury. In 30.3% of cases, newborns were large for gestational age. Gestational diabetes was found in 9.1% of OASIS cases, occipitoposterior position was found in 9.1% of cases. Induced labour took place in 39.4%, and oxytocin infusion was applied in 60.6% of OASIS cases. Vacuum extraction was performed in 12.1% of deliveries with OASIS. The average BMI in 3a and 3b injuries was 29.9. In 3c degree it was 28.0, and in the fourth degree, it was 32.1. In 27.0% of OASIS cases due to the extent of the injury surgeon engagement was necessary. When compared with vaginal deliveries in 2012 we found a significant increase in OASIS in primiparas, large for gestational age, occipitoposterior position, induced labour, vacuum extraction and hypertension (P < 0.01). There is also increased incidence of OASIS in episiotomy and oxytocin use group (P < 0.05).

CONCLUSION:

Low incidence of OASIS in our department is a result of active management of delivery, manual perineal protection and timely episiotomy.

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function

PURPOSE

To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure.

METHODS

A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions.

RESULTS

Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain.

CONCLUSIONS

OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Prevalence and predictors of double incontinence 1 year after first delivery

INTRODUCTION AND HYPOTHESIS

Urinary (UI) and anal incontinence (AI) are common pelvic floor disorders (PFD), and postpartum women experiencing double incontinence (DI), the combination of UI and AI, tend to have more severe symptoms and a greater impact on quality of life. Our objective was to investigate the prevalence and predictors of postpartum DI and UI alone 1 year after first delivery.

METHODS

In this prospective cohort study, 976 women reported the prevalence of DI and UI alone 1 year after their first delivery in one of two hospitals in Norway using the St Marks score and the ICI-Q UI SF.

RESULTS

DI was significantly reduced from 13% in late pregnancy to 8% 1 year later, whereas 30% reported UI at both time points. Incontinence in late pregnancy predicted incontinence 1 year after delivery. Higher age was associated with UI alone. Compared with caesarean delivery, normal vaginal or instrumental delivery increased the risk of UI alone more than three and four times respectively. Obstetric anal sphincter injuries showed a four-fold increase in the risk of DI.

CONCLUSIONS

Nearly 50% reported incontinence symptoms 1 year after first delivery. Continence status during pregnancy was one of the main predictors of postpartum continence status. Mode of delivery increased the risk of postpartum UI, whereas obstetric anal sphincter injuries increased the risk of postpartum DI.

[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]

Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

Fecal incontinence and parity in the Dutch population: A cross-sectional analysis

Background

It is assumed that pregnancy and childbirth increase the risk of developing fecal incontinence (FI).

Objective

We investigated the incidence of FI in groups of nulliparous and parous women.

Methods

Retrospectively, we studied a cross-section of the Dutch female population (N = 680) who completed the Groningen Defecation & Fecal Continence questionnaire. We also analyzed a subgroup of healthy women (n = 572) and a subgroup of women with comorbidities (n = 108).

Results

The prevalence of FI and the Vaizey and Wexner scores did not differ significantly between nulliparous and parous women. Parous women were 1.6 times more likely to experience fecal urgency than nulliparous women (95% CI, 1.0–2.6, p = 0.042). Regression analyses showed that parity, mode of delivery, duration of second stage of labor, obstetrical laceration or episiotomy, and birth weight seem not to be associated with the likelihood of FI.

Conclusions

Pregnancy and childbirth seem not to be associated with the prevalence and severity of FI in the Dutch population. Vacuum and forceps deliveries, however, might result in a higher prevalence of FI. Although the duration of being able to control bowels after urge sensation is comparable between nulliparous and parous women, parous women experience fecal urgency more often.

Electrophysiological Basis of Fecal Incontinence and Its Implications for Treatment

The majority of patients with neuropathic incontinence and other pelvic floor conditions associated with straining at stool have damage to the pudendal nerves distal to the ischial spine. Sacral nerve stimulation appears to be a promising innovation and has been widely adopted and currently considered the standard of care for adults with moderate to severe fecal incontinence and following failed sphincter repair. From a decision-to-treat perspective, the short-term efficacy is good (70%-80%), but the long-term efficacy of sacral nerve stimulation is around 50%. Newer electrophysiological tests and improved anal endosonography would more effectively guide clinical decision making.

Risk factors for obstetric anal sphincter injuries (OASI) at a tertiary centre in south India

INTRODUCTION AND HYPOTHESIS

Despite several studies that have reported risk factors for obstetric anal sphincter injuries (OASI), data from the Indian subcontinent are scarce. The purpose of this study was to identify risk factors for these sphincter injuries in an Indian population.

METHODS

This was a case-control study within a retrospective cohort of vaginal deliveries at a tertiary care facility. All vaginal births beyond 24 completed weeks of gestation and birth weight ≥500 g from January 2008 to December 2012 were identified from the hospital electronic database. Cases were women with OASI sustained during vaginal delivery; the rest constituted controls. Potential risk factors for occurrence and severity of OASI were assessed initially using bivariate analysis and then a logistic regression model.

RESULTS

The incidence of sphincter injury was 2.1% of vaginal births and 1.1% of all deliveries, and major-degree (3c and 4th-degree) tears constituted 20.9% of tears. After adjusted analysis, significant predictors for injury included primiparity, delivery at or beyond 41 weeks of gestation, epidural analgesia, instrumental delivery, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against sphincter injuries, particularly in forceps and ventouse deliveries. Shoulder dystocia was significantly associated with major-degree tears, while episiotomy appeared to be protective.

CONCLUSION

Risk factors are similar to those in other population groups; however, primiparity appears to be associated with lesser risk and forceps delivery with greater risk of sphincter trauma than previously reported.

Interview-based versus self-reported anal incontinence using St Mark's incontinence score

INTRODUCTION AND HYPOTHESIS

St Mark's incontinence score (SMIS) was originally designed and validated for use in an interview setting (iSMIS), and there is conflicting evidence for the validity of the self-administered SMIS (sSMIS). Our objective was to compare self-administered and interview-based reports of anal incontinence (AI) symptoms.

METHODS

A total of 147 women reported symptoms of AI on a sSMIS before inclusion in a clinical study investigating the effect of conservative treatment for AI 1 year after delivery. After clinical investigations, an iSMIS was completed by one of two consultant surgeons blinded to the sSMIS results. The correlation and agreement among the individual items of the iSMIS and the sSMIS were assessed using Spearman's rho and weighted kappa statistics, respectively.

RESULTS

The mean iSMIS and sSMIS reported was 4.0 (SD: 3.6) and 4.3 (SD: 4.0), respectively. Spearman's rho showed a strong relationship between the two total SMIS scores (r = 0.769, n = 147, p < 0.001), and explained variance was 59% (r²=0.591). Except for the individual item about gas incontinence, women reported more frequent AI symptoms on the sSMIS than on the iSMIS. The assessment of consistency among the individual items of the iSMIS and sSMIS showed substantial agreement (κ ≥ 0.60) for all items except for fair agreement for the item about formed stool incontinence (κ = 0.22), and moderate for the item about any change in lifestyle (κ = 0.5).

CONCLUSIONS

The level of consistency between the two methods of reporting anal incontinence symptoms suggests that the St Mark's score may be used as both an interview-based and a self-administered incontinence score.

Internal anal sphincter: Clinical perspective

OBJECTIVE

To summarise current knowledge of Internal anal sphincter.

BACKGROUND

The internal anal sphincter (IAS) is the involuntary ring of smooth muscle in the anal canal and is the major contributor to the resting pressure in the anus. Structural injury or functional weakness of the muscle results in passive incontinence of faeces and flatus. With advent of new assessment and treatment modalities IAS has become an important topic for surgeons. This review was undertaken to summarise our current knowledge of internal anal sphincter and highlight the areas that need further research.

METHOD

The PubMed database was used to identify relevant studies relating to internal anal sphincter.

RESULTS

The available evidence has been summarised and advantages and limitations highlighted for the different diagnostic and therapeutic techniques.

CONCLUSION

Our understanding of the physiology and pharmacology of IAS has increased greatly in the last three decades. Additionally, there has been a rise in diagnostic and therapeutic techniques specifically targeting the IAS. Although these are promising, future research is required before these can be incorporated into the management algorithm.

[Predictive factors of 2-month postpartum anal incontinence among patients with an obstetrical anal sphincter injury]

OBJECTIVES

To determine prevalence of short-term postpartum anal incontinence after obstetrical anal sphincter injury and prognostic factors.

MATERIALS AND METHODS

Retrospective study including every patient with an obstetrical anal sphincter injury between January 2006 and December 2012 in one tertiary maternity unit. Patients were interviewed and examined at 2-month postpartum. Anal incontinence was defined by the presence of at least one of the following symptoms: flatus incontinence, faecal incontinence and faecal urgency.

RESULTS

Among 17,110 patients who delivered vaginally during period study, 134 (0.8%) presented an anal sphincter injury. Postpartum obstetrical data were available for 110 of them. Among those patients, 50 women (45.5%) had at least one symptom of anal incontinence at 2-month postpartum and 8 (7.3%) had faecal incontinence. Only maternal age and second stage duration were significantly associated with anal incontinence after obstetrical anal sphincter injury. The degree of sphincter damage at delivery (IIIa, b, c, IV) was not associated with the risk of anal incontinence at 2-month postpartum.

CONCLUSION

Maternal age and second stage duration were the only risk factor for anal incontinence after obstetrical anal sphincter injury in this study. High prevalence of anal incontinence at 2-month postpartum of obstetrical anal sphincter injury is observed no matter what is the degree of anal sphincter damage. Our results highlight the importance to diagnose all obstetrical anal sphincter injuries whatever the degree of damage.

[Management of postpartum anal incontinence: A systematic review]

AIM

To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management.

MATERIALS AND METHODS

A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery.

RESULTS

The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years).

CONCLUSION

Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

Secondary repair of severe chronic fourth-degree perineal tear due to obstetric trauma

Obstetric injury is the commonest cause of anal incontinence. We report a case of anal incontinence as a result of severe chronic fourth-degree perineal tear secondary to birthing with complete disruption of the perineum. Secondary repair consisting of an anterior sphincter repair and levatorplasty in a poor resourced area rendered excellent immediate clinical result. The outcome of anterior sphincter repair following obstetric trauma is good but long-term follow-up is required because of the underlying complexity of obstetric injury. As prevention is not always possible, immediate recognition and adequate primary treatment is of importance.

Anal incontinence and Quality of Life in late pregnancy: a cross-sectional study

OBJECTIVE

To evaluate the association between different types of anal incontinence (AI) and Quality of Life (QoL) in late pregnancy.

DESIGN

Cross-sectional study.

SETTING

Two maternity units in Norway 2009-2010.

POPULATION

Primiparae aged 18 or over.

METHODS

Participants answered questions about AI during the last 4 weeks of pregnancy on the St. Mark's score and impact of QoL in the Fecal Incontinence QoL score. Socioeconomic data were obtained from hospital records.

MAIN OUTCOME MEASURES

Self-reported AI and impact on QoL.

RESULTS

1571 primiparae responded; 573 (37%) had experienced AI during the last 4 weeks of pregnancy. One third of the incontinent women reported reduced QoL in the domain 'Coping'. 'Women experiencing urgency alone reported markedly better QoL compared to any other AI symptoms. AI appeared to have the strongest impact on the domains 'Coping' and 'Embarrassment'. Depression was only associated with experiencing the combination of all three symptoms [odds ratio (OR) 13; 95%confidence interval (CI) 3.2-51]. Experiencing flatus alone weekly or more was associated with the highest impact on 'Embarrassment' (OR 20; 95%CI 6.4-61) compared with all other symptoms or combination of AI symptoms, except the combination of all three AI symptoms.

CONCLUSIONS

Between 3 and 10% of the primiparae in this material experienced AI to such a extent that it affected QoL. The greatest impact was seen in the QoL domain 'Coping'. These findings highlight the importance of an increased awareness of AI in late pregnancy among health professionals and the need to implement routine discussions about AI with expectant and new mothers.

Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study

OBJECTIVE

To evaluate the prevalence and predictors of anal incontinence (AI) in late pregnancy and 1 year after delivery.

DESIGN

Prospective population-based cohort study.

SETTING

Two maternity units in Norway 2009-2010.

POPULATION

Primiparae aged 18 years or over.

METHODS

Primiparae answered questions on the St. Mark's score about AI during the last 4 weeks of pregnancy. One year later, the same questionnaires were distributed by postal mail. Socio-economic and delivery-related data were obtained from hospital records.

MAIN OUTCOME MEASURES

Self-reported AI.

RESULTS

Answers on AI in late pregnancy were obtained from 1571 women, and 1030 responded 1 year later. Twenty-four per cent experienced one and 4.7% experienced three or more AI symptoms in late pregnancy. One year later, this was reduced to 19% and 2.2%, respectively. Multivariate logistic regression analyses were applied. Formed and loose stool incontinence were strongly associated at both time points. The main predictor of AI 1 year after delivery was AI in late pregnancy. Obstetric anal sphincter injury increased the risk of incontinence of stool and flatus (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.6) after delivery. Urgency was associated with greater age (OR, 1.8; 95% CI, 1.0-3.3) and operative delivery (OR, 2.0; 95% CI, 1.3-2.9).

CONCLUSION

One in four primiparae experienced AI in late pregnancy. One year later, still one in five suffered from incontinence. Sphincter injury predicted incontinence of stool and flatus, whereas greater age and operative delivery predicted urgency. The identification and adequate follow-up of pregnant women with AI may reduce AI after delivery.

Prevalence and Risk Indicators for Anal Incontinence among Pregnant Women

The aim of this study was to assess the prevalence and risk factors of anal incontinence in an unselected pregnant population at second trimester. A survey of pregnant women attending a routine ultrasound examination was conducted in a university hospital in Oslo, Norway. A questionnaire consisting of 105 items concerning anal incontinence (including St. Mark's score), urinary incontinence, medication use, and comorbidity was posted to women when invited to the ultrasound examination. Results. Prevalence of self-reported anal incontinence (St. Mark's score ≥ 3) was the lowest in the group of women with a previous cesarean section only (6.4%) and the highest among women with a previous delivery complicated by obstetric anal sphincter injury (24.4%). Among nulliparous women the prevalence of anal incontinence was 7.7% and was associated to low educational level and comorbidity. Prevalence of anal incontinence increased with increasing parity. Urinary incontinence was associated with anal incontinence in all parity groups. Conclusions. Anal incontinence was most frequent among women with a history of obstetric anal sphincter injury. Other obstetrical events had a minor effect on prevalence of anal incontinence among parous women. Prevention of obstetrical sphincter injury is likely the most important factor for reducing bothersome anal incontinence among fertile women.

Characterization of colorectal symptoms in women with vesicovaginal fistulas

OBJECTIVE

To characterize colorectal symptoms in women with a history of an obstetric vesicovaginal fistula (VVF).

METHODS

Patients under evaluation with a VVF during two 2-week surgical service trips to Evangel Hospital VVF Center in Jos, Nigeria, in 2010 were assessed for symptoms of fecal incontinence (FI) using the Vaizey and Colorectal-Anal Impact (CRAIQ) questionnaires. Women with rectovaginal fistulas were excluded. Each participant's impression of overall health was assessed using a visual analog scale (VAS) from 0 (poor) to 15 (excellent). A study nurse translated questionnaires into native languages.

RESULTS

The mean age of the 83 women included was 29 years. Three women (3.6%) reported FI and 42 (50.6%) reported constipation. All of the women with FI reported that it affected their quality of life on the CRAIQ. Average VAS score was 10.8 overall and 6.8 for women with FI.

CONCLUSION

In this population of women with VVF but no rectovaginal fistulas, we found a low prevalence of fecal incontinence and a high prevalence of constipation. Despite significant pelvic floor trauma resulting in VVF, the majority of patients appeared to have an intact bowel continence mechanism.

Sacral neuromodulation for the treatment of fecal incontinence: analysis of cost-effectiveness

PURPOSE

The cost-effectiveness and budget impact of introducing sacral nerve modulation (SNM) as a treatment for fecal incontinence in Italy were evaluated in a simulation model.

METHODS

A decision-analysis model with a Markov submodel was used to represent clinical pathways for treatment of patients with fecal incontinence in a scenario with SNM and a scenario without SNM. Data were obtained from published studies and from an expert panel. Evaluation of resource consumption was conducted from the perspective of the Italian National Health Service, and costs were retrieved from the Italian NHS procedures reimbursement list. The time horizon was 5 years, and a 3% discount rate was applied to costs and outcomes. Effectiveness was measured in symptom-free years and in quality-adjusted life-years (QALYs). Fecal incontinence prevalence data and SNM usage forecasts were used to estimate budget impact over the next 5 years.

RESULTS

The incremental cost-effectiveness ratio for introducing SNM was €28,285 per QALY gained for patients with a structurally deficient anal sphincter and €38,662 per QALY gained for patients with intact anal sphincters. If a threshold of €40,000 per QALY gained is set as the level that a decision-maker would regard as cost-effective, the probability that the introduction of SNM will be cost-effective would be 99% for patients with a structurally deficient sphincter and 53% for patients with an intact sphincter. Budget impact analysis showed that introducing SNM would have an estimated budget impact of 0.56% over 5 years on the budget allocated for fecal incontinence treatment.

CONCLUSION

Our data show SNM to be an efficient investment with an acceptable incremental cost-effectiveness ratio and a limited impact on the total allocated budget for fecal incontinence.

Using the Brink score to predict postpartum anal incontinence

OBJECTIVE

To evaluate whether antepartum pelvic floor muscle strength, as measured by the Brink scale, predicts postpartum anal incontinence.

STUDY DESIGN

This prospective cohort study of primigravid women used validated questionnaires and standardized pelvic examinations to evaluate subjects during the third trimester and at 2 postpartum time points.

RESULTS

Of the initial 129 subjects, 102 and 81 completed 2 week and 6 month postpartum visits. 35% had cesarean deliveries. The antepartum prevalence of fecal incontinence (14%) did not differ significantly from the postpartum (17% at 2 weeks, 11% at 6 months). However, the prevalence of flatal incontinence fell from antepartum (65%) to postpartum (47% at 2 weeks, P = .001; 49% at 6 months, P = .012). Mean Brink score decreased postpartum; no correlations were found between Brink score and questionnaire scores.

CONCLUSION

Anal incontinence symptoms are common in the third trimester of a first pregnancy and may regress or resolve after delivery. Brink score did not predict postpartum anal incontinence.

Bowel disturbances are the most important risk factors for late onset fecal incontinence: a population-based case-control study in women

BACKGROUND & AIMS

Age, diarrhea, and certain chronic illnesses are risk factors for fecal incontinence (FI). However, the contribution of obstetric injury to the development of FI later in life is unclear. We sought to better understand the risk factors for FI.

METHODS

Through the Rochester Epidemiology Project, a nested case-control study of 176 randomly selected women with FI (cases; mean age, 58 years) and 176 age-matched community controls was conducted in a population-based cohort from Olmsted County, Minnesota. Risk factors for FI were evaluated by reviewing inpatient and outpatient medical (including original obstetric) records. Analyses focused on conditions that preceded the index date (incidence date of FI for case in each matched pair).

RESULTS

In 88% of cases, FI began at age ≥40 years; severity was mild (37%), moderate (58%), or severe (5%). By multivariable analysis, current smoking (odds ratio [OR], 4.7; 95% confidence interval [CI], 1.4-15), body mass index (OR per unit, 1.1; 95% CI, 1.004-1.1), diarrhea (OR, 53; 95% CI, 6.1-471), irritable bowel syndrome (OR, 4.8; 95% CI, 1.6-14), cholecystectomy (OR, 4.2; 95% CI, 1.2-15), rectocele (OR, 4.9; 95% CI, 1.3-19), and stress urinary incontinence (OR, 3.1; 95% CI, 1.4-6.5), but not obstetric events, were independent risk factors for FI.

CONCLUSIONS

Bowel disturbances rather than prior obstetric injury are the main risk factors for FI. Measures to ameliorate bowel disturbances and other potentially reversible risk factors should be implemented before anal imaging is performed on women with FI.

Repeatability of innervation zone identification in the external anal sphincter muscle

AIMS

Knowledge of the distribution of the innervation zones (IZs) of the external anal sphincter (EAS) may be useful for preventing anal sphincter incompetence during vaginal delivery. A method proposed for the automatic estimation of the distribution of IZs of EAS from high-density surface electromyography (EMG) was evaluated for repeatability in continent volunteers.

METHODS

In 13 healthy female subjects (age: 35 +/- 11 years) surface EMG signals were acquired using an anal probe with three circumferential electrode arrays (of 16 contacts each) at different depths within the anal canal (15 mm distance between the centers of adjacent arrays), during four independent experimental sessions. Three maximal voluntary contractions (MVCs) of 10 sec were performed for each session for a total of 12 contractions per subject. Repeatability of the estimation of the distribution of IZ was tested by evaluating the coefficient of multiple correlations (CMC) between the IZ distributions estimated from the signals recorded from each subject.

RESULTS

A high repeatability (CMC > 0.8) was found comparing IZ distributions estimated from signals recorded by each array within the same session. A slightly lower value was obtained considering signals recorded during different sessions (CMC > 0.7), but a higher value (CMC > 0.8) was obtained after aligning the estimated IZ distributions. The realignment compensates for the operator's error in repositioning the probe in the same position during different sessions.

CONCLUSION

This result justifies clinical studies using high-density surface EMG in routine examinations, providing information about IZs of EAS and assessing the possibilities of preventing neuronal trauma during vaginal delivery.

Faecal incontinence after first instrumental vaginal delivery using Thierry's spatulas

OBJECTIVE

The purpose of this study is to estimate the prevalence of faecal incontinence after first vaginal delivery and to assess the impact of Thierry's spatulas-assisted delivery.

METHODS

A prospective observational study of primiparas who underwent a vaginal delivery at term was conducted. Faecal incontinence was assessed at 2 and 6 months postpartum by a questionnaire (Wexner score >or=5 was considered significant). Univariate and multivariate analyses were performed.

RESULTS

Five hundred thirty-eight women were recruited with undergoing 176 spatulas-assisted deliveries and 362 spontaneous vaginal deliveries. The response rate was 85.9% (2 months) and 80.5% (6 months). The prevalence of faecal incontinence was similar between the two groups at 2 months (14.3% and 9.7%). Episiotomy (odds ratio [OR] = 5.0) and maternal age over 35 years (OR = 4.1) were independently associated with faecal incontinence after adjustment.

CONCLUSIONS

Anal symptoms are common after the first vaginal delivery. Thierry's spatulas do not increase the prevalence of faecal incontinence after delivery given that an episiotomy is performed.

Quality of life in women with postpartum anal incontinence

OBJECTIVE

To estimate the effect of anal incontinence on postpartum quality of life (QOL).

METHODS

We conducted a longitudinal follow-up study of women reporting anal incontinence on a statewide postpartum survey to estimate the effect of anal incontinence on QOL up to 2 years postpartum. Quality of life was assessed every 6 months for 2 years based on the Uebersax incontinence impact questionnaire. The effect of severe anal incontinence on QOL was determined by multivariate logistic regression.

RESULTS

A total of 1,050 women reported persistent anal incontinence and returned at least two completed QOL surveys during the 2-year study period. Among women with anal incontinence, 51% reported frustration caused by anal incontinence, 26% reported that anal incontinence affected their emotional health, 18.5% reported anal incontinence affected their child-caring abilities, and 16.2% reported a negative effect on social activities. One in three women with anal incontinence reported severe symptoms. Compared with women with mild anal incontinence, women with severe anal incontinence were four to seven times as likely to report that anal incontinence affected emotional health and the ability to perform daily activities. However, only 10% of women sought medical help for anal incontinence at 6 months, 13.5% at 1 year, and 16.7% at 2 years.

CONCLUSION

Even 2 years after delivery, more than a quarter of women who experience a new onset of anal incontinence after childbirth report persistently negative QOL. Despite this, few women discuss anal incontinence with their medical providers.

LEVEL OF EVIDENCE

III.

Cesarean delivery for the prevention of anal incontinence

BACKGROUND

Caesarean delivery (CD) is a common form of delivery of a baby, rising in frequency. One reason for its performance is to preserve maternal pelvic floor function, part of which is anal continence.

OBJECTIVES

To assess the ability of CD in comparison to vaginal delivery (VD) to preserve anal continence in a systematic review

SEARCH STRATEGY

Search terms include: "Caesarean section, Cesarean delivery, vaginal delivery, incontinence and randomised". PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (Central) were searched from their inception through July, 2009.

SELECTION CRITERIA

Both randomised and non-randomised studies that allowed comparisons of post partum anal continence (both fecal and flatus) in women who had had babies delivered by either CD or VD were included.

DATA COLLECTION AND ANALYSIS

Mode of delivery, and when possible mode of all previous deliveries prior to the index pregnancy were extracted, as well as assessment of continence post partum of both faeces and flatus. In Non-RCTs, available adjusted odds ratios were the primary end point sought. Incontinence of flatus is reported as a separate outcome. Summary odds ratios are not presented as no study was analysed as a randomised controlled trial. Numbers needed to treat (NNT) are presented, that is, the number of CDs needed to be performed to prevent a single case of fecal or flatus incontinence, for each individual study. Quality criteria were developed, selecting studies that allowed maternal age adjustment, studies that allowed a sufficient time after the birth of the baby for continence assessment and studies in which mode of delivery of prior pregnancies was known. Subgroup analyses were done selecting studies meeting all quality criteria and in comparisons of elective versus emergency CD, elective CD versus VD and nulliparous women versus those delivered by VD or CD, in each case again, not calculating a summary risk statistic.

MAIN RESULTS

Twentyone reports have been found eligible for inclusion in the review, encompassing 31,698 women having had 6,028 CDs and 25,170 VDs as the index event prior to anal continence assessment . Only one report randomised women (with breech presentation) to CD or VD, but because of extensive crossing over, 52.1%, after randomisation, it was analysed along with the other 20 studies as treated, i.e. as a non-randomised trial. Only one of these reports demonstrated a significant benefit of CD in the preservation of anal continence, a report in which incontinence incidence was extremely high, 39% in CD and 48% in VD, questioning, relative to other reports, the timing and nature of continence assessment. The greater the quality of the report, the closer its Odds ratio approached 1.0. There was no difference in continence preservation in women have emergency versus elective CD.

AUTHORS' CONCLUSIONS

Without demonstrable benefit, preservation of anal continence should not be used as a criterion for choosing elective primary CD. The strength of this conclusion would be greatly strengthened if there were studies that randomised women with average risk pregnancies to CD versus VD.

Onset and risk factors for fecal incontinence in a US community

OBJECTIVES

The natural history of fecal incontinence (FI) in community subjects is uncertain and the onset rate is unknown. The aim of the study is to estimate the prevalence, new-onset rate, and risk factors for FI in community subjects.

METHODS

A random sample of 2,400 community subjects aged > or =50 years was surveyed in 1993, using a validated questionnaire. Responders were recontacted in 2003. FI was defined as self-reported problems with leakage of stool. Onset rate was calculated as the proportion of subjects without FI who became new cases. Logistic regression models were constructed to identify predictive factors for developing FI and changes in bowel habit associated with the onset of FI.

RESULTS

Overall, 1,540 (64%) subjects responded to the initial survey, and 674 (44%) of them responded to the second survey a median of 9 (8.8-9.5) years later. The prevalence of FI in the first survey was 15.3% (13.4-17.3%). In the second survey, 37 reported incident FI; thus, the onset rate of FI was 7.0% (5.0-9.6) per 10 years. Predictive factors at baseline for the onset of FI were self-reported diarrhea (odds ratio (OR)=3.8 (1.5, 9.4)), incomplete evacuation (OR=3.4 (1.2, 9.8)), and pelvic radiation (OR=5.1 (1.01, 25.9)). Development of urgency was the primary predictor among the set of predictors reflecting changes in bowel symptoms that were associated with the onset of FI (OR=24.9 (10.6, 58.4)).

CONCLUSIONS

The onset rate of FI is approximately 7% per 10 years in community subjects aged > or =50 years. Prevention may be possible if bowel habit is appropriately managed in high-risk individuals.

Fecal incontinence in pregnancy and post partum

OBJECTIVE

To assess the prevalence of fecal incontinence (FI) during pregnancy and post partum, and to determine any associations with demographic and birth variables.

METHODS

Secondary analysis of 240 primiparous women conducted during pregnancy and post partum. Women were asked at various time points if they had lost control over their stool or bowel movements, and if they were practicing Kegel exercises. Associations of bowel symptoms with demographic and birth data were evaluated.

RESULTS

Most participants were white (87%), with a median age of 30 years (range, 18-42 years). Women who reported fecal incontinence at 1 year were more educated than those who did not report it. No other demographic or birth data were associated with fecal incontinence at 1 year.

CONCLUSIONS

Prevalence of FI during pregnancy and post partum is low and not linked to low-risk birth. Furthermore, when FI occurs it is often sporadic. This should be reassuring to patients and providers alike.