Severity Of Anal Incontinence Research Articles

The long-term prevalence of anal incontinence in women with and without obstetric anal sphincter injuries

Introduction:Anal incontinence (AI) is a distressing and common condition for women. Women who sustain obstetric anal sphincter injuries (OASI) have been reported to have a higher prevalence of long-term AI than those who do not. However, the data is wide ranging, inconsistent and seldom comparative, with rates quoted varying between 13.1% and 74%. Methods:139 women who sustained OASI at their first delivery and 44 women who did not (controls) were contacted at 6 weeks and then a mean of 8 years following their first delivery. They were asked to complete a questionnaire including the St Mark’s Incontinence Score (SMIS) to assess the prevalence and severity of anal incontinence. Results:There was a high prevalence of anal incontinence (SMIS ≥1) in both women with OASI (62%) and controls (59%) (NS). The prevalence of severe AI (SMIS ≥ 6) was 27% in the OASI group and 18% in controls (NS). Higher grade tears and operative delivery were associated with higher rates of severe AI. In women with OASI, the mode of subsequent delivery did not impact the prevalence of AI. Conclusion:Women with OASI have a similar prevalence of long-term AI compared with women who do not sustain OASI. Some degree of AI is common 8 years post-partum, with our study demonstrating a high prevalence of 59% in controls. Brief summary:Women with and without OASI were contacted 5–15 years post-partum, and there was no difference in the rates of anal incontinence between the two groups.

Management and outcomes of anal sphincter injuries: A retrospective cohort study

Background/Aim: Anal sphincter injury (ASI) is a clinical condition that causes anal incontinence and can severely impair an individual’s quality of life. Overlapping sphincteroplasty (OSP) is the most preferred surgical method for repairing ASI. The present study aimed to discuss the demographic and clinical characteristics of patients who underwent ASI surgical repair in light of the current literature. Methods: Patients in two groups; males and females, who underwent an operation for grade 3-4 ASI in the General Surgery Clinic at Ataturk University between 2010 and 2021 were retrospectively analyzed. The severity of anal incontinence and quality of life post-operatively using the Wexner score were evaluated. For evaluating post-operative complications, the Clavien–Dindo Classification was used. Results: Over 12 years, 34 adult patients with a mean age of 35.8 (22–66) years underwent ASI surgery, namely 23 (67.6%) women and 11 (32.4) men. Considering the patients’ etiopathogenesis, obstetric injuries (55.9%) were the most common cause of ASI. All patients underwent overlapping sphincteroplasty (OSP), while 20.6% also underwent protective stoma. According to the Centers for Disease Control and Prevention (CDC), four patients were classified as Grade 1, four as Grade 2, seven as Grade 3 and one as Grade 5. At a mean follow-up of 35.8 months, the mean Wexner score was 3.59 and the success rate was 88.2% (P=0.445). Males had a longer average hospital stay (P=0.021) and a higher Wexner score (P=0.445), whereas females had a greater complication rate (P=0.388). The quality of life was high, but the Wexner scores were low in all patients. Conclusion: ASI most commonly occurs in women during childbirth. OSP has a high success rate, and opening a diverting ostomy when needed further increases this rate. The Wexner score is a simple and useful system for assessing anal incontinence.

Bidet Toilet Use May Cause Anal Symptoms and Nosocomial Infection.

Electric bidet toilets are widely used in Japan and are sanitary devices, that are integral to daily life. Approximately, half of the population washed the anus before or after defecation. Cleaning the anus after defecation using the bidets contributes to hand hygiene and local comfort, and it may be effective against constipation. However, excessive bidet use potentially causes anal pruritus and anal incontinence (AI). Physicians are advised to instruct patients with anal pruritus to avoid excessive cleaning of the anus and those with AI to discontinue bidet use. For the estimation of the inherent severity of AI, physicians should instruct a bidet user with AI to discontinue bidet use and assess the severity of AI later. Additionally, the nozzle surface and splay water of bidet toilets may be contaminated with fecal indicator bacteria, such as Escherichia coli and Pseudomonas aeruginosa, as well as antimicrobial-resistant bacteria, rendering them a potential vehicle for cross-infection. In the hospital setting, compromised patients must be cautious regarding the shared use of bidet toilets to prevent infection by antimicrobial-resistant bacteria. Specifically, they should be provided with bidet toilets exclusive for them or may need to be instructed to not use a bidet.

Obstetrical and epidemiological factors influence the severity of anal incontinence after obstetric anal sphincter injury

BackgroundObstetric anal sphincter injury (OASI) is one of the most severe obstetrical complications. Although risk factors for OASI have been identified, little is known about various parameters that can influence symptoms’ severity. The aim of this study is to explore whether obstetrical and epidemiological factors can have an effect on the severity of symptoms after OASI.Methods11.483 deliveries between January 2010 and December 2014 were reviewed, and data from 88 women with OASI are presented.ResultsThe only statistically significant differences between symptomatic and asymptomatic women were age (p = 0.02), body mass index (p = 0.04) and the use of forceps (p = 0.04). Women with more severe symptoms were more likely to have received oxytocin during the second stage of labor (p = 0.03) and had shorter delivery to follow-up interval (p = 0.008).ConclusionsModifiable factors such as use of forceps and oxytocin should be taken into consideration in clinical practice.

Anal incontinence and vesico-sphincter events in systemic sclerosis: An epidemiologic bicentric cohort study.

To estimate the frequency and severity of anal incontinence and vesico-sphincter events, associated factors, and impact on the quality of life of patients with systemic sclerosis. Questionnaires assessing anal incontinence (Miller score), vesico-sphincter events (Urogenital Distress Inventory) and quality of life [Short Form Health Survey 36v2 (SF-36), and Hospital Anxiety and Depression Scale] were mailed to 139 patients with systemic sclerosis at the university hospitals of Besançon and Poitiers, France. Clinical data were collected from the medical records to identify risk factors. Among the 121 (87%) responders, severe vesico-sphincter events or severe anal incontinence occurred in 3.4% and 12.4% of cases, respectively. Frequent urination (66.3%) and anal incontinence to gas (50.4%) were the most frequent symptoms. Anal incontinence was associated positively with vesico-sphincter events, unrelated to obstetrical factors. No correlations were seen with age, sex, or systemic sclerosis characteristics. In multivariate analysis, moderate or severe vesico-sphincter events was associated with higher anxiety and depression scores and lower SF-36 scores; the same results were observed for anal incontinence, but did not reach significance. Vesico-sphincter events and anal incontinence are common in systemic sclerosis, and sometimes severe, with a potential negative impact in quality of life. These results will be confirmed by a case-control study with dynamic and manometric assessment, and could legitimate a systematic screening to ensure early therapy and multidisciplinary individual management.

The epidemiology of anal incontinence and symptom severity scoring.

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

3D pelvic floor ultrasound findings and severity of anal incontinence

The aim of our study was to determine the association between the severity of anal incontinence and levator ani deficiency, anal sphincter defects, anorectal angle, and colonic motility abnormalities. This was a retrospective study. Subjects were categorized into three groups: normal, minor anal incontinence, and major anal incontinence according to their answers to the PFDI-20 questionnaire. 3D endovaginal ultrasound was utilized to assess levator ani muscle and the anorectal angle. Levator ani muscle subdivisions were scored based on avulsion from the pubic bone and muscle thickness, based on our previous work. 3D endoanal ultrasound was utilized to assess anal sphincters. Colonic motility abnormalities were defined as diarrhea, constipation or both. Ninety-seven patients were included in the analysis: 45 with major anal incontinence, 29 with minor anal incontinence, and 23 continent women. On multivariate logistic regression, sphincter defect, anorectal angle, and colonic motility abnormalities were associated with anal incontinence severity. Women with an external anal sphincter defect had a 20.36-fold chance of having severe anal incontinence compared with patients with no defect (OR 20.36, 95% CI 5.4, 76.6); those with both defective sphincters had a 102.5-fold chance of having severe anal incontinence (OR 102.5, 95% CI 10.2, >999). Anorectal angle ≥170° was significantly associated with the severity of anal incontinence (OR = 4.07, 95% CI 1.53, 10.79), as was the presence of colonic mobility abnormality (OR 5.31, 95% CI 1.86, 15.19). 3D pelvic floor ultrasound can be an efficient tool for anal incontinence evaluation in women. Anal sphincter defects, colonic motility abnormalities, and anorectal angle were associated with the severity of anal incontinence. While there was a trend toward worsening levator ani deficiency among those with major anal incontinence, this did not reach statistical significance.

Episiotomy and the development of postpartum dyspareunia and anal incontinence in nulliparous females.

The impacts of an episiotomy on a woman's sex life and ability to relax the pelvic musculature remain largely unknown. The aim of the present study was to assess the impact of an episiotomy on the development of postpartum dyspareunia and anal incontinence. A total of 200 patients participated in the present study. The patients were grouped as follows: vaginal delivery with episiotomy (Group 1, N=100) and Caesarian section (Group 2, N=100). An interview, which asked about the presence of dyspareunia or anal incontinence, was conducted with the participants at 12 weeks postpartum. The mean age (years) of Group 1 was 22.6±4.4, and the mean age of Group 2 was 24.1±4.6. Anal incontinence was detected in 4 patients (4%) in Group 1 and 2 patients (2%) in Group 2. Dyspareunia was present in 21 patients (21%) in Group 1 and 8 patients (8%) in Group 2. No significant differences were detected in the severity of anal incontinence between the two groups. The amount of time to the first coitus following delivery and the total amount of intercourse was compared between the two groups. It appears that episiotomies do not lead to anal incontinence. However, episiotomies may cause dyspareunia, a condition that may negatively affect a women's sex life. Therefore, routine episiotomies are not suggested.

The relationship between etiology, symptom severity and indications of surgery in cases of anal incontinence: a 25-year analysis of 1,046 patients at a tertiary coloproctology practice

The etiology of anal incontinence (AI) is often multifactorial. There is little data on the relationship between the etiology of AI, symptom severity, and the need for surgery. The aim of our study was to investigate this association in a large number of unselected patients with AI referred to a tertiary specialist coloproctological practice. Patients with AI seen at our unit between 1983 and 2008 were analyzed. The main etiologies were categorized as congenital, traumatic, neurologic, idiopathic, post-operative, post-obstetric, secondary to rectal prolapse, or inflammatory bowel disease. The severity of AI was graded using the validated Pescatori incontinence scale. Overall, 1,046 patients were studied. The AI score was higher in patients with congenital (4.7 ± 1.1), traumatic (4.6 ± 1.4), and neurological (4.4 ± 1.2) incontinence. Surgical treatment was indicated in 214 cases (20.5%). Patients with AI related to trauma and congenital anomalies required surgery in 43.5 and 31.4% of cases, respectively, a percentage significantly higher than that for patients with other etiologies (P = 0.002). Prolapse-related AI usually responded to correction of the prolapse. Patients with congenital, traumatic, and neurological AI tend to have greater symptom severity. Traumatic, rectal prolapse-related, and congenital AI cases more often require surgery.

Measure of the Voluntary Contraction of the Puborectal Sling as a Predictor of Successful Sphincter Repair in the Treatment of Anal Incontinence

Overlapping sphincteroplasty is the surgery of choice for incontinent patients with an anterior defect after childbirth. Numerous predictive factors have been proposed, but no preoperative variables have been successfully shown to be reproducible. The purpose of this study was to assess the prognostic value of voluntary contraction of the puborectal sling before sphincter repair for anal incontinence. This prospective study evaluated 109 consecutive women who underwent surgery for postobstetric anal incontinence. Voluntary contraction of the puborectal sling was measured by perineal ultrasound before the surgery. Severity of anal incontinence was evaluated preoperatively and postoperatively with the Miller Incontinence Score (total incontinence = 18, complete continence = 0). The proportion of patients with scores <or=3 was 16.7 percent when the preoperative voluntary contraction of the puborectal sling was <or=4 mm, 48.1 percent when it was 4.1 to 8 mm, and 98.7 percent when it was >8 mm (P < 0.001). Using <or=8 mm to define abnormal shortening, the sensitivity of the test was 0.95 (95 percent confidence interval, 0.75-1.00) and specificity was 0.84 (95 percent confidence interval, 0.75-0.91). A preoperative voluntary contraction of the puborectal sling >8 mm convincingly discriminates between patients with a good functional outcome and those with an unsatisfactory outcome after sphincter repair for postobstetric anal incontinence.

The coexistence of anal incontinence in women with urinary incontinence

To investigate the coexistentence of anal incontinence (AI) in patients with urinary incontinence (UI). UDI 6 questionnaire was applied to consecutive 800 patients for the determination of symptomatic UI. Cases were also questioned for AI. The patients with the complaint of UI were evaluated for the coexistence of AI. Each patient with AI, had completed the Cleveland Clinic Florida Fecal Incontinence questionnaire for the determination of the severity of AI. Chi-square and Mann-Whitney U test were used for the evaluation of qualitative data. Multivariable analysis using logistic regression was done to test the overall significance of all variables that were significantly associated with UI using univariate analysis. There were 233 (29.1%) cases of UI and 105 (13.1%) cases of AI. 60 (7.5%) of these patients were suffering from both UI and AI. 60 (57.1%) of 105 patients with AI also had UI. In patients with UI, the coexistence of AI was found in 25.7%. There was a positive correlation between UI and AI (R = 0.240, Chi-square P < 0.001). In logistic regression model, AI [(OR) 3.5, 95% confidence interval 2.26, 5.49], parity and episiotomy were found to be associated with UI. Parity and vaginal delivery by episiotomy were risk factors for the occurrence of AI. AI is positively correlated with UI patients. Symptoms of AI must be questioned in all gynecology patients. Unnecessary episiotomy should be avoided.

M1054 Impact of Anal Incontinence Severity On Functional Status Measured By the Fecal Incontinence Quality of Life Scale (FIQOL)

M1054 Impact of Anal Incontinence Severity On Functional Status Measured By the Fecal Incontinence Quality of Life Scale (FIQOL)

Clinical, sonographic and manometric characteristics and impact on quality of life of anal incontinence in 92 men referred for endoanal ultrasonography

Anal incontinence (AI) is a frequent symptom with considerable impact on quality of life. The aim of this study was to describe the clinical, sonographic and manometric characteristics of a male population with AI. Endoanal ultrasonography (EAU) was performed in 92 men referred for exploration of AI. Anal incontinence severity was evaluated by the Jorge and Wexner score (JW). The gastrointestinal quality-of-life index (GIQLI) was determined in 57% of patients. Anorectal manometry was performed in 62.6% of patients. The average JW score was 11+/-1. Anal incontinence had considerable impact on quality of life: average GIQLI=81+/-4. Seventeen patients presented an anal sphincter defect on EAU, 16 of whom had a history of coloproctological surgery. Prior surgery was significantly more common among patients who had a defect on ultrasonography; manometry showed significantly lower resting anal pressure. Our study confirms the severity of AI in a male population and its impact on quality of life. It also highlights the high prevalence of anal sphincter defects in patients with a history of anal surgery.

ORAL PRESENTATION 4: Sexual Function, Quality of Life, and Severity of Anal Incontinence Following Anal Sphincteroplasty

ORAL PRESENTATION 4: Sexual Function, Quality of Life, and Severity of Anal Incontinence Following Anal Sphincteroplasty

Risk Factors for Female Anal Incontinence: New Insight Through the Evanston-Northwestern Twin Sisters Study

To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance. A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately. Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21-6.0; flatal: OR 1.90, 95% CI 1.11-3.24), menopause (fecal: OR 2.10, 95% CI 1.15-3.8; flatal: OR 2.11, 95% CI 1.43-3.13), increasing parity (parity > or = 2; fecal: OR 3.09, 95% CI 1.25-7.65; flatal: OR 2.72, 95% CI 1.65-4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12-3.98; flatal: OR 1.72, 95% CI 1.14-2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries. Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence.

Anal incontinence among women with one versus two complete third-degree perineal lacerations

Objective: To compare the rate of anal incontinence and severe incontinence among women who had 0, 1, and ≥ 2 additional vaginal deliveries after sustaining a third-degree perineal laceration and between subjects with one versus two third-degree tears. Method: A telephone survey was done to assess the anal function of all subjects who sustained a complete third-degree tear as a nullipara. Result: The rate of anal incontinence and severe incontinence was similar among women who had 0, 1, and ≥ 2 additional deliveries (11/65, 11/67, and 12/40, p = 0.179; 2/65, 1/67, and 2/40, p = 0.811) and between women who had one sphincter tear and no additional delivery versus those with two tears and ≥ 2 subsequent deliveries (11/65 and 10/37, p = 0.225. 2/65 and 2/37, p = 0.460). Conclusion: Additional vaginal deliveries and a repeat sphincter tear after the initial third-degree laceration were not associated with a higher rate or severity of anal incontinence.

Prevalence and Severity of Anal Incontinence in Women With and Without Additional Vaginal Deliveries After a Fourth-Degree Perineal Laceration

The aim of this study was to compare the prevalence and severity of anal incontinence among women who had undergone no, one, or at least two additional vaginal deliveries after sustaining a fourth-degree sphincter tear as a nullipara. We conducted a telephone survey to determine our subjects' anal function. The incontinence score was determined by adding the content (flatus, liquid, and solid stool = 1, 2, and 3 points, respectively) and frequency (less than weekly, weekly, and daily = 1, 2, and 3 points, respectively) points. Severe incontinence is defined as having a score of 5 or 6 points and the incontinence having a severe effect on the subject's daily activities. Of the 148 women interviewed, 52 had undergone zero (Group 1), 60 had had one (Group 2), and 36 had had at least two (Group 3) additional vaginal deliveries. Among the three groups, 20 of 52 (38 percent), 14 of 60 (23 percent), and 10 of 36 (28 percent), respectively, reported anal incontinence (P = 0.208). The proportion that had 1 or 2 points (8/20, 4/14, and 3/10, respectively, P = 0.75) and 3 or 4 points (10/20, 9/14, and 2/10, respectively, P = 0.097) was similar among the three groups. Two of 20 (10 percent), 1 of 14 (7 percent), and 5 of 10 (50 percent), respectively, had a score of 5 or 6 points (P = 0.012). For the three groups, 0 of 20, 0 of 14, and 4 of 10 (40 percent) reported that their incontinence had a severe effect on their daily activities (P = <0.001), and 0 of 52, 0 of 60, and 4 of 36 (11 percent) had severe incontinence (P = 0.002). The proportion that had severe incontinence was significantly higher among women who had undergone at least two additional deliveries.

Long-Term Outcomes after Anal Dilatation for Anal Fissure

Background: Recurrence and anal incontinence are recognized as troublesome complications following the treatment of fissure in ano by anal dilatation. Most previous studies of anal dilatation have evaluated outcomes, only, over the short term. Patients and Methods: Attempts were made to contact 104 patients who had been treated by anal dilatation for fissure in ano during the period 1975–1990. Each patient contacted was sent a postal questionnaire. Each patient was assigned an incontinence score based on the information returned and this score was compared with the scores of five age and sex matched controls. Patients requesting reevaluation of their incontinence in their questionnaires were further examined by endoanal ultrasound and anorectal manometry. Results: 45 patients responded, 14 had died, and 45 were lost to follow up. The median follow-up interval was 15.5 years. The total self reported recurrence rate was 24%. Patient's incontinence scores were low and did not differ significantly from matched population controls. Conclusions: Fissure in ano treated by anal dilatation has a significant recurrence rate. The incidence and severity of anal incontinence in those treated by anal dilatation is no different to that of the general population. Other treatment modalities should be evaluated over the longer term before anal dilatation is discarded as a treatment option for fissure in ano.

Does Cesarean Delivery Prevent Anal Incontinence?

In Brief OBJECTIVE To compare the incidence and severity of anal incontinence in primiparas after cesarean delivery versus spontaneous vaginal delivery. METHODS A total of 184 primiparas who delivered by cesarean (104 emergency, 80 elective) and 100 who delivered vaginally were interviewed 10 ± 2 months postpartum. A comprehensive bowel function questionnaire was completed. Bowel-specific questions included bowel habits, laxative use, urgency, flatus, urge and passive incontinence, soiling, and pad use, before and during pregnancy and postpartum. Obstetric details were confirmed from obstetric records. RESULTS Anal incontinence was first present in nine (5%) mothers after cesarean delivery and eight (8%) after vaginal delivery (relative risk 0.611, 95% confidence interval 0.25, 1.53). Severe symptoms necessitating pad use affected two (3%) mothers after elective cesarean and one (1%) after vaginal delivery. Two (3%) mothers after elective cesarean, one (1%) after emergency cesarean, and two (2%) after vaginal delivery had at least two symptoms. Anal incontinence followed prelabor emergency cesarean in two mothers. Of the 22 mothers who sustained a second-degree tear, five (23%) had new anal incontinence compared with only one (3%) of 40 mothers with an intact perineum (Fisher exact test value = 9.697, P = .014). CONCLUSION Because severe anal incontinence followed elective and prelabor emergency cesarean, it seems that pregnancy itself can lead to pelvic floor disorders. A high incidence of anal incontinence is associated with a second-degree tear. Measures to detect and reduce postpartum anal incontinence should target all pregnant women and mothers, even after prelabor cesarean delivery. Previously healthy primiparas can have severe anal incontinence after elective or prelabor cesarean delivery.

Does cesarean delivery prevent anal incontinence?

Objective To compare the incidence and severity of anal incontinence in primiparas after cesarean delivery versus spontaneous vaginal delivery. Methods A total of 184 primiparas who delivered by cesarean (104 emergency, 80 elective) and 100 who delivered vaginally were interviewed 10 ± 2 months postpartum. A comprehensive bowel function questionnaire was completed. Bowel-specific questions included bowel habits, laxative use, urgency, flatus, urge and passive incontinence, soiling, and pad use, before and during pregnancy and postpartum. Obstetric details were confirmed from obstetric records. Results Anal incontinence was first present in nine (5%) mothers after cesarean delivery and eight (8%) after vaginal delivery (relative risk 0.611, 95% confidence interval 0.25, 1.53). Severe symptoms necessitating pad use affected two (3%) mothers after elective cesarean and one (1%) after vaginal delivery. Two (3%) mothers after elective cesarean, one (1%) after emergency cesarean, and two (2%) after vaginal delivery had at least two symptoms. Anal incontinence followed prelabor emergency cesarean in two mothers. Of the 22 mothers who sustained a second-degree tear, five (23%) had new anal incontinence compared with only one (3%) of 40 mothers with an intact perineum (Fisher exact test value = 9.697, P = .014). Conclusion Because severe anal incontinence followed elective and prelabor emergency cesarean, it seems that pregnancy itself can lead to pelvic floor disorders. A high incidence of anal incontinence is associated with a second-degree tear. Measures to detect and reduce postpartum anal incontinence should target all pregnant women and mothers, even after prelabor cesarean delivery.