Obstetrics & Gynecology:
Mode of Delivery and Fecal Incontinence at Midlife: A Study of 2,640 Women in the Gazel Cohort
Fritel, Xavier MD1; Ringa, Virginie MD, PhD1; Varnoux, Noëlle1; Zins, Marie MD2; Bréart, Gérard MD, PhD1
From 1Institut national de la santé et de la recherche médicale (INSERM), UMR S149, IFR69, Epidemiological Research on Perinatal Health and Women's Health, Villejuif, France; Université Pierre-et-Marie-Curie Paris 6, Paris, France; and 2INSERM, U687, Saint-Maurice, France; Equipe RPPC du Cetaf, Saint-Maurice, France; IFR69, Villejuif, France.
The authors thank Jo Ann Cahn for editorial assistance.
Presented at Intensive Care Society/International Urogynecological Association (ICS/IUGA) joint meeting, Paris, France, August 23–27, 2004.
Corresponding author: Dr. Xavier Fritel, Gynécologie & Obstétrique, CHD Félix Guyon, F-97405 Saint-Denis cedex, Réunion, France; e-mail: firstname.lastname@example.org.
Financial Disclosure The authors have no potential conflicts of interest to disclose.
OBJECTIVE: To estimate obstetric risk factors of fecal incontinence among middle-aged women.
METHODS: We conducted a mail survey of the Gazel cohort of volunteers for epidemiologic research. In 2000, a questionnaire on anal incontinence was mailed to 3,114 women who were then between the ages of 50 and 61 years; 2,640 (85%) women returned the completed questionnaire. Fecal incontinence was defined by involuntary loss of stool. Logistic regression was used to estimate the effect of obstetric and general risk factors.
RESULTS: Prevalence of fecal incontinence in the past 12 months was 9.5% (250). Significant risk factors for fecal incontinence were completion of high school (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1–2.0), self-reported depression (OR 2.1, 95% CI 1.6–2.7), overweight or obesity measured by body mass index (BMI) (OR 1.5 for BMI of 25–30, 95% CI 1.1–2.0; OR 1.6 for BMI more than 30, 95% CI 1.1–2.5), surgery for urinary incontinence (OR 3.5, 95% CI 2.0–6.1), and anal surgery (OR 1.7, 95% CI 1.1–2.9). No obstetric variable (parity, mode of delivery, birth weight, episiotomy, or third-degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous, primiparous, secundiparous, and multiparous women (11.3%, 9.0%, 9.0%, and 10.4%, respectively), and among parous women, it was similar for women with spontaneous vaginal, instrumental (at least one), or only cesarean deliveries (9.3%, 10.0%, and 6.6%, respectively).
CONCLUSION: In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.
LEVEL OF EVIDENCE: III
Fecal incontinence is a serious handicap and its prevalence increases with age.1–3 Because injury to the anal sphincter may occur during vaginal delivery, childbirth is thought to be a predisposing event that may lead to fecal incontinence.4,5 Several months after delivery, fecal incontinence is more frequent in women with instrumental deliveries and less frequent in those with cesarean deliveries than among women with vaginal deliveries.6 It is unclear, however, if cesarean delivery still exerts a protective effect later in life.7,8
Our main purpose was to estimate the prevalence of fecal incontinence among middle-aged women enrolled in a cohort study and to assess its obstetric risk factors, while taking other characteristics into account. Our secondary purpose was to analyze the association between fecal incontinence and other pelvic floor disorders.
PARTICIPANTS AND METHODS
Our population belongs to the French Gazel cohort (www.gazel.inserm.fr), which began in 1989 with more than 20,000 men and women employed by the French national power company (Electricité de France-Gaz de France) who volunteered to participate in an epidemiologic research study coordinated by INSERM (Institut National de la Santé et de la Recherche Médicale, that is, the French National Institute for Health and Medical Research).9 Women of the Gazel cohort aged 45–50 years between 1990 and 1996 (n=3,114) were included in a separate prospective survey, the “Women and Their Health” project. Its principal objective is to study women's health as they reach menopause and afterward.10 They receive a general health questionnaire each year as part of the overall Gazel survey and a specific questionnaire about women's health issues every 3 years. In 2000, when the women were between 50 and 61 years of age, an additional questionnaire about incontinence and obstetric history was mailed to all the women in this survey. All our data come from the mail questionnaires, primarily the questionnaire focusing on incontinence and obstetric history. Two previous reports about urinary incontinence based on the same questionnaire and database have previously been published.11,12
The prevalence of anal incontinence over the previous year was estimated from responses to this question: “In the past 12 months, have you experienced involuntary loss of gas or stool? Yes or No.” Fecal incontinence was defined by involuntary loss of liquid or solid stool. Severity of anal incontinence was estimated according to Pescatori's scoring system,13 which takes into account degree (flatus, liquid stool, solid stool) and frequency (less than once a week, at least once a week, every day) of anal incontinence. Pescatori scores range from 2 (loss of flatus less than once a week) to 6 (loss of solid stool every day). Severe anal incontinence was defined by a score of 4 or higher. Stress urinary incontinence was assessed by responses to the question: “Does urine leak when you are physically active, cough, or sneeze? Never, Rarely, Sometimes, Often, or All the time.”14 Women who answered “Sometimes,” “Often,” or “All the time” were considered to have stress urinary incontinence. Other pelvic floor symptoms (urinary urge incontinence, voiding difficulties, constipation, defecation difficulties, lower abdominal pain, pain at intercourse, vaginal bulge) were assessed by the same method.
We tested a wide assortment of potential risk factors for fecal incontinence: general characteristics (age at questionnaire, educational level, body mass index [BMI], and menopausal status), medical history (diabetes mellitus, hysterectomy, surgery for urinary incontinence or pelvic organ prolapse, anal surgery, and depression), life style (household income, marital status, smoking habits, and regular physical exercise), and obstetric history (parity, episiotomy, third-degree perineal tear, birth weight, and mode of delivery). Depression was defined by self-reported depression, depressed mood, anxiety, or stress during the previous 12 months. Continuous variables were transformed into categories of three classes. Standard cutoff points were used when they existed (BMI and birth weight); otherwise, classes were separated at the 25th and 75th percentiles (age and income). We compared women with fecal incontinence to all others and conducted a multivariable analysis with backward stepwise logistic regression (Table 1). Candidate variables for the multivariable model were those with P<.10 on univariable analysis. Variables remained in the final multivariable model only if the odds ratio (OR) was significant after backward elimination; otherwise, they were excluded. Our population's size and characteristics enabled us to show a significant 6% difference in the prevalence of fecal incontinence among the parous women compared with the nulliparous (17% compared with 11%) and a difference of 7% among those with spontaneous vaginal delivery compared with cesarean delivery (13% compared with 6%) with a power of 80% (α=0.05, β=0.20, bilateral test). We examined the association between anal incontinence according to the Pescatori score and both parity and mode of delivery (Table 2).
To achieve our secondary objective, we studied the association between fecal incontinence and other pelvic floor disorders, as defined above (Table 3). The univariable and multivariable analyses used logistic regression, as described above.
The odds ratios and their 95% confidence intervals are reported for all. All analyses were performed with Statview (SAS Institute Inc, Cary, NC). The Gazel cohort scientific committee and the Commission Nationale de l'Informatique et des Libertés (French Data Protection Authority) approved this study, which received no external funding.
Questionnaires were sent to 3,114 women, and 2,640 (85%) completed and returned them. Details of the population's characteristics and obstetric history have been already published.11 Briefly, median age was 54 (range 50–61) years and median parity 2 (0–6); 79% were postmenopausal (Table 4). Comparisons between respondents and nonrespondents showed no significant differences for age, BMI, parity, marital status, or smoking. Respondents had a higher educational level than nonrespondents. Data about anal continence were missing for 136 women and data concerning its severity for 11. Prevalence of anal incontinence in the past 12 months was 38.5% (1,016), with 28.6% (755) experiencing flatus incontinence only and 9.5% (250) fecal incontinence. The degree and frequency of anal incontinence symptoms are reported in Table 5, and the association of fecal incontinence with other anorectal, pelvic, or urinary symptoms in Table 3.
Characteristics associated with fecal incontinence were high BMI (overweight and obesity), anal surgery, urinary incontinence surgery, completion of high school, and self-reported depression or stress (Table 1). No obstetric variable (parity, mode of delivery, birth weight, episiotomy, or third-degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous, primiparous, secundiparous, and multiparous women (11.3%, 9.0%, 9.0%, and 10.4%, respectively). Among parous women, the prevalence of fecal incontinence was similar for women with spontaneous vaginal, instrumental (at least one), or only cesarean deliveries (9.3%, 10.0%, and 6.6%, respectively). We found no association between severity of anal incontinence and parity or mode of delivery (Table 2).
In our population of women in their 50s, the prevalence of fecal incontinence was 9.5%. Risk factors for fecal incontinence were overweight and obesity, anal surgery, urinary incontinence surgery, completion of high school, and lower household incomes. Its prevalence was similar among nulliparous and parous women and among women with spontaneous, instrumental, or cesarean deliveries.
Our population sample is not exactly representative of middle-aged French women, because women enrolled in the Gazel cohort were recruited from a work setting and volunteered to participate in medical research. We know, for example, that the women who agreed to participate in Gazel had a higher education level and were in better health than nonparticipating employees.9–11 The prevalence of fecal incontinence found in our study is consistent with results from other studies of women in their 50s (Table 6).1–3,15,16
The prevalence of fecal incontinence increases with age.1–3 Even in asymptomatic women, manometry shows that age alters the mechanisms of anal continence.17 We did not find any association with age, but the narrow range of the age distribution in our study sample (50–61 years) may explain this result.
The effect of pregnancy itself on anal continence has not been clearly demonstrated. Several cross-sectional studies report a higher prevalence of anal and fecal incontinence among women with children, but this association disappears after adjustment for other risk factors.16,18,19 The large survey (10,116 men and women) by Perry et al2 found no difference between men and women aged 40 years or older in the prevalence of fecal incontinence (6.2 compared with 5.7, respectively). van Brummen et al20 report a similar prevalence of flatus or fecal incontinence at the beginning of a first pregnancy, at the end of the pregnancy, and at 3 and 12 months postpartum. In their study, the only factors associated with flatus incontinence 12 months after first delivery were BMI and presence of the symptom at 12 weeks of gestation. It is not surprising that the relation between parity and fecal incontinence is so weak when we consider that the median age of onset of fecal incontinence is 55 years.1
The effect of mode of delivery on anal continence is still debated. Vaginal delivery is known to expose the anal sphincter to laceration, especially during first or instrumental deliveries or when birth weight is high.21,22 Even without clinical tears, vaginal delivery may lead to occult injury of the anal sphincter, visible on endosonography.5 The clinical significance of these occult defects is unclear. Chaliha et al23 reported similar prevalence rates for fecal incontinence before and after first delivery and found no association between anal symptoms and anal sphincter defects. In cohort studies, the differences between women with vaginal and cesarean deliveries appear to weaken with time since delivery (Table 7).6,24–27 MacArthur et al6 showed that 3 months after a first delivery, fecal incontinence is more frequent after spontaneous or forceps delivery than after cesarean delivery (8.8%, 13.9%, and 5.0%, respectively). In the same population 6 years later, however, no difference was observed between women with spontaneous vaginal and cesarean deliveries.25 The only randomized trial evaluating vaginal delivery compared with planned cesarean delivery for breech presentation found no significant difference concerning fecal incontinence.26,27 Similarly, cross-sectional studies (of somewhat older women, on average) found no differences for women with cesarean and vaginal deliveries, especially when other risk factors were taken into account.1,3,16,28,29 In our study, fecal incontinence was slightly less frequent and anal incontinence less serious after only cesarean deliveries and slightly more frequent and more serious after at least one forceps delivery (Tables 1 and 2), but this difference is not significant. This may be due to a lack of power, but it also means that the effects of mode of delivery, if they exist, are minor.
Third- and fourth-degree anal sphincter tears are associated with fecal incontinence 1 year after childbirth,20 but the association is not found 6 years after delivery.25 In our work, fecal incontinence was slightly more frequent among women reporting anal tears during delivery, but the difference is not significant.
We found an association between history of anal surgery and fecal incontinence. Our study did not collect details of the surgery, but we can reasonably suppose that it most often involved minor procedures (for hemorrhoids, fissures, or fistula), which involve a risk of fecal incontinence when the internal sphincter is cut or damaged.30,31 Bharucha et al1 thus found an increased risk of fecal incontinence among patients with a history of anorectal surgery (univariable OR 2.3, 95% confidence interval [CI] 1.6–3.3), anal fissure (OR 1.6, 95% CI 1.2–2.2), or anal fistula (OR 2.9, 95% CI 1.7–5.0). There is no known effect of urologic surgery that explains the association we found with fecal incontinence. Nonetheless, we know that anal and fecal incontinence are often associated.3,15,16,28 This association may be explained by tissue characteristics that predispose women to pelvic floor disorders.
We observed that women with a higher educational level were more likely to report fecal incontinence. Overall, respondents in the Gazel cohort have a higher educational level than nonrespondents.9,11 We also note that only 19% of our sample had completed high school (including passing the baccalaureate examination). It may be that the better educated women find it easier to admit this type of symptom, which may be perceived as stigmatizing, humiliating, or taboo. This association was not reported in two other studies that considered educational level, but this result may be explained in part by the type of the population studied or by adjustments for other characteristics, such as race or comorbidities.3,19 The association between obesity and anal incontinence has previously been reported.16,18,32 The mechanism of this association remains unknown.
Melville et al3 also reported an association between depression—major depression in their study—and fecal incontinence. We did not measure depression with a specific validated scale, but simply asked women to report a history of depression, depressed mood, or stress. The cross-sectional nature of our study sheds no light on the question of whether incontinence causes depression in women or whether depression itself causes incontinence. It is possible that both depression and incontinence share a common pathway. On the other hand, depressed subjects may be more sensitive to symptoms or more likely to report symptoms than nondepressed subjects.
The principal limitation of this study was that fecal incontinence was not clinically confirmed. In addition, we were unable to distinguish planned and cesarean delivery during labor. We note, however, that the women questioned had given birth for the first time 30 years earlier on average (1970), at a time when elective caesarean deliveries were still rare. Despite these limitations, our study is a large epidemiologic survey about anal incontinence among middle-aged women and includes a detailed questionnaire about their delivery. In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.
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