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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© 2007 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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