Psychological impact and risk factors associated with new onset fecal incontinence
Introduction
Fecal incontinence (FI) refers to the involuntary loss of solid or liquid stool or mucus and is a distressing condition associated with significant economic costs particularly in institutionalized patients [1], [2]. The costs are likely to be underestimated given that many people with FI do not report their symptoms to health care providers [3]. There is a strong need to gain a greater understanding of the epidemiology, impact and risk factors of FI in the general population so that these people may be potentially identified and treated before FI results in serious consequences including in some older people admittance to nursing home facilities [4].
The majority of epidemiological studies on FI have been focussed on the prevalence and incidence of FI in special populations including nursing home residents and patients presenting to medical and obstetric clinics [4], [5], [6]. More recent population based studies have shown that the prevalence of FI in the general population is relatively high, with estimates that between 8 and 15% of the population are affected [7], [8], [9], [10], [11], [12]. However, data on the new onset of FI in the general population remain scarce. Only one study by Rey et al. in 2010 [12] found the new onset rate of FI among U.S. adults aged over 50 years to be 7%, but whether this onset rate is also indicative of younger people with FI in the population is unknown, and no other population-based data are available.
While FI has been associated with important personal and social consequences in patients presenting for care, the impact of FI in people from the general population is poorly understood. Some population-based studies have shown that FI negatively affects quality of life [13], [14], [15], [16] while others have shown that only experiencing more moderate to severe FI impairs quality of life [8], [10]. For example, Bharucha et al. in a sample of 5300 women from the Rochester Epidemiology Project found that only 6% with mild, 35% with moderate, and 82% with severe FI symptoms reported moderate to severe impairment in quality of life [10]. These studies however were limited to people over 40 years or women only [8], [10], [13], [14], [15], [16]. There is even less population-based data on whether FI is associated with psychological problems such as anxiety and depression. Melville found that depression was significantly associated with FI in a community sample of women aged 30 to 90 years [13] which has been confirmed in another community study of women [17]. Further population-based studies are needed to determine the psychological impact of FI in both men and women from the general population.
While the risk factors associated with FI in referral centers including obstetrical injury, diabetes mellitus, neurological diseases and chronic diarrhea are well known [4], [6], [18], the majority of population-based studies have shown that diarrheal symptoms are more important risk factors for FI than obstetrical injury [19], [20]. Whitehead et al. in a U.S. population based study found that loose watery stools, > 21 stools per week along with multiple chronic illness, urinary incontinence and age were independent risk factors associated with FI in women, while in men age, loose watery stools, poor self rated health and urinary incontinence were risk factors for FI [11]. In another population sample of 1000 Australians, Kalantar et al. found GI symptoms including loose stools, urgency as well as perianal injury and surgery were significantly associated with FI [9]. Bharucha et al. has since confirmed that rectal urgency is strongly associated with FI in women, particularly in those with severe FI [20].
More recently, Rey et al. 2010 in a random sample of 2400 US adults aged over 50 years found GI symptoms including self-reported usual bowel pattern, number of bowel movements per week, urgency, loose/watery stools, straining, time needed for defecation, feeling of anal blockage, anal trauma, and pelvic radiation along with age and gender to be independently associated with reporting FI cross sectionally [12]. However when they looked at risk factors for developing FI over a 10 year period only self‐reported diarrhea, feeling of incomplete rectal evacuation and pelvic radiation, and in females a diagnosis of rectocele before the first survey, were significant. No other studies have evaluated the risk factors associated with the development of FI in the general population over time, and it is unknown whether these factors would also be predictive of the new onset of FI in younger populations. There is limited evidence that FI related symptoms differ in older and younger women presenting for treatment [21].
Thus, in a 12-year longitudinal, prospective, population-based study, we aimed to evaluate the rate of new onset, psychological impact and risk factors (demographic and gastrointestinal) associated with FI over 12 years.
Section snippets
Subjects
Subjects (n = 1775) aged 18 years and older who had participated in a random population survey of 4500 persons 12 years earlier and who agreed to be recontacted for future research were included in this study [22]. The sampling frame for the initial study consisted of the 1996 electoral roll for the local government area of Penrith, which represents 3.6% of the Sydney population. Based on 1996 census data [23], the population of Penrith is representative of the Australian population as a whole, in
Prevalence of FI at baseline and follow-up
Among those people who participated in the follow-up survey (n = 1002), we found that 13.2% (n = 132) reported leakage of stool over the past 12 months at baseline, with this increasing to 18.5% 95% CI 16.1, 21.1 (n = 182) at the 12 year follow-up.
Onset and disappearance of FI
Of the 1002 people who responded to the follow-up survey, there were 114 people (11.4%) who reported the new onset of fecal incontinence at follow-up (i.e. they did not report having leakage of stool over the past 12 months in the first survey but did at the
Discussion
In this study we have provided data for the first time on the incidence, psychological impact and associated risk factors for developing FI in Australian adults aged over 18 years. We found that 10% of our sample developed the new onset of FI over a 12 year period. This is relatively comparable to the 6% incidence rate of FI reported by Rey et al. [12] in a U.S. study of people aged over 50 years over a shorter period of 9 years. Notably we also found that 5% of our sample who reported FI on the
Author contributions
Dr Koloski - involved with the study concept and design, acquisition of data, study supervision, analysis and interpretation of data, drafting of the manuscript and critical revision of the manuscript.
Dr Jones - involved with the study concept and design, acquisition of data, analysis and interpretation of data.
Dr Kalantar ‐ involved with critical revision of the manuscript for important intellectual content, administrative support and study supervision.
Dr Weltman ‐ involved with critical
Conflict of Interest
There are no conflicts of interests.
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Cited by (21)
Association between fecal incontinence and suicidal ideation in adult Americans: Evidence from NHANES 2005–2010
2023, Journal of Psychosomatic ResearchFactors Associated With Timing of Return to Intercourse After Obstetric Anal Sphincter Injuries
2016, Journal of Sexual MedicineCitation Excerpt :Pauls et al24 reported that women with fecal incontinence of solid stool had poorer sexual function after anal sphincteroplasty surgery. They also found that fecal incontinence was related to depression, which was associated with fecal incontinence in other studies.25,26 In contrast to other studies, we did not find a relation between resumption of sexual function and depression.27,28
Anorectal disorders
2016, GastroenterologyCitation Excerpt :Persons with FI report that poor bowel control restricts their social life; other issues pertain to toilet location, hygiene/odor issues, coping strategies, fear, physical activities, embarrassment, and unpredictability of bowel habits.27 Co-existent psychological problems may include anxiety and depression,28,29 poor self-esteem, and problems with sexual relationships.30 Quality of life issues can be evaluated by generic or disease-specific instruments, such as the Rockwood Fecal Incontinence Quality of Life Scale, modified Manchester Health Questionnaire, Fecal Incontinence and Constipation Assessment Quality of Life scale.
Fecal incontinence was associated with depression of any severity: insights from a large cross-sectional study
2023, International Journal of Colorectal DiseaseEditorial: faecal incontinence in ulcerative colitis
2023, Alimentary Pharmacology and Therapeutics