Psychological impact and risk factors associated with new onset fecal incontinence

Abstract

Objectives

We aim to evaluate the psychological impact and risk factors associated with new onset FI over 12 years in adults over 18 years for the first time in a population-based study.

Methods

Participants (n = 1775) were a random population sample from Penrith, Australia who responded to a survey in 1997 and completed a 12-year follow-up survey (response rate = 60%). FI was defined as having leakage of stool over the past 12 months. The original and follow-up surveys contained valid questions on demographic, gastrointestinal and psychological symptoms.

Results

114 (11.4%) reported new onset FI at the 12 year follow-up. People who reported FI at the 12 year follow-up were significantly more anxious and depressed. In terms of baseline risk factors only bloating (OR = 1.3; 95%CI 1.0–1.6, P = 0.026) was an independent predictor of developing new onset FI. However, current bowel symptoms measured at follow-up including less likelihood of < 3 bowel motions a week, increased urgency and mucus were independently associated with having FI at follow-up.

Conclusion

FI is associated with anxiety and depression. Baseline GI symptoms do not appear to be as important as current bowel symptoms in determining who develops FI.

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.