4/13/2015
F. Atashzadeh
1
Fecal incontinence related
to pregnancy, vaginal
delivery, and cesarean
Foroozan Atashzadeh Shorideh
PhD nursing Candidate, Shahid Beheshti
Medical University
4/13/2015
F. Atashzadeh
2
Fecal incontinence has a
significance impact on quality of
life.
 Vaginal delivery is the major risk
factor for the development of
pelvic organ prolapse and urinary
and fecal incontinence, resulting
from damage to the pelvic floor
muscles, nerves and connective
tissue.

Bortolini et al 2010
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Definition
Fecal incontinence refers to the
involuntary loss of solid or liquid
stool.
 Anal
incontinence also includes
involuntary release of flatus.
 The
consequences of AI can be
detrimental to the psychological,
social, and sexual wellbeing of the
patient.

Tin et al , 2010
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Prevalence

depending on the population studied,
the definition of type of stool loss, and
the frequency of episodes
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Causes of Fecal Incontinence
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How does pregnancy affect pelvic
floor dysfunction?
This is probably the result of the extra
weight of the uterus and baby on the pelvic
floor.
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PREGNANCY AND FECAL
INCONTINENCE

In studies of nulliparous women, the
prevalence of fecal incontinence increased
from 1% prior to pregnancy to 7% during
pregnancy.
Chaliha et al 1999, 2001
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Labor and fecal incontinence

The risk of fecal incontinence associated
with second stage of labor appears to be
similar to the risk of vaginal delivery.
Liebling 2005, Bahl 2004
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vaginal delivery and fecal
incontinence



Controversial
Anal
incontinence
was
significantly
increased after spontaneous vaginal delivery
compared to cesarean delivery (OR 1.32,
95% CI 1.04-1.68).
The risk of fecal incontinence alone was not
significantly increased.
Pretlove et al 2008
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Fecal incontinence after first
instrumental vaginal delivery
using Thierry’s spatulas
Parant et al 2010
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
Fecal incontinence was assessed at 2 and 6
months

postpartum by a questionnaire (Wexner
score 5 was considered significant)
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Results
538
women

4/13/2015
176
spatula
14.3%
Fecal
incontinence
362
spontaneous
9.7%
Fecal
incontinence
Episiotomy (odds ratio [OR]=5.0) and
maternal age over 35 years (OR=4.1) were
independently
associated
with
fecal
incontinence after adjustment.
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Role of anal sphincter laceration

In women with obstetric anal sphincter
injuries (OASIS), the risk of subsequent
fecal incontinence is estimated to be 9 to 28
percent.
Pollack et al 2004
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Vaginal delivery or cesarean?

vaginal delivery (76%) was associated with
a
greater
risk
of
fecal
incontinence
compared with cesarean delivery (24 %), if
the delivery conferred a laceration or
required instrumentation.
Guise et al 2009
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Operative vaginal delivery



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Operative vaginal delivery is a risk factor
for anal sphincter laceration and other
pelvic floor disorders.
This risk is further increased if the fetus is
in the occipital posterior position.
The risk of OASIS appears to be higher in
forceps deliveries than in vacuum-assisted
delivery.
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Type of episiotomy

Median

Mediolateral episiotomy
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Birth weight

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an odds ratio of 1.47 for a sphincter
laceration with each 500 g increase in fetal
birth weight
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Prolonged second stage of labor

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exceeds 60 minutes
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Maternal birth position

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standing, squatting or lithotomy positions
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Maternal age

As an example, an observational study of
women reported an increase in odds ratio of
1.09 per year of maternal age (95% CI 1.061.12).
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Role of neural injury

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Major risk factors
for nerve damage
associated
with
childbirth
are
forceps
delivery,
length of second
stage of labor, and
increasing
birth
weight.
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Role of time since delivery
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5 years after
vaginal delivery
6.4%
18 years after
vaginal delivery
10%
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Clinical manifestations and
diagnosis




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Fecal and anal incontinence
Medical history
Occult anal sphincter laceration (endoanal
ultrasound)
Physical examination (inspection of the
perianal area and vagina and a digital rectal
examination)
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Diagnostic procedures





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endoanal ultrasound
anorectal manometry
pudendal
nerve
terminal
measurement
defecography
electromyography
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latency
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Function: Anorectal manometry in
fecal incontinence
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Electrophysiologic tests


EMG – needle electrodes into the superficial
portion of the external sphincter or puborectalis
muscle – myoelectric activity
Pudendal nerve terminal motor latency –
measures the delay between the application of an
electrical stimulus and external sphincter muscle
response. Prolonged – pudendal neuropathy
Defecography




Videodefecography – barium thickened to the
consistency of stool is introduced into the rectum.
Evacuation is monitored with flouroscopy
Assessment of the anorectal angle at rest and
during defecation
Excessive perineal descent, failure of the
puborectalis muscle to relax, rectocele and
internal intususception
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Anal Endosonography

An ultrasound probe is placed in the anal
canal or transvaginally to detect sphincter
injuries and to evaluate pelvic floor
structures.
Anatomy: Rectal Ultrasound
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Anatomy: Endoanal Coil MRI
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Treatment



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Medical therapy
Biofeedback
Surgery
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Treatment

Improving stool consistency

Increase intake of bulking agents – bran,
psyllium

Antidiarrheal agents – loperamide, lomotil,
cholestyramine
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
Bowel management

Fecal disimpaction

Scheduled toileting



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Glycerin suppositories daily, 30 min postprandial
Attempt to defecate at the same time daily
Daily tap water enema
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Biofeedback



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Biofeedback therapy inexpensive, quick and safe
option
Success dependent on the expertise of the clinician
and the motivation and the ability of the patient to
understand and cooperate
Dementia, absent rectal sensation, inability to
contract the external sphincter are the least likely
to respond
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Biofeedback

70% restoring continence

90% reduction in incontinent episodes

Best outcome after anorectal surgery

Lowest success – spinal cored injury
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Is there a sound scientific basis
for the claim that having an
elective c-section protects the
pelvic floor?
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Does perineal massage prevent
fecal incontinence?
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What is the best mode of delivery
in women with a history of anal
sphincter laceration or fecal
incontinence?
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Will elective c-section prevent sexual
dissatisfaction during intercourse or uterine
prolapse?
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Are there any circumstances when I might
wish to consider elective c-section?
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