Epidemiology, Pathophysiology, and Classification of Fecal Incontinence: State of the Science Summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Workshop

Abstract

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but is often underreported as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (co-morbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multi-faceted anorectal dysfunctions. The type (urge, passive or combined); etiology (anorectal disturbance, bowel symptoms or both); and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Novel approach to treat fecal incontinence with muscle stem cell-based therapy

“…In addition, the financial burden to treat FI as well as related complications is substantial and exceeds $4000 per year in both Europe and the USA [5].…”

Towards a more scientific approach to measuring barriers to seeking health care in women with fecal incontinence: the BCABL questionnaire

“…Hence, most of the available qualitative research data on care seeking, that is primarily based on thematic or deductive analysis of patient narratives, is not able to demonstrate the full impact of each care barrier with a significant overlap between barriers [4]. Another major problem is the assumption that care seeking is primarily dependent on the severity of FI without further critical evaluation of this observation or factor analysis to determine the contribution of other condition-specific quality of life measures [2]. In fact, mild FI is sometimes a greater problem for affected women than severe incontinence [7].…”

“…In fact, mild FI is sometimes a greater problem for affected women than severe incontinence [7]. Finally, survey instruments to assess the epidemiology of FI are limited by differences in definition (incontinence to feces versus incontinence to feces and flatus, or incontinence only versus incontinence and fecal soiling), onset (over the last month or last year), severity (whether or not a social or hygienic problem) and frequency (daily or episodic) [2,7].…”

“…In fact, mild FI is sometimes a greater problem for affected women than severe incontinence [7]. Finally, survey instruments to assess the epidemiology of FI are limited by differences in definition (incontinence to feces versus incontinence to feces and flatus, or incontinence only versus incontinence and fecal soiling), onset (over the last month or last year), severity (whether or not a social or hygienic problem) and frequency (daily or episodic) [2,7].It is obvious that we lack a validated and structured method to measure factors interfering with care seeking in women with FI and that we need a robust scientific approach to the development of a new research tool. Brown et al elegantly review the subject in this issue of the International Urogynecology Journal [8].…”

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Although barriers to seeking care in women with fecal incontinence (FI) have been identified consistently in the literature [1][2][3][4], research on this topic is inadequate for methodological reasons. Most importantly, there is currently no validated technique for reproducible measurement of these barriers.

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