6/9/2015f. atashzadeh1. fecal incontinence related to pregnancy, vaginal delivery, and cesarean...

04/18/23 F. Atashzadeh 1

Fecal incontinence related to pregnancy, vaginal delivery, and cesarean

Foroozan Atashzadeh ShoridehPhD nursing Candidate, Shahid Beheshti Medical University


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

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

Prevalence

depending on the population studied,

the definition of type of stool loss, and

the frequency of episodes


Causes of Fecal Incontinence

04/18/23 6F. Atashzadeh

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.


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

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

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

Fecal incontinence after first

instrumental vaginal delivery

using Thierry’s spatulas


Parant et al 2010

Fecal incontinence was assessed at 2 and 6

months

postpartum by a questionnaire (Wexner

score 5 was considered significant)


Results

Episiotomy (odds ratio [OR]=5.0) and maternal age over 35 years (OR=4.1) were independently associated with fecal incontinence after adjustment.


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

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

Operative vaginal delivery

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.


Type of episiotomy

Median

Mediolateral episiotomy


Birth weight

an odds ratio of 1.47 for a sphincter laceration with each 500 g increase in fetal birth weight


Prolonged second stage of labor

exceeds 60 minutes


Maternal birth position

standing, squatting or lithotomy positions


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 1.06-

1.12).


Role of neural injury Major risk factors

for nerve damage associated with childbirth are forceps delivery, length of second stage of labor, and increasing birth weight.


Role of time since delivery


5 years after vaginal delivery

6.4%

18 years after vaginal delivery

10%

Clinical manifestations and diagnosis

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)


Diagnostic procedures

endoanal ultrasound anorectal manometry pudendal nerve terminal latency

measurement defecography electromyography


Function: Anorectal manometry in fecal incontinence


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

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


Anatomy: Endoanal Coil MRI


Treatment

Medical therapy Biofeedback Surgery


Treatment

Improving stool consistency

Increase intake of bulking agents – bran,

psyllium

Antidiarrheal agents – loperamide, lomotil,

cholestyramine


Bowel management Fecal disimpaction

Scheduled toileting Glycerin suppositories daily, 30 min postprandial Attempt to defecate at the same time daily

Daily tap water enema


Biofeedback

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


Biofeedback

70% restoring continence

90% reduction in incontinent episodes

Best outcome after anorectal surgery

Lowest success – spinal cored injury

Is there a sound scientific basis

for the claim that having an

elective c-section protects the

pelvic floor?


Does perineal massage prevent

fecal incontinence?


What is the best mode of delivery

in women with a history of anal

sphincter laceration or fecal

incontinence ?


Will elective c-section prevent sexual

dissatisfaction during intercourse or uterine

prolapse?


Are there any circumstances when I might

wish to consider elective c-section?


6/9/2015f. atashzadeh1. fecal incontinence related to pregnancy, vaginal delivery, and cesarean...

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