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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. References

Four hundred and sixty-five women attending a urodynamic clinic were interviewed, and completed a detailed bowel questionnaire, about their urinary and bowel symptoms. All the women underwent video-cystourethrography with pressure and flow studies. The reported incidence of faecal incontinence was 15.3% (n= 71) on direct questioning and 26% 0(n = 121) on the postal questionnaire. Faecal incontinence was more common in women with a urodynamic diagnosis of detrusor instability (30′%1 (n= 26)) than among women diagnosed as having genuine stress incontinence (21% (n= 38)). Denervation and myogenic injuries sustained during childbirth have been suggested as a common cause for genuine stress and faecal incontinence, but there may be an alternative mechanism to explain why women with detrusor instability suffer from faecal incontinence.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. References

It has been estimated that faecal incontinence affects between 1% and 16% of women, with the prevalence increasing with age. It is eight times more common in women than men and more than half of patients do not report their symptoms to their general practitioner. Faecal incontinence has been linked with urinary incontinence through a common mechanism of denervation and myogenic injury following childbirth's3. In a small study4 a substantial proportion of women (31%) with urinary incontinence were reported to suffer from faecal incontinence. There is no information in the literature about urodynamic diagnoses in women with urinary incontinence and the symptoms of faecal incontinence. We report a prospective study of women referred for investigation of urinary incontinence who underwent video-urodynamics and were interviewed and questioned about the symptom of faecal incontinence, defined as the involuntary loss of liquid or solid stool.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. References

All women with urinary symptoms referred to the urodynamic clinic during a four-month period were recruited into this study; consent was obtained from each woman who took part in the study. Before attending for urodynamics a postal questionnaire enquiring about symptoms of faecal incontinence and constipation was completed by each woman(Fig. 1).

image

Figure 1. Bowel questionnaire.

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Initially each woman voided into a flow meter and the urinary residual was measured. Videocystourethrography (VCU) was performed with the patient lying supine during bladder filling at a rate of 100 mL/min with room temperature contrast medium (Omnipaque, Nycomed, Bucks, UK). Provocative cystometry was performed (coughing and heel bouncing) while using X-ray screening. After a pressure/flow study a urodynamic diagnosis was made. Each woman was interviewed about urinary and bowel symptoms using a standard questionnaire, the interviewer was blinded to the woman's responses in the postal questionnaire. Three grades of genuine stress incontinence (mild, moderate and severe) were reported; severe indicated profuse leakage with every cough and mild indicated a small leakage after severe provocation. The moderate group consisted of incontinence intermediate between these two categories. Systolic detrusor instability occurs during bladder filling and is a detrusor pressure rise associated with symptoms of urgency. Provoked detrusor instability is a detrusor pressure rise associated with a provocative manoeuvre and urgency. Low compliance is a detrusor pressure rise of 0.03 cmH, O /mL associated with urgency during filling. Detrusor hyper-reflexia is detrusor instability associated with neurological disease. Women with systolic, provoked detrusor instability, detrusor hyperreflexia and low compliance have also been amalgamated into a single group labelled detrusor overactivity. A separate subgroup labelled idiopathic detrusor instability included women with a urodynamic diagnosis of systolic and provoked detrusor instability. This distinction has been made as low compliance and detrusor hyperreflexia may be due to other causes.

The terminology of the International Continence Society has been used throughout this article6.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. References

Four hundred and sixty-five women were entered into this study. Fourteen other women (3′51) who underwent VCU during this time were excluded as they did not complete the postal questionnaire completely prior to attending. Eighty-six (18.5%)) were found to have detrusor overactivity on urodynamics. Of these women, 11 (13%) admitted to faecal incontinence on interview, compared with 26 women (30%) when completing the bowel questionnaire. One hundred and eighty-three women were diagnosed as having genuine stress incontinence, of whom 30 (16%) had faecal incontinence as a symptom on direct questioning, compared with 38 (21%) when answering the bowel questionnaire. There was a significant difference between the women with a diagnosis of detrusor instability and genuine stress incontinence and their reporting of faecal incontinence at interview or by postal questionnaire (x2= 10.1, P < 0.02, x2 test). Fifty-three of the women (29%) admitted to genuine stress incontinence and 30 (35%) of the women admitted to detrusor instability. There was no significant difference between the groups according to age and parity when classified by urodynamic diagnosis and the presence of faecal incontinence.

At interview, six (13%), of women in the more homogenous group of idiopathic detrusor instability reported faecal incontinence and 13 (29%) when answering the questionnaire. Table 1 shows the individual urodynamic diagnostic categories and the bowel symptom question responses.

Table 1.  Urodynamic diagnoses and the bowel symptoms on direct questioning and after completion of a questionnaire. GSI = genuine stress incontinence; DI = detrusor instability; LC = low compliance; DHR = detrusor hyper-reflexia. Values are given as n/n (%).
 Postal questionnaire:At interview
DiagnosisTo flatus, liquid or solid stoolTo liquid or solid stoolIncontinence: liquid or solid stoolConstipationProlapse/perineal discomfort
All women169/465 (36.34)121/465 (26.02)71/465(15.26)140/465(30.10)118/465(25.37)
GSI
  mild7/27 (25.92)5/27(18.51)4/27 (14.81)9/27 (33.33)7/27 (25.92)
  moderate25/62 (40.32)14/62(22.58)15162(24.19)19/62 (30.64)27162(43.54)
  severe29/94(30.85)19/94(20.21)11/94(11.70)25/94(26.59)22/94 (23.40)
All GSI61/183(33.33)38/183(20.76)30/183(16.39)53/183(28.96)56/183(30.60)
DI
  prov10/28(35.71)10/28(35.71)4/28 (14.28)15/28(53.57)7/28 (25.00)
  sys5/17(29.41)3/17(17.64)2/17(11.76)5/17 (29.41)4/17 (23.52)
Idiopathic DI15/45(33.33)13/45(28.88)6/45(13.33)17/45(37.77)11/45(2444)
  DHR2/8 (25.00)4/8 (50.00)118 (12.50)2/8 (25.00)1/8 (12.50)
  LC13/33(39.39)9/33 (27.27)4/33(12.12)8/33 (24.24)6/33(18.18)
All detrusor overactivity30/86 (3488)26/86(30.23)11/86(12.79)30/86(34.88)18/86(20.93)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. References

Faecal incontinence is an embarrassing problem to which women are reluctant to admit, due to the associations with childhood and senescence. That more women admitted to faecal incontinence when filling in a self-completed questionnaire than on direct questioning is consistent with the taboo associated with this condition.

Denervation as a proposed cause for weakness of the pelvic floor and anal sphincter has been supported by histological and electrophysiological studies7. Women with genuine stress incontinence have also been found to have damage to the pudendal nerve supplying the urethral sphincter8 and have smaller urethral sphincters than women without urinary symptoms. Thus there appears to be a common mechanism producing genuine stress incontinence and faecal incontinence and we should find these two pathologies co-existent.

Surprisingly, in this study there were proportionately as many women complaining of faecal incontinence who had detrusor instability than genuine stress incontinence. This observation is not consistent with faecal incontinence being secondary to nerve and muscle damage as damage to the pudendal nerve is not the mechanism by which detrusor instability occurs. These women with detrusor instability either have weakened anal sphincter muscles due to a process associated with detrusor instability or the faecal incontinence is due to another factor, such as increased gastrointestinal motility such as irritable bowel where diarrhoea could lead to faecal incontinence10. Irritable bowel disease is associated with faecal incontinence in women with urinary incontinence4. Similar proportions of women with detrusor instability and genuine stress incontinence complained of constipation and symptoms of vaginal prolapse. As the degree of vaginal prolapse found on examination was not specifically recorded, this requires further investigation. A large proportion of women with urinary incontinence suffer from faecal incontinence and it is important to enquire about these symptoms ideally through a self-completed questionnaire.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. References