Study Gets Answers about Older Women's Incontinence

By: Jean Johnson for Body1

“I think having accidents is one of the worst red flags that can go up as we age,” Irene Doty of Los Angeles said. “I remember this one friend of the family – he’s not female, but he still had a problem. We used to take him out to dinner every few months after his knees got so bad that he couldn’t get around on his own any more.

Take Action

Speak up and get help Talk to your doctor to find ways to better your problem. Some ways to manage fecal incontinence include: Diet modifications Changes in exercise Biofeedback to increase strength in the muscle of the anus Medications for better stool formation

“He called me up after one of those occasions, and in so many words said he’d had an accident while we were driving him home after dinner. He wanted to know if I had smelled anything,” Doty said.

“We really hadn’t had any idea that had happened, although we could tell something was bothering him. He was relieved to hear that, although he dropped the subject as soon as he made his point and got his answer. What mattered to him most, I think, was not only about that he hadn’t been offensive that time, but that we kept on making dates with him as long as he was able to go out for a bite.”

Doty adds that she does not know whether her friend had the episode because he was riding in the car and could not get to a toilet or whether he actually lost control over his bowel. “It’s one of those things you don’t feel right about prying into very closely,” she explained. “At least I was uncomfortable with asking too many questions. Dignity takes enough blows as our physical bodies desert us.”

Results of a New Study

Researchers at the University of Washington, along with a team at the University of Michigan, mailed 6,000 surveys querying women on instances of fecal incontinence – a condition they defined as the loss of control over the bowel at least once during a month-long period.

A little over half the surveys – 3,563 – were returned, with an average of 7.2 percent of the group admitting that they suffered from the problem. While the study team said that men have fecal incontinence as well as women, they decided to limit their survey to women exclusively.

Jennifer L. Melville, M.D., M.P.H. of the University of Washington Medical School, who works in the obstetrics and gynecology department, and her colleagues, some of whom were associated with the Michigan Bowel Control Program at the University of Michigan Health System, published their results in the December 2005 issue of the American Journal of Obstetrics and Gynecology. The survey targeted members of the Group Health Cooperative of Puget Sound, a Seattle-area HMO.

More specifically, data showed that 12.5 percent of women in their 60s and 15 percent of women in their 80s had fecal incontinence. Rates for those in their 70s dropped to 10.8 percent, a figure researchers could not explain.

Nonetheless, the message was that the loss of control over one’s bowel can be problematic. While researchers underscored that fecal incontinence is not necessarily a normal consequence of aging, analysis showed that numbers of women who experienced the unpleasant problem did increase as the group aged.

More than 7.5 percent of the women in their 50s who responded to the questionnaire, for example, had fecal incontinence as compared to 3.6 percent of women in their 30s and 3.7 percent in their 40s.

This “is an indicator of the services and treatments that will be needed with the aging of out population,” wrote the research team. “Practitioners that care for women, especially those over the age of 50, should be aware of the prevalence of fecal incontinence and the significant impact it can have on the quality of a woman’s life.”

“Wow, that’s me,” said Doty. “Does this mean the next time I see my doctor she’s going to ask me about my bowel habits? I mean it’s one thing for an older man to go downhill that way, but at my age?”

Not to worry – at least based on the results of this study – said professor of clinical obstetrics at Weill Medical College in New York, Yvonne S. Thornton, M.D. As with many studies, there are problems to consider before accepting conclusions at face value. “It’s a flawed design model. It’s what they remember and don’t remember,” said Thornton, clearly skeptical that patients can accurately recount their own medical histories and that scientific conclusions can be drawn from this sort of murky data.

More, Thorton questioned the sampling. “Those women who don’t have fecal incontinence aren’t even going to fill out the questionnaire,” she said.

Quality of Life

Detractors aside, one of the researchers cooperating in the study, Dee E. Fenner, M.D., a founder of the Michigan Bowel Control Program, associate professor of obstetrics and gynecology, and director of gynecology at the University of Michigan Medical School is clearly focused on getting help for people who suffer from fecal incontinence.

“We found half of the subjects with fecal incontinence reported that their bowel symptoms had a large impact on their quality of life,” Fenner said.

Indeed, study data showed that 47 percent of the respondents regularly wore a pad to protect their clothing, and 57 percent of the women said their loss of control over their bowel had resulted in significant lifestyle changes.

Sixty three percent reported fecal incontinence episodes at least monthly and 37 percent of the women suffer weekly embarrassments. Also, when they inquired about the precise nature of the events, researchers found 47 percent had liquid stools, 23 percent experienced the loss of solid stools and 30 percent of the group had both problems. Finally, the number of bowel movements that women with fecal incontinence had was generally higher than their normally functioning counterparts.

Possible Causes and Related Medical Conditions

The study supported the conclusion that damage to the anal sphincter or rectum figures prominently in fecal incontinence.

While ulcerative colitis and Crohn’s disease can cause scarring of the rectum and limit its ability to retain stools, damage to the anal sphincter is often related to the female reproductive system.

Staying Healthy

Fecal Incontinence is Linked to: Older age Urinary incontinence Greater number of births History of births using forceps or a vacuum-assisted device Past hysterectomy Overweight and obesity Major depression Other medical conditions, particularly diabetes

Indeed, “anal sphincter damage after operative delivery has been well documented,” the authors wrote. They observed that fecal incontinence is linked to a history of births in which the delivering physician used forceps or a vacuum-assisted device.

At issue is the stretching of the nerves that stimulate the anal sphincter. When these relax and weaken, muscles in the sphincter respond accordingly and lose their ability to open and close normally. In addition to multiple deliveries, manipulated deliveries and hysterectomies, researchers looked at other types of trauma that could compromise the integrity of the anal sphincter including diabetes that affects the nervous system.

That said, the team was careful to caution that Cesarean sections did not protect women and rather than seeing less fecal incontinence with women who had had C-sections, their study showed more.

Further, while 15.7 women in the group had diabetes, more than 10 percent of the women in the study reported major depression. Still, since this is the first study the team knows of that even considered those factors, researchers emphasize that results are highly preliminary. Particularly in the case of depression; Melville and her colleagues are not sure whether fecal incontinence causes depression or is a result of it.

Being overweight or obese also figures into the equation since the mean Body Mass Index (BMI) of those reporting loss of control over their bowel was 29.3, a number that bordering on government definitions of obesity. According to the BMI scale, a BMI of 25 to 30 is considered overweight and a BMI of 30 or above is considered obese. The research team also noted that since diabetes is more common in older and overweight individuals, they could not determine if it was a causal problem or simply an associated one.

Finally, 70 percent of those experiencing fecal incontinence also had urinary incontinence.

Although connections are still tenuous at best, and because patients are highly reluctant to report fecal incontinence to their physicians, researchers argued that patients displaying any of the reported symptoms should receive more careful screening.

“Clinicians should have a heightened awareness of the possibility of fecal incontinence in women with major depression, urinary incontinence, increased medical morbidity (such as diabetes), and a history of operative vaginal delivery,” said Melville.

Treatments

Dee Fenner concurred with her colleague. “Increased attention should be paid to this debilitating condition, especially considering the aging of our population and the available treatments for fecal incontinence,” said Fenner. “It is very important to the health of women that clinicians are aware of the prevalence of fecal incontinence and can treat their patients accordingly.”

Various ways of managing and treating fecal incontinence are available. Some patients experience relief from changes in diet and exercise, or from using biofeedback to exercise the sphincter muscles in the anus. Also, there are medications available that improve the formation of stools. Lastly, for those who are appropriate candidates, surgeons can repair the sphincter muscles, implant an artificial bowel sphincter or perform non-surgical procedures that reshape the sphincter for better function.

In fact, people like Doty’s friend and the women surveyed by the Melville-Fenner team no longer need to suffer in secret shame and isolation. At the very least, patients who discuss fecal incontinence with their physicians can gain information on how to manage the problem. In the best of all possible worlds they can even access treatment that will resolve the issue and restore quality of life.

Last updated: 01-May-06