| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology; Clinical Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Department of Medicine; Department of Radiology; and Division of Biostatistics, Mayo Clinic, 200 First Street SW, Rochester, Minnesota.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Methods: In 55 subjects with fecal incontinence, 42 subjects with obstructed defecation, and 45 healthy subjects without defecatory symptoms, a urogynecologist assessed pelvic organ prolapse by the pelvic organ prolapse quantification system, and a gastroenterologist evaluated perineal descent during simulated evacuation. A multiple logistic regression model evaluated whether obstetric-gynecological variables, including pelvic organ prolapse, could discriminate among controls, subjects with fecal incontinence, and subjects with obstructed defecation.
Results: Fifty-five percent of controls, 42% of those with obstructed defecation, and 29% of those with fecal incontinence had stage II or greater prolapse by clinical examination. Eleven percent of controls, 7% of those with obstructed defecation, and 47% of subjects with fecal incontinence had a forceps delivery. Eighteen percent of controls, 31% of those with obstructed defecation, and 64% of those with fecal incontinence had a hysterectomy. Even after controlling for a higher prevalence of obstetric risk factors and hysterectomy, fecal incontinence was associated with a lower risk of stage II or greater pelvic organ prolapse (odds ratio for fecal incontinence in 
stage II pelvic organ prolapse relative to stage 0 pelvic organ prolapse = 0.1, 95% confidence interval 0.01–0.53). In contrast, pelvic organ prolapse severity was not associated with control versus obstructed defecation status. Seven percent of controls, 18% of subjects with obstructed defecation, and 7% of those with fecal incontinence had increased perineal descent during simulated evacuation. Excessive perineal descent was associated (P < .01) with pelvic organ prolapse.
Conclusion: Despite a higher prevalence of risk factors for pelvic floor injury, pelvic organ prolapse severity was lower in those with fecal incontinence than in subjects without bowel symptoms. However, a subset of subjects with defecatory disorders, predominantly obstructed defecation, have excessive perineal descent, which is associated with pelvic organ prolapse.
Level of Evidence: II-3
It is also conceivable that pelvic organ prolapse and fecal incontinence are associated because both conditions share similar risk factors, particularly obstetric trauma.1,6 Moreover, in subjects with pelvic organ prolapse, excessive perineal descent may cause a pudendal neuropathy, which in turn may cause anal sphincter weakness, predisposing to fecal incontinence.7 On the other hand, subjects with a rectal evacuation disorder often strain excessively during defecation, which may predispose to pelvic organ prolapse. However, previous studies did not observe an association between fecal incontinence and pelvic organ prolapse.8,9 In uncontrolled studies, the prevalence of fecal incontinence in women with pelvic organ prolapse or urinary incontinence was approximately 20%.8,9 Urinary incontinence, irritable bowel syndrome, and reduced anal sphincter tone, but not pelvic organ prolapse, were risk factors for fecal incontinence in these studies.
The objective of this study was to compare the prevalence of pelvic organ prolapse in fecal incontinence and obstructed defecation with controls without bowel symptoms. Our primary hypothesis was that the prevalence of pelvic organ prolapse would be higher in subjects with fecal incontinence and obstructed defecation than in controls.
|
SUBJECTS AND METHODS |
|---|
|
TOP
ABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
All subjects had a clinical interview and physical examination. Pelvic organ prolapse was assessed by a single urogynecologist using a standardized previously described approach, ie, the pelvic organ prolapse quantification staging system.11 After voiding, each subject was examined during maximum straining in the dorsal lithotomy position with her back at a 45° angle.12 The maximal protrusion was determined after 3 attempts and verified by the subject with a mirror or by touch. The posterior blade of a Grave's speculum was used to support the anterior and posterior vaginal wall during the examination. A plastic ruler was used to measure the length of the perineal body and genital hiatus, while a ring forceps with 1-cm markings was used to measure points Aa, Ba, C, D, Bp, Ap, and TVL as described elsewhere. Measurements were recorded to the nearest 0.5 cm.13
A single gastroenterologist assessed perineal descent by observing perineal motion when subjects were asked to expel the examining finger by straining in 129 out of 142 subjects;14 perineal descent was not recorded in the other 13 subjects. Perineal descent during simulated evacuation was assessed as normal, reduced (signifying a nonrelaxing pelvic floor), or increased (ie, perineal ballooning).14
The associations between subject group (ie, controls, subjects with fecal incontinence, and subjects with obstructed defecation) and pelvic organ prolapse severity, obstetric history, and hysterectomy status were evaluated by 
2 or Fisher exact test. A multiple logistic regression model evaluated whether age, body mass index (BMI), and obstetric-gynecological factors could discriminate between controls and subjects with fecal incontinence and, separately, between controls and subjects with obstructed defecation. Obstetric-gynecological risk factors incorporated in this model included the number of vaginal deliveries (categorized as < 4 or 4), any forceps delivery, the number of episiotomies/perineal tears, hysterectomy, and pelvic organ prolapse quantification status. For these analyses, pelvic organ prolapse quantification stages II and III were grouped together, because only 4 subjects had stage III prolapse. The odds ratios (and 95% CIs) for subject subgroup (versus controls) were estimated, for example, in those with pelvic organ prolapse quantification stage II/III relative to those with stage 0, adjusting for age, BMI, and important obstetric factors. Associations were assessed by 2 or Fisher exact test.
Sample size estimates were based on a previous study in which 50% of women, with an average age of 44 years, had stage II or greater pelvic organ prolapse, ie, the primary outcome variable in this study.15 Assuming a similar prevalence of stage II or greater pelvic organ prolapse in this study, the proposed sample size (ie, 55 subjects with fecal incontinence, 55 subjects with obstructed defecation, and 45 controls) would have provided 80% power (using a 2-sided 
level of 0.05) to detect an association between pelvic organ prolapse and each disorder (separately), corresponding to stage II or greater pelvic organ prolapse prevalence of 23% or less or 77% or more compared with 50% in controls. With 42 subjects (ie, the actual number of subjects with obstructed defecation studied), this study had 80% power (using a 2-sided level of 0.05) to identify stage II or greater pelvic organ prolapse prevalence of 21% or less or 79% or more in subjects with obstructed defecation compared with 50% in controls.
|
RESULTS |
|---|
|
TOP
ABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
|
|
Fifty-five percent of controls, 42% of subjects with obstructed defecation, and 29% of subjects with fecal incontinence had stage II or greater pelvic organ prolapse. Univariate and multiple logistic regression models suggested that fecal incontinence was associated with less severe pelvic organ prolapse, even though subjects with fecal incontinence were older and were more likely to have had obstetric risk factors or a hysterectomy (Table 2). Thus, even after controlling for a higher prevalence of obstetric risk factors and hysterectomy, fecal incontinence was associated with a lower risk of stage II or greater pelvic organ prolapse (odds ratio for fecal incontinence in stage II pelvic organ prolapse relative to stage 0 pelvic organ prolapse = 0.1, 95% CI 0.01–0.53). In contrast, pelvic organ prolapse severity was not significantly different between controls and subjects with obstructed defecation.
Perineal descent during simulated evacuation was associated (P < .001 by Fisher exact test) with subject status. Among controls, perineal descent was normal in 89%, reduced in 4%, and increased in 7%. A higher proportion of subjects with obstructed defecation had abnormal (ie, reduced, 44%, or increased, 18%) perineal descent. In fecal incontinence, perineal descent was normal in 70%, reduced in 24%, and increased in 7%. Moreover, perineal descent and pelvic organ prolapse severity assessed by clinical examination were associated (P < .01;Table 3). Only 41 of 85 (48%) subjects with normal descent, 7 of 30 subjects (23%) with reduced descent, but 10 of 14 subjects (71%) with increased perineal descent by clinical examination had stage II or greater pelvic organ prolapse (Table 3).
|
|
DISCUSSION |
|---|
|
TOP
ABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
These findings are representative of patients recruited at a tertiary referral center and need to be confirmed by population-based studies. Control subjects were recruited by public advertisement and did not have defecatory symptoms, either by interview or by a detailed questionnaire. The prevalence of stage II or greater pelvic organ prolapse in controls (ie, 55%) is comparable to the prevalence of pelvic organ prolapse in a large study.15 Although we reviewed obstetric records when available, recall bias may have influenced assessment of obstetric risk factors for pelvic organ prolapse and defecatory disorders. The urogynecologist evaluating pelvic organ prolapse severity was not blinded to subject status because he also discussed management of symptoms and findings (eg, pelvic organ prolapse, urinary incontinence) with subjects. We suspect that potential observer bias should not significantly affect our results because the pelvic organ prolapse assessment is objective and standardized. Because our a priori hypothesis was that the prevalence of pelvic organ prolapse would be higher in patients, potential bias would have tended to increase pelvic organ prolapse severity in patients with defecatory disorders, thereby reducing differences between patients and controls. Differences in pelvic organ prolapse quantification severity between controls and subjects with obstructed defecation were not statistically significant, perhaps because of a type II error.
Although the prevalence of pelvic organ prolapse in the overall group of subjects with fecal incontinence was lower compared with controls, a subset of subjects, particularly those with obstructed defecation, had excessive perineal descent, suggestive of pelvic laxity.20,21 A previous study from our institution suggested that 78% of subjects with excessive perineal descent by clinical examination also had excessive perineal descent (ie, > 4-cm descent) by scintigraphic proctography.20 In this study, a single observer assessed perineal descent by clinical examination. We have recently shown that clinical examination and magnetic resonance imaging agreed in characterizing perineal descent as normal, reduced, or increased in 66% of subjects. Moreover, the clinical examination did not significantly under- or overestimate descent compared with magnetic resonance imaging.19 Excessive perineal descent was associated with pelvic organ prolapse, suggesting that these subjects had generalized pelvic laxity. In a retrospective study, pelvic floor retraining by biofeedback therapy had modest effects on constipation symptoms in subjects with the descending perineum syndrome, perhaps because ligamentous laxity is unlikely to normalize with muscle exercises.20 Multidisciplinary approaches involving urogynecologists and coloproctologists should be especially considered for these subjects, particularly because excessive perineal descent is a risk factor for stretch injury to the pudendal nerve.7
To summarize, despite a higher prevalence of risk factors for pelvic floor injury, pelvic organ prolapse severity was lower in subjects with fecal incontinence than in subjects without defecatory symptoms. These findings suggest that fecal incontinence is predominantly due to anorectal dysfunctions rather than generalized pelvic floor weakness. However, a subset of subjects with defecatory disorders, predominantly obstructed defecation, have excessive perineal descent, which is associated with pelvic organ prolapse.
|
Footnotes |
|---|
Corresponding author: Adil E. Bharucha, MD, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: bharucha.adil{at}mayo.edu.
doi:10.1097/01.AOG.0000171104.72972.34
|
REFERENCES |
|---|
|
TOP
ABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SS. Functional disorders of the anus and rectum. Gut 1999;45 suppl 2:II55–9.
3. Snooks SJ, Barnes PR, Swash M. Damage to the innervation of the voluntary anal and periurethral sphincter musculature in incontinence: an electrophysiological study. J Neurol Neurosurg Psychiatry 1984;47:1269–73.[Abstract]
4. McIntosh LJ, Frahm JD, Mallett VT, Richardson DA. Pelvic floor rehabilitation in the treatment of incontinence. J Reprod Med 1993;38:662–6.[Medline]
5. Roberts RO, Jacobsen SJ, Reilly WT, Pemberton JH, Lieber MM, Talley NJ. Prevalence of combined fecal and urinary incontinence: a community-based study. J Am Geriatr Soc 1999;47:837–41.[Medline]
6. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186:1160–6.[Medline]
7. Kiff ES, Barnes PR, Swash M. Evidence of pudendal neuropathy in patients with perineal descent and chronic straining at stool. Gut 1984;25:1279–82.
8. Jackson SL, Weber AM, Hull TL, Mitchinson AR, Walters MD. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 1997;89:423–7.[Abstract]
9. Meschia M, Buonaguidi A, Pifarotti P, Somigliana E, Spennacchio M, Amicarelli F. Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse. Obstet Gynecol 2002;100:719–23.
10. Bharucha AE, Locke GR, Seide B, Zinsmeister AR. A new questionnaire for constipation and fecal incontinence. Aliment Pharmacol Ther 2004;20:355–64.[Medline]
11. Baden WF, Walker TA. Physical diagnosis in the evaluation of vaginal relaxation. Clin Obstet Gynecol 1972;15:1055–69.[Medline]
12. Barber MD, Lambers A, Visco AG, Bump RC. Effect of patient position on clinical evaluation of pelvic organ prolapse. Obstet Gynecol 2000;96:18–22.
13. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.[Medline]
14. Pemberton J. Clinical features of posterior pelvic floor dysfunction. In: Pemberton J, Swash M, Henry MM, eds. The pelvic floor: its function and disorders. Edinburgh (UK): W. B. Saunders; 2002. p. 167–71.
15. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000;183:277–85.[Medline]
16. Maglinte DD, Kelvin FM, Fitzgerald K, Hale DS, Benson JT. Association of compartment defects in pelvic floor dysfunction. AJR Am J Roentgenol 1999;172:439–44.
17. Law PA, Danin JC, Lamb GM, Regan L, Darzi A, Gedroyc WM. Dynamic imaging of the pelvic floor using an open-configuration magnetic resonance scanner. J Magn Reson Imaging 2001;13:923–9.[Medline]
18. Bharucha AE, Fletcher JG, Harper CM, Hough D, Daube JR, Stevens C, et al. Relationship between symptoms and disordered continence mechanisms in women with idiopathic fecal incontinence. Gut 2005;54:546–55.
19. Bharucha AE, Fletcher JG, Seide B, Riederer SJ, Zinsmeister AR. Phenotypic variation in functional disorders of defecation. Gastroenterology 2005;128:1199–210.[Medline]
20. Harewood GC, Coulie B, Camilleri M, Rath-Harvey D, Pemberton JH. Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining. Am J Gastroenterol 1999;94:126–30.[Medline]
21. Bartolo DC, Read NW, Jarratt JA, Read MG, Donnelly TC, Johnson AG. Differences in anal sphincter function and clinical presentation in patients with pelvic floor descent. Gastroenterology 1983;85:68–75.[Medline]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
