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Fecal incontinence related to pregnancy and vaginal delivery

Last literature review version 17.3: September 2009  |  This topic last updated: June 10, 2009   (More)

INTRODUCTION — Fecal incontinence has a significant impact on quality of life [1,2]. Although disorders of stool consistency and a wide variety of anorectal conditions can cause fecal incontinence, the association between fecal incontinence and pregnancy, vaginal delivery, and anal sphincter laceration will be discussed here. Other etiologies of fecal incontinence and the effects of childbirth on the pelvic floor are reviewed elsewhere. (See "Fecal incontinence in adults" and "Pelvic floor disorders associated with pregnancy and childbirth".)

DEFINITIONS — Fecal incontinence refers to the involuntary loss of solid or liquid stool, while the term anal incontinence also includes involuntary release of flatus. Fecal incontinence will be the focus of this topic review.

PREVALENCE — The prevalence of fecal incontinence varies depending on the population studied, the definition of type of stool loss, and the frequency of episodes.

  • In one population-based, age-stratified postal survey of women aged 30 to 90 years (n = 6000), the prevalence of fecal incontinence (defined as at least monthly loss of liquid or solid stool) was 7.7 percent (range 3 to 15.7 percent) [3].
  • At three to six months after vaginal or cesarean delivery, as many as 13 to 25 percent of women report fecal incontinence [4,5]. However, the prevalence falls to 1 to 6 percent by 12 months [6,7].

PREGNANCY AND FECAL INCONTINENCE — Pregnancy appears to be a risk factor for fecal incontinence. In studies of nulliparous women, the prevalence of fecal incontinence increased from 1 percent prior to pregnancy to 7 percent during pregnancy [6,8].

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 [9,10]. In small case control studies, similar incidence of fecal incontinence has been reported for women who underwent cesarean delivery after laboring compared with those who had an instrumented vaginal delivery.

VAGINAL DELIVERY AND FECAL INCONTINENCE — The role that vaginal delivery plays in symptoms of fecal incontinence is controversial [4,11,12]. In a systematic review of comparative studies with short-term follow-up, risk of anal incontinence (ie, fecal or flatal incontinence) was significantly increased after spontaneous vaginal delivery compared to cesarean delivery (OR 1.32, 95% CI 1.04-1.68) [13]. However, the risk of fecal incontinence alone (ie, liquid or solid stool) was not significantly increased. Similarly, in a population-based study of 6152 women, vaginal delivery was associated with a greater risk of fecal incontinence compared with cesarean delivery (76 versus 24 percent) [14] if the delivery conferred a laceration or required instrumentation.

Anal sphincter laceration is the most established and potentially most modifiable risk factor for developing fecal incontinence after vaginal delivery. Other risk factors include operative vaginal delivery (eg, vacuum or forceps-assisted delivery), increasing maternal age, vaginal parity, and depression [3].

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 [15-18]. Women with clinically evident sphincter tears are significantly more likely to report fecal incontinence, fecal urgency, and flatal incontinence, compared to women without sphincter tears [11]. Risk of fecal incontinence is increased with laceration of the internal anal sphincter as compared to the external anal sphincter [19].

Risk factors for OASIS include operative vaginal delivery, median episiotomy, fetal macrosomia, and increasing maternal age [20]. Because of the strong association between sphincter laceration and fecal incontinence, these risk factors are discussed in detail below:

Operative vaginal delivery — Operative vaginal delivery is a well-documented risk factor for anal sphincter laceration and other pelvic floor disorders. This risk is further increased if the fetus is in the occiput posterior position. The risk of OASIS appears to be higher in forceps deliveries than in vacuum-assisted delivery [21-23], although some studies have reached the opposite conclusion [24]. (See "Pelvic floor disorders associated with pregnancy and childbirth" and "Operative vaginal delivery".)

Median episiotomy — Extension of a median episiotomy which creates a third or fourth degree laceration or deep vaginal tear is one of the more common complications of episiotomy. Median episiotomy incurs a higher risk of anal sphincter laceration than mediolateral episiotomy. Episiotomy may increase the average perineal tear length; increased tear length appears to be associated with the severity of the laceration [25]. Risk factors for severe lacerations include macrosomia, previous third or fourth degree laceration (in multiparous women), median episiotomy, instrumented vaginal delivery, Asian ancestry, and nulliparity. (See "Approach to episiotomy", section on 'Complications'.)

Birth weight — Multiple studies have shown that larger birth weights are associated with anal sphincter lacerations [16,24,26,27]. As an example, a population-based study (n = 284,783) reported an odds ratio of 1.47 for a sphincter laceration with each 500 g increase in fetal birth weight [28]. While the majority of published reports support the association between birth weight and anal sphincter laceration, conflicting data exist [29]. Increasing birth weight is associated with operative vaginal delivery [30].

Prolonged second stage of labor — Second stage of labor that exceeds 60 minutes appears to be associated with anal sphincter lacerations [31].

Maternal birth position — There is some suggestion that women who give birth in the standing, squatting or lithotomy positions may have an increased risk of anal sphincter laceration [31,32]. In a large population-based study, women who underwent vaginal, noninstrumented deliveries had a significantly increased risk of anal sphincter tear if the delivery occurred in squatting or lithotomy position as compared to other positions, including supine, semirecumbent, or lateral recumbent (OR 2.02, 95% CI 1.58-2.59 and OR 2.05, 95% CI 1.09-3.82, respectively) [31].

Maternal age — Increasing maternal age at delivery has been associated with significantly higher rates of OASIS and postpartum fecal incontinence [33-35]. 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) [34].

Role of neural injury — Labor and vaginal delivery are associated with partial denervation of the pelvic floor in most women. Studies suggest that neuromuscular injury resolves during the first year after delivery for the majority of women. This may account for the spontaneous resolution of incontinence over that same period. However, in some cases, electrophysiologic evidence of denervation injury can be seen five to six years after delivery, and denervation injury may accumulate with increasing parity.

Major risk factors for nerve damage associated with childbirth are forceps delivery, length of second stage of labor, and increasing birth weight. This topic is discussed in detail separately. (See "Pelvic floor disorders associated with pregnancy and childbirth".)

Studies of pudendal nerve function after labor and delivery have not found a significant effect of neuropathy on subsequent fecal incontinence [36-38].

Role of time since delivery — Studies of women in their 50s to 60s suggest that, by that age, causes other than pregnancy and delivery history are more important in correlating with fecal incontinence. This was illustrated by the following studies, which evaluated women at 5, 18, and 30 years after delivery:

  • In one prospective cohort study, at five years after vaginal delivery, fecal incontinence occurred in 6.4 percent of women; 31 percent of women who had sustained a sphincter tear versus 2.2 percent of those without a tear. Predictors of incontinence included anal incontinence symptoms at both five and nine months postpartum [17].
  • In a study conducted 18 years after vaginal delivery in women with a history of OASIS, the overall rate of severe fecal incontinence was 10 percent; 13.1 percent in women who sustained a sphincter tear versus 7.8 percent in those who did not (RR 1.7, 95% CI 1.0-2.8). Interestingly, however, only 6.4 percent of the fecal incontinence in the study subjects could be attributed to the original sphincter laceration [39].
  • A 30-year retrospective cohort study reported no difference in fecal incontinence among three groups of women: those who delivered vaginally and had a sphincter laceration; those who delivered vaginally with episiotomy and no sphincter laceration; and those who delivered by cesarean delivery [18].

Similarly, in a study of over 2600 women in their 50s, the prevalence of fecal incontinence was similar for nulliparous, primiparous and multiparous women; 11, 9, and 9 percent, respectively. Prevalence was also similar among the parous women, irrespective of mode of delivery [40].

CLINICAL MANIFESTATIONS AND DIAGNOSIS — Fecal and anal incontinence are clinical diagnoses.

Medical history — The history should initially focus on determining whether fecal incontinence is present, and its severity. True incontinence must be differentiated from frequency and urgency without loss of bowel contents.

Women suffering from anovaginal or rectovaginal fistulas present with complaints of uncontrollable passage of gas or feces from the vagina. A malodorous vaginal discharge and fecal soiling of the undergarments are also common complaints. (See "Rectovaginal, anovaginal, and colovesical fistulas", section on 'Clinical manifestations'.)

Occult anal sphincter laceration — Anal sphincter lacerations are not always recognized at the time of delivery and occult injuries to the sphincter may contribute to postpartum fecal incontinence. In observational studies, occult anal sphincter lacerations have been detected with endoanal ultrasound in large numbers in women after spontaneous (9 to 36 percent), vacuum (0 to 21 percent), and forceps deliveries (80 to 83 percent) [36,41,42].

Occult anal sphincter lacerations are not always symptomatic; anal incontinence was reported by up to 23 percent of women with sonographic diagnoses of anal sphincter injury [36,41,42].

The clinical usefulness and feasibility of screening for occult anal sphincter laceration in women after childbirth is controversial [43,44]. In asymptomatic women, it appears that occult sphincter lacerations have no long term effect on anal continence [43]. In a prospective cohort study of primiparas with occult anal sphincter lacerations, at 10-year follow-up, only women who were symptomatic in the immediate postpartum period had deterioration over time of anal continence.

Conversely, there is some suggestion that sonographic detection and subsequent sphincter repair may decrease the development of severe fecal incontinence [44]. In the only randomized trial (n = 752) which addressed this question, primiparas with no clinically recognized anal sphincter laceration were assigned to undergo or not undergo an endoanal ultrasound immediately after delivery; lacerations diagnosed via ultrasound and confirmed via surgical exploration were repaired. Of the 376 women in the ultrasound group, 21 (5.6 percent) had sonographically diagnosed sphincter tears. At 3 and 12 months postpartum, significantly fewer of the women who had anal ultrasound reported severe fecal incontinence (12 and 11 women at 3 and 12 months, respectively), as compared to those who did not undergo anal ultrasound (31 and 23 women) (RR -5.4, 95% CI -8.9 to -2.0 and RR -3.5, 95% CI -6.8 to -0.3, respectively). Using these data, it was estimated that 29 women would have to undergo endoanal ultrasound to prevent one case of severe fecal incontinence.

Physical examination — The physical examination should include inspection of the perianal area and vagina and a digital rectal examination. Perianal sensation can be assessed by eliciting the anal wink sign (anocutaneous reflex); sphincter muscular function can be tested by instructing patients to bear down and squeeze the examining finger during the rectal examination.

Most anovaginal and rectovaginal fistulas of obstetric origin are located in the lower third of the vagina, just inside the introitus. They are readily apparent on physical examination as a red velvety area. There is often thinning of the rectovaginal septum and tenting of the anal mucosa, which are palpable on rectal examination.

A full discussion of the approach to physical exam for patients with fecal incontinence can be found separately. (See "Fecal incontinence in adults", section on 'Physical examination' and "Rectovaginal, anovaginal, and colovesical fistulas", section on 'Evaluation'.)

Diagnostic procedures — Most women with fecal incontinence can be treated empirically without specific diagnostic evaluation. Diagnostic procedures available to further evaluate fecal incontinence include endoanal ultrasound, anorectal manometry, pudendal nerve terminal latency measurement, defecography and electromyography. A comprehensive discussion of these procedures can be found elsewhere. (See "Fecal incontinence in adults".)

TREATMENT — The goal of treatment is to improve continence and bowel-related quality of life. Three main approaches are most commonly used for treatment of fecal incontinence: medical therapy, biofeedback, and surgery. A full discussion of the treatment of fecal incontinence can be found separately, major therapeutic measures are briefly summarized below. (See "Fecal incontinence in adults".)

In cases of episiotomy breakdown, repair can be performed when the wound surface is free from exudate and covered by pink granulation tissue. Women who have chronic third or fourth degree lacerations typically have incontinence to gas and liquid feces, but may not lose solid stool, because the puborectalis mechanism is usually intact. (See "Repair of episiotomy and perineal lacerations associated with childbirth" and "Delayed surgical management of the disrupted anal sphincter".)

In women with chronic third or fourth degree laceration, it is imperative to begin with good medical management of fecal incontinence prior to pursuing a surgical repair. Supportive measures can be instituted in most patients. This may include avoiding foods (eg, caffeine) or activities (eg, exercise after eating) known to worsen symptoms, optimizing stool consistency with fiber supplements, ritualizing bowel habits, and improving perianal skin hygiene.

If the patient continues to have bothersome fecal incontinence despite the optimization of medical and dietary management, as well as pelvic floor exercises, then surgical repair is indicated. It is extremely important, however, to ensure that a patient is adequately counseled and has realistic expectations with regard to her outcome. Most studies cite dismal continence rates of 10 to 51 percent five years after anal sphincteroplasty [45-47]. Thus, patients need to be aware that while surgery can improve their incontinence, most women will continue to have some difficulty controlling flatus and liquid stools. Women should never be told that "normal" pre-injury function can be restored.

RECURRENCE WITH SUBSEQUENT VAGINAL DELIVERY

Anal sphincter laceration — For women with a history of a prior sphincter laceration, the risk of a subsequent laceration is increased two- to seven-fold after a subsequent vaginal delivery [48-51]. Despite this increased overall risk of recurrent laceration, the absolute risk remains low. Most studies cite risks of recurrent laceration which range from 3.6 to 7.2 percent [52-54]. The recurrence risk is highest if the subsequent delivery is operative (OR 6.5, 95% CI 1.5-9.4), and when a median episiotomy is performed (OR 17.4, 95% CI 7.5-51.0) [49].

Fecal incontinence — In a woman with a history of anal sphincter laceration, it is controversial whether subsequent vaginal delivery affects fecal continence [28,39,55-58]. In general, it appears that in women with previous OASIS, vaginal delivery increases the short-term risk of persistent fecal incontinence [55-57]. The presence of transient incontinence after sphincter laceration and repair is also predictive of the likelihood of developing persistent incontinence with a subsequent delivery. However, this increased risk was not found in studies in which women were followed for five or more years [28,39,58].

APPROACH TO OBSTETRIC MANAGEMENT

Primary patient choice cesarean delivery to prevent fecal incontinence — The role of primary patient choice cesarean delivery for the prevention of fecal incontinence is a topic of debate. There is insufficient evidence to support primary cesarean delivery for this indication. Research findings, while controversial, suggests no difference in long-term rates of fecal incontinence when cesarean delivery is performed [12,36,59]:

  • The Term Breech Trial is the only large (n = 2000) randomized trial comparing outcomes of women assigned to planned cesarean or planned vaginal delivery of a singleton breech fetus. The overall prevalence of fecal incontinence was 2.2 percent and planned cesarean delivery conferred no protection against fecal incontinence compared to planned vaginal delivery (RR 1.10, 95% CI 0.47-2.58) [59]. Limitations of this trial were that only 21 women developed fecal incontinence and almost one-half of the women in the planned vaginal delivery group underwent cesarean birth. Additionally, the incidence of fecal incontinence in this study was lower than is generally reported. (See 'Prevalence' above.)

  • In a large population-based survey that included over 1500 women, the prevalence of fecal incontinence did not differ among women who had a cesarean, instrumental, or spontaneous vaginal delivery. In fact, pregnancy itself seemed to contribute to the development of incontinence and other pelvic floor disorders rather than mode of delivery [12].

Perineal massage — Perineal massage in the weeks immediately preceding vaginal delivery does not prevent fecal incontinence. A systematic review including three randomized trials of antenatal perineal massage (for at least the last four weeks of pregnancy) revealed no difference in postpartum fecal or flatal incontinence compared to no antenatal perineal massage [60].

Mode of delivery in women with a history of anal sphincter laceration or fecal incontinence — There are insufficient high quality data to provide guidance regarding the delivery mode of a woman with a history of a sphincter laceration. Women with transient anal incontinence symptoms following an initial delivery have a 1 in 6 chance of developing permanent symptoms following a subsequent vaginal delivery. It is estimated that 2 to 23 cesarean deliveries would need to be performed in women with prior OASIS to prevent a single recurrent anal sphincter laceration [51,61]. (See 'Recurrence with subsequent vaginal delivery' above.)

Experts recommend that a woman with persistent fecal incontinence and a poorly functioning anal sphincter be offered a planned cesarean for subsequent deliveries. In counseling a woman with a history of OASIS, it is important to explain the uncertainties regarding risk of recurrent or persistent anal incontinence, as well as operative risks associated with cesarean delivery. (See "Cesarean delivery on maternal request".)

Operative vaginal delivery — Current evidence supports use of vacuum rather than forceps delivery to minimize maternal morbidity when the gestational age is greater than 34 weeks and the likelihood of success is very high. However, there is inadequate evidence upon which to base a recommendation for use of either vacuum or forceps for all circumstances when operative vaginal delivery is attempted. (See "Operative vaginal delivery", section on 'Risks'.)

Episiotomy — Avoidance of routine use of episiotomy is known to reduce both perineal trauma and healing complications after vaginal delivery. Similar to operative vaginal delivery, median episiotomy is a known and modifiable risk factor for anal sphincter tear. Mediolateral episiotomy may also extend into an anal sphincter laceration; however, this occurs frequently with extension of a mediolateral episiotomy, but less frequently than with median episiotomy. (See "Approach to episiotomy", section on 'Routine versus restricted use'.)

Repair of anal sphincter laceration

Primary sphincter repair technique — Primary sphincter repair (immediately after delivery) is important to minimize the risk of fecal incontinence [44]. Anal sphincter repair should be performed by an experienced surgeon with proper lighting, anesthesia, and instrumentation. However, even with immediate repair, 40 to 50 percent of women will still develop anal incontinence, clearly demonstrating the importance of primary prevention of OASIS [62,63]. (See "Repair of episiotomy and perineal lacerations associated with childbirth".)

Repair can be accomplished with either an end-to-end approximation or an overlapping repair of the torn sphincter. A systematic review of three randomized trials reported that the overlap technique was associated with lower risk of anal incontinence (weighted mean difference -1.70, 95% CI -3.03 to -0.37) and a reduced risk of worsening incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women) [64].

Secondary sphincter repair — In women with clinically recognized OASIS and primary sphincter repair (immediately after delivery), 35 percent may still have sonographically detectable defects of the internal anal sphincter 6 to 12 months postpartum [65]. The risk of sphincter gaps after primary repair was reported as greater in women who had a fourth- versus third-degree perineal laceration (OR 15.4, 95% CI 4.8-50).

Treatment of fecal incontinence by secondary sphincteroplasty (remote from delivery) is successful in approximately 66 percent of patients [66]. Improvement in fecal incontinence after secondary sphincteroplasty appears to be similar in women who have and have not had previous primary sphincter repair [67,68]. (See "Delayed surgical management of the disrupted anal sphincter".)

INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Fecal incontinence".) We encourage you to print or e-mail these topics, or to refer patients to our public web site www.uptodate.com/patients, which includes these and other topics.

SUMMARY AND RECOMMENDATIONS

  • As women age, the impact of obstetric anal sphincter injury on fecal incontinence is superseded by the impact of aging on the continence mechanism. (See 'Role of time since delivery' above.)

  • Perineal massage is not protective against the development of postpartum fecal incontinence. (See 'Perineal massage' above.)

  • Operative delivery and median episiotomy are risk factors for anal sphincter laceration. Modifying obstetrical practices could potentially decrease the incidence of this debilitating condition. (See 'Operative vaginal delivery' above and 'Median episiotomy' above.)

  • In women with a history of fecal incontinence or obstetric anal sphincter injury, the optimal mode of delivery for subsequent pregnancies is uncertain. Many experts advise that a woman with persistent fecal incontinence and a poorly functioning anal sphincter be offered a planned cesarean for subsequent deliveries. The patient and her clinician must weigh the pros and cons of both delivery methods. (See 'Mode of delivery in women with a history of anal sphincter laceration or fecal incontinence' above.)

  • Choice of repair technique of anal sphincter laceration (end-to-end versus overlap) should depend upon surgical experience. There is insufficient evidence showing that either method affects subsequent fecal incontinence. (See 'Primary sphincter repair technique' above.)

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