PREVALENCE AND CONSEQUENCES OF FECAL INCONTINENCE IN MIDDLE EASTERN WOMEN

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PREVALENCE AND CONSEQUENCES OF FECAL INCONTINENCE
IN MIDDLE EASTERN WOMEN

• Diaa E.E. Rizk
• Professor of Obstetrics and GynaecologyFaculty
  of Medicine, Ain Shams University,
• Cairo, Egypt.

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• The complete protection of the perineum has
  undoubtedly remained a weak spot in our art.
• Franz Ritgen (A German Obstetrician and
  Gynaecologist), 1855.
• The pelvis fulfils more extensive functions in
  the female body than in the male. In the female,
  it shelters the largest part of the sexual
  apparatus in addition to the distal end of the
  intestinal canal and urinary passages and thereby
  assumes great importance in reproduction. Nature
  has placed the canal that opens at the lowermost
  part of the trunk in such a position that the
  pelvis can maintain the burden of the abdominal
  viscera and provide support and purchase for the
  enclosed organs.
• Carl Litzmann ( A German Anatomist) Die Foramen
  des Beckens, 1861.

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A tribute to a great Egyptian Surgeon who
contributed to the global art and science of
fecal incontinence
Professor Ahmed Shafik (10/5/1933 - 31/10/2007)
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Introduction

• Fecal incontinence FI is usually defined as a
  condition in which involuntary loss of liquid or
  solid stools causes social or hygienic
  inconvenience.
• Anal incontinence is another term that is used to
  denote any involuntary leakage, whether of gas or
  feces, through the anal orifice.
• FI is an embarrassing and debilitating symptom
  that represents a significant public health
  problem.

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Introduction

• This disorder is more common in women
  particularly with high parity, advancing age and
  menopause when the sex ratio shows a female to
  male preponderance of 81
• Thus, a high prevalence of FI is expected in
  Middle Eastern women.
• The experience of colorectal surgeons and
  gastroenterologists in the Middle East, however,
  was that FI is rarely reported by women.
• It was important to find an explanation for this
  observation.

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BACKGROUND

• Several studies have commented on the prevalence
  of FI in women from western communities and the
  psychosocial and economical consequences of
  having this disorder
• Ethnic differences in prevalence and attitudes to
  FI have not, however, been reported
• Such epidemiological studies are important for
  projecting the need for health services and
  therapeutic intervention in the Middle Eastern
  population

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OBJECTIVES

• Establish if FI is recognized in the local Middle
  Eastern culture
• Determine the prevalence of this disorder in a
  representative sample of women
• Evaluate the determinants of health care
• seeking behavior

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Methods

• A selected group of UAE women at risk of having
  FI such as multiparous women aged 20 or more
  years to increase the detection rate.
• Sample size calculation indicated that a study of
  450 subjects was adequate to achieve a high
  degree of precision (95) in estimating the true
  prevalence of FI in the general female population
  of the UAE aged 20 years or older (approximately
  180,000).
• A priori assumption was that the expected
  prevalence of FI is 10 , similar to the average
  rate reported in western countries.
• Rizk DEE, Hassan MY, Shaheen H, Cherian JV,
  Micallef R, Dunn E. The prevalence
• and determinants of health care-seeking behavior
  for fecal incontinence in
• multiparous United Arab Emirates females. Dis
  Colon Rectum 2001 44 1850-6.

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Subjects

• Subjects were randomly selected from the
  community (n225) and health care centers
  (n225).
• The community stage consisted of a simple random
  sample of eligible women identified through the
  listings of the UAE women association and
  contacted at home.
• The clinic-based stage was a consecutive sample
  of eligible female patients visiting the services
  of the Primary health care centers irrespective
  of the reason for their visit.

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Data Collection

• Direct interview about inappropriate stool loss
  in the previous year only Current FI (history
  of FI but not in the last year, flatus
  incontinence and fecal soiling were NOT
  considered to be FI).
• A structured questionnaire generated after a
  review of the literature with pilot testing on 30
  employees to assess clarity and suitability for
  the target population.
• Data were collected by a trained research nurse
  using face to face interview at the clinic or
  home.
• The survey consisted of 39 items that included a
  number of demographic, reproductive and lifestyle
  variables.

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Results

• 51 women (11.3) were incontinent, 26 to liquid
• stool and 25 to solid stool.
• 38 women (8.4) had double incontinence.
• 65 women (14.4) were incontinent to flatus only.
  
• 30 women (59) did NOT seek medical advice.
• Only 90 women (20) had been asked about FI by a
  physician.

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Table 1. Reasons for not seeking treatment (N51)
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Table 2. Consequences of having FI (N51)
Incontinent women (N51)
Interference with regular praying 47 (92.2)
Feeling disgusted and dirty 43 (84.3)
Feeling conscious, ashamed and embarrassed especially with husband and children 39 (76.4)
Inability to have sexual intercourse 22 (43.1)
Limitation of social activities such as shopping and visiting friends 14 (27.4)
Difficulty in performing physical activities including housework and job assignments 10 (19.6)
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Table 3. Perceived causes of incontinence (N450)
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Results

• Coping mechanisms in incontinent women were
• 1- frequent washing (52.9),
• 2- regular changing of underwear (49.1)
• 3- wearing a protective perineal pad (37.2 )
• 4- decreasing food intake (25.4)
• 5- stop doing any work (7.8).

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Discussion

• Comparable studies of western women of a similar
  age spectrum have reported prevalence rates of FI
  between 1 and 16.
• Results from various studies is limited by
  differences in
• a- Definition of incontinence (incontinence to
  feces only -fecal incontinence- or feces and
  flatus -anal incontinence),
• b- Onset (current or past),
• c- Severity (whether or not it is a social or
  hygienic problem) and frequency (daily or
  episodic)
• d- Patient populations (community dwelling or
  hospitalized and were seeking care or not )
• e- Ethnic group examined
• f- Study design including sampling techniques
  and standards and methods of data collection.

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Conclusions

• FI is common in Middle Eastern women but
  incontinent subjects rarely seek medical help
  because of social traditions, cultural beliefs
  and lack of information.
• FI severely impairs the quality of life of Middle
  Eastern women by interfering with praying. This
  factor alone can severely impair the quality of
  life of any Moslem women who have FI and
  highlights the cross-cultural and ethnic
  differences in women attitudes to this disorder.

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Conclusions

• Detection of fecal incontinent women by their
  primary health care providers remains suboptimal
  in the Middle East and requires education about
  the condition and targeted history taking and
  physical examination.
• Expert advice to women is necessary to correct
  misconceptions about FI being normal or
  untreatable.
• The data obtained here might be of value in
  similarly identifying the real extent of female
  FI in our Egyptian population and in planning the
  subsequent medical and social care of incontinent
  women.