6/9/2015F. Atashzadeh1

Fecal incontinence related to pregnancy, vaginal delivery, and cesarean Foroozan Atashzadeh Shorideh PhD nursing Candidate, Shahid Beheshti Medical University 6/9/2015F. Atashzadeh2

 Fecal incontinence has a significance impact on quality of life.  Vaginal delivery is the major risk factor for the development of pelvic organ prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. 6/9/2015F. Atashzadeh3 Bortolini et al 2010

Definition  Fecal incontinence refers to the involuntary loss of solid or liquid stool.  Anal incontinence also includes involuntary release of flatus.  The consequences of AI can be detrimental to the psychological, social, and sexual wellbeing of the patient. 6/9/2015F. Atashzadeh4 Tin et al, 2010

Prevalence  depending on the population studied, the definition of type of stool loss, and the frequency of episodes 6/9/2015F. Atashzadeh5

Causes of Fecal Incontinence 6/9/20156F. Atashzadeh

How does pregnancy affect pelvic floor dysfunction? This is probably the result of the extra weight of the uterus and baby on the pelvic floor. 6/9/2015F. Atashzadeh7

PREGNANCY AND FECAL INCONTINENCE  In studies of nulliparous women, the prevalence of fecal incontinence increased from 1% prior to pregnancy to 7% during pregnancy. 6/9/2015F. Atashzadeh8 Chaliha et al 1999, 2001

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. 6/9/2015F. Atashzadeh9 Liebling 2005, Bahl 2004

vaginal delivery and fecal incontinence  Controversial  Anal incontinence was significantly increased after spontaneous vaginal delivery compared to cesarean delivery (OR 1.32, 95% CI ).  The risk of fecal incontinence alone was not significantly increased. 6/9/2015F. Atashzadeh10 Pretlove et al 2008

Fecal incontinence after first instrumental vaginal delivery using Thierry’s spatulas 6/9/201511F. Atashzadeh Parant et al 2010

 Fecal incontinence was assessed at 2 and 6 months  postpartum by a questionnaire (Wexner score 5 was considered significant) 6/9/201512F. Atashzadeh

Results  Episiotomy (odds ratio [OR]=5.0) and maternal age over 35 years (OR=4.1) were independently associated with fecal incontinence after adjustment. 6/9/201513F. Atashzadeh 538 women 176 spatula 14.3% Fecal incontinence 362 spontaneous 9.7% Fecal incontinence

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. 6/9/2015F. Atashzadeh14 Pollack et al 2004

Vaginal delivery or cesarean?  vaginal delivery (76%) was associated with a greater risk of fecal incontinence compared with cesarean delivery (24 %), if the delivery conferred a laceration or required instrumentation. 6/9/2015F. Atashzadeh15 Guise et al 2009

Operative vaginal delivery  Operative vaginal delivery is a risk factor for anal sphincter laceration and other pelvic floor disorders.  This risk is further increased if the fetus is in the occipital posterior position.  The risk of OASIS appears to be higher in forceps deliveries than in vacuum-assisted delivery. 6/9/2015F. Atashzadeh16

Type of episiotomy  Median  Mediolateral episiotomy 6/9/2015F. Atashzadeh17

Birth weight  an odds ratio of 1.47 for a sphincter laceration with each 500 g increase in fetal birth weight 6/9/2015F. Atashzadeh18

Prolonged second stage of labor  exceeds 60 minutes 6/9/2015F. Atashzadeh19

Maternal birth position  standing, squatting or lithotomy positions 6/9/2015F. Atashzadeh20

Maternal age  As an example, an observational study of women reported an increase in odds ratio of 1.09 per year of maternal age (95% CI ). 6/9/2015F. Atashzadeh21

Role of neural injury  Major risk factors for nerve damage associated with childbirth are forceps delivery, length of second stage of labor, and increasing birth weight. 6/9/2015F. Atashzadeh22

Role of time since delivery 6/9/2015F. Atashzadeh23 6.4%5 years after vaginal delivery 10%18 years after vaginal delivery

Clinical manifestations and diagnosis  Fecal and anal incontinence  Medical history  Occult anal sphincter laceration (endoanal ultrasound)  Physical examination (inspection of the perianal area and vagina and a digital rectal examination) 6/9/2015F. Atashzadeh24

Diagnostic procedures  endoanal ultrasound  anorectal manometry  pudendal nerve terminal latency measurement  defecography  electromyography 6/9/2015F. Atashzadeh25

Function: Anorectal manometry in fecal incontinence 6/9/201526F. Atashzadeh

Electrophysiologic tests  EMG – needle electrodes into the superficial portion of the external sphincter or puborectalis muscle – myoelectric activity  Pudendal nerve terminal motor latency – measures the delay between the application of an electrical stimulus and external sphincter muscle response. Prolonged – pudendal neuropathy

Defecography  Videodefecography – barium thickened to the consistency of stool is introduced into the rectum.  Evacuation is monitored with flouroscopy  Assessment of the anorectal angle at rest and during defecation  Excessive perineal descent, failure of the puborectalis muscle to relax, rectocele and internal intususception

6/9/201529F. Atashzadeh

6/9/201530F. Atashzadeh

Anal Endosonography  An ultrasound probe is placed in the anal canal or transvaginally to detect sphincter injuries and to evaluate pelvic floor structures.

Anatomy: Rectal Ultrasound 6/9/201532F. Atashzadeh

6/9/201533F. Atashzadeh

6/9/201534F. Atashzadeh

Anatomy: Endoanal Coil MRI 6/9/201535F. Atashzadeh

Treatment  Medical therapy  Biofeedback  Surgery 6/9/2015F. Atashzadeh36

Treatment  Improving stool consistency  Increase intake of bulking agents – bran, psyllium  Antidiarrheal agents – loperamide, lomotil, cholestyramine 6/9/201537F. Atashzadeh

 Bowel management  Fecal disimpaction  Scheduled toileting  Glycerin suppositories daily, 30 min postprandial  Attempt to defecate at the same time daily  Daily tap water enema 6/9/201538F. Atashzadeh

Biofeedback  Biofeedback therapy inexpensive, quick and safe option  Success dependent on the expertise of the clinician and the motivation and the ability of the patient to understand and cooperate  Dementia, absent rectal sensation, inability to contract the external sphincter are the least likely to respond 6/9/201539F. Atashzadeh

Biofeedback  70% restoring continence  90% reduction in incontinent episodes  Best outcome after anorectal surgery  Lowest success – spinal cored injury

6/9/201541F. Atashzadeh

Is there a sound scientific basis for the claim that having an elective c-section protects the pelvic floor? 6/9/2015F. Atashzadeh42

Does perineal massage prevent fecal incontinence? 6/9/2015F. Atashzadeh43

What is the best mode of delivery in women with a history of anal sphincter laceration or fecal incontinence? 6/9/2015F. Atashzadeh44

Will elective c-section prevent sexual dissatisfaction during intercourse or uterine prolapse? 6/9/2015F. Atashzadeh45

Are there any circumstances when I might wish to consider elective c-section? 6/9/2015F. Atashzadeh46

6/9/2015F. Atashzadeh47