Anal incontinence in primiparae: Prevalence, Predictors and Quality of Life

Abstract

Anal incontinence (AI) is a symptom-based diagnosis and involves involuntary loss of solid or loose stool, flatus or faecal urgency defined as the inability to defer defecation. The main aetiology is considered to be related to pregnancy and childbirth. AI is often viewed as a woman’s problem, with as many as one in five Norwegian women over the age of 30 experiencing symptoms of AI. Due to the socially debilitating consequences of AI, and that few health professionals routinely ask questions related to patients’ continence status, symptoms may be under-reported. Patients with symptomatic AI are reluctant to seek medical advice, and it is estimated that only one in five patients with AI seek medical help. The prevalence of AI increases with age and particularly after menopause. However, findings from other countries suggest that the onset of AI symptoms is often reported in relation to a woman’s first pregnancy or delivery. The prevalence of AI in pregnancy and postpartum in Norway was scarcely documented at the start of the project.

The present study is a prospective cohort study conducted in the period May 2009-April 2011. A total of 1571 primiparae were included from the maternity wards at Ostfold Hospital Trust Fredrikstad and St. Olavs Hospital Trondheim. The participants answered questions on standardised questionnaires regarding the prevalence and frequency of AI and how symptoms of AI affected their health-related Quality of Life in late pregnancy and one year after delivery. Sociodemographic and deliveryrelated data were collected from the participants’ hospital records.

The main aim of this study was to estimate the prevalence of AI among primiparous women, and to evaluate the impact of AI on health-related quality of life in late pregnancy and the first year after delivery. More specifically, the aims of the three separate papers were:

Paper I: To evaluate the prevalence and predictors of specific AI symptoms, including urgency, in late pregnancy and one year after delivery.

Paper II: To explore how experiencing different types of AI in late pregnancy affects health-related quality of life among primiparous women.

Paper III: To explore the changes in continence status from late pregnancy and throughout the first year postpartum among healthy primiparae and investigate factors associated with persistent and new onset AI symptoms twelve months postpartum

The results from the three papers were:

Paper I: AI was reported by 37% in late pregnancy, compared to 25% one year after delivery. Urgency was the most frequently reported symptom at both time points. Being unemployed and younger than 22 years at first delivery increased the risk of AI in late pregnancy. Higher education on the other hand, reduced the risk. Experiencing AI in late pregnancy was the strongest predictor of AI one year after delivery. Women with obstetric anal sphincter injury were at increased risk of flatus or stool incontinence, whereas operative delivery was associated with increased risk of urgency.

Paper II: Between 20 and 30% of the women experiencing AI in late pregnancy, reported this to affect their Quality of Life. The majority reported only a low impact on Quality of Life. Those experiencing urgency alone reported little or no impact on Quality of Life, whereas women experiencing more than one symptom reported moderate to severe impact on Quality of Life. Compared to urgency only, women experiencing flatus alone weekly or more or women reporting a combination all AI symptoms reported the highest impact in the QoL domain “Embarrassment”.

Paper III: One in three of the 862 participants responding in late pregnancy, six and twelve months postpartum experienced AI in late pregnancy and one third of these experienced persistent symptoms six and twelve months after delivery. New onset AI was reported by 15% both at six and twelve months postpartum. AI at one year after delivery was associated with young age and AI in late pregnancy or at six months. Occiput posterior presentation was the only delivery related risk factor increasing the risk of postpartum AI.

The results from the present study confirm previous findings that AI is relatively common in late pregnancy as well as one year after delivery. Experiencing symptoms of AI in late pregnancy is the strongest predictor of AI one year after delivery, and approximately half of women incontinent in pregnancy remained incontinent one year later. Women reporting more than one symptom of AI had a poorer Quality of Life compared with those experiencing only one symptom. Further, weekly or daily incontinence of flatus was the single symptom most strongly affecting Quality of Life. These results indicate that hormonal and mechanical changes occurring during pregnancy may have more impact on postpartum AI than vaginal delivery.