A theory of progression from obstructed defecation to fecal incontinence

Abstract

Fecal disorders have a relevant social impact because they impair the quality of life of the patient and add to the cost of healthcare. In order to shed light on the pathophysiology of fecal disorders it is helpful to consider the progression of obstructed defecation to fecal incontinence which occurs in women without anal sphincter defects who have descending perineum syndrome.The overall prevalence of chronic constipation in the general population is about 15 %, and the most common subtype among women is obstructed defecation. Obstructed defecation occurs in 47.7 % of Italian patients affected by chronic constipation. Dyssynergia alone is present in young women (median age 38 ± 14 years), whereas dyssynergia plus structural diseases, such as rectocele, rectal intussusception, mucosal prolapse and perineal descent materialize in middle-aged women (median age 52 ± 14 years) [1]. Therefore there is no doubt that ageing is implicated in the evolution from functional to anatomic pelvic floor disorders. In parallel, excessive abdominal straining at stool evacuation causes progressive perineal descent: the recurrent straining against defecatory outlet obstruction impairs pelvic floor muscle tone until it disappears completely. In this way descending perineum overlaps with pelvic floor dyssynergia [2]. Older age is correlated with both dynamic and fixed descending perineum [3], and excessive perineal descent is found in 78 % of elderly patients with evacuation disorders [4]. The organic descent of the hypotonic pelvic floor combined with pudendal neuropathy explains the appearance of fecal incontinence. Perineal descent involves the anterior, middle and posterior pelviperineal areas in women. Uro-gynecological structures and proctologic segments are all implicated and thus pelvic organ prolapse may coexist with rectoanal intussusception, rectal prolapse and rectocele [5].Fecal incontinence is a physically and psychologically disabling condition which has a negative impact on the quality of life of the patient. The prevalence of fecal incontinence in community-dwelling women in the USA varies considerably depending on the population studied, ranging from 2.2 to 17 % of women housed in communities and up to almost half of all nursing home residents. Fecal incontinence is often related to several specific diseases, such as diabetes mellitus, dementia, irritable bowel syndrome, cerebrovascular disease, pelvic-anal surgery, traumatic sphincter lesions and post-partum incontinence. Even when excluding the presence of these cases, women over 65 years often have combined chronic constipation and fecal incontinence (32.7 % of constipated women) and women with anal incontinence have greater values of descending perineum measures than those without anal incontinence [6]. Therefore, these last epidemiological data support the hypothesis of a link between obstructed and fecal incontinence via descending perineum syndrome.Obstructed defecation can be caused by organic or functional diseases which are difficult to untangle. Mechanic...

Low frequency of defecation and hard stool are not reliable indicators of constipation in Chinese population

“…This nding indicates that awareness of the problem among the general population by general practitioners and medical specialists should be increased to encourage individuals to seek help, so that physicians can offer timely and adequate treatment. It is known that untreated dyssynergic defecation and mild constipation can progress to severe constipation, which can lead to irreversible alterations of the pelvic oor, such as pudendal neuropathy, and fecal incontinence over the course of time [31].…”

A prospective non-comparative study to assess the effectiveness and safety of combination laxative therapy containing milk of magnesia, liquid paraffin and sodium picosulphate (Cremaffin-Plus®) in the management of constipation in patients with anal fissure/hemorrhoids/obstructive defecation syndrome

“…Subsequently this small amount of stool may leak out of the anus unconsciously, because of the impairment of conscious contraction of the anal sphincter. 21 The FIS is commonly used to assess the continence. Our study demonstrated a significant reduction (38.37%) in FIS score in patients of constipation with ODS after therapy with combination laxative therapy which could be attributed to the overall improvement in straining, consistency and frequency of defecation.…”

Perspective Chapter: Obstructed Defecation – From Diagnosis to Treatment

“…This may include passive faecal leakage or urge incontinence, and the coexistence of symptoms is missed by over 85% of referring clinicians [8]. In fact, the progression of longstanding obstructed defaecation to faecal incontinence is widely acknowledged, and an area of ongoing longitudinal research-these patients often have signs of mechanical dysfunction including perineal descent [9], presumably from excessive straining over years.…”