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In the name of Allah

In the name of Allah. Fecal incontinence related to pregnancy, vaginal delivery, and cesarean . Foroozan Atashzadeh Shorideh PhD nursing Candidate, Shahid Beheshti Medical University. Fecal incontinence has a significance impact on quality of life .

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In the name of Allah

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  1. In the name of Allah F. Atashzadeh

  2. Fecal incontinence related to pregnancy, vaginal delivery, and cesarean Foroozan Atashzadeh Shorideh PhD nursing Candidate, Shahid Beheshti Medical University F. Atashzadeh

  3. Fecal incontinence has a significance impact on quality of life. • Vaginal delivery is the major risk factor for the development of pelvicorgan prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. Bortolini et al 2010 F. Atashzadeh

  4. 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. Tin et al , 2010 F. Atashzadeh

  5. Prevalence • depending on the population studied, the definition of type of stool loss, and the frequency of episodes F. Atashzadeh

  6. Causes of Fecal Incontinence F. Atashzadeh

  7. 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. F. Atashzadeh

  8. PREGNANCY AND FECAL INCONTINENCE  • In studies of nulliparous women, the prevalence of fecal incontinence increased from 1% prior to pregnancy to 7% during pregnancy. Chaliha et al 1999, 2001 F. Atashzadeh

  9. 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. Liebling 2005, Bahl 2004 F. Atashzadeh

  10. vaginal delivery and fecal incontinence • Controversial • Anal incontinence was significantly increased after spontaneous vaginal delivery compared to cesarean delivery (OR 1.32, 95% CI 1.04-1.68). • The risk of fecal incontinence alone was not significantly increased. Pretlove et al 2008 F. Atashzadeh

  11. Fecal incontinence after first instrumental vaginal deliveryusing Thierry’s spatulas Parant et al 2010 F. Atashzadeh

  12. Fecal incontinence was assessed at 2 and 6 months • postpartum by a questionnaire (Wexner score 5 was considered significant) F. Atashzadeh

  13. Results • Episiotomy (odds ratio [OR]=5.0) and maternal age over 35 years (OR=4.1) were independently associated with fecal incontinence after adjustment. F. Atashzadeh

  14. 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. Pollack et al 2004 F. Atashzadeh

  15. 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. Guise et al 2009 F. Atashzadeh

  16. 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 inforceps deliveries than in vacuum-assisted delivery. F. Atashzadeh

  17. Type of episiotomy • Median • Mediolateral episiotomy F. Atashzadeh

  18. Birth weight  • an odds ratio of 1.47 fora sphincter laceration with each 500 g increase in fetal birth weight F. Atashzadeh

  19. Prolonged second stage of labor  • exceeds 60 minutes F. Atashzadeh

  20. Maternal birth position  • standing, squatting or lithotomy positions F. Atashzadeh

  21. 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 1.06-1.12). F. Atashzadeh

  22. 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. F. Atashzadeh

  23. Role of time since delivery  F. Atashzadeh

  24. 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) F. Atashzadeh

  25. Diagnostic procedures  • endoanal ultrasound • anorectal manometry • pudendal nerve terminal latency measurement • defecography • electromyography F. Atashzadeh

  26. Function: Anorectal manometry in fecal incontinence F. Atashzadeh

  27. 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

  28. 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

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

  32. Anatomy: Rectal Ultrasound F. Atashzadeh

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  35. Anatomy: Endoanal Coil MRI F. Atashzadeh

  36. Treatment • Medical therapy • Biofeedback • Surgery F. Atashzadeh

  37. Treatment • Improving stool consistency • Increase intake of bulking agents – bran, psyllium • Antidiarrheal agents – loperamide, lomotil, cholestyramine F. Atashzadeh

  38. Bowel management • Fecal disimpaction • Scheduled toileting • Glycerin suppositories daily, 30 min postprandial • Attempt to defecate at the same time daily • Daily tap water enema F. Atashzadeh

  39. 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 contractthe external sphincter are the least likely to respond F. Atashzadeh

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

  41. F. Atashzadeh

  42. Is there a sound scientific basis for the claim that having an elective c-section protects the pelvic floor? F. Atashzadeh

  43. Does perineal massage prevent fecal incontinence?  F. Atashzadeh

  44. What is the best mode of delivery in women with a history of anal sphincter laceration or fecal incontinence?  F. Atashzadeh

  45. Will elective c-sectionprevent sexual dissatisfaction during intercourse or uterine prolapse? F. Atashzadeh

  46. Are there any circumstances when I might wish to consider elective c-section? F. Atashzadeh

  47. F. Atashzadeh

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