ORIGINAL ARTICLE
Prevalence of unreported bowel symptoms in women with pelvic
floor dysfunction and the impact on their quality of life
Leonardo Robson Pinheiro Sobreira Bezerra&José Ananias Vasconcelos Neto&
Camila Teixeira Moreira Vasconcelos&Sara Arcanjo Lino Karbage&Amene Cidrão Lima&
Isabella Parente Ribeiro Frota&Adriana Bombonato de Oliveira Rocha&
Sandra Rebouças Macedo&Cassia Fernandes Coelho&Marília Karla Nunes Costa&
Geisele Cavalcante de Souza&Sthela Murad Regadas&Kathiane Lustosa Augusto
Received: 25 September 2013 / Accepted: 25 December 2013 #The International Urogynecological Association 2014
Abstract
Introduction and hypothesisLittle information is available on the recurrent coexistence of pelvic organ prolapse (POP), urinary (UI) and/or anal (AI) incontinence and defecatory dysfunctions and the relationship between these disorders. The purpose of this study is to report the prevalence, bother, and impact on quality of life (QoL) of unreported bowel symptoms in women presenting to a Brazilian tertiary urogy-necology clinic.
Methods The study was a cross-section survey of 172 patients with symptoms of pelvic floor disorders (PFD). Patients who reported any defecatory and/or continence disorders were included in the study group, and the others were included in the control group. Patients with UI were also compared with those with double incontinence (DI): AI and UI. Univariate
analysis was conducted using the Mann–WhitneyUtest for
continuous nonparametric data.
Results After the interview, 54.6 % (n=94) of patients pre-sented AI and/or defecatory disorders: 67.0 % constipation, 41.4 % AI, and 34.0 % fecal urgency. Women from the study group scored worse in the QoL questionnaires compared with women from the control group. Among women with UI, 23.21 % had associated AI. Women with DI scored worse in the QoL questionnaires.
Conclusion Anal and urinary dysfunctions are usually
asso-ciated and have a great impact on a woman’s QoL. An
integrated approach across specialties should lead to improved patient care. Therefore, our study is relevant because it em-phasizes the importance of urogynecologists routinely inves-tigating such symptoms. To do so, standardized question-naires should be included in the evaluation of all these patients.
Keywords Urinary incontinence . Uterine prolapse .
Constipation . Anal incontinence . Quality of life
Introduction
The lower urinary tract, anorectal channel, and internal geni-tals, and pelvic floor are closely related both anatomically and
functionally [1,2]. Pelvic organ prolapse (POP), urinary (UI)
and anal (AI) incontinence, voiding and defecation problems, and sexual dysfunction make up a group of conditions known concomitantly as pelvic floor disorders (PFD). These defects may be associated with a wide array of symptoms, although
some women are asymptomatic [1,3]. Symptoms of PFD may
be associated with an important decrease in the quality of life
(QoL) in these women [4,5]. AI is the involuntary loss of
L. R. P. S. Bezerra
Hospital Geral César Cals (HGCC), Fortaleza, Brazil
J. A. Vasconcelos Neto
:
A. C. Lima:
K. L. Augusto Hospital Geral de Fortaleza (HGF), Fortaleza, BrazilC. T. M. Vasconcelos
:
C. F. Coelho:
S. M. Regadas Universidade Federal do Ceará (UFC), Fortaleza, BrazilS. A. L. Karbage (*)
Universidade de Fortaleza (Unifor), Fortaleza, Brazil e-mail: sara_arcanjo@hotmail.com
I. P. R. Frota
:
A. B. de Oliveira RochaUniversidade de São Paulo (USP), Fortaleza, Brazil
S. R. Macedo
Universidade Christus (Unichristus), Fortaleza, Brazil
M. K. N. Costa
:
G. C. de Souzaflatus, liquid, or solid stool that causes a social or hygene problem. We used the definitions conforming to the standards
proposed by the International Continence Society (ICS) [6].
Anorectal dysfunction includes continence disorders (as result of neurogenic or mechanical defects), defecatory dysfunctions (as result of functional and anatomic abnormalities), or both
[2]. A high prevalence of defecatory symptoms in women
with PFD, particularly POP and UI, have been found in various epidemiologic studies. Parity and previous pelvic floor surgery are significantly associated with continence
and defecatory dysfunction [7–9]. Sharing the common risk
factors aforementioned, women with UI are also more likely
to have concomitant AI than those without UI [10]. The
presence of concomitant AI, named double incontinence (DI), may further decrease the already reduced QoL of women
with UI symptoms [10,11]. Very little information is available
on the frequent coexistence of POP, UI and/or AI, and defecatory dysfunctions and the relationship between those
disorders [3,12–15]. Boreham et al. evaluated women who
presented for gynecologic care and found 28.4 % prevalence
of AI and 9.9 % prevalence of DI [16]. A study conducted in
Brazil found an AI prevalence of 40.54 % among women with
UI and 27.91 % among those with POP [17]. Resolution of
defecatory symptoms, ability to perform daily activities, and sexual function goals are at least as important as UI resolution and prolapse symptoms, which may be the reason for many
women seeking care [15]. This reinforces the importance of
health professionals thoroughly investigate all signs and symptoms derived from PFD during the clinical interview
[18]. It should be considered as an outcome measure when
determining efficacy of therapy [4].
The purpose of this study is to report the prevalence, bother, and impact on QoL of unreported bowel symptoms in women presenting to a Brazilian tertiary urogynecology clinic. The study was performed to optimize the detection of unreported AI and/or defecatory disorders and improve the patient care pathway in a urogynecological assessment.
Methods
We undertook a cross-section survey involving patients with bowel dysfunction in a urogynecology department. Ethics committee approval was previously obtained. The study assessed 172 patients referred to a tertiary urogynecologic outpatient clinic who reported with symptoms of PFD: POP
[POP Quantification (≥2) ] and/or UI. It was conducted from
July 2011 to July 2013. A detailed medical and urogynecologic history and physical examination were ob-tained from each woman. Initially, no patient complained of defecatory and/or continence disorders as a primary com-plaint. After the initial assessment, all patients were
questioned about the presence of defecatory complaints and AI and urgency.
In the first stage of the study, patients were divided into two groups according to the presence or absence of bowel symp-toms. Both groups were questioned about their QoL, answer-ing the validated version of the generic Medical Outcomes
Study 36-Item Short-Form Health Survey (SF-36) [19]. In the
second section of the study, patients with UI were divided into two distinct groups: one with UI only and the other with DI. All patients answered validated versions of specific QoL questionnaires: International Consultation on Incontinence
Questionnaire Short Form (ICIQ-SF) [20], King’s Health
Questionnaire (KHQ) [21], and Pelvic Floor and Incontinence
Sexual Impact Questionnaire (PISQ-12) [22]. All patients
were assessed by the physiotherapist to evaluate pelvic floor muscle strength using the PERFECT scheme (Prepresenting power (or pressure, a measure of strength, using a manometric perineometer), Endurance, Repetitions, Fast contractions, and
Every Contraction Timed) [23].
Patients with DI were evaluated using the Wexner score and classified as mild, intermediate, or severe [Cleveland Clinic Florida Incontinence Scale (FIS)]. Evacuatory disorder
was also assessed using the Wexner score [24], and
constipa-tion was classified as mild, moderate or severe [Cleveland
Clinic Florida Constipation Scale (CS)] [25]. Finally, UI and
DI groups were compared.
Statistical analysis
Patients’ demographic details; urinary, bowel, and prolapse
symptoms; and findings at physical examination were
com-pared between study and control groups. A level ofp<0.05
was adopted for significance. Univariate analysis was
con-ducted using the Mann-–Whitney test for continuous
nonpara-metric data. Statistical analysis was performed using SPSS 18.0.
Results
There were 172 women in this study, none of whom complained of symptoms of AI and/or defecatory disorders
initially. After the interview, 54.6 % (n=94) presented AI
and/or defecatory disorders: 67.0 % constipation, 41.4 % AI, and 34.0 % fecal urgency. Constipation was classified as mild in 36.8 %, moderate in 57.9 %, and severe in 5.3 %. AI was classified as mild in 86.1 % and interme-diate in 13.9 %. There were no differences in age, preg-nancies, parity, abortions, menopausal status, social class, education, income, body mass index (BMI), PERFECT, and prolapse status between patients with and without AI
Groups with and without bowel symptoms were compared in relation to their QoL. Women with bowel symptoms scored
worse (p<0.05) on the SF-36 in five of eight domains (general
health, functional capacity, vitality, pain, and mental health). There was no difference for the PISQ-12 between groups
(Table3).
In the second part of the study, 168 women with UI were assessed: 39 (23.21 %) had DI. There were no differences in
age, pregnancy, parity, BMI, PERFECT, menopausal status, income, and prolapse status between patients with UI and those
with DI, except education (UI 6.2 % vs DI 7.7 %,p=0.03) and
forceps delivery (UI 0.1 % vs DI 0.2 %,p=0.03). Women with
DI scored worse on the KHQ (personal relationships), SF-36 (general health, functional capacity, vitality), and ICIQ-SF compared with women with UI only. This difference was not
statistically significant for PISQ-12 only (Table4).
Table 1 Characteristics of the
studied population of women Without anal incontinence and/or defecatory disorders (n=78) (%)
With anal incontinence and/or defecatory disorders (n=94) (%)
Pvalue*
Home Urban Rural
86.6 13.4
88.6 11.4
0.69
Marital status Without partner With partner
36.2 63.8
43.8 56.2
0.33
Sensation of ball in vagina No
Yes
34.8 65.2
31.9 68.1
0.70
Vaginal laxity No Yes
33.3 66.7
25.8 74.2
0.29
Menopause No Yes
40.3 59.7
43.8 56.2
0.65
Table 2 Characteristics of the studied population of women
NBnewborn,BMIbody mass in-dex,POP-QPelvic Organ Pro-lapse Quantification,PERFECT Prepresenting power (or pressure, a measure of strength, using a manometric perineometer), En-durance, Repetitions, Fast con-tractions, and Every Contraction Timed ,SDstandard deviation
Without anal incontinence and/or defecatory disorders (n=78) (average ± SD)
With anal incontinence and/or defecatory disorders (n=94) (average ± SD)
Pvalue*
Age 55,0±12,0 53.3±12.9 0.35
Schooling 6.31±4.13 6.87±4.33 0.40
Income 1191.69±742.51 1100.88±797.09 0.21
Pregnancies 5.11±3.83 4.56±2.16 0.71
Births 4.25±3.70 3.79±1.89 0.58
Abortions 0.75±0.89 0.79±1.02 0.57
Vaginal deliveries 3.79±3.83 3.33±1.81 0.38
Forceps 0.14±0.48 0.21±0.44 0.21
Caesarean sections 0.36±0.62 0.29±0.45 0.09
Weight of the largest NB 3821.86±938.78 3761.87±842.89 0.96
BMI 28.2±5.6 27.8±4.4 0.26
POP-Q stage
Median (P25-P75) 2 (2.0–3.0) 2 (1.0–2.0) 0.27 PERFECT
Discussion
Women with PFD may be asymptomatic or may report a variety of distressing symptoms involving urinary, bowel, or
sexual functions [4,9,26]. It is unclear whether the anatomical
position of the bladder, bowel, and uterus compromises blad-der and bowel function directly or whether abnormal anatomy and dysfunction of the pelvic floor share a common etiology
[3,12–15]. In one study, gynecologists enrolled 302 women
with POP and stress urinary incontinence (SUI) who were willing to determine the prevalence of anorectal disorders, the prevalence of obstruction was 36 %, outlet constipation was
19 %, and anorectal pain was 25 % [27]. Many gynecologists
do not routinely inquire about bowel dysfunction [26]. Soligo
et al. found a 32 % prevalence of constipation in women with
urinary symptoms and/or genital prolapse [26]. Dua et al. also
reported that colorectal symptoms may get ignored in women
presenting to gynecology clinics with prolapse [14].
Table 3 Comparison of ques-tionnaire scores in relation to quality of life
Bold data indicate statistical significance.
SF-36Medical Outcomes Study 36-Item Short-Form Health Sur-vey,PISQ-12Pelvic Floor and Incontinence Sexual Impact Questionnaire, SD standard deviation
*Mann–WhitneyUtest
Without anal incontinence and/or defecatory disorders (n=78) (average ± SD)
With anal incontinence and/or defecatory disorders (n=94) (average ± SD)
Pvalue*
SF-36
General health, Functional capacity
Physical aspects limitation Emotional limitation Social limitation Vitality Pain Mental health 60.1±26.6 61.4±23.8 51.0±43.9 54.1±50.8 71.8±26.1 41.6±21.6 58.2±23.0 62.6±29.2 47.2±24.9 55.1±25.7 40.8±44.7 37.8±44.3 60.4±29.3 48.3±27.2 48.3±24.7 51.8±25.6 0.04 0.00 0.08 0.07 0.15 0.01 0.04 0.00
PISQ-12 27.5±8.7 26.1±7.5 0.32
Table 4 Comparison of ques-tionnaire scores on quality of life
Bold data indicate statistical significance.
SF-36Medical Outcomes Study 36-Item Short-Form Health Sur-vey,PISQ-12Pelvic Floor and Incontinence Sexual Impact Questionnaire, KHQ King's Health Questionnaire, ICIQ-SF International Consultation on In-continence Questionnaire Short Form,SDstandard deviation *Mann–WhitneyUtest *Mann-Whitney
Urinary incontinence (UI) (n=129) (average ± SD)
Anal and urinary incontinence (DI) (n=39) (average ± SD) P
value*
SF-36
General health Functional capacity Physical aspects limitation Emotional limitation Social limitation Vitality Pain Mental health 56.5±27.0 62.8±27.0 47.6±43.2 47.9±48.5 59.9±24.9 48.1±26.2 59.2±23.5 58.0±29.2 43.0±28.7 45.9±23.8 25.0±40.3 33.6±46.9 54.5±28.6 34.5±22.0 38.5±25.0 49.0±29.7 0.00 0.03 0.23 0.11 0.33 0.00 0.11 0.12
PISQ-12 27.5±8.9 25.9±7.0 0.12
KHQ
General health perception Impact of UI
Limitations of daily activities Physical limitations Social limitations Personal relationships Emotional limitations Sleep and energy
42.9±25.5 70.8±30.1 51.8±35.0 57.2±40.8 28.9±28.1 42.6±39.2 59.3±36.5 52.0±34.5 59.0±25.6 84.3±27.3 66.6±30.7 72.7±30.0 43.9±36.3 65.1±36.1 61.5±31.5 65.1±32.0 0.14 0.21 0.33 0.12 0.38 0.03 0.60 0.18 Measurements of gravity 55.7±24.2 68.4±18.1 0.05
In our study, all women sought treatment at a urogynecol-ogy clinic exclusively due to urinary complaints and/or genital prolapse. However, more than half (54.6 %) said they had defecatory complaints after questioned by the health profes-sional (constipation 67.0 %, AI 41.4 %, fecal urgency 34.0 %). The prevalence of constipation and AI in our patients was
higher compared with data from other studies [9,19,21]. This
is perhaps because of the content of the Northeastern Brazilian diet, sedentary lifestyle, poor access to health care, and
con-sequent delay in treatment [28]. More studies are needed to
cover these responses.
These data concern us because of the direct impact on QoL of such patients, as determined by our results. Furthermore, the presence of defecatory symptoms can directly influence patient satisfaction rates after established treatments for POP or UI. If these unreported defecatory symptoms are not treat-ed, patients may maintain a persistently poor QoL postopera-tively, even if they are continent and/or without POP. There-fore, many patients seek the urogynecology service with only one major complaint, and after thorough research and detailed physical examination, the health professional can uncover other important associated disorders. The use of specific tools, i.e., Wexner Incontinence Scale and Wexner Constipation Scale, helps detect these disorders preoperatively, allowing the health care professional to determine the ideal treatment approach.
Many authors found the relationship between obstructive bowel symptoms and the presence of posterior vaginal-wall
prolapse [9, 12, 13, 29] persisted even after controlling for
confounding factors, such as age, BMI and concomitant apical
and anterior vaginal-wall prolapse [12]. In women with POP,
defecatory symptoms may be more common, [20] and the
presence of rectocele correlates with the symptoms of stool trapping (splinting and sensation of incomplete evacuation)
[8]. In other study, straining at stool was significantly more
common in women with uterovaginal prolapse and women
with SUI compared with controls [21]. Groenendijk et al.
found a poor association between anatomical and functional abnormalities of the pelvic floor. Defecation symptoms were unrelated to anatomical abnormalities, patient characteristics, or psychological factors, except for constipation, which was associated with psychological factors and perineal descent
[13]. Saks et al. found that obstructive bowel symptoms are
associated with the site but not with the severity of prolapse. Because of that, they suggest that obstructive bowel symp-toms frequently coexist with posterior vaginal-wall prolapse but that posterior vaginal prolapse probably does not cause
obstructive symptoms [12]. The combination of symptoms
results from POP, UI, and constipation sharing a common etiology, and one may not necessarily cause another. Consti-pation seems to be a confounding factor and not necessarily a true contributor to prolapse. This divergence may be attributed to the lack of use of standardized definitions of functional
bowel and anorectal disorders in the field of gynecology [9].
In our study, we found no differences in POP between groups. AI and/or defecatory disorder symptoms were found indepen-dently of POP-Q stage. More longitudinal studies are required to assess the causal relationship between POP and AI and/or defecatory disorders.
AI was more common in women with PFD than in normal controls. Nichols et al. found that women with PFD were significantly more likely to report AI, which may be due to higher rates of anatomic anal sphincter disruption. In community-based surveys, AI is strongly associated with UI
and overactive bladder in both men and women [30]. In our
study, we found 23.2 % of women with DI in the group with UI. These women with DI reported a significantly negative impact in important domains of general QoL evaluation on the SF-36: general health, functional capacity, and vitality were worse than reported by women with UI only. This impact was even more striking in our study in women with DI, where worse QoL scores were also observed in specific question-naires for UI on the KHQ and ICIQ-SF. Therefore, the pres-ence of AI worsens the QoL of women with UI.
Our study found that women with PFD and concomitant AI
and/or defecatory disorders scored worse (p<0.05) for SF-36
in five of eight domains (general health, functional capacity, vitality, pain, and mental health). Poorer scores on the mental scale may be due solely to bowel symptoms. Obstructive defecation was also independently associated with a dimin-ished general QoL as measured by the SF-36, with a greater
impact on mental health than on physical health. [15].
Func-tional constipation has a significant impact on QoL,
particu-larly in regard to mental well-being [24].
Evidence shows that patients with advanced POP reported significantly lower QoL on the physical scale of the SF-12. These patients were more likely to feel self-conscious, less likely to feel physically attractive, less likely to feel feminine, and less likely to feel sexually attractive than normal controls
[4]. A French study found that the degree of POP was not
statistically associated with sexual function. However, urinary, pelvic, and defecatory symptoms were associated with a
de-crease in a couple's sexual well-being [5]. Interestingly, in our
function or perhaps a general QoL sexual questionnaire. We recognize this important limitation of our study. Also, evalu-ating a greater number of patients would strengthen our discussions.
PFD cause symptoms that clearly have an impact on a
woman’s daily activities and negatively affect her QoL. We
believe that women seek care from health care providers only when these symptoms are severe. Emphasis has been placed on assessing symptoms through standardized outcome mea-sures to determine treatment efficacy for PFD. However, symptoms reported from those patients are part of a multifac-eted experience and must be considered to exist in multiple psychological domains. Epidemiological information on PFD is difficult to obtain, as many women hide the problem or accept it as a natural consequence of aging or vaginal deliv-eries. Moreover, the costs and logistics of implementing com-plex gynecological exams in large populations become a
challenge to these searches [18]. The relationship between
these symptoms and UI, POP, or AI and/or defecatory disor-ders is slightly more complex. More longitudinal studies are required to assess the causal relationship and etiology of these conditions.
Conclusions
The high prevalence of women with PFD presented with AI and/or defecatory disorders may be due to the fact that we have a very selected population, which may over-represent the prevalence in the community. We should also remember that these patients presented to a urogynecology service, expecting treatment for POP and UI. They probably had not report
bowel issues because they didn’t think they’re related.
There-fore, our study is relevant since it emphasizes the importance of urogynecologists routinely investigating such symptoms. These dysfunctions are usually associated and have a great
impact on a woman’s QoL. An integrated approach across
specialties should lead to improved patient care. To prevent the suboptimal management of patients with PFD, standard-ized questionnaires for AI and/or defecatory disorders should be included in the evaluation of all these patients.
Conflicts of interest None.
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