Faecal Incontinence: The Role Of Ageing And Gender

Key Messages

  • Faecal incontinence has a very high prevalence
  • The etiological cause of faecal incontinence differs between males and females
  • Ageing has a significant effect on bowel control
  • Treatment of faecal incontinence needs to be tailored to the differing etiological causes
Faecal incontinence (FI) affects up to 1 in 5 Australian men and 1 in 8 Australian women1. This is higher than the prevalence of diabetes (6%) and asthma (11%).  Dr Danette Wright, colorectal clinical fellow, recently delivered a fascinating presentation at the Continence Foundation Australia NSW State Meeting, discussing the role of ageing and gender in FI. Males and females are both affected by FI at high rates, however Dr Wright discussed how the mechanism of incontinence can be quite different.  
 
FI is an issue that needs to be taken seriously with the ageing population, as  it is one of the three major causes (alongside dementia and mobility issues) of nursing home admission1.
 

The Etiology Of FI Differs Between The Sexes 

Two recent cohort studies2,3 compared the etiology of FI in males and females. Female FI was more likely to be caused by impaired internal anal sphincter (IAS) and external anal sphincter (EAS) function, indicating obstetric history is a significant factor.  Males with FI were more likely to have normal sphincter function.  Females and males had equal levels of rectal hypersensitivity, however males were more likely to have rectal hyposensitivity.  Interestingly, quality of life was much worse in females with FI than males3.
 

The Effect Of Ageing On Bowel Control 

Dr Wright also explored why the rates of FI are so much higher in the elderly. Extrinsic factors play a role, such as:
  • Poor diet (leading to a change in stool consistency) 
  • Immobility 
  • Co-morbid disease 
  • Medication 
  • Previous injury (such as obstetric trauma or spinal injury)
In addition, reduced sensation of the rectum occurs with ageing, and there is also an increase in collagen in the rectal wall. This leads to increased rectal compliance, making mucosal prolapse more likely, and decreasing the function of the rectum as a reservoir. 
 
In females, there is thinning of the IAS (leading to reduced resting pressures), and thickening of the EAS, but this has no correlation with continence, so is thought to be due to fibrosis. However, in males, age-related anal sphincter changes are minimal (in the absence of disease).
 

Management: Target The Etiological Cause

Dr Wright discussed treatment options for faecal incontinence, and emphasised that treatment of males and females needs to be tailored to the differing etiological causes.  She discussed that the key elements of management are:
  • Fix the stool consistency: with dietary changes, ceasing medications contributing to diarrhoea, fibre supplementation, and anti-diarrheal medication 
  • Pelvic floor physiotherapy referral: strengthen pelvic floor and anal sphincter muscles, correct defecation dynamics, biofeedback with rectal balloon therapy for rectal hyper- or hyposensitivity
  • Surgical referral: if failed conservative management

Don’t Forget To Ask About Bowels 

Patients are often embarrassed to discuss bowel issues with their healthcare providers, especially faecal incontinence. Given the high prevalence and significant impact on quality of life that this condition has, screening for bowel problems is recommended. A great screening tool by Vaizey is available on our Referrer Resources here.
 
 
References 
1 Continence Foundation Australia  www.continence.org.au
 
2 Townsend, Carrington, Grossi, Burgell, Wong, Knowles, & Scott. (2016). Pathophysiology of faecal incontinence differs between men and women: a case matched study in 200 patients. J Neurogastroenterol Motil, 28(10), 1580-1588. 
 
3 Mundet, Ribet, Arco, & Clave. (2016). Quality of life differences in female and male patients with faecal incontinence. J Neurogastroenterol Motil, 22(1).