Abstract
Objectives
Despite its prevalence and associated distress, fecal incontinence is not well understood. There are limited data regarding associations between fecal incontinence and race. The goal of this study was to estimate the prevalence of fecal incontinence, and to secondarily identify demographic, lifestyle and medical factors associated with fecal incontinence, especially with regards to race.
Methods
This was a planned secondary analysis of a population-based cross-sectional telephone interview survey of 2812 black and white community-dwelling women living in southeastern Michigan. The primary outcome measured was the prevalence of self-reported fecal incontinence, defined as any loss of stool during the previous 12 months. Logistic regression modeling was used to identify characteristics independently associated with fecal incontinence.
Results
16.7% of subjects reported fecal incontinence in the previous year. Fecal incontinence was approximately twice as common in white women (20%) as black women (11%). Factors associated with fecal incontinence differed between the two races, although its prevalence in both racial groups increases with higher numbers of medical comorbidities, increased frequency of bowel movements per week, and depression.
Conclusions
One in six women report fecal incontinence, although it occurs one-half as often in black as in white women. While there are common characteristics shared by women with fecal incontinence in both racial groups, white women experience fecal incontinence in complex with other pelvic floor disorders. For black women, fecal incontinence is an isolated pelvic floor disorder associated with mobility impairment.
Keywords: Fecal incontinence, Epidemiology, Pelvic floor dysfunction, Racial differences
INTRODUCTION
Fecal incontinence (FI) is the second most prevalent pelvic floor disorder (superseded only by urinary incontinence),1 affecting almost 11 million American women in 2010.2 The disorder has a marked impact on quality of life, and is associated with social isolation, embarrassment and depression.3–6 Furthermore, there is a substantial economic burden imposed by FI, with average annual economic costs estimated at more than $4000 per person.7
Despite its high prevalence and impact, there are few studies addressing the epidemiology of fecal incontinence in population-based samples of community-dwelling women. Moreover, there are conflicting data about racial disparities in the epidemiology of fecal incontinence.8–11 The aim of this study was to therefore estimate the prevalence of fecal incontinence in a population-based sample. We secondarily sought to identify characteristics associated with fecal incontinence, including race.
MATERIALS AND METHODS
This is a planned secondary analysis of the Establishing the Prevalence of Incontinence (EPI) Study, an Institutional Review Board of the University of Michigan-approved (IRBMED #2000-0824) population-based cross-sectional analysis conducted with the primary aim of exploring racial differences in urinary incontinence between black and white community-dwelling women in southeastern Michigan.12 The methods and major findings from this study have been published previously, but briefly, black and white women aged 35–64 years old were interviewed by trained female professional telephone interviewers from the Survey Research Center of the University of Michigan Institute for Social Research. All subjects provided verbal consent for the interviews. Telephone records from areas in southeastern Michigan of known racial composition were purchased, allowing for sampling of both racial groups in adequate numbers. Women were considered eligible for participation in the study if they were 35–64 years old, self-identified as either black or white, and had not been pregnant during the previous 12 months. Women who self-reported as other ethnicities were excluded. 1922 black and 892 white women completed the telephone survey, yielding a 69% response rate.
All of the subjects were asked questions regarding demographics, lifestyle and health history. There were also questions asked regarding pelvic floor function, including defecatory and urinary symptoms. Fecal incontinence was defined as any loss of stools or bowel movements in the previous year. Subjects were identified as having constipation if they answered, “No,” to the question, “When you do move your bowels, does the stool come out easily?” If a subject self-reported urinary incontinence (defined in this study as the involuntary loss of any amount of urine at least 12 times in the past 12 months), the type of incontinence was characterized by responses to a 10-item questionnaire modified from the Medical, Epidemiologic, and Social Aspects of Aging questionnaire.13
A post-hoc power calculation for this planned secondary analysis was performed using published prevalence rates for FI in black and white women.8 Using our sample sizes from the EPI study and the prevalences in the study by Goode, et al., we estimate that we have 97.0% power to detect a difference in the prevalence of fecal incontinence comparing black and white women, using a 95% two-sided confidence interval.
Interval variables were compared using Student’s t-tests; categorical variables were compared using Chi-squared tests. For logistic regression, models were constructed by starting with independent variables found to be significantly associated with fecal incontinence in bivariate analyses. These variables were then systematically incorporated into multivariable models in order to identify those factors that independently and significantly predicted self-reported fecal incontinence. Because it was hypothesized that the prevalence of urinary incontinence was lower in black than white women, black women were intentionally oversampled to ensure adequate representation of incontinent women in both groups. However, all data have been weighted by age, race and geographic location to reflect the population from which the sample was taken, as has been previously described.12 p values < 0.05 were considered significant. OpenEpi version 2.3.1 was used for power calculations.14 All other statistical analyses were performed using SAS version 9.1 software (SAS Institute, Cary, NC).
RESULTS
Characteristics of the women interviewed for this study have been previously published.12 16.7% of the subjects reported fecal incontinence during the previous year. Characteristics that are significantly different in women with and without FI are presented in Table 1. Factors for which a significant difference was not identified included level of education, household income, the average number of cigarettes smoked per day, the average number of beverages consumed per day, the amount of alcoholic beverages consumed per week, heavy lifting (more than 30 pounds) at least one time per week, needing to wait for scheduled bathroom breaks at work, a history of a stroke, having a regular doctor for medical problems, severity of urinary incontinence, taking estrogen replacement therapy, a history of gynecologic cancer, prior pelvic radiation therapy, and obstetric delivery method (having had at least one vaginal delivery or having only had Cesarean sections). There was a small difference suggesting a lower proportion of women with FI getting regular pelvic exams, as compared to women without fecal incontinence (79.0% versus 82.8%), but this did not reach statistical significance at our sample size (p = 0.053).
Table 1.
Factors Associated with Fecal Incontinence
| Characteristic | Respondents with FI | Respondents without FI | p value |
|---|---|---|---|
| Demographics | |||
| Race | < 0.0001 | ||
| White | 76.4 | 61.5 | |
| Black | 23.6 | 38.5 | |
| Age (Distribution) | 0.0003 | ||
| 35 – 44 years | 32.1 | 40.5 | |
| 45 – 54 years | 37.6 | 36.9 | |
| 55 – 64 years | 30.4 | 22.6 | |
| Average Age (Years) | 49.7 ± 8.7 | 47.8 ± 7.8 | < 0.0001 |
| BMI (kg/m2) | < 0.0001 | ||
| < 25 | 27.0 | 36.4 | |
| 25 – 29.9 | 23.9 | 28.6 | |
| ≥ 30 | 49.1 | 34.9 | |
| Average BMI (kg/m2) | 31.2 ± 8.7 | 28.8 ± 7.0 | < 0.0001 |
| Working for Pay | 57.2 | 71.9 | < 0.0001 |
| Marital Status | 0.003 | ||
| Married/Living Together | 48.1 | 53.5 | |
| Separated/Divorced | 30.8 | 25.2 | |
| Widowed | 6.2 | 3.7 | |
| Never Married | 14.9 | 17.6 | |
| Lifestyle Factors | |||
| Ever Smoked Cigarettes | 59.4 | 51.4 | 0.002 |
| Current Cigarette Smoker | 53.4 | 46.5 | 0.04 |
| Caffeine Consumption (Daily) | 0.02 | ||
| None | 18.7 | ||
| Low (1–2 Glasses) | |||
| Moderate (3–5 Glasses) | |||
| High (> 5 Glasses) | |||
| Average Caffeine Consumption (# of Glasses/Day) | 3.4 ± 9.0 | 2.3 ± 2.7 | 0.009 |
| Mobility Impaired | 22.4 | 8.8 | < 0.0001 |
| Exercise Involving Frequent Bouncing at least Once/Week | 75.8 | 68.9 | 0.004 |
| Gets Regular Breast Exams | 57.4 | 62.9 | 0.03 |
| Medical History | |||
| Number of Comorbidities | 1.9 ± 1.3 | 1.2 ± 1.1 | < 0.0001 |
| Neurologic Disease | 7.9 | 2.3 | < 0.0001 |
| Spinal Cord Injury | 4.6 | 1.2 | < 0.0001 |
| Diabetes | 19.5 | 10.2 | < 0.0001 |
| Chronic Lung Disease | 25.0 | 14.9 | < 0.0001 |
| Depressive Symptoms | 57.9 | 38.6 | < 0.0001 |
| Self-Reported Health Status | <0.0001 | ||
| Excellent | 6.1 | 17.5 | |
| Very Good | 30.4 | 35.8 | |
| Good | 30.3 | 33.0 | |
| Fair | 24.7 | 11.5 | |
| Poor | 8.5 | 2.2 | |
| Pelvic Floor Symptoms | |||
| Continent of Urine | 51.2 | 78.0 | < 0.0001 |
| Urinary Incontinence Type | < 0.0001 | ||
| SUI | 21.3 | 40.1 | |
| UUI | 16.5 | 12.1 | |
| MUI | 35.8 | 18.2 | |
| Below Threshold | 26.4 | 29.7 | |
| Nocturia | 82.4 | 70.8 | < 0.0001 |
| Nocturnal Enuresis | 37.4 | 19.4 | < 0.0001 |
| Bladder Pain | 32.0 | 14.7 | < 0.0001 |
| UTI in Past Year | 21.4 | 11.7 | < 0.0001 |
| Constipation | 14.0 | 10.1 | 0.01 |
| Bowel Movements (# per Week) | 0.003 | ||
| < 3 | 4.5 | 7.2 | |
| 3 – 21 | 93.2 | 92.0 | |
| > 21 | 2.3 | 0.9 | |
| Average Bowel Movements (# per Week) | 8.8 ± 8.8 | 7.4 ± 6.1 | 0.001 |
| OB/GYN History | |||
| Postmenopausal | 55.3 | 41.2 | < 0.0001 |
| Prior Hysterectomy | 22.4 | 16.8 | 0.005 |
| Prior Surgery for Urinary Incontinence | 6.0 | 1.5 | < 0.0001 |
| Prior Surgery for Prolapse | 9.4 | 3.6 | < 0.0001 |
| Prior Surgery for Urinary Incontinence or Prolapse | 10.3 | 4.0 | < 0.0001 |
Demographic, lifestyle and medical history characteristics significantly different in women with and without fecal incontinence. Data are presented as the percentage of subjects or mean ± standard deviation. All data are weighted to reflect the complex sampling design, projecting the study sample to the population from which it was drawn.
BMI: Body Mass Index; SUI: Stress Urinary Incontinence; UUI: Urgency Urinary Incontinence; MUI: Mixed Urinary Incontinence; UTI: Urinary Tract Infection
11.0% of the black women in our population, as compared to 19.9% of the white women, reported fecal incontinence during the prior year (p < 0.0001). Characteristics found to be significantly different in black and white women with self-reported FI (testing for the same variables used for the entire study population, as above) are presented in Table 2. Although the distributions of BMI were significantly different in black and white women with fecal incontinence, comparison of the average BMI in these groups failed to reach statistical significance at the 0.05 level with our sample sizes (black women with FI: 32.3 ± 4.9, white women with FI 30.8 ± 11.8, p = 0.06; data are presented as mean ± standard deviation).
Table 2.
Racial Differences in Factors Associated with Fecal Incontinence
| Characteristic | Black Respondents with FI |
White Respondents with FI |
p value |
|---|---|---|---|
| Demographics | |||
| BMI (kg/m2) | 0.009 | ||
| < 25 | 15.6 | 30.6 | |
| 25 – 29.9 | 27.4 | 22.8 | |
| ≥ 30 | 57.1 | 46.7 | |
| Education | 0.009 | ||
| < 12 years | 8.3 | 9.9 | |
| High School Graduate/GED | 21.2 | 24.7 | |
| Some College | 44.3 | 27.4 | |
| ≥ College Graduate | 26.1 | 38.1 | |
| Lifestyle Factors | |||
| Average Smoking (# of Cigarettes Daily) | 11.3 ± 5.0 | 18.2 ± 14.6 | < 0.0001 |
| Average Caffeine Consumption (# of Glasses/Day) | 2.0 ± 1.4 | 3.8 ± 13.3 | 0.01 |
| Lifts/Carries at least 30 lb Once/Week | 55.4 | 66.6 | 0.04 |
| Medical History | |||
| Chronic Lung Disease | 16.6 | 27.6 | 0.02 |
| Pelvic Floor Symptoms | |||
| Continent of Urine | 74.2 | 44.2 | < 0.0001 |
| Bowel Movements (# per Week) | 0.05 | ||
| < 3 | 8.7 | 3.2 | |
| 3 – 21 | 89.2 | 94.4 | |
| > 21 | 2.1 | 2.4 | |
| OB/GYN History | |||
| Prior Hysterectomy | 31.8 | 19.5 | 0.008 |
| Prior Surgery for Urinary Incontinence | 1.9 | 7.2 | 0.04 |
Demographic, lifestyle and medical history characteristics that are significantly different in black and white women with fecal incontinence. Data are presented as the percentage of subjects or mean ± standard deviation. All data are weighted to reflect the complex sampling design, projecting the study sample to the population from which it was drawn.
BMI: Body Mass Index; GED: General Equivalency Diploma
We next used logistic regression to identify characteristics predictive of fecal incontinence. The model was constructed originally using the characteristics identified as having a significant association with FI (Table 1). Forward stepwise logistic regression analysis was then performed to parse out the independent variables associated with fecal incontinence. The model using the entire study population is shown in Table 3. This model has a max-rescaled R2 of 0.20, indicating 20% of fecal incontinence can be explained by this model. We also evaluated the receiver operating characteristic (ROC) area under the curve (AUC) from this model. The ROC AUC is a measure of how well the model can discriminate between women with and without FI. This measure ranges from 0.5 (suggesting that the model predicts fecal incontinence no better than chance) and 1.0 (suggesting the model can perfectly discriminate between women with and without FI). A “good” model should have an ROC AUC of at least 0.7.15 For our model, the ROC AUC is 0.73, suggesting good discrimination by the model. Tables 4 and 5 present the individual models for prediction of FI in black and white women (constructed in a similar fashion as that for the entire study population), respectively. The multivariable logistic regression model of fecal incontinence in black women has a max-rescaled R2 of 0.10 and an ROC AUC 0.71; the model of FI in white women has a max-rescaled R2 of 0.29 and an ROC AUC of 0.59.
Table 3.
Logistic Regression Model of Fecal Incontinence – All Subjects
| Characteristic | Odds Ratio Point Estimate | 95% Confidence Interval | p value |
|---|---|---|---|
| Race (Black vs. White) | 0.55 | 0.43 – 0.71 | < 0.0001 |
| Number of Caffeinated Beverages Daily | 1.05 | 1.02 – 1.07 | 0.0009 |
| Number of Medical Comorbidities | 1.28 | 1.15 – 1.42 | < 0.0001 |
| Self-Reported Health Status | 1.33 | 1.18 – 1.51 | < 0.0001 |
| Number of Bowel Movements per Week | 1.06 | 1.04 – 1.09 | < 0.0001 |
| Neurologic Disease | 1.99 | 1.20 – 3.30 | 0.008 |
| Depression | 1.56 | 1.25 – 1.96 | 0.0001 |
| Incontinent of Urine | 2.36 | 1.88 – 2.96 | < 0.0001 |
| Nocturia | 1.34 | 1.01 – 1.76 | 0.04 |
| Prior surgery for Urinary Incontinence | 2.51 | 1.38 – 4.57 | 0.003 |
Variables composing the multivariable logistic regression model predicting fecal incontinence for the entire study population.
Table 4.
Logistic Regression Model of Fecal Incontinence – Black Subjects
| Characteristic | Odds Ratio Point Estimate | 95% Confidence Interval | p value |
|---|---|---|---|
| Number of Medical Comorbidities | 1.37 | 1.15 – 1.63 | 0.0004 |
| Number of Bowel Movements per Week | 1.06 | 1.02 – 1.10 | 0.002 |
| Mobility Impaired | 2.26 | 1.31 – 3.90 | 0.003 |
| Depression | 1.84 | 1.21 – 2.80 | 0.005 |
Multivariable logistic regression model predicting fecal incontinence in black respondents.
Table 5.
Logistic Regression Model of Fecal Incontinence – White Subjects
| Characteristic | Odds Ratio Point Estimate | 95% Confidence Interval | p value |
|---|---|---|---|
| Number of Medical Comorbidities | 1.33 | 1.18 – 1.50 | < 0.0001 |
| Number of Bowel Movements per Week | 1.05 | 1.02 – 1.08 | 0.0008 |
| Self-Reported Health Status | 1.38 | 1.20 – 1.60 | < 0.0001 |
| Depression | 1.43 | 1.09 – 1.87 | 0.01 |
| Incontinent of Urine | 2.49 | 1.92 – 3.23 | < 0.0001 |
| Nocturia | 1.55 | 1.13 – 2.14 | 0.007 |
| Bladder Pain | 1.76 | 1.32 – 2.35 | 0.0001 |
Multivariable logistic regression model predicting fecal incontinence in white respondents.
DISCUSSION
We find that race is significantly associated with fecal incontinence, with the self-reported prevalence in white women twice as high as that of black women. This is in contrast to the results from several other population-based studies suggesting that race is not significantly associated with FI.8–11 Our investigation involved 5-to-8-fold more black women than the bulk of previously published studies, thereby greatly enhancing our power to identify racial discrepancies. Furthermore, the subjects in all but one of these studies (Varma, et al.) were 65 years old and older, so they may not be directly comparable to the women in our study. In support of this notion, there was a trend towards a lower odds ratio comparing fecal incontinence in black women versus white women in multivariable logistic regression modeling by Varma and colleagues.10 Other factors that may contribute to differences in our findings and those in previously published studies include the geographic locations assessed and means of data collection used.
The results of this study suggest that the prevalence of fecal incontinence, defined as any loss of stool in the previous year, is 16.7% of adult women. Our estimate is in line with other population-based studies, which have calculated the female fecal incontinence prevalence to range from approximately 2–21%.2, 8–10, 16–24 Variability among these results likely stems from known effects of such factors as definition of fecal incontinence used, the population studied, and methodology of data collection.
Our logistic regression models highlight key correlates of fecal incontinence. Irrespective of race, the number of medical comorbidities, the number of bowel movements per week, and symptoms of depression are all higher in women with fecal incontinence than continent women. These factors have been similarly shown to be associated with FI in other studies, and highlight key medical and lifestyle conditions that can be targeted for prevention and/or treatment.21, 23 It should be noted that, as has been seen in other studies, our bivariate analyses suggest that constipation is associated with fecal incontinence.8, 25 However, this risk factor did not remain significant in our multivariable analyses, suggesting that constipation is a confounding characteristic for FI.
We also found factors whose association with fecal incontinence differed between the two racial groups. The prevalence of FI in black women is approximately one-half that of white women, similar to the proportions seen for urinary incontinence in the parent EPI study. We also find that for white woman, lower urinary tract/pelvic floor symptoms, including urinary incontinence, nocturia and bladder pain, are significantly associated with FI, similar to other reports in the literature.8, 20, 21, 23, 24, 26 By contrast, our logistic regression modeling suggests that for black women, lower urinary tract symptoms do not significantly predict fecal incontinence. Rather, mobility impairment, along with medical comorbidities, depression, and the number of weekly bowel movements, is associated with FI. These differences represent critical targets not only for research in treatment and prevention, but in possibly understanding the etiologies of fecal incontinence. Our data suggest that FI may reflect poor pelvic floor function in white women, but for black women, it may be more a consequence of overall health status and presents as an isolated pelvic floor dysfunction.
In our sample that evaluated women between the ages of 35 and 64 years of age, we do not find older age to be an independent risk factor for fecal incontinence. By contrast, multiple studies have identified increasing age to be associated with FI,21–23, 27 In univariate analysis, we did find that women with fecal incontinence were older than their continent counterparts, but age was too collinear with other variables in our model to remain independently associated with FI in logistic regression. The oldest women in our sample were 64 years old. This contrasts with other published studies that included subjects 65 years and older.9, 21–23, 27 We therefore suspect that the differences between our results and others in the literature reflect differences in our study population, the different definitions of fecal incontinence used, and the information collected. Similarly, higher BMI was associated with fecal incontinence in our univariate analyses, but did not remain independently associated with FI in multivariable regression. The literature is relatively heterogeneous with respect to the relationship between FI and BMI, so this remains an interesting area of contention.10, 21, 23 Our data suggest that BMI is not directly associated with fecal incontinence, but rather, is a covariate of other characteristics that are linked to FI. Whether or not such characteristics are analyzed may help explain the variability in the correlation between BMI and FI in the literature.
Early studies that focused on FI symptoms soon after birth indicated that vaginal delivery was a major risk factor for fecal incontinence in young women in these select populations.28, 29 Subsequent well-designed studies have indicated that the effects of pregnancy and childbirth across the lifespan are diminished by other factors leading to fecal incontinence.28, 29 In fact, a recent Cochrane review demonstrated that primary elective Cesarean delivery is not protective against anal incontinence.30 Our data support this notion, with similar rates of women with and without fecal incontinence reporting delivery only via Cesarean sections, and this was not influenced by race. There is less agreement, however, about the possible effect of hysterectomy on fecal incontinence. Several studies were unable to demonstrate an independent association between a history of hysterectomy and FI,21, 22, 31, whereas others suggest a significant relationship between the two.8 Although our univariate analyses suggested higher rates of hysterectomy among women with FI, and in black women as compared to white women with FI, these differences did not persist in multivariable logistic regression. Our data therefore support the notion that hysterectomy is not an independent risk factor for fecal incontinence.
There are several strengths to this study, including its population-based sample, broad range of ages included, large sample size, large proportion of black women recruited, and high response rate. We must also acknowledge several limitations of the study. This is a secondary analysis of the EPI study, which was designed to study urinary incontinence, so we may be underpowered to detect differences in factors related to fecal incontinence. For example, we may not have detected a true association between fecal and urinary incontinence in black women due to the low prevalence rate of urinary incontinence in this group. Because FI was not the primary interest of the EPI study, subjects were not asked about factors specifically known to be associated with fecal incontinence, such as the consistency of their stools or the presence of inflammatory bowel diseases.32 This is further evidenced by the fact that the highest max-rescaled R2 for our logistic regression models was 0.29, suggesting that approximately 70% of the prevalence of FI results from factors not included in our analyses. We classified subjects as having FI based on a single-item question, rather than a validated screening instrument. As such, we may not be able to directly compare our results to other published data, nor can we guarantee that there was a consistent sociocultural understanding of our survey question about fecal incontinence by both racial groups. Furthermore, our classification of FI may overestimate the prevalence of FI given that it is based on this single-item question without addressing such questions of quantity of stool lost or bother from the incontinence. For our study, only black and white women in southeastern Michigan were recruited, but information about additional racial groups and geographic locations are needed to expand the information from our data. It is difficult to compare results of epidemiologic studies about fecal incontinence given that determining whether someone has fecal incontinence is highly dependent on the definitions used, including frequency of leakage and consistency of material leaked, i.e., gas, mucus, liquid and/or solid stool. As this was a cross-sectional study, it is important to remember that causality or temporal relationships between fecal incontinence and associated factors cannot be determined. We also recognize that there is an inherent risk of volunteer bias in our data given the study design.
In conclusion, fecal incontinence affected almost 17% of community-dwelling women in our study population. The prevalence of FI in black women is approximately one-half that of white women, similar to the proportions for urinary incontinence. Race is an independent characteristic associated with fecal incontinence, even after adjusting for other factors. Having more medical comorbidities, higher numbers of bowel movements per week, and depression are all associated with higher rates of FI, irrespective of race. However, pelvic floor function appears to be impaired in white, but not black women with fecal incontinence. By contrast, black women with fecal incontinence are more likely to suffer comorbid mobility impairment. These differences in risk factors may indicate different mechanisms for the development of fecal incontinence. For white women, FI may be part of a pelvic floor problem, whereas for black women, the inability to get to the toilet secondary to impaired mobility, along with poor health and more frequent bowel movements, leads to FI. Further investigation and understanding of these differences can lead to better screening for women at risk and therapies directed at the underlying cause of FI.
Summary.
16.7% of community-dwelling women self-report fecal incontinence, with differences in risk factors noted between black and white women.
ACKNOWLEDGEMENTS
The authors thank Kenneth E. Guire, M.A., for technical assistance with statistical analysis. We gratefully acknowledge research support from NIH R01HD/AG41123 with additional investigator support from Office for Research on Women’s Health and the National Institute of Child Health and Human Development SCOR 1 P50 HD044406.
Footnotes
Results in this manuscript were presented as a podium presentation at the 33rd Annual Scientific Meeting of the American Urogynecologic Society, Chicago, IL, October 3–6, 2012.
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