By Chiara Ghetti, MD

Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis

Dr. Ghetti reports no financial relationships relevant to this field of study.

SYNOPSIS: Irritable bowel syndrome has a negative effect on women’s quality of life and affects one-third of women who present for care with fecal incontinence.

SOURCE: Markland AD, et al; Pelvic Floor Disorders Network. Irritable bowel syndrome and quality of life in women with fecal incontinence. Female Pelvic Med Reconstr Surg 2017;23:179-183.

The objective of this study was to determine the prevalence of irritable bowel syndrome (IBS) in women presenting for treatment of fecal incontinence and to determine the effect of IBS on quality of life. This was an ancillary analysis of the Adaptive Behaviors among women with Bowel Incontinence (ABBI) study, a multicenter, prospective cohort study designed to evaluate adaptive behaviors among women with bowel incontinence. Eligible women experienced fecal incontinence of liquid stool, solid stool, or mucus occurring at least monthly for three consecutive months and planned to undergo treatment for fecal incontinence. Women reporting prior rectal or colon cancer, inflammatory bowel disease, pelvic irradiation, a current or prior rectal fistula(e), removal of any portion of the colon/rectum, rectal prolapse, or severe neurological conditions were excluded.

Subjects completed validated questionnaires in person or by telephone before treatment. Questionnaires included assessment of IBS symptoms using the Rome III symptom-based diagnostic criteria, and multiple validated general health-related and condition-specific quality-of-life scales, as well as validated assessments of other pelvic floor symptoms. In this study, IBS was categorized according to the Rome III clinical criteria. In addition, subjects could self-report whether they previously received a diagnosis of IBS.

The authors enrolled 133 women. Of these, 119 completed Rome III IBS questionnaires, and 111 reported whether they had received a previous diagnosis of IBS. According to the Rome III IBS criteria, 37 women had IBS. The most common subtypes were IBS-mixed (41%) and IBS-diarrhea (35%). Twenty-four of 111 patients had a previous IBS diagnosis. Of the subjects who met Rome III IBS criteria, 23 had never received a diagnosis of IBS. There were no significant differences in baseline sociodemographic characteristics, prior treatments, and stool consistency between subjects with fecal incontinence alone compared to subjects with IBS and fecal incontinence. Women with fecal incontinence and IBS reported significantly worse quality of life compared to women without IBS, despite similar fecal incontinence severity and stool consistency. More women with fecal incontinence and IBS reported premenopausal symptoms than women with fecal incontinence alone.

COMMENTARY

The findings reported in this study suggest that IBS affects one-third of women with fecal incontinence presenting for care in tertiary centers, and 76% of the women with IBS and fecal incontinence met clinical criteria for IBS-mixed and IBS-diarrhea subtypes. Two-thirds of the women who met criteria for IBS never had been told by a provider that they had IBS. Women with IBS and fecal incontinence experienced a significant negative effect on quality of life.

The strengths of this study include its prospective, multicenter cohort design and the use of validated questionnaires alongside IBS diagnostic criteria. The major limitation of this study is its small cohort size and small number of women with IBS. The authors were limited in the analyses performed and could not perform multivariable statistical modeling, thus limiting the strength of conclusions related to the differences found between women with fecal incontinence with and without IBS. Nonetheless, this study highlights the importance of assessing IBS symptoms in women presenting for fecal incontinence treatment. From my clinical experience, I would like to further emphasize the importance of assessing IBS symptoms and constipation in all women, and especially in women presenting with any pelvic floor symptom.

IBS has been estimated to affect 10-15% of the general adult population and is the most commonly diagnosed gastrointestinal condition. IBS symptoms are more prevalent in women than in men.1 Jelovsek et al reported 19% prevalence of IBS or one of its subtypes in subjects with pelvic floor disorders presenting for care at a tertiary urogynecologic practice.2 IBS is divided into four subtypes: IBS-C (constipation), IBS-D (diarrhea), IBS-M (mixed, equal diarrhea and constipation types), and IBS-U (unclassified). The Rome diagnostic criteria were developed as the diagnostic criteria for IBS. Now in their third iteration, the Rome III criteria state that a patient must have recurrent abdominal pain at least three days per month over the previous three months, and the discomfort must be associated with two or more of the following: improvement with defecation, onset associated with a change in frequency of stool, or onset associated with a change in consistency of stool.3,4 The American College of Gastroenterology Task Force has defined IBS as abdominal pain or discomfort that occurs in association with altered bowel habits over a three-month period. Studies have shown that patients with IBS have worse quality of life, higher economic burdens, and higher healthcare utilization compared to those without IBS. IBS is heterogenous in nature and is thought to be multifactorial. Patients who meet the clinical diagnostic criteria for IBS and do not have “alarm” features, including anemia, weight loss, and a family history of colorectal cancer, inflammatory bowel disease, or celiac sprue, require little formal testing to arrive at the diagnosis of IBS.5,6

Constipation also is also extremely common in the general population. It is thought to affect 16% of all adults and 33% of adults > 60 years of age. Heavy lifting and repetitive straining secondary to constipation long have been associated with pelvic organ prolapse and are considered risk factors.7 Jelovsek et al reported a high prevalence of constipation in women with urinary incontinence and pelvic organ prolapse. Thirty-six percent of the 302 patients studied reported symptoms of constipation, with similar rates between women with either pelvic floor disorder.2

Constipation is defined as symptoms of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. Difficult stool passage includes straining, a sensation of difficulty passing stool, incomplete evacuation, hard or lumpy stools, prolonged time to pass stool, or need to perform manual maneuvers to pass stool.4,5 Chronic idiopathic constipation refers to the presence of such symptoms for at least three months.4,5 The American Gastroenterological Association treatment algorithm for chronic constipation recommends a trial of fiber alone or alongside a laxative. In addition, biofeedback therapy has been reported to improve symptoms more than 70% in patients with defecatory disorders.6

IBS and constipation are very common in the general population. Markland et al focused on the presence and effect on women with fecal incontinence; however, functional bowel disorders are highly prevalent in women with all pelvic floor disorders. Not only is treatment of constipation considered a possible modifiable risk factor for pelvic floor disorders, but screening for and treatment of IBS and constipation may produce a significant effect on patients’ quality of life and well-being.

REFERENCES

  1. Chang L, et al. American Gastroenterological Association Institute Technical Review on the pharmacological management of irritable bowel syndrome. Gastroenterology 2014;147:1149-1172.e2.
  2. Jelovsek JE, et al. Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence. Am J Obstet Gynecol 2005;193:2105-2111.
  3. Occhipinti K, Smith JW. Irritable bowel syndrome: A review and update. Clin Colon Rectal Surg 2012;25:46-52.
  4. Ford AC, et al; Task Force on the Management of Functional Bowel Disorders. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014;109(Suppl 1):S2-26; quiz S27.
  5. American College of Gastroenterology Task Force on Irritable Bowel Syndrome, Brandt LJ, Chey WD, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol 2009;104(Suppl 1):S1-35.
  6. Bharucha AE, et al. American Gastroenterological Association technical review on constipation. Gastroenterology 2013;144:218-238.
  7. Jelovsek JE, et al. Pelvic organ prolapse. Lancet 2007;369:1027-1038.