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Chapter 2 Epidemiology of Faecal Incontinence
Table 2.3. Prevalence variations in time,place and person for different thresholds of faecal incontinence
17
Author Year Place Threshold Age Prevalence % F :M ratio
Roberts et al. 1999 USA Minor 50+ 13.1 15.2 11.1 1.37
Kalantar et al. 2002 Sydney, Minor 18+ 11.2 11.6 10.8 1.07
Australia
Crome et al. 2001 UK Minor 70+ 10.0 11.3 7.9 1.43
Clarke et al. 1984 UK Minor to 75+ 9.4 – – No
moderate difference
Lam et al. 1999 Sydney, Minor to 20+ 7.8 4.5 12.4 0.36
Australia moderate
Nakanishi et al. 1997 Japan Minor 65+ 7.5 6.6 8.7 0.75
Kok et al. 1992 Netherlands Minor 60+ 7.2 F 7.2 – Not
Perry et al. 2002 UK Minor 40+ 6.2 5.7 6.2 0.92
Walter et al. 2002 Sweden Moderate 31–76 10.0 10.9 9.7 1.12
Wetle et al. 1995 USA Moderate 65+ 8.1 7.8 8.5 0.91
Perry et al. 2002 UK Moderate 40+ 3.3 3.1 3.6 0.86
Campbell et al. 1985 New Moderate 65+ 3.1 – – <1
Zealand
Edwards and Jones 2001 UK Moderate 65+ 3.0 4 1 4
Chen et al. 2003 Taiwan Moderate 20+ 2.8 F 2.8 – Not
Crome et al. 2001 UK Major 70+ 3.8 3.7 4.0 0.93
Talley et al. 1992 USA Major 65+ 3.7 3.1 4.5 0.69
Nakanishi et al. 1997 Japan Major 65+ 2.0 2.2 1.8 1.22
Perry et al. 2002 UK Major 40+ 1.9 1.7 2.2 0.77
Lam et al. 1999 Sydney, Major 20+ 1.8 1.1 2.7 0.41
Australia
Thomas et al. 1984 UK Major to 15+ 1.4 1.39 1.46 0.95
moderate
Walter et al. 2002 Sweden Major 31–76 0.7 1.4 0.4 3.5
group
All Female Male
available
available
et al. 1995),suggesting prevalence may vary between different facilities because of differences in selection criteria.
Social Group. Few population-based studies have considered socio-economic factors.Crome et al. (2001) showed a slightly higher prevalence for occasional (minor) incontinence in public rented (8.5%) compared to own homes (6.5%) but the levels were
similar for frequent (major) incontinence. Secondary analysis of the MRC Incontinence Study (UK) suggests that the prevalence of monthly (moderate) leakage increases with worsening socio-economic status (Table 2.4). There were no statistically significant differences between white and South Asian groups either before or after adjusting for other social factors.
2
18
Catherine W. McGrother
Fig. 2.1. Prevalence of faecal incontinence in women – population studies
Fig. 2.2. Prevalence of faecal incontinence in men – population studies
Fig. 2.3. Prevalence of faecal incontinence by frequency of leakage
Chapter 2 Epidemiology of Faecal Incontinence
Fig. 2.4. Female:male prevalence ratios by age group – population studies
Table 2.4. Social groups associated with faecal incontinence in Leicestershire,UK
Social group Univariate Multivariate
Socio-economic group Homeowner 1.0 1.0
Private rental 1.55* 1.51**
Public rental 1.75** 1.44**
19
Ethnic group White 1 –
South Asian 0.75
Gender Female 1.0 1.0
Male 1.23** 1.32**
Age 40–49 1.0 1.0
50–59 1.31* 1.28*
60–69 2.04** 1.98**
70–79 2.64** 2.49**
80* 3.99** 3.61**
* p<0.01, ** p<0.001.
Disability. Information concerning people with learning disability (LD) is available
from the Leicestershire population-based Learning Disability Register (McGrother et
al. 1996).Comparison of the prevalence of faecal incontinence with the general population in Leicestershire (Perry et al. 2002) shows a greater than sevenfold higher rate
for those aged over 40 years (Table 2.5). A threefold increase is present for the mobile
sub-group with relatively normal physical functioning, compatible with independent
living. Prevalence among non-mobile people with LD is similar to that in elderly people in long-term care facilities in Leicestershire (Arthur et al.2002).
2
20
Catherine W. McGrother
Table 2.5. Prevalence of faecal incontinenceain people with learning disability and the general
population in Leicestershire UK
Age Learning Disability General population
b
Mobile
Non-mobile All Community Long-term care
40–49 3.8 30.3 9.1 0.7 –
50–59 4.4 21.8 8.9 1.1 –
60–69 7.4 24.5 12.0 1.5 37.2
70+ – 18.5 7.7 2.4 28.7
All 4.4 25.4 9.4 1.4 29.1
a
Weekly leakage.
b
Walks unaided.
c
65–69 years age group.
2.3 Associated Factors
Urinary Incontinence. Faecal incontinence is consistently associated with urinary
incontinence in adults (Table 2.6). In the general population in women,across a variety of age groups over 20,the strength of association ranged from an odds ratio of 1.5 to
17 (adjusted for age).The association was convincing for urge incontinence but marginal for stress incontinence. In men, similar overall estimates ranged from 3.0 to 5.1.
Non-age adjusted estimates showed similar ranges for women (2.1–11.5) and men
(2.1–3.1). Residents in long-term care showed relatively strong associations between
10.4 and 20.5 for multivariate analyses and 25 for non-age adjusted odds ratios (Aggazzotti et al. 2000; Nelson et al. 1998; Ouslander et al. 1993).
c
Health Factors. There was consistent evidence from population-based studies with
multivariate analyses to support associations between FI and poor health (Kalantar et
al. 2002; Crome et al.2001; Nakanishi et al.1997; Nelson et al.1995), poor physical func-
Table 2.6. Association between urinary and faecal incontinence in population studies
Author Age OR men OR women Type Adjustment
Koskimaki et al. (2001) 50, 60, 70 – 17 (7.5, 40) Urge Age
Nuotio et al. (2003) ‘older’ NS 7.84 Urge Age
McGrother et al.(2005) 40+ 5.1 (3.9–6.5) 5.3 (3.9–7.2) OAB Age
Roberts et al. (1999) 50+ 3 (1.9–4.8) 1.8 (1.2–2.7) All Age
Chen et al. (2003) 20+ – 3.2 (1.6) Urge Multivariate
Edwards and Jones (2001) 65+ – 11.5 (p<0.0001) All Unadjusted
Kok et al.(1992) 60–84 – 5.8 (1.6–21.0) All Unadjusted
Diokno et al. (1990) 60+ 3.2 (p=0.001) 2.5 (p=0.0005) All Unadjusted
Wetle et al. (1995) 65+ 2.1–7.9
a
Varying with age, sex and severity.
1.8 (1.2–2.7) SUI
1.5 (0.7–3.0) SUI
a
2.1–7.9
a
All Unadjusted
Chapter 2 Epidemiology of Faecal Incontinence
tioning (Crome et al.2001; Talley et al. 1992; Edwards and Jones 2001),depression (Edwards and Jones 2001; Crome et al. 2001;Black et al. 1998),anxiety (Edwards and Jones
2001; Crome et al.2001) and diarrhoea or loose stool (Talley et al. 1992; Kalantar et al.
2002). Other health factors identified in lone studies were constipation (Lam et al.
1999), incomplete defaecation and urgency (Kalantar et al. 2002), bodily pain (Crome
et al. 2001),and stroke (Nakanishi et al. 1997). Diabetes and dementia were also associated with isolated and double FI, respectively (Nakanishi et al. 1997). Although beyond the scope of the systematic review, consistent evidence was also observed from
prospective studies that instrumental vaginal delivery and sphincter damage were associated with FI (Macarthur et al. 1997; Faltin et al. 2001; Eason et al.2002; de Leeuw et
al. 2001).Among residents in long-term care, there was consistent evidence for association with poor mobility and dementia, and some indication of links with neurological disease and diarrhoea (Chassagne et al. 1999; Johanson et al.1997).
2.4 Conclusions
The results of this review are consistent with earlier reviews concerning the range of
prevalence for faecal incontinence in the general population. There was a reasonable
degree of consistency between individual studies on the prevalence of age-related
moderate or more faecal incontinence affecting between 2.8% and 10.0% of adults,
similarly in men and women, increasing with age. Males predominated at a younger
age, whereas females had higher prevalence at old age, but the differences were slight.
There was little evidence of differences in prevalence over time or between countries.
Prevalence in long-term care was much higher than in the community, especially for
major incontinence, and people with learning disability also experienced high rates.
There was evidence of a link with adverse socio-economic status, but no difference
was observed between whites and South Asians.There was a strong link between urinary and faecal incontinence.Faecal incontinence was also consistently related to poor
perceived health,including depression,anxiety,diarrhoea and physical functioning in
the general population.There was also consistent evidence for an association with instrumental vaginal delivery.
Methodologically,it appeared that prevalence estimates were primarily dependent
on the frequency and implicit severity of the wording of questions used plus the inclusion of people in long-term care.On the basis of this review, faecal incontinence could
be defined conceptually as ‘any involuntary leakage of faeces (liquid or solid) from the
bowel.However, the word ‘involuntary’ implies a degree of severity and ‘faeces’is not a
common term. Also, different thresholds are needed for particular purposes (e.g. for
health promotion or care). Therefore practical translation into a question would be ‘do
you ever leak (liquid or solid) from your bowel when you don’t mean to (day or night),
with responses ‘continuously, daily, weekly, monthly, yearly or never’.
Faecal incontinence may be an effective marker for impairment but the coherent
whole that it represents is unclear and likely to involve other lower-bowel symptoms
such as urgency and constipation, representing disorder of the lower-bowel system.
Within such an umbrella, research measuring the public health burden and identifying causes and effects is likely to focus on the whole lower-bowel system including the
following elements:
21
(a) Burden, the presence and severity of faecal incontinence (and related lower-bow-
el symptoms); impact (as a whole) on QOL; clinically significant disorder (as a
whole); and felt need (i.e. use or want care)
22
Catherine W. McGrother
(b) Causes and effects, the type and severity of faecal incontinence and related lower
bowel symptom syndrome; clinical management group and underlying pathophysiological process.
2
Realistic conceptual and terminological standards for each element are needed as a
basis for investigation, together with validated assessment and procedural standards
for research including reporting for meta-analysis purposes. Effective multidisciplinary research depends on knowledge of the relationship between these elements rather than the primacy of one over another.
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23
Chapter 3
Chapter 3 Economic Costs of Urinary Incontinence in Ger-
Economic Costs of Urinary Incontinence
in Germany
Günter Neubauer, Sandra Stiefelmeyer
25
3
Contents
3.1 Prevalence and Social Importance . . . . . . . . . . . . . 26
3.2 From a Medical to an Economic Approach . . . . . . . . 27
3.3 Direct Costs . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.4 Indirect Costs . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.5 Economic Impact in Germany . . . . . . . . . . . . . . . 29
3.6 From Treating to Healing . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3
26
Günter Neubauer,Sandra Stiefelmeyer
3.1 Prevalence and Social Importance
Urinary and fecal incontinence is a frequent public health problem with negative social consequences. Failure to control the elimination of urine or stool causes psychological problems, complicates medical illness, makes management difficult and produces major economic consequences. Susceptibility is the result of anatomical, social,
economic and cultural factors.Also, urinary incontinence is a major clinical problem
that has a profound effect on quality of life and activities of daily living (Hollywood
and O’Dowd 1998) and isolates the affected person from friends and family. Women
with urinary incontinence report fear,frustration, shame and humiliation, and worry
about the odor of urine from pads and wet underclothing. Urinary incontinence is
physically debilitating and socially incapacitating, and is associated with loss of selfconfidence,feelings of helplessness, depression and anxiety.
The probability of incontinence increases with age. The nature of incontinence
changes from stress incontinence to urge incontinence with age as a result of an increasing prevalence of multiple disorders and organ dysfunction. This change has a
significant implication for clinical management.While stress incontinence is typically
managed with strengthening exercises for pelvic floor muscles, with or without neuromuscular electrostimulation and surgery, management of urge incontinence also include a bladder training program, drugs and transcutaneous electrostimulation aimed
at the spinal micturition reflex center.
Studies regarding the prevalence of urinary incontinence suggest that this problem
is widespread among women and men of all ages. The prevalence of urinary incontinence ranges from 10% to 60%, depending on the country and population studied.
Women are much more susceptible to urinary incontinence than men.Anatomical and
physiological differences,such as reproductive and hormonal changes associated with
pregnancy and menopause, explain the differences prevailing between male and female. It is highly probable that socioeconomic and cultural factors play a crucial role
in urinary incontinence. However, the extent of the influence of these factors on
women’s health remains relatively unknown. In contrast, fecal incontinence is less investigated and only few data are reported, mainly from clinical experience with patients with this disorder. These studies are methodologically rather weak in information. They generally focus on a narrow part of the problem that cannot be extrapolated to the entire population with incontinence.
The costs of urinary and fecal incontinence is not adequately described by the dollars spent in the healthcare system. Nonetheless, in the current climate of economic
healthcare rationalization,it remains useful to calculate the measurable costs of a disorder, as least to justify expenditure on this rather than upon some other medical
problem. The costs of an illness comprises three components: direct costs, which include personal costs (pads, replacement of urine-soaked clothes) and treatment costs
(met by patients and by several government subsidies); indirect costs, which include
lost productivity both in the home and in outside employment; and intangible costs,
which are most difficult to measure financially, but include psychological distress and
impaired physical or mental health.
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