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214
Box 10.4 Case Study 2: Hospitalized Surgical Patient after Reversal of an Ostomy
Malcolm is a 25-year-old male, who was diagnosed with ulcerative colitis and
initially treated with a colostomy due to the extent of the acute lesions.
Malcolm has had his colostomy for about 1year now. He has been anxious to
have the ostomy reversed because he is to be married in 3months and does not
want to have the embarrassment of the ongoing care of the ostomy especially
on his honeymoon. His ancé, Debbie, seems very supportive but quite anx-
ious as she has limited knowledge of Malcolm’s chronic disease and the life-
long implications. She said to the nurse that Malcolm does everything himself
so she has little to do with it. However, she says that she has a very weak
stomach and that if needed to help, she would have problems with that.
Malcolm is now 2days post-operative reversal of the ostomy. His post-op
recovery has been excellent, especially because he was in good physical and
mental health. He is eating and drinking a regular diet, ambulating indepen-
dently and well managed for pain with regular acetaminophen. Although he
knew that he might experience some fecal incontinence, he was nevertheless
devastated when it happened today for the third time. He has been having
semi-formed stools throughout the day. He states that once he feels the urge
that he has less than a few minutes to get to a toilet or else he loses stool. He
is wearing a medium-sized continence pad held in place by his underwear.
Malcolm states that all this is so embarrassing for him; especially when he
knows he has gone into the pad and it smells. He is to be discharged tomorrow
and feeling quite fearful and anxious that his fecal incontinence will continue.
He is afraid to tell Debbie, as he knows how squeamish she is about the whole
situation.
Interventions by the advanced practice nurse:
• Referrals were made to: the registered dietician for high ber diet change
and counseling, the pharmacist for medication counseling reuse of bulking
medications, the physiotherapist to reinforce pre-op teaching of pelvic
oor exercises and urge suppression, and the social worker for counseling
on the impact on their relationship.
• The advanced practice nurse also began discharge planning and gave infor-
mation to the ancé and Malcolm about contacting Crohn’s and Colitis
Society for ongoing education and support groups.
• In addition, referrals were made to the pelvic oor physiotherapist in the
community to continue treatment of the pelvic oor muscles and to a com-
munity-based continence care clinic for follow-up on Malcolm’s bowel
status, teaching both his ancé and Malcolm management strategies.
J. Pittman and T. Beeson
215
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© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_11
11
Management ofFecal/Anal Incontinence
During Pregnancy andPostpartum
ChristinaHicks (Hegan) andMarleneCorton
Abstract
This chapter discusses the potential pathophysiology of anal and/or fecal incon-
tinence during pregnancy and the postpartum period and prevalence of such
incontinence, appropriate assessment, and various treatment options. This chap-
ter explains risk factors associated with fecal incontinence in rst and subsequent
pregnancies and the postpartum, including risks associated with obstetrical anal
sphincter injuries, pudendal nerve injury, and chronic fourth-degree lacerations.
Quality of life and impact on psychosocial factors, including sexual function is
also discussed. Case studies are provided to emphasize the role of the advanced
practice nurse in assessment and treatment of fecal incontinence within this spe-
cial population.
11.1 Introduction
Anal incontinence is dened as the involuntary loss of gas, feces, and/or mucus [1].
Fecal incontinence is dened as the involuntary loss of feces only [1]. Anal and/or
fecal incontinence is a life-altering condition sometimes associated with onset
C. Hicks (Hegan) (*)
Women’s Health Nurse practitioner, University of Texas Southwestern Medical Center,
Urogynecology Clinic, Dallas, TX, USA
e-mail: Christy.hicks@utsouthwestern.edu
M. Corton
Division of Female Pelvic Medicine and Reconstructive Surgery, University of Texas
Southwestern Medical Center, Urogynecology Clinic, Dallas, TX, USA
e-mail: Marlene.corton@utsouthwestern.edu
220
during pregnancy [2] or the postpartum period [3]. Postpartum anal incontinence,
specically, is dened by the International Continence Society (ICS) and
International Urogynecological Association (IUGA) as a “complaint of involuntary
loss of atus or feces during the postpartum period and up to 12months after deliv-
ery” [4]. Postpartum fecal incontinence is dened by the ICS/IUGA denition of
“complaint of involuntary loss of feces (solid and/or liquid) during the postpartum
period and up to 12months after delivery” [4].
Fecal incontinence is twice as likely among parous women as nonparous women
[2], but may occur during a rst pregnancy. Van Brummen etal. [5] conducted a
prospective cohort study of 487 nulliparous women and reported a 42.3% rate of
new onset anal incontinence and 3.9% rate of new onset fecal incontinence during
the rst trimester in rst pregnancies. Various theories regarding pathophysiology
of anal incontinence have been proposed. Among parous women, the most common
theorized cause is previous anal sphincter injury (third- or fourth-degree laceration)
sustained during vaginal childbirth [3]. Anal and/or fecal incontinence can greatly
impact quality of life [6, 7]. Identication and prompt treatment is important in
order to prevent psychological, emotional, and/or physical impact on patients’
lives [8].
This chapter begins by discussing special considerations for anal and fecal
incontinence during pregnancy and postpartum, exploring etiology, risk factors, and
prevalence of anal and fecal incontinence in pregnancy and postpartum [4]. It then
reviews the unique conditions of obstetrical anal sphincter injuries, cloacal-like
deformities, and rectovaginal and anorectal stulas, as well as the mechanics of
fecal incontinence associated with pudendal nerve injury and hemorrhoids and
hemorrhoidal tags. Additional attention is given to unique considerations in mul-
tiparous women with anal and/or fecal incontinence in subsequent pregnancies, as
well. Then education regarding special considerations for both subjective and objec-
tive assessment is discussed. Various management and treatment modalities are also
discussed, including information regarding the use of perineal clinics for counseling
and counseling specically on mode of delivery. Finally, quality of life and future
treatments in development are addressed.
11.2 Etiology ofandRisks forAnal andFecal Incontinence
inPregnancy
There is very little data regarding fecal incontinence rst reported during pregnancy,
especially during rst pregnancies. Factors that may affect fecal incontinence
include stool volume, consistency, transit time, rectal distensibility, anal sphincter
function, and anorectal sensation and reexes [9]. During pregnancy, hormonal
changes may play an important role in physiological changes of the colon, anus,
rectum, and pelvic oor musculature [2]. One theory for fecal incontinence during
pregnancy suggests that the hormone relaxin, secreted during the rst trimester,
C. Hicks and M. Corton
221
may contribute through depolymerization of collagen bonds [10]. Loosening of col-
lagen ligaments may have direct effect on the perineal body and rectovaginal sep-
tum [10]. The hormone progesterone may inuence fecal continence during
pregnancy through ligament laxity, which may stretch the pubic symphysis and
potentially contribute to pelvic oor muscle dysfunction and, subsequently, defeca-
tory dysfunction, pelvic organ prolapse, perineal descent, and difcult defecation
[9]. Furthermore, progesterone may play a role in smooth muscle relaxation of the
anal sphincter [9]. Androgen, estrogen, and progesterone receptors have been found
within the anal epithelium below the pectinate (dentate) line, potentially inuencing
anal canal closure or resting tone [9].
Another factor that may inuence fecal continence during pregnancy is the
increase in abdominal pressure that results from increasing uterine size and volume
[10]. The enlarged uterus may press against the pelvic oor musculature, resulting
in dysfunction [9]. Anal canal elongation during pregnancy may also contribute to
anal continence by increasing ow resistance [11]. Flow resistance may occur when
the anal canal elongates, but anal canal volume remains constant, potentially imped-
ing stool ow [11]. The puborectalis muscle, which is part of the levator ani mus-
cles, also provides support to the anorectal junction, possibly acting as another
mechanism of continence [12].
11.3 Prevalence andRisk Factors forAnal andFecal
Incontinence During Pregnancy
Reported prevalence rates of fecal incontinence in pregnancy vary between 3
and 9% by the end of the rst trimester and around 3% at 36weeks of gestation
[2]. One cross-sectional study of 228 pregnant women reported a prevalence
rate of up to 10% during pregnancy [10]. Anal incontinence may be most preva-
lent during the third trimester of pregnancy [13], with reported rates as high as
65% [14].
Risk factors for fecal incontinence during pregnancy include advanced maternal
age, high body mass index [15, 16], excessive weight gain during pregnancy, strenu-
ous physical activity, and cigarette smoking [16, 17] (see Box 11.1). Risk factors for
anal incontinence during pregnancy include maternal age, excessive weight gain
during pregnancy, obesity, and unemployment status [18]. Obesity may play a role
through increased abdominal pressure on an already weakened pelvic oor, which
consequently may impair healing of perineal lacerations and anal sphincter repairs
[19]. Therefore, one might consider that with more women waiting to have children
until later in life and the increasing rates of obesity in our society, anal and fecal
incontinence rates among pregnant women are likely to increase. With limited
information available regarding anal and fecal incontinence in pregnancy, more
research is needed for further understanding of the etiologies of anal and fecal
incontinence during this period.
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
222
11.4 Etiology andRisk Factors forAnal andFecal
Incontinence inPostpartum Women
A strong risk factor for anal and fecal incontinence among postpartum women
is anal sphincter tears and/or injury sustained at time of delivery [3]. Anal
sphincter perineal tears refer to those involving the external anal sphincter and/
or internal anal sphincter. More severe third-degree tears, such as those involv-
ing greater than 50% of the external anal sphincter (classified as 3b tears) and
those also including the internal anal sphincter (classified as 3c tears), may
pose a higher risk for postpartum anal incontinence [2, 20–23]. Similarly, per-
sistent anal sphincter defects have been associated with anal incontinence post-
partum [20]. Data suggest that anal sphincter injury contribute to 45% of anal
incontinence cases in postpartum women [16, 22, 24–26]. Other risk factors for
postpartum anal incontinence include forceps and vacuum-assisted deliveries
[27], median episiotomy, multiparity, advanced, maternal age, and [22, 25]
second-degree perineal tears [2, 3, 21, 23–25]. Operative deliveries have been
associated with a higher rate of anal incontinence up to 15years postpartum
[26]. The impact of prolonged second stage of labor on anal incontinence is
controversial [28]. While one study suggested prolonged second stage of labor
may increase risk of fecal incontinence [29], another study was not able to
demonstrate this relationship [25, 27, 30]. Although maternal obesity has been
associated with anal incontinence in the postpartum period [15, 20, 28], a
recent study suggested that anal incontinence was actually less common among
overweight and obese women after sustaining an obstetrical anal sphincter
injury [25, 31, 32].
Box 11.1 Risk Factors for Fecal Incontinence during Pregnancy
• Advanced Maternal Age
• High Body Mass Index
• Excessive Weight Gain in Pregnancy
• Low BMI weight gain of ≥ 18.5kg
• Normal BMI weight gain of ≥ 10kg
• Overweight BMI weight gain of ≥ 9kg
• Obese BMI weight gain of ≥ 6kg
• Strenuous Physical Activity
• Cigarette Smoking
In Subsequent Pregnancies:
• History of Fecal Incontinence during rst Pregnancy
• History of Occult Sphincter Tear in rst Pregnancy
C. Hicks and M. Corton
223
ab
Fig. 11.1 Third- and fourth-degree obstetrical anal sphincter injuries. (Reprinted with permission
from Dr. Shayzreen Roshanravan and Dr. Marlene Corton)
11.4.1 Obstetrical Anal Sphincter Injuries
Third- and fourth-degree perineal lacerations/tears sustained during vaginal births
(see Fig.11.1), often referred to as anal sphincter lacerations, may greatly inuence
the probability of developing fecal incontinence in the postpartum period [3]. One
prospective study reports increased incidence and severity of bother with subse-
quent obstetrical anal sphincter injuries, reporting a 3.3% incidence of fecal incon-
tinence in women with no injury, 10.4% incidence in women with one obstetrical
anal sphincter injury, and 16.5% incidence in women with two injuries [33]. In one
meta-analysis of 22 studies including 651,934 women, 2.4% of women sustained
third- or fourth-degree lacerations [30]. Third-degree lacerations are those that dis-
rupt the external anal sphincter, either partially or completely [3, 24]. They may also
extend to the internal anal sphincter [24]. The World Health Organization (WHO)
classies third-degree obstetric lacerations by percentage of damage to the external
anal sphincter and presence of internal anal sphincter involvement [24]. External
anal sphincter disruption of less than 50% thickness is classied as a 3a third-degree
obstetric laceration [24]. A 3b laceration involves over 50% thickness of the exter-
nal anal sphincter [24] and a 3c laceration is one that involves disruption of the
internal anal sphincter [24]. Fourth-degree obstetric lacerations disrupt the external
anal sphincter, the internal anal sphincter, and anorectal mucosa [3, 24]. While both
third- and fourth-degree lacerations are associated with increased risk for fecal
incontinence, fourth-degree lacerations may carry an increased risk compared to
third-degree lacerations due to muscle contracture forces during the healing process
[13, 21, 23]. The internal anal sphincter contributes up to 85% of anal canal resting
pressure, while the external anal sphincter contributes approximately 15% [12].
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
224
The external anal sphincter contributes to continence when continence is threat-
ened, by voluntarily contracting the muscle, similar to a Kegel contraction [12].
Because the internal anal sphincter contributes up to 85% of anal canal resting pres-
sure [12], isolated internal anal sphincter injury may lead to atus incontinence
[32]. Injury to the pudendal nerve and thus denervation injury to the external anal
sphincter may also occur during vaginal birth [12, 34–39].
One retrospective analysis of women requiring surgical repair of anal sphincter
tears at time of delivery showed rates of subsequent fecal incontinence or fecal
urgency were as high as 47% [34]. Tin etal. [7] reported that roughly 7.7% of
women with third- and fourth-degree lacerations may develop subsequent fecal
incontinence with formed stool and roughly 19.7% may develop subsequent fecal
incontinence with loose stool. The Behavioral Therapy of Obstetric Sphincter
Tears (BOOST) study conducted by the Pelvic Floor Disorders Network [23]
described the incidence of fecal incontinence in primiparous women who sustained
anal sphincter lacerations at time of delivery. In this study, the incidence of fecal
incontinence in 343 women who had anal sphincter injury repair was reported as
7%, 4%, and 9% at 6 weeks, 12 weeks, and 24 weeks, respectively [23]. The
BOOST study, which started as a clinical trial, was converted to an observational
cohort study due to the lack of reported fecal incontinence after third- or fourth-
degree obstetrical anal sphincter injuries [23]. Suspected reasons for previously
reported high rates of fecal incontinence in other studies include potential nerve
injury, inadequate surgical repair, and/or partial dehiscence of surgical repair due
to faulty healing from competing muscle contraction forces on the anal sphincter
complex [3, 40, 41].
Obstetric anal sphincter injuries may go underdiagnosed at time of delivery. In a
cross-sectional study of 563 women with no history of third- or fourth-degree lac-
erations diagnosed at time of rst or subsequent deliveries, 80% were found to have
anal sphincter defects diagnosed by endoanal sonography at 15–24years postpar-
tum [42]. Clinically undiagnosed anal sphincter defects which are found on endo-
anal sonography (occult tears) have been associated with higher rates of fecal
incontinence [42].
Although controversial, levator ani muscle trauma may also be associated with
anal incontinence. Magnetic resonance imaging studies have demonstrated higher
prevalence of levator ani muscle damage in women suffering from anal sphincter
tears, suggesting that the combination of sphincter tear and levator ani damage may
contribute to an increased risk for fecal incontinence [40]. However, one cross-
sectional study of 608 women found no association between levator ani muscle
injury and fecal incontinence up to 15–24years after rst delivery [43]. Another
longitudinal study of 453 parous women found no signicant impact of levator avul-
sion on anal incontinence [35]. In another prospective cohort study of 62 primapa-
rous women with anal sphincter injury, levator ani avulsion was found to be
independently related to anal incontinence at up to 13weeks postpartum [36]. In a
retrospective study of 1273 women, anal incontinence was found to have only a
weak association with levator avulsion [37].
C. Hicks and M. Corton