PREVALENCE AND CONSEQUENCES OF FECAL INCONTINENCE IN MIDDLE EASTERN WOMEN Diaa E.E. Rizk Professor of Obstetrics and Gynaecology Faculty of Medicine, Ain Shams University, Cairo, Egypt.

The complete protection of the perineum has undoubtedly remained a weak spot in our art. Franz Ritgen (A German Obstetrician and Gynaecologist), The pelvis fulfils more extensive functions in the female body than in the male. In the female, it shelters the largest part of the sexual apparatus in addition to the distal end of the intestinal canal and urinary passages and thereby assumes great importance in reproduction. Nature has placed the canal that opens at the lowermost part of the trunk in such a position that the pelvis can maintain the burden of the abdominal viscera and provide support and purchase for the enclosed organs. Carl Litzmann ( A German Anatomist); Die Foramen des Beckens, 1861.

A tribute to a great Egyptian Surgeon who contributed to the global art and science of fecal incontinence Professor Ahmed Shafik (10/5/ /10/2007)

Introduction Fecal incontinence [FI] is usually defined as a condition in which involuntary loss of liquid or solid stools causes social or hygienic inconvenience. Anal incontinence is another term that is used to denote any involuntary leakage, whether of gas or feces, through the anal orifice. FI is an embarrassing and debilitating symptom that represents a significant public health problem.

Introduction This disorder is more common in women particularly with high parity, advancing age and menopause when the sex ratio shows a female to male preponderance of 8:1 Thus, a high prevalence of FI is expected in Middle Eastern women. The experience of colorectal surgeons and gastroenterologists in the Middle East, however, was that FI is rarely reported by women. It was important to find an explanation for this observation.

BACKGROUND Several studies have commented on the prevalence of FI in women from western communities and the psychosocial and economical consequences of having this disorder Ethnic differences in prevalence and attitudes to FI have not, however, been reported Such epidemiological studies are important for projecting the need for health services and therapeutic intervention in the Middle Eastern population

OBJECTIVES Establish if FI is recognized in the local Middle Eastern culture Determine the prevalence of this disorder in a representative sample of women Evaluate the determinants of health care seeking behavior

Methods* A selected group of UAE women at risk of having FI such as multiparous women aged 20 or more years to increase the detection rate. Sample size calculation indicated that a study of 450 subjects was adequate to achieve a high degree of precision (95%) in estimating the true prevalence of FI in the general female population of the UAE aged 20 years or older (approximately 180,000). A priori assumption was that the expected prevalence of FI is 10 %, similar to the average rate reported in western countries. * Rizk DEE, Hassan MY, Shaheen H, Cherian JV, Micallef R, Dunn E. The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females. Dis Colon Rectum 2001; 44:

Subjects Subjects were randomly selected from the community (n=225) and health care centers (n=225). The community stage consisted of a simple random sample of eligible women identified through the listings of the UAE women association and contacted at home. The clinic-based stage was a consecutive sample of eligible female patients visiting the services of the Primary health care centers irrespective of the reason for their visit.

Data Collection Direct interview about inappropriate stool loss in the previous year only Current FI (history of FI but not in the last year, flatus incontinence and fecal soiling were NOT considered to be FI). A structured questionnaire generated after a review of the literature with pilot testing on 30 employees to assess clarity and suitability for the target population. Data were collected by a trained research nurse using face to face interview at the clinic or home. The survey consisted of 39 items that included a number of demographic, reproductive and lifestyle variables.

Results 51 women (11.3%) were incontinent, 26 to liquid stool and 25 to solid stool. 38 women (8.4%) had double incontinence. 65 women (14.4%) were incontinent to flatus only. 30 women (59%) did NOT seek medical advice. Only 90 women (20%) had been asked about FI by a physician.

Table 1. Reasons for not seeking treatment (N=51)

Table 2. Consequences of having FI (N=51) Incontinent women (N=51) Interference with regular praying 47 (92.2) Feeling disgusted and dirty43 (84.3) Feeling conscious, ashamed and embarrassed especially with husband and children 39 (76.4) Inability to have sexual intercourse 22 (43.1) Limitation of social activities such as shopping and visiting friends 14 (27.4) Difficulty in performing physical activities including housework and job assignments 10 (19.6)

Table 3. Perceived causes of incontinence (N=450)

Results Coping mechanisms in incontinent women were: 1- frequent washing (52.9%), 2- regular changing of underwear (49.1%) 3- wearing a protective perineal pad (37.2 %) 4- decreasing food intake (25.4%) 5- stop doing any work (7.8%).

Discussion Comparable studies of western women of a similar age spectrum have reported prevalence rates of FI between 1 and 16%. Results from various studies is limited by differences in: a- Definition of incontinence (incontinence to feces only - fecal incontinence- or feces and flatus -anal incontinence), b- Onset (current or past), c- Severity (whether or not it is a social or hygienic problem) and frequency (daily or episodic) d- Patient populations (community dwelling or hospitalized and were seeking care or not ) e- Ethnic group examined f- Study design including sampling techniques and standards and methods of data collection.

Conclusions FI is common in Middle Eastern women but incontinent subjects rarely seek medical help because of social traditions, cultural beliefs and lack of information. FI severely impairs the quality of life of Middle Eastern women by interfering with praying. This factor alone can severely impair the quality of life of any Moslem women who have FI and highlights the cross-cultural and ethnic differences in women attitudes to this disorder.

Conclusions Detection of fecal incontinent women by their primary health care providers remains suboptimal in the Middle East and requires education about the condition and targeted history taking and physical examination. Expert advice to women is necessary to correct misconceptions about FI being normal or untreatable. The data obtained here might be of value in similarly identifying the real extent of female FI in our Egyptian population and in planning the subsequent medical and social care of incontinent women.