Presented at the NIH State-of-the-Science Conference: Prevention of Fecal and Urinary Incontinence in Adults - Bethesda, MD - December 10-12, 2007

Epidemiology is the study of the distribution and determinants of a disease or condition and includes its prevalence, incidence, and risk factors or correlates. Understanding the epidemiology of fecal incontinence (FI) and urinary incontinence (UI) is important to the search for potential causal factors, as well as protective factors, and the development of approaches to the primary and secondary prevention of these conditions.

Prevalence estimates vary widely for both FI and UI. This variation has been attributed to differences in definition of the conditions, data collection methods, populations selected, and sampling methods. Definitions used in epidemiological studies encompass a wide range of severity by incorporating various criteria based on frequency, type, quantity, duration, or symptom bother. Data collection has been conducted by in-person interview, telephone interview, or anonymous questionnaire. Each method carries the potential for under- or overreporting of incontinence and thus has the potential to influence prevalence estimates.

Fecal Incontinence

FI is usually defined as the involuntary loss of solid or liquid stool. Anal incontinence is a broader concept that includes loss of solid or liquid stool, flatus, or mucus. The two terms are sometimes used interchangeably, and some surveys have included the loss of flatus in the definition of FI.

Estimates of the prevalence of FI in community-based populations range from 0.4% to 18%.^1,2 Considering those studies that used the most unbiased methods, such as anonymous, self-administered questionnaires, estimates range from 11% to 15%.^3–5 Most surveys report increased prevalence of FI with age.^6,7 Population-based studies of older adults report prevalences of FI ranging from 3.0% to 32%.^7–9 Several studies have reported the FI is more common among women compared to men, but the literature is mixed on the issue of gender.

In nursing homes, prevalences range from 45% to 55%.^10,11 This range may be explained partly by FI being one of the most common reasons for nursing home admission.^4,8 FI in nursing homes has been associated with functional impairment, dementia, and sensory impairments—all factors that place a person at risk for institutionalization.

Studies of the incidence of FI in the general population are rare. One study reported a cumulative 5-year incidence of 8.5% among older adults.⁷ Most other incidence studies have been conducted in special populations, such as patients undergoing medical or surgical procedures and postpartum women. Studies of FI in the postpartum period have identified anal sphincter injury during childbirth as a major cause of FI in young healthy women.^12,13

Urinary Incontinence

UI is the involuntary loss of urine. A large literature exists on the prevalence of UI, primarily in women and in Caucasian populations. UI is uniformly more common among women compared to men by a ratio of 2:1. In women, prevalences based on liberal definitions range from 5% to 69%,² with most being in the 25% to 45% range.^14–16 In most studies that include a wide age range, the prevalence of UI increases progressively up to middle age, levels off until about age 70, and then increases steadily among older adults.^16,17

Prevalence of UI is higher among women living in long-term-care settings. Prevalences range from 23% to 72%, with a median of about 55%.^18,19 Based on studies showing that presence of UI increases the risk of institutionalization, it has been assumed that this higher prevalence is due to selection. In addition, cognitive, functional, and sensory impairments that contribute to UI are also risk factors for placement in nursing homes.

Higher prevalences are also found in studies of pregnant women, in whom estimates range from 32% to 64% for any UI.^20,21 Prevalence tends to be low in the first trimester, greater in the second trimester, and even higher in the third trimester. Established risk factors for UI in women include age, parity, obesity, and cognitive and functional impairment. Other possible risk factors that have been investigated include race, fetal and obstetric factors, menopause, hormone therapy, hysterectomy, smoking, and family history.

Fewer studies have been published describing the prevalence of UI in men. In the general population of men, prevalence of UI ranges from 1% to 39%. UI increases steadily with age and ranges from 11% to 34% in older men.²² As in women, prevalence of UI is higher among men in long-term-care settings.

Men undergoing prostatectomy are at particular risk for UI. Incontinence tends to be most severe immediately after surgery and to improve over time. Transurethral resection of the prostate (TURP) is associated with a fairly low incidence of UI (approximately 1%). However, radical prostatectomy carries a much higher risk of UI, with prevalences based on patient self-report ranging from 8% to 56% at 1 year following surgery.^23–25

There are fewer studies of the incidence of UI. In community-dwelling women, 1-year incidence ranges from 1% to 11.1% for women under 60 years of age ^26,27 and from 5% to 29% for those over 60 years.^7,28 Studies of the incidence of UI in men are rare. In older men, the 1-year incidence of UI ranges from 6.3% to 16.9% and is higher in the older age groups.^7,28

Summary

UI and FI are prevalent conditions that affect men and women of all ages. Epidemiological data provide evidence for several risk factors, some of which are modifiable, and identify at-risk populations of men and women who could potentially benefit from prevention.

Written by: Burgio K, Ph.D.

References

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25. Bishoff JT, Motley G, Optenberg SA, et al. Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population. J Urol. 1998;60:454–458.
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