Published online before print December 2, 2002, doi: 10.1161/01.STR.0000044169.54676.F5
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(Stroke. 2003;34:144.)
© 2003 American Heart Association, Inc.
Original Contributions |
New-Onset Fecal Incontinence After Stroke
Prevalence, Natural History, Risk Factors, and Impact
From the Departments of Healthcare of the Elderly (D.H.) and Public Health (C.C., C.D.A.W.), King’s College, and the Elderly Care Unit (A.G.R.), Guy’s and St Thomas’ Hospitals Trust, London, UK.
Correspondence to Dr Danielle Harari, Clinical Senior Lecturer (Consultant), Elderly Care Unit, 9th Floor, North Wing, St Thomas’ Hospital, Lambeth Palace Rd, London SE1 7EH, UK. E-mail danielle.harari{at}kcl.ac.uk
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Abstract |
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Background and Purpose— Fecal incontinence (FI) is a common complication after stroke, yet epidemiological research into this distressing condition is limited. The purpose of this study was to describe the prevalence, natural history, associations, and impact of new-onset FI after stroke.
Methods— Stroke patients in the community-based South London Stroke Register (January 1995 to 2000) without preexisting FI were characterized regarding bowel continence at 7 to 10 days, 3 months, and 1 and 3 years after stroke. FI was defined as any degree of bowel leakage.
Results— Prevalence of poststroke FI was 30% (7 to 10 days), 11% (3 months), 11% (1 year), and 15% (3 years). One third of patients with FI at 3 months were continent by 1 year; conversely, 63% incontinent at 1 year had been continent at 3 months. Characteristics of 91 patients with FI and 755 without FI at 3 months were compared using multiple logistic regression. Acute stroke associations of neglect (adjusted odds ratio [OR], 1.9; 95% CI, 1.0 to 3.5) and initial urinary incontinence (OR, 6.2; 95% CI, 3.2 to 11.9) were no longer significant after adjustment for clinical factors at 3 months. Final independent associations were anticholinergic drug use (OR, 3.1; 95% CI, 1.1 to 10.2) and needing help with toilet use (OR, 3.5; 95% CI, 1.4 to 17.3). FI at 3 months increased the risk of long-term placement (28% vs 6%) and death within 1 year (20% vs 8%).
Conclusions— New-onset FI in stroke survivors is common but may be transient. Modifiable risk factors for FI 3 months after stroke are constipating drug use and difficulty with toilet access, raising implications for developing treatment and prevention strategies.
Key Words: constipation • fecal incontinence • outcome • prevalence • stroke
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Introduction |
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Fecal incontinence (FI) is a common complication after stroke, affecting 40% of individuals immediately after stroke and 10% to 19% of 6-month survivors.1,2 There is, however, a lack of clinical research into this distressing condition in stroke patients.3 Although risk factors for FI immediately after stroke have been identified,1 those for incontinence beyond the acute phase have not been studied. In a cohort study of 135 stroke patients, Brocklehurst et al2 observed that 14% of those fecally incontinent became so beyond 8 weeks after the acute event, leading to speculation that constipation, immobility, and dependence may be primary underlying causes. These previous studies included individuals with preexisting FI; excluding this group to study only cases of new-onset FI after stroke enables a more accurate analysis of stroke-related associations. Furthermore, no previous studies have looked at targeted risk factors for FI in longer-term survivors, with adequate control for confounders. The present study specifically examined the relative influence on bowel continence of direct stroke factors versus clinical and functional factors associated with stroke, such as immobility, medications, etc. In this way, potentially modifiable factors for FI in longer-term stroke survivors can be identified, thus informing strategies for treatment and prevention. This is also the first study to characterize new-onset FI after stroke.
The aims of this study were to document the prevalence of new-onset FI after stroke, to examine the natural history, and to identify independent associations of new-onset FI in patients at 3 months after stroke.
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Methods |
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The South London Stroke Register (SLSR) is a prospective, community-based register of first-in-a-lifetime stroke patients that includes an urban population of 234 533 individuals. Data are collected in the acute stroke phase (within the first 10 days) by research registrars and at 3 months, 1 year, and then annually by face-to-face interviews with a trained fieldworker. When reliable answers cannot be secured directly from patients (owing to cognitive impairment, communication difficulties, or severe illness), the information is sought from family, care givers, nursing home or hospital staff, or community health workers. Medical information is also obtained from hospital and general practitioner records. Stroke is defined according to the World Health Organization criteria.4 Detailed methods of the SLSR have been previously reported.5
Patients are characterized regarding bowel continence status according to the Barthel Index bowel subscore. The Barthel Index assessment is a global functional measurement tool that has been validated for use in stroke patients and includes all basic activities of daily living.6,7 In response to the question "Do you lose control of your bowel motions?", patients, care givers, or nurse observers report "never," "occasional accident," or "all the time." For the purpose of this study, fecal incontinence was defined as "loss of bowel control occasionally or all the time." At enrollment onto the SLSR, patients, care givers, or health workers are asked about Barthel Index measures of function and continence immediately before the stroke. Those reporting preexisting FI were excluded from the analysis to study poststroke FI of new onset.
The Barthel Index was measured at 4 time points after stroke: 7 to 10 days, 3 months, 1 year, and 3 years. Prevalence of FI was computed at these time points, and the natural history of the condition was examined. At the 3-month follow-up point, 91 patients with poststroke FI were compared with 755 continent individuals in a cross-sectional analysis to identify associations. Demographics, acute stroke characteristics, and clinical, functional, and psychosocial characteristics at 3 months were examined for associations with poststroke FI. Stroke diagnosis was classified by use of CT imaging or MRI according to the Oxford Community Stroke Project classification as total anterior circulation, partial anterior circulation, posterior circulation, or lacunar infarct; primary intracerebral or subarachnoid hemorrhage; or unclassified.8 Acute stroke severity factors were Glasgow Coma Scale <15,9 urinary incontinence (UI; Barthel Index subscore), visual field defect, expressive or receptive dysphasia, sensory or visual neglect, and dysphagia (failed swallow test). Stroke risk factors were diabetes mellitus, preceding transient ischemic attack, hypertension, and atrial fibrillation. Clinical, functional, and psychosocial characteristics at 3 months were living situation (at home, long-term care facility, still in hospital); cognition (Mini-Mental [MMSE] test score)10; medications known to impact the gut; UI; level of dependence for toilet use, transfers, and stair climbing (Barthel Index subscores); district nurse and home-help input since the acute stroke; general health perception (SF-36 subscore11); and social support ("If you needed help, do you have anyone, eg, friends, family, or neighbors, you can turn to?").
Bivariate associations for FI at 3 months poststroke were calculated and, on the basis that case mix is likely to have an effect on outcome, were initially adjusted for age, sex, and ethnicity. Statistically significant (P
0.10) variables were included in multiple analysis by using variable selection by backward stepwise logistic regression adjusted for age, sex, and ethnicity and were based on the likelihood ratio statistic (P to enter=10%, P to remove=5%). To investigate whether 3-month clinical, functional, and psychosocial characteristics influence associations between acute stroke factors and poststroke FI, a preliminary multiple logistic regression model including acute stroke characteristics only (adjusted for age, sex, and ethnicity) was used. This was then further adjusted for 3-month characteristics in the final model. Multiple analysis was also used to examine associations between FI at 7 to 10 days after stroke and acute stroke factors, adjusted for age, sex, and ethnicity.
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Results |
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The SLSR recruited 1563 patients between January 1995 and January 2000. Figure 1 shows study patient exclusions at different time points.
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Prevalence and Natural History of New-Onset FI After Stroke
The prevalence of FI in the study population at 4 time points after stroke was as follows: 7 to 10 days, 29.7% (317/1069); 3 months, 10.8% (91/846); 1 year, 10.9% (75/688); and 3 years, 15.0% (43/286). The natural history of poststroke FI was observed at each of the 4 time points. Of the 317 patients with FI at 7 to 10 days, 113 (36%) had died before the 3-month follow-up, 48 (15%) were still incontinent, and 95 (30%) were continent (data unavailable in 60). Of the 752 patients who were continent at 7 to 10 days, 32 (4%) had died before the 3-month follow-up, 563 (75%) were still continent, and 21 (3%) had become incontinent. Because of unavailable bowel continence data at 7 to 10 days, an additional 22 patients reported FI at 3 months, making a total of 91 patients with FI 3 months after stroke. Of those 91 patients, 18 (20%) had died at the 1-year follow-up, 21 (23%) were still incontinent, and 32 (35%) were continent. Of the 772 continent patients at 3 months, 59 (8%) had died at 1 year, 539 (70%) remained continent, and 47 (6%) had become incontinent. Of the 43 patients incontinent at 3 years, 67% (29/43) had been continent at 1 year. Moreover, FI resolved in only 3 individuals between years 1 and 3.
Associations of New-Onset FI in 3-Month Stroke Survivors
The unadjusted bivariate associations with FI in 3-month stroke survivors and demographic characteristics are shown in Table 1. Age 80 years and beyond was associated, whereas sex and ethnicity showed no clear relationship.
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Table 2 shows bivariate associations between FI and acute stroke characteristics, adjusted for age, sex, and ethnicity. Regarding stroke diagnosis, 3-month survivors with total anterior circulation infarcts were more likely to be incontinent than those with partial anterior circulation, posterior circulation, or lacunar type strokes. Cerebral or subarachnoid hemorrhage versus infarction showed no association. All markers of stroke severity (impaired conscious level, initial UI, visual field defect, dysphasia, neglect, and dysphagia) were associated with poststroke FI. No relationship was observed, however, with stroke risk factors.
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Table 3 shows bivariate associations between clinical, functional, and psychosocial characteristics at 3 months and poststroke FI at 3 month, adjusted for age, sex, and ethnicity. As expected, the strongest association was with UI at 3 months—only 7 (8%) patients with FI did not report double incontinence. Because of this association and the obvious interaction with initial UI, this variable was not included in the final model. Several markers of dependence were associated with FI, including long-term care placement; still being in hospital; impaired cognition; needing assistance in using the toilet, transferring, walking and climbing stairs; and having district nurse visits. Clinically, the use of anticholinergic and nonsteroidal anti-inflammatory drugs increased the risk of fecal incontinence. Patients with FI after stroke were more likely to be in long-term care (odds ratio, [OR] 8.7; 95% CI, 4.8 to 15.6, P<0.05) and to receive district nurse services (OR, 1.8; 95% CI, 1.0 to 3.2, P=0.06) than continent patients but were equally likely to report or not report poor general health perception or lack of support from friends and family.
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Table 4 shows that when the acute stroke characteristics were adjusted along with age, sex, and ethnicity in a multiple regression model, only initial UI and visual and/or sensory neglect remained associated with FI at 3 months. After further adjustment for significant clinical and functional variables at 3 months, however, even these acute stroke factors were no longer associated. The strongest independent risk factor for FI at 3 months after stroke was needing help to use the toilet. Use of anticholinergic drugs was also independently associated.
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Discussion |
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This is the first community-based study to examine the prevalence, natural history, outcomes, and associations of new-onset FI in stroke survivors.
The prevalence of new-onset poststroke FI in this study was 30% at 7 to 10 days, 11% at 3 months, 11% at 1 year, and 15% at 3 years. Previous prevalence studies have included in their poststroke analysis individuals with preexisting FI.1,2,6 According to that definition, Brocklehurst et al2 observed FI in 23% of patients immediately after stroke (31/135), in 16% at 2 weeks, and in 8% (7/92) at 1 year. The Copenhagen Stroke study documented FI in 40% of 935 stroke patients on hospital admission, in 18% at hospital discharge, and in 9% at 6 months.1 Our study confirms that the prevalence of this distressing condition is high in stroke survivors living at home but importantly also shows that FI in this population can be transient rather than always being persistent and chronic. In a significant proportion of patients, FI developed in the recuperative rather than the acute phase after stroke (62% of patients incontinent at 1 year had become so over the preceding 9 months). Similarly, in Brocklehurst’s study, 14% of fecally incontinent patients became so >8 weeks after stroke.2 Conversely, 35% of our patients incontinent at 3 months regained continence at the 1-year time point. These findings suggest the presence of reversible underlying causes for poststroke FI and have important implications for prevention of the condition.
This study examined such potentially modifiable causes and after adjustment for several relevant factors, found that needing help to use the toilet was the strongest risk factor for new-onset FI at 3 months after stroke. Stroke survivors needing help with toilet access had a >3-fold risk of FI (adjusted OR, 3.49; 95% CI, 1.4 to 17.3). This functional risk factor should be regarded as potentially reversible; longitudinal studies of community-based stroke populations show that between 3 months and 1 year, the rate of dependence in at least 1 activity of daily living (ADL) can fall from 37% to 27%.12 Impaired ADL function from any cause in older persons is influenced by treatable factors such as nutritional status, vision and hearing impairment, pain, anxiety, and depression.13,14 In stroke patients specifically, treatment of depression during the first 2 years after stroke has been shown to enhance recovery of ADL functions.15 Poor mobility is a known independent risk factor for FI in elderly persons,16,17 although mobility is only 1 aspect of needing help to use the toilet. Other contributory factors in stroke patients include impaired dexterity, vision, sensation, communication, cognition, and affect. Mobility and dexterity can of course be directly impacted by physical and occupational therapy and intercurrent illnesses, by medical intervention.
Use of anticholinergic medications (including antipsychotics, tricyclic antidepressants, oxybutynin, or antiemetics) significantly increased the risk of FI in stroke survivors. Use of these medications predispose toward constipation18,19 by reducing contractility of the smooth muscle of the gut by an antimuscarinic effect at acetylcholine receptor sites; in some cases, long-term use may induce chronic colonic dysmotility.18–20 Constipation may lead to impaction and overflow incontinence in vulnerable people, such as stroke patients,21,22 and as an underlying cause may contribute to the observed later onset and fluctuating course of FI. Overflow incontinence is a treatable, preventable, yet often overlooked condition in older people and in those with neurological diseases.21–23 Stroke patients are susceptible to constipation for both physiological and clinical reasons. A study of lower-gut function in hemispheric stroke patients demonstrated a diffuse pattern of delayed colonic transit compatible with slow-transit constipation.24 Common clinical risk factors for constipation in stroke patients include impaired mobility,18,25,26 dehydration,27–29 polypharmacy,27 and dietary factors.28 Difficult toilet access, as identified in the present study, will also predispose individuals to rectal impaction,21,28,30 a condition associated with continuous leakage of stool-stained mucus. Good practice would dictate that stroke patients presenting with FI should invariably be evaluated for the presence of constipation with overflow.
Other risk factor studies have included patients with preexisting FI in their analysis and have mostly examined associations with initial FI.1,2 On these terms, the Copenhagen Stroke Study found that initial FI was independently associated with age, diabetes, lesion size, other disabling disease, and stroke severity (Scandinavian Stroke Scale score).1 Brocklehurst et al2 described unadjusted associations between initial FI and impaired mobility, diminished consciousness, and bilateral extensor plantars. For comparison purposes, we examined independent associations of new-onset initial FI (n=317) and found associations with UI; Glasgow Coma Score <15; visual field defect; dysphagia; and age 65 and over (Table 5). These data show that stroke severity indicators, particularly altered consciousness, are significant risk factors for acute-phase FI. However, stroke severity was not associated with FI at 3 months, when the only related acute stroke factors were initial UI and visual/sensory neglect. However, even these factors were no longer statistically significant after adjustment for 3-month clinical and functional characteristics, implying that their link to FI is more as an indicator of impaired ability to use the toilet (whether through communication or physical difficulties) rather than as a marker of specific neurological deficits such as stroke location or size.31 Our findings would therefore suggest that stroke-related factors do not independently affect bowel continence in longer-term stroke survivors but rather exert influence through associations with other clinical and functional factors.
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Although it is known that initial poststroke FI coexists with UI in 80% to 98% of cases,1,31 the present study shows that UI remains very strongly associated with FI at later stages after stroke. A partial explanation may lie in shared risk factors for persistent UI; studies show that similar mobility difficulty and impaired function are primary associations rather than stroke-specific factors.2,31–34 In fact, urodynamic studies in incontinent stroke survivors show a similar diagnostic profile to that of incontinent patients without stroke,32 with detrusor dysfunction predominating.33 The few data available on anorectal function after stroke suggests that likewise there may be no specific pathophysiology underlying FI in stroke survivors.24 The prevalence is not dissimilar either; new-onset UI affects 40% of patients immediately after stroke, with 19% still incontinent at 3 months and 15% at 2 years.35 A previous publication-based study on SLSR data found independent associations of new-onset UI at 3 months to be age >75 years, motor weakness, dysphagia, and visual field defect.35
In the acute phase of stroke, initial UI is a strong predictor of 6-month mortality,1 severe disability, and institutionalization among stroke survivors.1,31,35,36 Our findings suggest that FI is also linked with mortality, in that 36% of patients with initial FI compared with 4% of continent patients had died at 3 months after stroke, and 20% of 3-month survivors with FI versus 8% of those continent at 3 months had died by 1 year. Likewise, in the Copenhagen Stroke Study, of patients with full FI, 53% had died by discharge compared with 24% of those with partial FI and 3% of continent patients.1 At 6 months, 63% of initially incontinent patients had died compared with 7% who were initially continent.1
This study also provided some indication of the impact of FI on other adverse outcomes. Incontinent patients were more likely to be in long-term care (28% versus 6%, P<0.001) and to receive district nurse services (20% versus 11%, P=0.019) than continent patients at 3 months, which suggests that FI in stroke survivors may increase the risk of institutionalization and the need for nursing support in the community. These findings also have health and social care cost implications. FI takes its toll on care givers, surpassing even dementia as a leading reason for requesting nursing home placement. Interestingly, incontinent patients were no more likely to report poor general health perception or lack of support from friends and family in this study. This psychological tolerance of bowel dysfunction by people with chronic neurological conditions has previously been observed in spinal cord patients,37 but the psychosocial impact of FI on stroke survivors and their care givers certainly merits further investigation.
Another clinical implication from this study is that health care providers should be alert to case-finding FI in stroke survivors living at home, as onset may occur some time after the acute event. Older individuals with FI will often not volunteer the problem to their general practitioner,38 and regrettably, doctors and nurses do not routinely inquire about the symptom. In stroke patients, this ‘hidden problem" can lead to worsening social isolation, dependence, and poor health, particularly as their preexisting disability restricts their access to primary care.
One limitation to this study is that information on relevant clinical factors such as tube feeding, diarrhea, constipation, and diet were not available. Furthermore, in looking at the natural history of FI, we had no knowledge of relevant interventions that may have influenced it. An inherent shortcoming of nonrandomized study analysis is the inability to adjust for all possible confounders. Our definition of FI was the Barthel Index subscore; although the Barthel Index has been validated as a comprehensive tool, the specific validity of the bowel continence component has not been established. In support of these data, however, a recently published UK community study of self-reported FI in people aged 65 and older showed comparable prevalence rates to the 3% premorbid rate reported in our population.39 Furthermore, we were using the subscore to identify the presence or absence of the condition, rather than to measure severity of incontinence, and as such, it should be as reliable as comparable tools used in research literature such as the US Minimum Data Set.16 The final analytical model was conditional on including patients who were able to complete an MMSE; reasons for not completing the test were aphasia or patient too ill or too confused. We repeated the final logistic regression model after replacing the MMSE score at 3 months by a binary indicator for MMSE present and MMSE absent (for reasons listed above). There were no significant associations between MMSE response and outcomes. This implies that including patients with MMSE scores does not introduce bias in our outcomes analysis.
In conclusion, these results suggest that the potentially modifiable factors of using constipating drugs and of functional difficulties with toilet access are most strongly correlated with new-onset FI 3 months after stroke. Disability is a more important factor than age, sex, or stroke-specific factors in causing FI in longer-term stroke survivors. The clinical implications of our findings are that (1) case-finding FI in stroke survivors living at home should be included in routine practice and (2) treatable causes of FI, particularly functional difficulties and underlying constipation, should be sought. The conclusions from this study are that new-onset FI in stroke survivors is prevalent and is primarily an indirect consequence of cerebrovascular disease, emphasizing the importance of evaluating potentially modifiable causes for the condition in this population.
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Acknowledgments |
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Funding support was provided from Action Research, Northern and Yorkshire R&D Cardiovascular Diseases Programme, The Charitable Foundation of Guy’s and St Thomas’ Hospital, and The Stanley Thomas Johnson Foundation, Switzerland. We would like to thank all those participating in the South London Community Stroke Register project and all of the local general practitioners who have provided support for the project.
Received May 14, 2002; revision received July 12, 2002; accepted July 30, 2002.
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