Faecal incontinence in North Queensland

Faecal incontinence, the uncontrolled loss of liquid or solid stool, can have a profound, negative effect on a person's quality of life, including their social and economic status. Up to 15% of metropolitan community residing adults and over 50% per cent of those in residential aged care suffer with the condition. The prevalence of faecal incontinence rises with age and by 2047 one quarter of the Australian population will be over 65 raising serious concerns with regard to continence management. The overall aim of the research contained in this thesis is to expand the evidence base of faecal incontinence in regional and rural Australia, specifically conducting epidemiological and clinical research in order to direct health policy and practice. This thesis describes six studies that explored several important areas of clinical and public health relevance: disclosure of faecal incontinence - comparative study on two tools in a clinical setting; prevalence of faecal incontinence in the population - cross-sectional postal survey of northern Queensland community residing adults; quality of life of patients with faecal incontinence - survey of clinical patients; two randomised clinical trials investigating anorectal biofeedback – a comparative study of exercise regimen and another comparing the standard anorectal biofeedback program with / without supplementary self-managed home biofeedback; and the impact of relaxation breathing on anal pressure - an observational study of biofeedback patients. The overall aim of this body of work was to expand the evidence base of faecal incontinence in regional and rural Australia. The research setting was Northern Queensland and the people with faecal incontinence who live and work in this regional, rural and remote part of Australia. Disclosure of faecal incontinence Adult patients attending the urogynaecology and colorectal outpatient clinics at the Townsville Hospital in 2003/4 were invited to complete a self-administered faecal incontinence questionnaire and answer faecal incontinence questions asked by their treating doctor. There was a substantial difference in disclosure using the two measurement instruments. The discordance was predominantly due to issues of definition, understanding, terminology and embarrassment. Once adjusted for the measurement differences, the prevalence was 26.0% (95% CI, 20.9%– 31.1%), which confirmed findings from an earlier survey in a similar population. Other findings included: • Routine patient consultations with general practitioners should include faecal incontinence questions for those with risk factors • A more specific definition which excludes historical data and isolated instances of diarrhoea due to acute illness is desirable • A measurement instrument suitable for population surveys should contain simple language and acknowledge issues of embarrassment. Prevalence Faecal incontinence was defined as accidental leakage of solid or liquid stool in the previous twelve months which was not caused by a virus, medication or contaminated food. A bowel habit survey was mailed to 3620 private listings compiled from the 2006/7 Cairns and Townsville telephone directories. A response rate of 48.1% from 1523 responses was achieved. This region is particularly mobile which may explain the low response rate. Of the northern Queensland adult community members surveyed 12.7% reported faecal incontinence. This rate increased with age for men; overall there were no gender or locality differences. When soiling with flatus and urgency were included, stool related accidental bowel leakage was substantially higher at 18.2%. Using the broader definition of accidental stool leakage that did not exclude faecal incontinence resulting from an acute illness, the prevalence was 28.1%, the highest reported in Australia. Quality of life The quality of life of more than 22% of study participants who attended the urogynaecology and colorectal outpatient clinics at the Townsville Hospital in 2003 and 2004 for matters other than faecal incontinence was severely affected by faecal incontinence. Colorectal clinic participants had poorer quality of life than those attending the urogynaecology clinic. The negative impact on participants' lives worsened with the loss of both solid and liquid stool and increased frequency and quantity of soiling. Biofeedback therapy Anorectal biofeedback is a conservative therapy for patients with mild to moderate faecal incontinence who have not responded to general practitioner prescribed advice. The aim of anorectal biofeedback is to enable patients to identify, contract, and relax the anal sphincter and pelvic floor muscles which support the abdominal contents against gravity and help maintain urinary and faecal continence. A balloon is positioned in the rectal vault and inflated until the patient registers its presence. A catheter with a pressure transducer placed in the patient's anal canal measures pelvic floor muscle activity converting anal pressure readings to a display screen for immediate visual feedback. Exercises: A randomised study compared an untested exercise regimen of sustained plus rapid exercises with the standard exercise regimen of sustained exercises at the Townsville Hospital Anorectal Physiology Clinic. This study was in response to demands for randomised clinical trials investigating anal sphincter and pelvic floor exercises. Seventy-two participants attended clinic sessions once weekly for four weeks followed by four weeks of home practice and a follow-up assessment session. A postal survey was conducted two years later. No significant differences were found between the two exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality of life, or faecal incontinence severity measures. Compliant participants had better outcomes than those who practiced fewer exercises. Eighty six per cent of participants reported improved continence and incontinence severity decreased significantly. Results were sustained two years later. Location: Regional participants lived a median distance of 8km from the clinic, while rural participants travelled up to 903km to attend clinic sessions. Risk factors for faecal incontinence were similar for rural and regional participants, although rural participants reported poorer general health and their symptoms affected their lifestyle more negatively. Initially improvement in rural participants' outcomes was marginally better than those of regional participants. However two years later, severity and quality of life continued to improve among regional participants, but rural participants had regressed to pre-treatment levels. An additional follow-up session with the biofeedback therapist, ongoing local support by continence advisors or a telephone helpline, newsletter, or webpage should be investigated for rural patients to help maintain similar longterm improvement in continence and quality of life to regional participants.