In Australia, about 15% of the population has faecal incontinence. Although men and women are affected in equal proportions, women tend to have a more severe form of the condition. In addition to this, as many as one third of women suffer from urinary incontinence. Although most of us accept continence as a natural part of life and indeed do not give any thought to the prospect of losing normal function, well over a third of the population has a significantly diminished quality of life as a result of incontinence.
Normal continence is maintained by the muscles of the pelvic floor. By far the most important factor leading to incontinence is childbirth. Vaginal delivery initiates a process of weakening of the pelvic floor muscles, both by directly stretching the muscles as well as by injury to the nerves that control the sphincter muscles. The muscles are weakened further after menopause and hence incontinence is particularly prevalent amongst older women, but also occurs in the young.
The management of incontinence has been improved over the past decade by new innovations in surgical as well as non-surgical treatments. Medications that modify the physiology of bladder and bowel function are often helpful. Biofeedback, a sophisticated type of physiotherapy, can help many patients with incontinence of moderate severity. Minor incontinence is often due to prolapse of the lower rectal lining into the anal canal and may be dealt with by simple rubber band ligation (as for most haemorrhoids). More significant disturbances of sphincter control require more sophisticated evaulation and management programmes.
New developments in surgical treatment include the placement of a plastic artificial sphincter around the bladder or rectal outlet. The sphincter can also be reconstructed using a muscle taken from the thigh, which is then controlled by a pacemaker placed under the skin. These treatment modalities involve quite extensive surgery and are costly, but are well received by some patients who have severe incontinence and do wish to have a colostomy bag. Although the results are not always successful, about two thirds of patients are significantly improved and will enjoy a substantially better quality of life when measured on objective Quality of Life (QOL) scales. Recently, a technique of attaching electrodes to the spinal nerves to stimulate the pelvic floor nerves has also been successfully used.
There are now several studies from Sweden, the USA, Holland, and Australia, which have attempted to estimate the community cost of incontinence. Using the available figures, which measure only medical costs and do not include the economic effects of time off work, or the psychological effects, the annual cost in Australia is in excess of 100 million dollars. Given that most studies report concern that their costs are under-estimated, this figure is likely to be conservative. In recognition of this, in 1999 the Federal Minister for Health and Aged Care allocated several million dollars to establish a national committee to address the problem.
In addition to incontinence, it is estimated that one third of all gynaecological operations are carried out for pelvic floor conditions directly attributable to childbirth. It is likely that this at least doubles the size of the economic burden mentioned above.
Efforts to improve continence in the community have focussed on the treatment of incontinence. Unfortunately, there has been little attention paid to the prevention of birth injuries, which constitute the most important causal factor in incontinence.
There has been much debate about safe birth options, but this has focussed almost exclusively on maternal and infant mortality. The debate about relative rates of Caesarean section and natural delivery, as well as the place of home births, has completely bypassed the effects of childbirth on the pelvic floor muscles and the consequences thereof. The 1998 Senate Report Inquiry “Rocking the Cradle – a Report into Childbirth Procedures” concluded that “Childbirth in Australia is safe for mothers and babies. Preventable adverse effects outcomes are rare and decreasing”. In NSW, the Shearman Report of 1989 examined obstetric services in NSW and made a number of wide-ranging recommendations about safe birthing. These reports into birthing have completely neglected pelvic floor injury.
Incontinence represents a major community problem that will only be improved by comprehensive research into the nature of birth injuries and the development of safer birthing methods, which prevent pelvic floor injuries. Efforts to move in this direction have thus far been lacking on the part of government and the medical profession. Well-designed studies with adequate research funding will be the only effective way of reducing the prevalence of a disabling condition that significantly reduces the quality of life of a large proportion of the adult population, with attendant high economic cost to the community.