Study design, materials and methods
It was an analytical, population-based, observational, cross-sectional study that involved women over 60 years of age who were selected through multistage cluster sampling and random draw enrolled in primary health care unit (PHCU) of a specific county, assisted by Community Health Agents (CHA) who belong to the Community Health Agents Program (CHAP) and the Family Health Program (FHP).
The studied population consists of 30.530 people aged over 60 years. Of these, 16.905 (55.4%) are the female population. The city has 465 Community Health Agents (ACS), that cover 84.74% of the population. The sample size was calculated based on a 95% confidence level and a margin of error of 5 %. Then, at least 376 elderly women were necessary.
The selection process was determined through multi-stage cluster sampling, which involved a sequence of stages of random draws from PHCU. The first stage consisted of the random selection of 20 of the 40 PCHU that having a CHAP or FHP. In the second stage, one CHA from each drawn PHCU was randomly selected. In the third stage, each CHA was responsible for visiting 15 elderly women. When the sample size of the specific area exceeded 15 subjects, another CHA was drawn. In case of refusal or exclusion of the volunteer, a new draw was performed. The inclusion criteria were women living in households served by CHA, able to perform the Valsalva maneuver and able to sign the informed consent form. Patients with hearing, verbal, cognitive/mental impairments or neurological conditions that could compromise the interview and complete the questionnaire were excluded as well as women unable to tolerate the physical examination or with a history of pelvic cancer
The FIGO assessment scoring system (FASS) was used to evaluate the bowel symptoms and presence of pelvic organ prolapse. The assessment of the pelvic floor muscle strength was performed using the modified Oxford scale. Physical activity was defined as the performance of physical exercise at least three times a week for a period of not less than one hour.
The chi-square test was used to investigate proportional differences in the prevalence of bowel symptoms based on sociodemographic and clinical variables. Binary logistic regression, including adjusted analysis, was used to evaluate the associations of sociodemographic and clinical variables with the presence of symptoms. For modeling the regression analysis, only the variables that presented a significance level equal to or less than 0.20 in the chi-square test were considered for association with the presence of symptoms of pelvic floor dysfunction. The fit of the model was verified using the Hosmer-Lemeshow test. A significance level of p<0.05 was considered. Data were analyzed using SPSS 22.0 version.
Results
A total of 399 elderly women participated in the study, aged 60 to 93 years-old (68.64 ± 6.65). A high percentage (70.2%) of the elderly women studied had at least one symptom related to pelvic floor dysfunction (PAD). Bowel symptoms were reported by one third of the elderly women, with difficulty in emptying being the most prevalent symptom (90%). However, most of them did not report discomfort (table 1). Initially the presence of bowel symptoms was associated to race, scholarity, physical activity, body mass index (BMI), number of vaginal deliveries, pelvic surgery, and previous hysterectomy (p<0.2). The prevalence analysis of bowel symptoms with the sociodemographic and clinical variables of elderly women using the adjusted regression model demonstrated that the physical activity routine was associated to better bowel emptying but also with anal incontinence. A greater number of vaginal deliveries was also a protective factor for emptying difficulties, but a previous history of abdominal hysterectomy and the presence of obesity were associated with worsening of bowel emptying. The perception of discomfort was proportional to the presence of intestinal symptoms (table 2).
Interpretation of results
The FASS, used in present study, defines anal incontinence (AI) as loss of gas, liquid or solid stools and difficulty in emptying as a feeling of incomplete emptying and/or the need to digitation. In this way, 11% of the elderly women surveyed reported symptoms of anal incontinence. The literature indicates that chronic constipation can trigger fecal incontinence in these women, leading to an increase in the prevalence (1). Physical activity may also cause fecal incontinence in younger women (18 and 40 years old), where 14.8% of them who practiced sports for more than 8 hours per week reported incontinence, compared to only 4.9% of less active women (2).
Obesity was also associated with difficulties in bowel emptying, corroborating with other studies who demonstrated an association of BMI with constipation and fecal incontinence. This finding might be justified by the fact that obese women have an abnormal stool consistency (3). Vaginal deliveries had a protective factor for emptying difficulties, despite of obstetric injuries can cause a sphincter rupture in up to 8% of vaginal deliveries or a delivery with forceps can increase this percentage to 35%. Another significant finding was that the previous hysterectomy had a positive association with anal incontinence, suggesting that pelvic floor dysfunctions can also be associated in these cases.