WebMD Medical News
Louise Chang, MD
Dec. 12, 2007 -- A routine procedure performed on up to 1 million American
women per year may be needlessly contributing to incontinence in those women,
an expert panel concluded Wednesday.
The procedure, known as episiotomy, involves cutting tissue between the
lower vagina and the anus when women are in childbirth. While it is often used
to aide delivery in cases of fetal distress or complicated childbirth, its use
in routine births should be curtailed, the experts say.
"The routine use of this procedure should be seriously
reconsidered," says C. Seth Landefeld, who led an expert consensus panel on
fecal and urinary incontinence sponsored by the National Institutes of
The procedure runs the risk of damaging the anal muscles, which in turn may
cause up to 1,000 cases of fecal incontinence per year, says Katherine
Hartmann, MD, PhD, deputy director of the Institute for Medicine and Public
Health at Vanderbilt University Medical Center.
"It has a proven risk of damage," Hartmann says. "The connection
is a pretty direct link."
Incontinence is the catch-all term for the involuntary loss of urine or
stool. The risk of fecal and urinary incontinence increase with age; they are
more common in women than men.
But both sexes are affected: It is estimated 5% of adults 65 to 74 and 20%
of those over 85 experience fecal incontinence. One in five women and one in 20
men are estimated to suffer urinary incontinence by the time they're 45,
according to the report.
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While the problem is widespread, it is vastly undertreated, the panel
"The shame, embarrassment, and stigma associated with these conditions
pose significant barriers to seeking professional treatment, resulting in many
persons who suffer from these conditions [going] without help," the report
In addition, most health plans don't pay doctors to do an independent
evaluation for incontinence or counsel on weight
loss, exercise, or specialized pelvic floor exercises that may help prevent
it, says Landefeld, who directs the Center on Aging at the University of
California, San Francisco.
And while articles in women's magazines often include suggestions for women
to perform Kegel exercises to strengthen the pelvic floor muscles, experts say
those exercises are frequently done incorrectly.
They urge more formal training for women to teach them how to isolate the
pelvic floor muscles in a way that can be effective against urinary
"Many women and men and many practitioners don't have a good idea of
what the pelvic floor is," says Eileen Hoffman, MD, an associate professor
of medicine at New York University. "You have muscles down there that if
you don't have tone in [them], you're much more likely to have
A high proportion of incontinence cases occur in nursing homes, according to
the report. But instead of physical problems, many cases occur simply because
elderly residents don't get to the bathroom in time.
The panel urged new policies that increase staffing at nursing homes so that
residents don't sit, sometimes for hours, needing to use the toilet.
"That is probably more expensive then just letting them sit there in
diapers," Landefeld says.
SOURCES: National Institutes of Health State-of-the-Science
Conference: Prevention of Fecal and Urinary Incontinence in Adults. C.
Seth Landefeld, director, Center on Aging, University of California, San
Francisco. Katherine Hartmann, MD, PhD, deputy director, Institute for Medicine
and Public Health, Vanderbilt University Medical Center. Eileen Hoffman, MD,
associate professor of medicine, New York University.
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