2015-05-08 20:29:09 UTC

Health-Care Burden and Costs of Constipation and Fecal Incontinence: The Silent Afflictions

May 6, 2015

Chronic constipation affects 1 in 6 Americans. How are you managing these patients?

Satish S. C. Rao, MD, PhD, FRCP, AGAF

Satish S. C. Rao, MD, PhD, FRCP, AGAF

Section of Gastroenterology/Hepatology, Department of Internal Medicine, Medical College of Georgia, Georgia Regents University, Augusta, GA

“Doctor, I feel tied to the bathroom, I spend hours and can’t get it out, life sucks.” Likewise, “Doctor I am afraid to go out, I don’t wear whites, I have stopped socializing, and I don’t eat out anymore for fear of soiling myself, nobody knows, it is most embarrassing.” Do these patient grievances sound familiar, have we all not heard this, and if so are we listening to these complaints? Are we attempting to find out “what and why” just as we do for a GI bleed or jaundice? Are we helping them, or are we wrapped up in our daily ritual of 15-minute consults and 20-minute procedures and just don’t have the time for these “nuisance symptoms”?

And who are these individuals, and what are they describing? Is this a rare phenomena? Certainly not, and you may be surprised to learn that chronic constipation affects one in six Americans. It is the third leading symptom prompting an outpatient clinic visit, and the fourth leading physician diagnosis for gastrointestinal disorders.1,2 Telephone interviews with 10,018 individuals gave an estimated prevalence of 14.7 percent.2 It disproportionately affects more women, and those who are overweight.2,3 Pregnancy is also associated with a higher prevalence of constipation. But, its prevalence has been underestimated, its natural history is unknown, and it may not resolve quickly, since 89 percent had similar symptoms one year apart, and 45 percent had symptoms for five years.2

Constipation affects daily life and resulted in 13.7 million days of restricted activity, also 12 percent missed work or school, and 60 percent had impaired ability to work.2 Also, it is associated with increased psychological distress, significant impairment of health-related quality of life, and poses a major health-care burden.3 The mean cost in 2010 per discharged patient was $17,518, and that increased several fold between 1997 and 2010.2 Also, expenditure for constipation was estimated at $235 million per year with 55 percent incurred from inpatient, 23 percent from emergency department and 22 percent from outpatient care. In almost 15,000 commercially insured patients in the U.S., mean annual all-cause costs for patients with chronic constipation were $11,991 (2010 USD).2

These numbers are merely the tip of the iceberg, as many patients do not seek health care or choose an alternative therapy or seek the “Internet doctor.” Surely, as gastroenterologists we can do better. Today, we should be able to identify patients with chronic constipation and differentiate their subtypes; slow transit constipation, dyssynergic defecation and constipation-predominant IBS. Also, the advent of high-resolution and high-definition anorectal manometry and wireless motility capsule tests have improved our diagnostic capabilities, and so have treatment options such as gut-targeted secretagogues and biofeedback therapy.2,4

And now, let’s discuss the equally distressing problem of stool leakage. Fecal incontinence is usually defined as the unintentional loss of solid or liquid stool, whereas flatus incontinence describes leakage of gas. Sadly, many individuals hide the problem from their families, friends and even doctors. Consequently, health-care providers have had difficulty in identifying those affected by fecal incontinence. Estimates of its prevalence range from 7 to 15 percent in community-dwelling women and 8 percent in men, and substantially higher among care-seeking populations, home-care populations and adults in long-term care setting.5

Although anal sphincter or neurological injury stemming from either obstetric trauma or pregnancy itself remains a leading cause, other significant risk factors include white race, depression, chronic diarrhea, urgency and urinary incontinence.4,5 But the inability to control what is regarded as a natural bodily process not only results in a loss of self-esteem and confidence but also leads many to become social recluses. When they gather courage to seek help, providers often fail to attribute sufficient importance to their symptom. Less than one third of patients with fecal incontinence had disclosed this problem to a provider, and only 17 percent with fecal incontinence were asked about the symptom when presenting for gynecologic care.5 Barriers include: a lack of understanding of the condition; embarrassment; the belief that fecal incontinence is a normal part of aging; unfamiliarity with whom to discuss this problem; priority of other medical conditions; and pessimism that there are no options or physicians can’t help. Also, the caregiver burden is significantly greater for fecal incontinence than for urinary incontinence as measured by hours of care, emotional distress and health deterioration in family caregivers.5

Another important consideration is the emotional consequences of fecal incontinence often exceed the physical manifestations. Fecal incontinence has a devastating impact on the quality of life, and this correlates with symptom severity. Consequently, the full cost burden of fecal incontinence is substantial. The total per patient annual estimated cost of providing care for this condition (2012 dollars) was higher in the U.S. ($4,111) compared to Netherlands ($3,521).5 Also, in the U.S., between 1998 and 2003, approximately 3,500 surgeries — predominantly overlapping anal sphincteroplasty — were performed annually for fecal incontinence with a total hospital cost of $34.1 million (adjusted to 2012 USD).5

These data are not mere statistics but speak volumes of these unvoiced problems and their consequences. Clearly, chronic constipation and fecal incontinence are not only common but also pose a major health-care burden and carry a significant impact both on the individual patient as well as on the society. I trust these hard facts and perspectives will resonate with you as you manage your next patient with these problems, and hope that you will strive to provide them with the best care possible.

Dr. Rao reports no conflict of interest for this report, but has served as a consultant for Forest Laboratories, Ironwood Pharmaceuticals, Takeda Pharmaceuticals, Salix Pharmaceuticals and Given Imaging.


1. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, Gangarosa LM, Thiny MT, Stizenberg K, Morgan DR, Ringel Y, Kim HP, Dibonaventura MD, Carroll CF, Allen JK, Cook SF, Sandler RS, Kappelman MD, Shaheen NJ. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012:143:1179-87.

2. Rao SSC, Camilleri MC. Approach to the patient with constipation. In: Principles of clinical gastroenterology, Yamada’s Textbook of Gastroenterology. 6th Edition. Publisher Wiley, Editors: Dr. Daniel Podolsky et al. 2015. (In Press).

3. Rao SS, Kinkade K, Schulze K, et al. Psychological profiles and quality of life differ in patients with dyssynergia and those with slow transit constipation. J Psychosom Res 2007;63:441.

4. Bharucha AE, Rao SSC. An update on anorectal disorders for gastroenterologists. Gastroenterology 2014;146:37-45.

5. Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of fecal incontinence: State of the Science Summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Workshop. Am J Gastroenterol 2015;110:127-136.

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