Title : Real world outcomes in fecal incontinence care: Effects of social determinants of health, hormonal therapy, dyssynergic defecation, and treatment engagement
Abstract:
Background & Aims: Fecal incontinence (FI) is a common and debilitating pelvic floor disorder that disproportionately affects women and frequently coexists with other anorectal dysfunctions. Although dyssynergic defecation (DD) is traditionally associated with constipation, its prevalence and clinical significance among women presenting with FI remain poorly characterized. Additionally, the influence of menopausal hormone therapy (HRT) and social determinants of health on pelvic floor physiology, treatment engagement, and outcomes is not well understood. We aimed to characterize anorectal physiologic findings, patterns of pelvic floor therapy utilization, and factors associated with treatment outcomes among women with FI in a large urban safety-net healthcare system.
Methods: We performed a retrospective review of female-identifying patients who underwent anorectal manometry (ARM) for evaluation of FI between January 2018 and December 2025. Demographic, clinical, physiologic, treatment, and social vulnerability data were collected from electronic medical records. Outcomes included ARM findings, engagement with pelvic floor therapy (PFT), treatment completion, symptom improvement, and loss to follow-up. Associations between hormone therapy use, anorectal physiology, and treatment outcomes were evaluated using univariable and multivariable analyses.
Results: Seventy-six women underwent ARM for FI evaluation. Mean age was 55 years, 46.1% identified as Hispanic, and 80% were postmenopausal. Social vulnerability was substantial, with a mean Social Vulnerability Index of 0.88; 70.3% lived in low-income areas and 48.6% resided in food deserts. ARM demonstrated a high prevalence of pelvic floor dysfunction: 81.6% of patients exhibited DD, while only 18.4% demonstrated normal defecatory mechanics. Type III dyssynergia was the most common subtype.
Engagement with evidence-based pelvic floor therapy was limited. Although 56.6% of referred patients attended at least two therapy sessions, only 28.9% completed all prescribed treatment. Patients who attended at least two sessions were significantly more likely to complete therapy (p=0.03). Greater social vulnerability was associated with lower rates of treatment engagement, increased loss to follow-up, and reduced symptom improvement, although these trends did not reach statistical significance.
Among postmenopausal women, vaginal estrogen use was associated with longer anal sphincter length compared with no hormone therapy (p=0.025), whereas systemic HRT showed no significant association with sphincter length. These findings complement broader population-level data demonstrating increased diagnostic identification of DD and greater utilization of anorectal physiologic testing and pelvic floor biofeedback among postmenopausal women receiving systemic HRT.
Conclusions: Women with FI in a safety-net healthcare setting demonstrate a high prevalence of underlying dyssynergic defecation and substantial social vulnerability. Despite the effectiveness of pelvic floor rehabilitation, treatment engagement and completion remain low, suggesting that structural and access-related barriers significantly influence outcomes. The association between vaginal estrogen use and increased anal sphincter length, together with the observed relationship between HRT exposure and DD-related care utilization, highlights the need for further investigation into hormonal influences on pelvic floor function. Interventions aimed at improving early therapy engagement and reducing social barriers may improve treatment completion and clinical outcomes among vulnerable populations.
