title: A systematic review of etiological factors for postpartum fecal incontinence.
abstract: BACKGROUND
  Conflicting results are reported about the contribution of maternal, obstetric and fetal characteristics to postpartum fecal incontinence (FI), which is hampering prevention and management of FI.
  
  
  OBJECTIVE
  To perform a systematic review identifying delivery-related etiological factors for postpartum FI. Search strategy. Literature searches of PubMed, EMBASE, CINAHL, DocOnline and reference lists from 1980 up to 2009 were conducted. Selection criteria. Prospective cohort studies evaluating maternal, obstetric or fetal risk factors for postpartum FI, with a follow-up period of at least three months, were assessed. We reviewed full reports in English, German or Dutch, with anal incontinence (AI), FI, flatus incontinence, soiling, urgency and FI severity scores as reported outcomes. Data collection and analysis. Data on study characteristics, methodological quality and outcome were extracted from 31 studies according to a standardized protocol. Clinical and methodological sources of heterogeneity permitted only a qualitative analysis.
  
  
  RESULTS
  A third- or fourth-degree sphincter rupture was the only etiological factor strongly (AI) or moderately (flatus incontinence) associated with postpartum FI. No association with other postulated risk factors was found, for example, birth weight or instrumental delivery. The potential co-existence of different risk factors impedes the interpretation of the influence of a single delivery-related risk factor.
  
  
  CONCLUSIONS
  This systematic review, including only longitudinal studies and recognizing the importance of separating results for different outcomes, identifies that a third- or fourth-degree sphincter rupture is the only factor that is strongly (AI) or moderately (flatus incontinence) associated with postpartum FI.
authors.affiliation: Department of Epidemiology, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands. emj.bols@epid.unimaas.nl
authors.forename: Esther M J
authors.initials: EM
authors.lastname: Bols
authors.forename: Erik J M
authors.initials: EJ
authors.lastname: Hendriks
authors.forename: Bary C M
authors.initials: BC
authors.lastname: Berghmans
authors.forename: Cor G M I
authors.initials: CG
authors.lastname: Baeten
authors.forename: Jan G
authors.initials: JG
authors.lastname: Nijhuis
authors.forename: Rob A
authors.initials: RA
authors.lastname: de Bie
mesh_terms: D001003:Anal Canal / Q000293:injuries*; D036861:Delivery, Obstetric / Q000009:adverse effects*; D005242:Fecal Incontinence / Q000209:etiology*; D005260:Female; D005414:Flatulence; D006801:Humans; D049590:Postpartum Period; D011247:Pregnancy; D011644:Puerperal Disorders / Q000209:etiology*; D012307:Risk Factors; D012421:Rupture / Q000209:etiology