Stroke and Cerebrovascular Disease

Fecal incontinence is a common complication after stroke and affects about 30-40% of patients in the acute phase and 11% at 3 and 12 months [16-18]. The occurrence of bowel and urinary symptoms is related to the size of vascular lesion; in particular, fecal incontinence is associated with the severity of the stroke [18]. Large ischemic frontoparietotemporal lesions can induce a higher incidence of urinary and bowel symptoms than can frontal injury alone. In the Copenhagen Stroke Study, patients with fecal incontinence in the first week after stroke were significantly more frequently women and more often had a history of former stroke comorbidity of other disabling diseases than patients without fecal incontinence [18]. The same study reported that lesions in patients with fecal incontinence were significantly more often due to a hemorrhage, were larger in size, and more often involved the cerebral cortex than those in patients without fecal incontinence. Patients with fecal incontinence also had significantly lower scores on the initial Barthel Index and Scandinavian Stroke Scale (SSS) [19].

Age, diabetes mellitus, severity of stroke (initial SSS score and diameter of lesion) and comorbidity of other disabling disease are significant risk factors for fecal incontinence [18]. Urinary and fecal incontinence appear to be a powerful indicator for poor prognosis in ischemic stroke [20]. Patients who develop fecal incontinence have a higher risk of death within 6 months compared with those who remain continent; furthermore, severe disability and institutionalization frequently occur among stroke survivors [18, 21-23]. Fecal incontinence is also linked with mortality. Harari et al. have shown that 36% of patients with initial fecal incontinence compared with 4% of continent patients had died at 3 months after stroke and 20% of 3-month survivors with fecal incontinence versus 8% of those continent at 3 months had died by 1 year [16].

Functional urinary and bowel disorders can result from a large cortical hemispheric lesion that interrupts the central, frontally dependent pathways for urinary and bowel storage and voiding [24]. In the acute phase of the illness, 30-40% of large ischemic stroke patients develop fecal incontinence within 2 weeks; however, this symptom tends to improve along with neurological signs. After a 6-month follow-up, between 3% and 9% of patients remain incontinent [25].

Harari et al. [16] have also provided some indication of the impact of fecal incontinence on other adverse outcomes. Incontinent patients were more likely to be in long-term care (28% vs. 6%) and to receive district nurse services (20% vs. 11%) than continent patients at 3 months. This suggests that fecal incontinence in stroke survivors may increase the risk of institutionalization and the need for nursing support in the community. It is presumed that incontinence is a predicting factor for poor prognosis for different reasons: the same lesion might cause neurogenic bowel and bladder dysfunction in addition to cognitive or motor impairment; moreover, fecal and urinary incontinence may induce marked psychological problems that hamper functional recovery.

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