Combined Treatment of Urinary and Fecal Incontinence
By Catherine Matthews, MD
Originally appeared in the March, 2012 issue of Quality Care®
One can only imagine how troubling it would be for an adult to lose control over either bladder or bowel function. When both occur together, the condition is referred to as “double incontinence”. The consequences of this can be physically, personally and socially devastating. Women with double incontinence have been shown to suffer from more anxiety and depression compared to women with urinary incontinence alone. In the older population, incontinence of any type significantly increases the risk of nursing home admission; therefore aggressively managing the problem early is essential.
The positive view of this is that help from dedicated specialists is available. Physicians, who are pelvic floor specialists in female pelvic medicine and reconstructive surgery, such as urogynecologists and some urologists, are specifically trained to treat women with pelvic floor disorders. These disorders include people with urinary and/or bowel leakage in addition to those with prolapse of the vaginal tissues and pelvic organs. The willingness to seek help from one qualified provider who can comprehensively address overlapping problems with therapies that can target both problems is important, as these are “compartments” of the same “department. ”
Which interventions have been shown to benefit both bowel and bladder control? Conservative therapies include an intensive bowel evacuation regimen, pelvic floor physical therapy and biofeedback. A minimally invasive surgical intervention that may help some individuals is sacral nerve stimulation, InterStim®. Another option may be the technique of injecting non-absorable materials or bulking agents, like Solesta®, around the anus which may bulk the muscle and improve sensation. Before discussing therapies, however, it is important to briefly describe the components that contribute most to bowel continence.
Good bowel function depends in part on routine and regularity. When treating my patients, it is my goal that they have one bowel movement every morning before leaving their house. Bowels should then remain quiet the rest of the day. The complete evacuation of the bowel every morning in the privacy of their home allows patients to be maximally relaxed and close to a bathroom in which they are comfortable. Constipation is a risk factor for urgency associated urinary leakage. Therefore, getting all stool successfully evacuated helps to treat both rectal seepage and urinary leakage.
Normal bowel control depends on three variables: Bowel consistency (hard, soft, loose etc), bowel motility (how quickly stool is moving through the colon) and anal sphincter function (the muscle that helps hold stool back at the end of the rectum). Bowel consistency is very important. Stools should be formed “6-inch logs” that are not too hard or too soft. Mushy stools can be very difficult to control and small hard pellets of stool can be very difficult to completely evacuate. Normal motility is also important. If you have an overactive bowel, like irritable bowel, it can be very difficult to get to the toilet in time after getting the urge to move your bowels. Similarly, if your bowels are very sluggish you might have to strain and strain to get things out. The anal sphincter is the final important element. This muscle is frequently injured during childbirth. If you have an anal sphincter injury you might have difficulty with holding stool back once you get the urge to go. Also, you will not be able to control gas or liquid stool. Normal evacuation of the bowel relies on a good gastro-colic reflex. This reflex stimulates your bowels to work after eating something. If you have noticed, people tend to have a bowel movement after a meal.
In order to improve bowel control and/or evacuation, we need to make sure that bowel consistency and motility are normal. If we can optimize these elements, bowel control should be good even if a patient has an anal sphincter injury or other problems with the rectum. The goal again is to have one complete BM (6-inch logs) every morning (but then no more for the rest of the day). This can be accomplished with the following regimen:
- Before bedtime, mix one tablespoon of methyl cellulose (like Citrucel or Miralax) with three ounces of water or juice in a dixie cup and drink it like you are taking a shot of alcohol. Follow this with one eight-ounce glass of water.
- When you first get up the next morning, drink one cup of hot tea or coffee (may be decaffeinated)
- Do 10-15 minutes of some kind of exercise: For example, walking the dog around the block, jumping jacks or marching in place.
- Eat a high fiber cereal for breakfast such as hot oatmeal. DO NOT SKIP BREAKFAST.
- As soon as you get the urge to have a BM, go to the toilet. If you sit for longer than five minutes and nothing happens, get up and wait for another urge to come. DO NOT sit on the commode and strain.
- If after two weeks of using this regimen, bowels remain loose or mushy, one can add half of an Immodium tablet after the morning bowel movement is completed. This dose can slowly be increased with the help of your health care provider.
Pelvic floor physical therapy with biofeedback has been shown to improve double incontinence. The goal of this treatment is to strengthen the muscles in the pelvis that allow us to cut off the urine and bowel stream. It is difficult to exercise these muscles without initially getting help in knowing how to contract and relax them. If you think of the analogy of the physical therapist being like a trainer at a gym who shows you how to work all those complicated machines, you can understand his or her role. Typically, four to eight sessions is required to learn how to effectively perform the right exercises.
The newest intervention for double incontinence is sacral nerve stimulation (SNS). Sacral nerve stimulation has been on the market for a decade combatting urgency urinary incontinence and more recently has been approved for fecal incontinence. The idea behind this is if we can make the nerves work better that control the bladder and bowel, continence of both is improved. SNS requires the placement of electrodes into the sacral area of the spine and the implantation of a device that looks like a pacemaker. Temporary wires are placed in the office to see if a patient has enough benefit to want to proceed with a permanent implant.
Unfortunately, no medications are FDA approved for treatment of double incontinence at this time.
About The Author
Dr. Catherine A. Matthews is an Associate Professor and Division Chief of Urogynecology and Reconstructive Pelvic Surgery at the University of North Carolina, Chapel Hill. She received her medical degree from the University of Virginia where she served as president of the medical honor society, Alpha Omega Alpha, and graduated Valedictorian of her class. Dr. Matthews completed her residency and specialty training in Obstetrics and Gynecology and Urogynecology at Virginia Commonwealth University Medical Center where she served on the faculty from 2001-2010.
Voted into “Best doctors in America”, she has dedicated her career to improving the quality of life for women who suffer from the potentially embarrassing conditions of urinary and bowel incontinence and pelvic organ prolapse. Dr. Matthews is nationally and internationally recognized for her expertise in robotic surgery for pelvic floor reconstruction and the repair of complicated genito-urinary fistulae. She also has a particular interest in the management of sexual dysfunction in postpartum women, anal sphincter repair, and defecation disorders.