Treatment Options For Fecal Incontinence
By Tracy Hull, MD
The ability to control gas and stool is a body function most people take for granted. While not life threatening, the uncontrolled loss of fecal matter (termed fecal incontinence) can be humiliating and lead to isolation and depression. Those affected may have to alter their lifestyle profoundly. For instance, going to the grocery store may require eating nothing the day prior to avoid a bowel "accident." Patients avoiding discussions with their health care provider due to shame and embarrassment compound the problem. Individuals should not assume that their healthcare provider would inquire about their bowel control. Doctors and nurse practitioners do not know to address this matter with their patients if the problem has never been made aware to them.
Over the past two decades heightened education, for both patients and healthcare providers, has slowly improved awareness regarding fecal incontinence (FI). One of the initial hurdles is the difficulty in obtaining an accurate estimate of the prevalence of FI as there is no universally accepted definition. The true prevalence has been reported to range from 2-24%. Women outnumber men, but contrary to some reports men are also affected. Older individuals suffer more than younger people. With our aging population, the problem will continue to come to gain importance. One study found 45% of older people living in a geriatric residential community or nursing home had some degree of FI. Additionally, fecal and urinary incontinence have been reported to be the most common reasons for individuals to be placed in a nursing home, based on some studies
One of the most common causes of FI (in women) is an anal muscle injury during childbirth. Another cause is constipation or fecal impaction. This can happen due to the medications a person is taking. Preexisting diseases and disorders can cause problems with the bowels. Some examples are Crohn's disease, ulcerative colitis, and irritable bowel syndrome. Additionally, radiation treatment to the pelvis, a traumatic injury to the anal sphincter muscles, a birth defect involving the anal muscles, or nerve injury can lead to bowel control problems. However, many patients who develop FI have no obvious cause.
Fortunately, as awareness has improved, progress has been made in helping people suffering from this disorder. Usually, it cannot be "cured" but the impact it has on daily quality of life can be greatly improved. An in-depth discussion with a caring health provider is the initial step. It allows for an open discussion of the exact symptoms, frequency, factors, which make the problem worse, and a plan for treatment. Sometimes other tests are ordered to plan treatment. This could include an ultrasound of the anal muscles. Just like a doctor can obtain an ultrasound of a baby in the womb or a gall bladder, the anal muscles can be imaged to look for an injury or abnormality.
Treatment usually begins with nonsurgical therapy. Sometimes changes in the diet along with medications that make stool thicker can dramatically improve bowel control. Physical therapy, with muscle retraining, may be recommended. These techniques are taught by a therapist who has had specialized training related to anal sphincter muscles with the goal to improve sensation and anal muscle strength.
There are multiple surgical treatments available. The choice is individualized and based on the cause of the FI. When feasible, simply repairing the damaged anal muscle is one option. Another treatment is implanting a silicone device under the skin, which wraps around the anal sphincter and is connected to a pump that is also implanted under the skin. This device is called an artificial bowel sphincter. The component that is wrapped around the anus looks like a balloon filled with fluid that puts pressure on the anal muscle to compress and occlude the outlet. When the pump is compressed the fluid is drawn out of the anal portion to follow the balloon to deflate and stool is allowed to exit the body. Another treatment for mild FI is inserting a thin needle up to 32 times in the anal muscle (with local anesthetic) and applying heat which leads to changes in the content of the muscle fibers. This treatment is called the SECCA procedure and although the exact way it works is not clear, it has been shown to improve the degree of bowel control.
There are also many surgical treatments being studied and fine-tuned. On the horizon are materials that are injected in the anal muscle to improve the bulk and thickness of the muscle. One type of injectible treatment has recently been approved by the government (FDA) so doctors will be able to offer this therapy in the near future. Another anticipated treatment awaiting approval from the FDA is Sacral Nerve Stimulation (SNS). This therapy allows direct stimulation of the nerves that lead to the anal muscles to improve bowel control. It has already been approved for urinary control in the US. Results of SNS from countries outside the US have been very encouraging and specialists treating patients with FI are hopeful that it will be available in the near future as another treatment choice for appropriate patients.
Increased awareness and understanding of FI continues to reduce the negative social stigma associated with it. Hopefully this will lead to more patients speaking with their healthcare providers for treatment options. Healthcare providers must be sensitive to the devastating consequences FI can inflict on the patient. With the prevalence higher in older individuals, healthcare providers will also be confronted in the immediate future with more patients needing treatment. Continued research will provide new treatments to compliment the existing options.
About The Author:
Tracy Hull, MD, is on staff in the Department of Colon and Rectal Surgery at the Cleveland Clinic Foundation. She is also a Full Professor. Hull has authored, or co-authored, over 100 peer reviewed articles and 54 book chapters. She has a special interest in pelvic floor dysfunction, anorectal physiology and ultrasonography. Her other interset are colon and rectal cancer, ulcerative colitis, Crohn's disease and diverticulitis.
