Anal sphincter weakness
• Injury—obstetric trauma, related to surgical procedures, e.g., hemorrhoidectomy internal sphincterotomy, fistulotomy, anorectal infection
• Non-traumatic—scleroderma, internal sphincter thinning of unknown etiology
Neuropathy—stretch injury, obstetric trauma, diabetes mellitus
Anatomical Disturbances of Pelvic Floor—fistula, rectal prolapse, descending perineum syndrome
Inflammatory Conditions—Crohn’s disease, ulcerative colitis, radiation proctitis
Neurological diseases—dementia, stroke, brain tumors, spinal cord lesions, multiple system atrophy (Shy Drager’s syndrome), multiple sclerosis
Diarrhea—irritable bowel syndrome, post-cholecystectomy diarrhea
Other risk factors—obesity and smoking
Components of a comprehensive history in fecal incontinence
Elucidate whether a patient has FI
• Patients may not volunteer the symptom spontaneously
Onset, natural history and risk factors
• Relationship of symptom onset/deterioration to other risk factors may suggest etiology
• Natural history, e.g., recent symptomatic deterioration may reveal reason for seeking medical attention
Bowel habits and type of leakage
• Disordered bowel habits are critical to pathogenesis of FI
• FI for solid stool suggests more severe sphincter weakness than for liquid stool
• Management should be tailored to specific bowel disturbance
Degree of warning before FI
• Urge and passive FI are associated with more severe weakness of the external and internal anal sphincter, respectively
• Urge FI is associated with reduced rectal capacity and increased rectal sensation
• These rectal sensory disturbances are potentially amenable to biofeedback therapy
Diurnal variation in FI
• Nocturnal FI occurs uncommonly in idiopathic fecal FI, and is most frequently encountered in diabetes and scleroderma
Impact of fecal FI on quality of life
• Critical to ascertain severity of FI
Urinary FI – presence and type
• Association between urinary and fecal FI
• Same therapy (e.g., pelvic floor retraining) may be effective for both conditions
Evaluate possible causes of FI
• A careful characterization of bowel habits with a questionnaire or bowel diary is very useful
• The obstetric history must inquire specifically for known risk factors for pelvic trauma, e.g., forceps delivery, episiotomy, and prolonged second stage of labor
• Medications, including laxatives, artificial stool softeners may cause or exacerbate FI
• Neurological diseases that cause FI invariably cause other, i.e. non anorectal manifestations before patients develop FI
To emphasize, obstetric anal sphincter injury is not, after adjusting for bowel disturbances, a major risk factor for FI occurring many decades after vaginal delivery in women [2, 3]. FI in the immediate postpartum period is more likely following third-degree (i.e., involving the external anal sphincter) and fourth-degree lacerations (i.e., extending through the external and internal anal sphincters) and with forceps or vacuum extraction .
What Diagnostic Tests Are Necessary?
Brief Review of the Literature
An algorithm for managing FI is shown in Fig. 37.1. Diagnostic tests are necessary when symptoms do not improve with treatment of the underlying disease, bowel disturbances, and local anorectal problems. An anorectal manometry with assessment of rectal sensation and rectal balloon expulsion is the initial step. The findings guide subsequent management. Endoanal imaging with ultrasound or MRI, occasionally supplemented with anal electromyography, should be considered in patients with anal weakness, especially when surgery is being considered.
Algorithm for managing fecal incontinence. Reproduced with permission from Bharucha AE, Rao SSC. An update on anorectal disorders for gastroenterologists. (Brief Review). Gastroenterology 2014;146(1):37–45. Abbreviation: EMG electromyography, NASHA Dx non-animal stabilized hyaluronic acid/dextranomer
What Can I Do to Control My Accidents?
Suggested Response to the Patient
First, it is important to consult your physician to ensure there is no serious underlying disorder responsible for FI.
Dietary modifications are often helpful in patients with diarrhea
Consider reducing or eliminating the consumption of foods that contain artificial sweeteners (e.g., sorbitol, high fructose corn syrups) and caffeine-containing foods (e.g., coffee, colas, and chocolate) for a brief period (e.g., 1 month) and observe for changes in your bowel movements and FI. High fructose corn syrups contain fructose and glucose. Certain sugars such as fructose and sorbitol are poorly absorbed from the intestine. Hence, they exert osmotic effects and predispose to formation of soft or loose stools. While breath tests can identify people who incompletely absorb fructose, a simpler approach is to eliminate foods containing such sweeteners (e.g., sodas) and markedly curtail consumption of caffeine.
Another option is to consider reducing consumption of dairy products (milk, cheese, chocolate milk, and cream), high gas producing vegetables (broccoli, onions, cabbage, cauliflower, garlic, artichoke), or vegetables containing insoluble fiber (salad, lettuce, tomatoes, raw vegetables, carrot, and corn).
If you have accidents with loose or watery stool, antidiarrheal agents such as loperamide (non-prescription) or lomotil (prescription) can be very helpful. When feasible, it is important to take loperamide (2 mg) 30 min before meals. Perhaps start by taking one or, if necessary, two tablets 30 min before meals, and supplement as necessary after each runny stool, up to a maximum of eight tablets daily.
Agents which bind bile salts (e.g., cholestyramine, colestipol, and colesevelam) also reduce diarrhea in patients with diarrhea due to irritable bowel syndrome or after cholecystectomy (gall bladder surgery). Normally, bile acids are almost completely absorbed in the small intestine. When not, they travel to the colon, where they irritate the colonic lining, causing diarrhea. Bile salt binders prevent diarrhea due to this mechanism.
If you have constipation and accidents, then your doctor may suggest that you eat fiber-rich foods, and prescribe fiber supplements or an osmotic laxative (e.g., polyethylene glycol).
It may be beneficial to go to the toilet at a specific time of day. For example, your doctor may recommend that you make a conscious effort to have a bowel movement after eating. This helps you gain greater control by establishing with some predictability when you need to use the toilet.
Physical therapy is effective for patients with accidental bowel leakage.
If the incontinence is due to a lack of anal sphincter control or decreased awareness of the urge to defecate, you may benefit from a bowel retraining program and exercise therapies that will help you improve muscle strength in the vicinity of your anus.
In other cases, bowel training involves an exercise therapy called biofeedback. Biofeedback involves inserting a small pressure-sensitive probe into your anus. This probe registers the strength of your anal sphincter. You can practice sphincter contractions and learn to strengthen your own muscles by viewing the scale’s readout as a visual aid. These exercises can strengthen your rectal muscles. It is also possible to improve rectal sensation with biofeedback therapy. Some patients have constipation and fecal incontinence. The constipation may be caused by pelvic floor dysfunction, also known as a defecatory disorder. This can be remedied with a different type of biofeedback therapy that is designed to improve coordination between movement of the abdomen and pelvic floor muscles during defecation.
If you have substantial symptoms after treatment with medications and biofeedback therapy, your physician may consider other options such as sacral nerve stimulation, perianal injection of a bulking agent, or as a last resort, a colostomy.
Brief Review of the Literature
Conservative therapies will benefit approximately 25% of patients and should be tried first (Fig. 37.1, Table 37.3) . These conservative measures include reduced intake of foods (e.g., poorly absorbed carbohydrates such as fructose, sorbitol, and others, caffeine) that can cause or aggravate diarrhea and/or rectal urgency, urge suppression techniques, and antidiarrheal agents (e.g., loperamide). For those failing to respond to medical therapy, biofeedback therapy remains the mainstay. Randomized controlled trials show that biofeedback therapy is superior to Kegel exercises .
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