Interior of the rectum
and anal canal |
No one wants to talk about it.
On the list of embarrassing complaints,
fecal incontinence is the one even your most forthcoming
patients will want to keep under wraps. Yet a recent
study found as many as one in four women experience
fecal incontinence, whether of stool or of flatus, within
six months of childbirth. Dr Stephen Vanner, director
of the gastrointestinal diseases research unit at Queen's
University, thinks those stats may be a little misleading,
but he stresses it's an extremely common problem —
probably more so than most physicians realize.
INSULTS
AND INJURIES
As Dr Vanner explains, fecal incontinence primarily
affects patients over 60, but it's an obstetrical issue
as well. "The nerves that innervate the sphincter can
be compromised during childbirth, and the sphincter
muscles can be damaged by the stretching," he says.
Patients who are overweight, who have to push for longer
periods of time, or who require forceps or an episiotomy
during delivery are more likely to suffer from incontinence,
according to the study published in Obstetrics and
Gynecology in February. Dr Vanner says most women
will recover shortly afterwards though, which is why
he finds the high incidence reported in the study surprising.
But it's clear damage incurred during childbirth can
lead to incontinence in later life. In fact, recent
statistics indicate it's the second most common reason
for nursing home admittance in the US.
That's not to say that men are
immune from this troubling condition. Dr Vanner recalls
one patient, an avid golfer, who gave up the sport entirely
when he became fearful of "losing control" on the course.
He says there are three basic categories of incontinence:
1. Fluid overload "If you
present too much liquid to the sphincter, you'll overwhelm
even a normal one," says Dr Vanner. Loose stool is much
harder to control than solid stool, so patients who
suffer frequent bouts of diarrhea are more likely to
complain of incontinence. Ironically, constipation can
also lead to incontinence: if impacted stool is blocking
the rectum, watery stool is more likely to leak out
around it.
2. Reduced elasticity Normally,
the walls of the rectum stretch to store stool, until
we consciously decide we want to evacuate. "A loss of
compliance there — patients who've had radiation
for cervical or prostate cancer, for example, can suffer
inflammation — will lead to incontinence," explains
Dr Vanner. Underlying conditions like IBS or Crohn's
disease can also damage the rectal wall. As a result,
patients can't store stool very well and often don't
make it to the washroom in time.
3. Sphincter damage Muscle
damage is especially common after childbirth or rectal
surgery. Patients can usually compensate for a time,
but as the muscles weaken with age, they may start to
develop symptoms. Diseases like diabetes mellitus and
multiple sclerosis, on the other hand, can disrupt the
functioning of the nerves that control the anal muscle
or regulate sensation.
Dr Vanner says a thorough history
and physical examination are often enough to diagnose
fecal incontinence, but in older patients, an investigation
of the colon may be warranted. "If there's any question
there's another condition that could be involved —
inflammation or a growth in the rectum — they should
have an endoscopic ultrasound as well," he says.
BOWEL
FIX
Dr Vanner sees a lot of patients, and the most common
thing he does is put them on a bulking agent like Metamucil
— he recommends the powder over the capsules —
to soak up any extra liquid. "Start patients on smaller
doses and titrate them up to 2 tbsp a day so they don't
feel bloated," he suggests, adding that almost all patients
will get some benefit from this simple inexpensive treatment.
In cases of more severe diarrhea,
or of urgency due to rectal wall damage, a constipating
agent like Imodium may be useful. "The less often you
need to go to the washroom, the less likely you are
to be incontinent," Dr Vanner explains.
The key thing is for patients to
take their medication regularly. "The biggest fear patients
have is being incontinent in public. Taking the medication
regularly makes the bowel pattern much more predictable,
which is what you want," he says.
Biofeedback techniques, like using
a rectal balloon to train patients to sense the presence
of stool, offer you more treatment options, though they're
not universally supported. The literature has found
conflicting results and most studies conducted thus
far were poorly-designed. But there's no great harm
in trying. "We find it's a safe and non-invasive thing
to do and there are probably a subset of patients that
get benefit," says Dr Vanner.
Surgery is possible in clear cases
of muscle damage or pelvic floor injury, but Dr Vanner
says it's truly the last resort. "We rarely do it because
the outcomes aren't particularly promising, and we never
do it in older patients," he says. "It's just not worth
it."
In the end, just broaching the
subject of fecal incontinence with your patients will
probably do them a lot of good. "If patients complain
about diarrhea, you need to ask about incontinence,"
says Dr Vanner. "It may in fact be why they're there,
but they were too mortified to say so." Tell them how
simple measures can often have a significant impact.
There may be a little trial and error, but most can
make a significant gain — many even recover.
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