Fecal Incontinence in Women: Causes and Treatment

Ashima Makol; Madhusudan Grover; William E Whitehead

Disclosures

Women's Health. 2008;4(5):517-528. 

In This Article

Treatment

The goal of treatment for patients with FI is to restore, or at least improve, continence and minimize the impact of FI on QOL. Complete continence may not be achievable, depending on the etiology, but amelioration is possible for almost every patient. Treatment progresses through a series of steps that are progressively more aggressive and costly until adequate relief is achieved. These steps are education and medical management of stool consistency, pelvic floor muscle exercises and lifestyle adjustments, biofeedback or behavior modification and surgery. Pads and containment devices are an important adjunct to all these treatments, since they help the patient to avoid embarrassing accidents while undergoing treatment. The brief discussion of treatment that follows is prescriptive and not entirely evidence based. The authors acknowledge that some of these recommendations are their own opinions rather than the consensus of professional societies.

Conservative medical management involves four techniques:

  • Educating the patient about the causes of FI and suggesting behavioral strategies for minimizing FI;

  • Teaching pelvic floor exercises during digital examination of the rectum and encouraging the patient to practice 100 squeezes/day;

  • Using antidiarrheal drugs or laxatives (as appropriate) to normalize stool consistency;

  • Recommendations regarding the use of pads and skin hygiene measures.

Anatomical drawings are used to explain to patients how continence is normally maintained and how their own injury or disease affects this mechanism. This is combined with behavioral suggestions to adopt a regular bowel habit, such as attempting to have a bowel movement after the same meal each day, and to prepare for coughing or lifting by first contracting pelvic floor muscles. Advice about avoiding foods such as caffeine that may cause loose stools may also be helpful.[12]

These exercises are intended to strengthen weak pelvic floor muscles through daily exercise. There is evidence that they are effective, when taught correctly, at reducing FI.[92,93] Some studies suggest they may be as effective as biofeedback.[94]

Antidiarrheal agents, such as loperamide hydrochloride (Imodium®, Janssen Pharmaceutical, Titusville, NJ, USA) or diphenoxylate/atropine sulphate (Lomotil®, Searle, Chicago, IL, USA) are the mainstay of drug treatment for diarrhea-related FI. Placebo-controlled studies have demonstrated reduction in the frequency of FI, improvement in stool urgency, increase in colonic transit time as well as increase in the resting anal sphincter pressure.[94–96] Codeine phosphate is also effective, but has significant systemic side effects and addiction potential. Ion-exchange resins, such as cholestyramine or colestipol, may be tried in patients with idiopathic bile salt malabsorption underlying their diarrhea and FI.[97] Most patients require low doses and titration is important to produce the desired result. One study has demonstrated that increasing dietary fiber is also helpful for reducing diarrhea-associated FI.[98] Enemas and suppositories play a role in the treatment of FI patients with incomplete rectal evacuation or postdefecation seepage.[99] Laxatives can also be used for constipation-associated FI, which is more commonly observed in children and the institutionalized elderly.[12]

Pads should not be seen as an alternative to treatment, but as an adjunct to ongoing treatment; they provide a measure of security against embarrassment. These pads come in a variety of sizes, shapes and materials. With guidance from a nurse or physician, patients will be able to select the type of pad that is most appropriate for them. In addition, medical management should include advice on skin hygiene.[12] Timely recognition of soiling and immediate cleansing of the perianal skin is important. Use of a moist cloth or tissue is better for cleaning than using dry toilet paper. Barrier creams, such as zinc oxide and calamine lotion, may be useful in preventing skin excoriation. Topical antifungals may be used to treat infection where needed. Stool deodorants can help disguise smell.

Biofeedback therapy is a form of motor skills learning. When learning a new motor skill, such as throwing a basketball, one tries repeatedly and learns from success and failure how to improve one's skill. However, when success is difficult to perceive, such as contraction of a weak anal sphincter muscle, it may be necessary to use machines to amplify weak contractions and display them in a form that the subject can use to facilitate learning. In addition to strengthening weak muscles, biofeedback is used to improve a subject's ability to perceive important physiological signals, such as the faint distensions of the rectum, which tell us when to contract the sphincters to avoid incontinence. This sensory training is accomplished by distending a rectal balloon with progressively smaller amounts of air and training the subject to attend to and to recognize weaker sensations than previously. Biofeedback training for FI involves both strength training and sensory training.[100–102]

Our laboratory carried out a randomized, controlled trial in which patients with symptoms of FI occurring at least once a week were first treated with conservative medical management to eliminate those who did not need biofeedback training.[93] The remaining patients were randomly assigned to receive either biofeedback or pelvic floor exercises alone for six biweekly sessions. A higher proportion of patients reported adequate relief after biofeedback training than after pelvic floor exercises (76 vs 41%, respectively), suggesting that biofeedback is superior to pelvic floor exercises and conservative management. However, the research team at St Marks Hospital in London, UK, did not find any difference between biofeedback and conservative management with pelvic floor exercises.[92] They believe that when patients are taught to perform pelvic floor exercises during a physical examination, with the therapist giving the patient verbal feedback based on the contractions they detect with their finger, the outcomes are as good as with instrumented biofeedback. Additional studies will be needed to resolve this important issue. It is clear, however, that intensive training by an experienced therapist can improve continence outcomes more than the use of conservative management.

The most commonly employed surgical treatments for FI are sphincteroplasty (plicating the separated ends of a torn sphincter muscle), injection of collagen or other bulking agents around the sphincter to increase anal canal resting pressure and colostomy or ileostomy. Obstetrical injury is the most common reason for performing a sphincteroplasty, and the short-term success rate is reported to be between 70 and 80%.[103] However, damage to the pudendal nerve is associated with a poorer outcome and by 5 years, fewer than 25% of women with a sphincteroplasty are still continent.[104]

The injection of collagen or other bulking agents into the sphincter walls may be indicated if there is decreased resting pressure in the anal canal and passive leakage from the rectum.[105] A recent variation is to implant expandable microballoons in the submucosa of the anal canal. This can be performed as an outpatient procedure and has shown, at short-term follow-up, to improve incontinence scores with minimal adverse events.[106] However, it remains experimental, pending future work in a larger sample of patients followed over a longer period of time.

Colostomy or ileostomy involves bringing the colon or ileum to the surface of the abdominal wall where fecal material can be collected in a bag. This is something that both patients and surgeons regard as a last resort, but it does produce social continence and may improve QOL.

Among the experimental approaches to treating FI, the most promising is sacral nerve stimulation.[107,108] In this procedure, the surgeon uses a needle to insert electrodes into the sacral nerve plexus and explores to identify a site at which stimulation causes the external anal sphincter to contract. If such sites are found, the patient is provided with a temporary stimulator for approximately 2 weeks. If the 2-week trial is successful, the stimulator can be permanently implanted. Large clinical trials have now been carried out, which demonstrate improvements in 80–90% and full continence in approximately half of patients who are implanted.[108,109] There are a significant number of complications, including infections, device failures and migration of electrodes, but the overall experience has been positive.[107,109,110]

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