FECAL INCONTINENCE:
If you don’t ask, they won’t tell! The inability to delay passage of stool or
flatus until a socially acceptable time and place is embarrassing and
ostracizing. Many won’t admit a problem even to their doctor. Excuses
abound for avoiding social situations when the real problem is fear of “an
accident”. Even marital intimacy can be a source of embarrassment and
avoided. Serious depression can result.
Anyone who has been in a delivery room will testify that vaginal delivery
does trauma to the perineal tissues, including the sphincter muscles and
the pudendal nerve. Recent ultrasound studies found that up to 30% of
“normal” deliveries result in injury to the internal or external sphincter
muscles. Ultrasound shows that nearly 40% of patients with recognized
sphincter injury had defects 3 months after repair.
Vaginal delivery, chronic constipation, diabetes and neurologic problems
can lead to poor conduction in the pudendal nerve. Anorectal surgery for
hemorrhoids, abscesses and fistulas can also injure the sphincters. Loss
of sphincter strength and endurance follows.
Inflammation in the rectum will interfere with the ability of the rectum
to stretch. The “capacitance”, or ability of the rectal wall to stretch at
a low pressure allows the relatively weak internal sphincter to maintain
closure when the strong but short acting external sphincter tires.
What questions should be asked? Begin with asking what leaks, when and how
it impacts life? What does the patient give up to avoid the risk of public
embarrassment?
Determining the degree of control deficit and the life impact for the
patient is the first step. A patient who has a small smear is not as
motivated, as one who cannot delay passage of formed stool for more than a
few seconds! Some have excellent control of formed stool but problems with
liquid or flatus. Others have no sense of the presence of stool in the
rectum until it is present on the perineum.
Are the sensation and anatomy normal? Does the anus look normal? Is there a gap? Is the perineal
body
thinned? Are any scars present? Is the anal wink reflex present? Is the
sphincter tone present circumferentially or is there a defect?
Simple interventions can greatly improve lifestyle. Thickening the stool and a regular bowel schedule will add a large
measure of freedom to many patients. A regular schedule will often allow
several hours of safety. If this fails some patients will benefit from
pelvic floor retraining. Far more than Kegel exercises, this guided
exercise program can improve rectal sensation, strength and endurance.
Reconstruction Some muscles will need to be repaired. The overlapping sphincter
repair will restore socially acceptable continence in 70-80% of patients.
Recent studies have shown some deterioration of control over time (5-10
years) but repeat repair has been effective.
New on the block! The artificial bowel sphincter is now available. Based on the proven
technology long available for the inflatable penile prosthesis and the
artificial urinary sphincter, this saline inflatable balloon cuff keeps
the anal canal closed until the patient is ready for defecation. The pump
located in the scrotum or labia is activated to deflate the cuff to allow
defecation. The cuff automatically re-inflates in about 30 minutes. There
is a high infection rate of up to 30% but this device can avoid a
permanent colostomy in patients with poor sensation or sphincters that
cannot be rebuilt.
Coming soon to an operating room near you! Sacral nerve stimulation has already been proven and approved for
urinary incontinence. It is also very promising in studies for treatment
of fecal incontinence. If the sacral nerve roots and pudendal nerve are
intact then use of a pacemaker like device to stimulate the nerves can
maintain contraction until deactivated to allow defecation.
Fecal incontinence can be helped. It should not be a life sentence to
confinement within 50 yards of the bathroom. Many tools and strategies are
available to help, if you ask.
Remember, if you don’t ask,
they won’t tell.
Medicare will now cover a screening colonoscopy
every ten years for average risk patients
Kitsap ColoRectal Surgery, Johnny B. Green, MD, FACS, FASCRS
Eastwood Building, 2528 Wheaton Way, #103, Bremerton, WA 98310
(360) 377-4717 -- (360) 377-4134 fax
www.kitsapcolorectal.com
