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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 13 - Fecal Incontinence

"It is more important to know what sort of person has a disease than to know what sort of disease a person has." - Hippocrates

Penfolds Koonunga Hill 2016 Shiraz Cabernet

PB#210 - Published April 2019

Pearls

1. Incidence of fecal incontinence (FI) is largely unknown due to underreporting

2. FI significantly and detrimentally impacts a woman's quality of life

3. Most treatment modalities show short-term benefit but there is little evidence comparing long-term benefits

4. Conservative means of managing FI may be effective without any adverse effects

5. Adequate repair of anal sphincter injury at time of vaginal delivery can lead to significant patient satisfaction and reduction in FI

Definitions and epidemiology

- FI: recurrent, involuntary loss of solid or liquid stool or mucus from the rectum

- Anal incontinence: more encompassing term, which includes the loss of flatus +/- loss of stool

- according to a survey, many women prefer the term "accidental bowel leakage"

- incidence is unclear, as 75-80% of individuals don't seek help or report sx

- prevalence is roughly equal between males and females

- prevalence increases w/ age

- loss of liquid stool is most common reported symptom (~6%), followed by mucus (~3%), and solid stool (1.6%)

- in patients who reported symptoms, "physicians did not provide guidance on how to address the quality-of-life effects of fecal incontinence"

- it's associated with depression, social isolation, shame, embarrassment, worsened sexual function, and increased economic burden

Etiology

- neurologic versus non-neurologic causes

- neurologic: spinal cord injury, spina bifida, and cerebral vascular accidents (not further addressed in this document)

- non-neurologic are more common, particularly obstetric anal sphincter injuries (OASIS)



Risk factors

- loose/watery stools

- increased frequency of stools

- chronic illnesses (e.g. diabetes, IBD)

- smoking

- obesity

- advanced age

- decreased physical activity

- anal intercourse

- history of pelvic radiation


Initial evaluation

- thorough medical history: parity, medications, PMH, smoking, elicitation of other risk factors

- qualification of fecal incontinence: consistency (solid versus liquid versus flatus), relationship to urgency

- validated instruments: FI Severity Index, FI Quality of Life Scale, or FI and Constipation Assessment Questionnaire

- PE: speculum exam (be on the lookout for prolapse), digital exam evaluates for masses, fistula, prolapse, and tone

- ancillary testing such as anal sphincter imaging, defecography, anorectal mammography, and pudendal nerve terminal motor latency tresting is not recommended routinely, though it might be considered if a patient is refractory to therapy or if an obvious sphincter defect is noted on physical exam

- any woman who presents with FI and a change in bowel habits should be considered for colonoscopy esp if she has any "red flag" symptoms of malignancy (weight loss, rectal bleeding, melena, etc.)


Treatment overview

- nonsurgical, less invasive procedural, surgical options exist

- only low-level evidence around efficacy exists

- intervention should be aimed at decreasing the frequency and severity of FI

- non-surgical options provide short-term improvement of symptoms without significant risk of adverse effects

- no intervention - not even surgical therapies - show little benefit beyond 6 months


Lifestyle changes

- dietary manipulation and bowel schedules

- food diaries can help identify food triggers that exacerbate rectal urgency, diarrhea, or both; can also help quantify water and fiber intake

- regular toileting may improve rectal emptying and thereby improve symptoms


Stool-modifying agents

- fiber: gradual up-titration can help to bulk stool in incontinence associated with loose stools; up-titrate slowly to avoid side effects (flatus, bloating, and abdominal cramping)

- loperamide, diphenoxylate w/ atropine, and codeine phosphate can help manage incontinence associated with diarrhea or loose stools

- loperamide more frequently found to cause constipation compared to psyllium

- in patients without constipation, daily loperamide can be helpful; up-titrate slowly to avoid constipation

- if constipation w/ overflow is the etiology for FI, lactulose or polyethylene glycol are mainstay therapy (Cochrane found that the latter was superior to the former)

- polyethylene glycol can be bought OTC, easily dissolved in 4-8 oz of water and taken daily or multiple times daily


Pelvic floor muscle exercises and physical therapy

- might be helpful with or without biofeedback, but insufficient evidence on the most effective protocol

- most studies have found some benefit without adverse effects, but no evidence yet of superiority to more conservative therapies

- electrical stimulation can also be added, but data is, again, limited

- biofeedback: sensors are placed to enhance patient's awareness of physiologic sensations in order to improve their ability to isolate and contract specific muscles without involving abdominal musculature

- Cochrane found that addition of biofeedback to pelvic floor muscle exercises may be more effective than muscle training alone

- Cochrane also found that addition of electrical stimulation may be further helpful (though other studies disagree and have actually found that up to 10% of patients may experience discomfort w/ electrical stimulation)


Anal Plug and vaginal bowel control device

- anal plug: systematic review of 4 RCTs found that they are effective in patients who can tolerate them

- most common adverse effects: rectal urgency (~25%), irritation (~15%), and soreness (~5%)

- vaginal bowel control device: useful in women whose FI didn't primarily results from chronic watery diarrhea; balloon inflated in vagina can be delfated to facilitate bowel movements

- 50% of women enrolled in one study were able to be appropriately fitted; of those, 75% achieved a 50% or greater reduction in symptoms

- most common adverse events: discomfort (15%), urinary symptoms (10%), pain (8%), and vaginal spotting (7%)


Anal sphincter bulking agents

- data on long-term effects are lacking, but, like other modalities, benefit may be seen for up to 6 months

- injection of bulking agents directly into anal sphincter: collagen, silicone, carbon-coated beads, and dextranomer in hyaluronic acid (NASHA-Dx)


Surgical treatments

- candidates: failed more conservative therapies (though can be considered first-line in the case of fistula or rectal prolapse) as only short-term improvement of symptoms has been documented and there is a significantly greater risk of adverse effects

- Per the Agency for Healthcare Research and Quality (AHRQ), data is insufficient to suggest efficacy beyond 3-6 months post-operatively

Neuromodulation:

> distinct from PTNS, which hasn't been approved for FI

> wire electrode is implanted adjacent to 3rd sacral nerve root

> period of initial testing after which a permanent battery can be placed

> can be considered for women w/ FI w/ or w/out anal sphincter disruption

> 2013 systematic review found pretty decent success rates (defined as 50% or greater reduction in symptoms)

> ~60% up to 36 months, then ~55% up to 118 months; at 56 months, 20% of pts reported complete continence

> adverse events include pain, infection, lead migration, hematoma, and need for battery replacement

Anal sphincter repair:

> Cochrane compared end-to-end and overlapping techniques for repairing sphincter injury at time of OASIS and found similar outcomes up to 36 months postpartum (see PB#198 for more info on preventing and managing obstetric lacerations at vaginal delivery)

> 50% of women report fecal incontinence symptoms 5-10 years after their repair

> despite this less encouraging objective data, 75% of pts report satisfaction with their results

> data on sphincteroplasty (remote from delivery) is more limited

> surgical complications range from 5-27% (wound infection most common and seen in 6-35% of cases); you may also see fecal impaction, wound hematoma, dyspareunia, defecatory dysfunction (incomplete evacuation, straining, or need to disimpact manually)


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