Pharma Update

Fecal Incontience

Shame. Embarrassment. Humiliation.

These are just a handful of descriptors for the feelings experienced by individuals with fecal incontinence. More than 6.5 million Americans have this condition — affecting children as well as adults.

Fecal incontinence is the involuntary passage of gas and feces. The personal impact of incontinence is profound because many individuals withdraw from all social contact, remaining in close proximity to a toilet to minimize incontinent episodes.1 “One of the issues is that they may have occult psychological or psychiatric issues,” says Emina Huang, MD, assistant professor of surgery at the University of Michigan Health System in Ann Arbor. “There is a percentage of these people that have been abused, assaulted or traumatized in some way. It is the No. 2 or 3 cause for patients being institutionalized into a nursing home because the family can’t take care of them anymore.”

“When somebody comes to see us in our office, we sit down with them and take a very careful history to try to formulate an idea of why they might have incontinence,” says Howard K. Berg, MD, FACS, FASCRS, a member of Colon Rectal Surgical Associates in Baltimore, Md. “The other thing that is important to do is to distinguish incontinence from leakage. A lot of people come in here and say that they have incontinence, but it’s actually just leakage — maybe of mucous

and a little bit of stool. That might come from something as simple as prolapsing hemorrhoids, rectal prolapse or something along those lines.”

To assist physicians with interviewing patients, a symptom-specific fecal incontinence quality of life scale has been developed. It was recently validated and is gaining widespread use.3 The scale is composed of a total of 29 items, forming four scales: Lifestyle (ten items), Coping/Behavior (nine items), Depression/Self - Perception (seven items), and Embarrassment (three items). Each of the four scales is capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems.4

The key to interviewing patients about this condition is not only asking them about their incontinence and gas, liquid stool or solid stool or how frequently they have these episodes, but how this affects their quality of life, says Amy Halverson, MD, assistant professor of surgery at the Feinberg School of Medicine, Northwestern University in Chicago.

Recalling a recent patient visit, Halverson says, “I talked to her and I asked the key question, ‘How does your worry about incontinence affect your life?’’ She said, ‘Oh, I never leave home before I have had my bowel movement in the morning. I can never make any appointments or do anything in the morning.’ Some people will never leave the house, go out to dinner, go to a movie or fly on an airplane because they’re so worried about their incontinence.”

Once the history is obtained, physicians will perform a physical exam and possibly other medical tests to pinpoint the cause of fecal incontinence:

• Anal manometry — checks the tightness of the anal sphincter and its ability to respond to anorectal signals, as well as the sensitivity and function of the rectum
• Anorectal ultrasonography — evaluates the structure of the sphincter muscles
• Proctography — shows how much the rectum can hold
• Proctosigmoidoscopy — allows physicians to look inside the rectum for signs of disease or other problems that could cause fecal incontinence, such as inflammation, tumors, or scar tissue
• Anal electromyography — tests for nerve damage.

The application that is most commonly used for those individuals who do not have a reparable injury would be medical management, says Marvin L. Corman, MD, vice chairman of the Department of Surgery at North Shore-Long Island Jewish Medical Center in New Hyde Park and professor of surgery at the Albert Einstein College of Medicine in Bronx, N.Y. “Medical management consists of establishing a workable time for elimination or defecation so that the person can be relatively safe and confident when they’re ambulating and when they’re outside and maybe not close to a toilet,” he says. “So, that involves dietary manipulation, obviously avoiding those foods that tend to cause looseness because you have more trouble trying to hold loose bowels than you would formed stools. Sometimes bulking agents like fiber products are helpful because they improve one’s ability to have a larger bowel movement and even sensation that there is something there.

You may give the patients slowing medicines, which are medications that slow down intestinal activities such as imodium, which is over-the-counter, or prescriptions drugs such as lomotil, paregoric, or codeine. There are a whole bunch of medicines that you can use to slow people down, but you don’t want to slow them down so they can’t move their bowels. If looseness is a problem you want to address that.”

Corman, author of Colon and Rectal Surgery, a leading book in the field, mentions further that suppositories can be used to evacuate the bowel before a person goes out, or enemas for the same purpose if patients can hold them.

Laxatives may be used as well.

One last option is to have patients perform Kegel exercises to strengthen muscles of the pelvic floor, thus improving the sphincter function. “If their baseline anal canal tone is normal and it’s their squeeze pressures that are abnormal, then we would recommend Kegel exercises to try and strengthen the muscles, and biofeedback, where a catheter is placed inside of the anus. When you contract the muscles you’ll see a little arrow on the meter move to give you an idea of how your muscles are working,” Berg says. “It gives you immediate feedback.”

Patients often experience significant improvement with these non-operative treatments. For those requiring surgical intervention, however, “there are a number of surgical options that are available,”

Corman says. “Some are more invasive and more radical than others. It depends on the ideology of the incontinence, if it’s known. Besides clinical assessment, it may entail physiologic studies to determine the status of the muscles and the nerves. When you have all the information, then there is an algorithmic approach to the management of patients based on the cause of the incontinence and the physical and laboratory findings.”

Surgical options vary from simple procedures such as repairing damaged areas, to complex procedures such as replacing anal muscle with muscle from the leg or forearm or performing a colostomy. “There are currently several other new options,” Huang says.

“One is the artificial sphincter.

Unfortunately, because it’s plastic tubing, it is associated with an infection rate that causes there to be revisions 30 percent to 50 percent of the time. That’s why sometimes it’s not our first choice.

“The SECCA procedure uses radiofrequency to create scar in the anal canal, which hopefully will passively improve continence. It’s unclear how that works. I don’t think you’ll hurt anybody with it, but while the improvement that you see is not dramatic, it may be enough to get somebody where they can have a more manageable lifestyle. There is also some experience, though not in my hands, with sacral nerve stimulation to try and improve the innervation to muscle in that area — to make it tougher.”

As new technologies and new therapies become available, patients will be provided with more therapies for fecal incontinence.

“We want those patients to come forward and get help and understand that there is help,” Huang says. “I actually had a speech therapist come from probably three hours away. When I told her that we could help her or at least get her evaluated, she started to cry. She said she had been living with this for 15 years and didn’t know that anything could be done.”

• Damage to the anal sphincter muscles, ring-like muscles at the end of the rectum
• Damage to the nerves of the anal sphincter muscles or the rectum that control or sense stool in the rectum
• Loss of storage capacity in the rectum, resulting from rectal surgery, radiation treatment, or inflammatory bowel disease
• Diarrhea
• Pelvic floor dysfunction, which is often associated with obstetric injury.

Did you Know...

The Internet offers a wealth of information on fecal incontinence. Here is a list of Web sites to investigate for more information:

Gastroenterology JournalProvides articles discussing the findings from the Advancing the Treatment of Fecal and Urinary Incontinence Through Research: Trial Design, Outcome Measures, and Research Priorities conference in Milwaukee, Wisconsin, November 3-5, 2002. www.gastrojournal.org International Foundation for Functional Gastrointestinal Disorders (IFFGD)Information on fecal incontinence. www.aboutincontinence.org.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)Presents facts about fecal incontinence. www.niddk.nih.gov

National Cancer Institute MetathesaurusProvides a comprehensive biomedical terminology database, containing 850,000 concepts mapped to 1,500,000 terms by over 4,500,000 relationships. http://ncimeta.nci.nih.gov/indexMetaphrase.html

PubMedLists several citations for biomedical articles from Medline and additional life science journals. PubMed includes links to many sites providing full text articles and other related sources. www.ncbi.nih.gov/entrez/query.fcgi

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