Published in UAB Insight, Spring 2008
Comprehensive Diagnosis and Treatment of Bowel and Fecal Incontinence
Bowel incontinence can have a devastating impact on quality of life,” says UAB urogynecologist Holly E. Richter, PhD, MD, “particularly fecal incontinence, which individuals often hide from families and friends. Treatment delay is unfortunate, since a proactive approach can prevent or lessen symptom severity. Many new and effective treatment options are available.”
Richter is director of the UAB Genitorectal Disorders Center, a part of the UAB Continence Center, which offers the full spectrum of treatment modalities for fecal incontinence, including nonsurgical therapies, minimally invasive procedures, and standard open procedures.
Fecal incontinence affects people of all ages but is far more common in child-bearing women and in older adults. The prevalence rate is 3% to 14%; for women aged >65 years it may rise to 20%. Prevalence in nursing homes is about 45% but varies according to physical and mental status. Prevalence rates of nearly 20% have been seen in women sustaining a sphincter tear at the time of vaginal delivery.
Studies of the causes of fecal incontinence are sparse. Bowel function is controlled by rectal sensation, rectal storage capacity, anal sphincter pressure, and established bowel habits. Compromise in any of these factors may cause fecal incontinence. Richter has linked routine episiotomy and instrumented delivery with sphincter tears, which increase incidence and severity of fecal incontinence in women (Curr Opin Obstet Gynecol. 2007;19:474-479). Multiparous women have a higher risk of incontinence than primiparous women. Obesity also is a risk factor. A recent UAB study indicates weight loss surgery decreases prevalence of urinary and fecal incontinence (Obstet Gynecol. 2007;110:1034-1040).
Depression, stroke, diabetes, inflammatory bowel disease, and irritable bowel syndrome also contribute to fecal incontinence in women and men. “The problem is less prevalent in younger men compared with older men, but may occur because of medical conditions or after anal or prostate surgery,” says UAB geriatrician Alayne D. Markland, DO, MSc.
Richter and colleagues use questionnaires, which patients complete at home, for initial assessment of risk factors and to characterize severity of the condition. Diagnostic testing may be indicated and determines if nerve, sensory, or muscle damage is a factor. Tests offered include anal manometry (to assess anal sphincter tightness and ability to respond to signals), anorectal ultrasonography (to evaluate anal sphincter structure), electromyography (to check for nerve damage), and pudendal nerve terminal motor latency study.
The clinic’s primary treatment modality is behavioral modification with counseling and education on lifestyle changes, dietary modifications, and pelvic muscle exercises. “Adjunctive therapy with biofeedback can train muscles to control bowel function. Sacral neuromodulation therapy, which has shown success with refractory urge urinary incontinence, is under investigation for fecal incontinence,” Richter says.
Physicians individualize treatment in the context of patients’ desires, activity levels, and medical comorbidities. A dataset with deidentified information allows clinicians to track symptom changes with therapy to establish the optimal treatment course. “With behavioral, pharmacological, and sometimes surgical interventions, we can improve incontinence symptoms as well as quality of life in most patients,” Richter says.
Incontinence Clinical Trials
| Randomized Controlled Trial of Tolterodine vs Low-Dose
Intravaginal Estradiol Cream for Overactive Bladder in
Postmenopausal Women |
A study for women comparing tolterodine with low-dose intravaginal estradiol cream for the treatment of urinary urgency, frequency, nighttime urination, or urine leakage with a feeling of urgency. |
| Trial of Midurethral Slings (TOMUS) |
A surgical study for women comparing the outcomes of retropubic and transobturator midurethral sling procedures for stress urinary incontinence or leakage. |
| Fiber Prescription Management (FIRM) |
A study for women with loss of bowel control testing a fiber supplement to improve stool consistency vs loperamide to slow bowel motility. |
| For information about these or other continence clinical trials at UAB, contact Leslie Abdo, RN, at 205.934.1777. |
For more information:
Dr. Holly Richter
1.800.UAB.MIST
mist@uabmc.edu