Fecal Incontinence and Constipation

3/18/2015 1

PELVIC FLOOR DYSFUNCTION

Toyia James-Stevenson, MDSeptember 12, 2015

Discuss epidemiology, etiology and risk factors

Explore potential barriers to care Evaluation of pelvic floor disordersExplore options for evaluation and

management

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FOCUS OF TALK

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FECAL INCONTINENCE

Fecal Incontinence - Unintentional loss of solid or liquid stool

Anal Incontinence - Includes leakage of gas and/or fecal incontinence

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DEFINITION

Prevalence in US of 7-15%Incidence will likely increase as population

agesIn adults > 65 dwelling in community

incidence of 17% over 4 yrs 6% have monthly symptoms

Most studies show a higher prevalence in Caucasian women than African American women

Prevalence = in Caucasian and AA Men04/19/23 5

EPIDEMIOLOGY

Whitehead WE, Borrud L, Goode PS et al. FI in US adults: epidemiology and risk factors. Gastro 2009;137:512–7

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PREVALENCE BY SEX AND AGE

I. Ditah, P. Devaki, H.N. Luma, et al. Prevalence, trends, and risk factors for fecal incontinence in United States adults, 2005-2010; Clin Gastroenterol Hepatol, 12 (2013), pp. 636–643.

Chronic DiarrheaRectal UrgencyBurden of Chronic Illness (Comorbid count, DM)

Urinary IncontinencePelvic SurgeryCaucasian Race

Smoking (also RF for external sphincter atrophy on MRI)

ObesityInstrumented

Vaginal DeliveryDecreased physical

activityAdvanced Age

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RISK FACTORS

Bharucha AE, et al;Am J Gastro. 2015 Jan;110(1):127-36

Chronic DiarrheaRectal UrgencyBurden of Chronic Illness (Comorbid count, DM)

Urinary IncontinencePelvic SurgeryCaucasian Race

Smoking (also RF for external sphincter atrophy on MRI)

ObesityInstrumented

Vaginal DeliveryDecreased physical

activityAdvanced Age

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RISK FACTORS

Bharucha AE, et al;Am J Gastro. 2015 Jan;110(1):127-36

Instrumented vaginal deliveryThird and fourth-degree lacerations Incidence has declined over past 2 decades from 13% to 8% following vaginal delivery

Sphincter Injury not major risk factor for FI occurring decades later after adjusting for bowel disturbance

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OBSTETRICAL INJURY

Prevalence: 15% in community-dwelling 18-33% in hospitalized 50-70% in NH

Within 10 months of NH admission, 20% of continent develop FI ? NH practices low functional status high comorbidity

Risk Factors- dementia, chronic dz, mobility impairment

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ELDERLY

Nelson RL. Epidemiology of FI. Gastro 2004;126(Suppl 1):S3–S7.

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Pathogenesis and Etiology of Fecal IncontinenceAnal Sphincter Weakness Injury: obstetric, surgical (hemorrhoidectomy, internal sphincterotomy, fistulotomy) Nontraumatic: scleroderma, IAS thinning of unknown etiology Neuropathic: stretch injury, obstetric, DM

Anatomical Disturbance of Pelvic Floor: fistula, rectal prolapse, descending perineum syndrome

Anorectal Inflammation: Crohn’s, Ulcerative colitis, radiation proctitis, anorectal infection

CNS Disease: dementia, stroke, brain tumors. spinal cord lesions, MS, multisystem atrophy (Shy-Drager’s syndrome)

Bowel Disturbance: diarrhea (e.g. IBS, post-cholecysectomy) constipation with or without impaction or overflow diarrhea

Passive – stool leakage with little or no forewarning (often have low resting pressure)

Urge – occurs despite active efforts to retain stool May have abnl squeeze pressure and durationMay have reduced rectal capacity with rectal hypersensitivity

Seepage – Leakage after BMIncomplete evacuation or impaired sensation

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CLINICAL SUB-TYPES OF FI

Can have devastating impact on quality of life

Loss of dignity, modesty, confidenceMany do not share with closest relatives,

friends or physiciansProviders may consider it less important that

screening for other health issues (triglycerides, DM, excessive ETOH, urinary incontinence)

Caregiver burden >>urinary incontinence04/19/23 13

WHY IS THIS IMPORTANT?

HELPING OUR AGING POPULATION MAINTAIN DIGNITY AND AUTONOMY IS

IMPORTANT!

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REASONS GIVEN FOR NOT CONSULTING PHYSICIAN

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Kunduru et al, Clinical Gastroenterology and Hepatology 2015;13:709–716

124 pts surveyed88 consulters36 nonconsulltersSimilar Fecal Incontinence Severity Index (FISI)

Mean age: 5687.9% women

Consulters had higher depressom scpres (P=0.04)

Nonconsulters less aware of available treatments (P<0.01)

PT SUGGESTIONS FOR IMPROVING FI CONSULTATION

Patients may prefer that their provider initiate conversation about FI

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Kunduru et al, Clinical Gastroenterology and Hepatology 2015;13:709–716

BARRIERS TO CARE

A small email survey of 11/56 physician responders found that in nonscreeners:- 50% felt time constraints was major barrier to screening

- 75% thought FI was rare (<5% prevalence)- All felt it was pt or caregivers responsibility to address

- All felt screening for FI less important than screening for other health issues (DM, excessive Etoh intake, urinary incontinence, cholesterol)

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Kunduru et al, Clinical Gastroenterology and Hepatology 2015;13:709–716

Routine screening by practitioners is important“Accidental Bowel Leakage” may be better term

An Internet study of women >45 yoOnly 30.9% of 1095 pt had heard term “FI”71.1% preferred “Accidental Bowel Leakage”22.5% preferred “bowel incontinence”6.4% preferred “FI”

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IMPROVING ACCESS FOR PATIENTS

Brown HW, Wexner SD. Int J Clin Pract 2012;66:1101–8.

CAN CHANGES IN TERMINOLOGY AFFECT ACCESS TO CARE?

• Access improved when “impotence” was replaced with “erectile dysfunction”

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1995 2015

Lack of US data on economic impactNo prospective studies comparing cost

effectiveness of conservative therapy versus SNS or bulking agents

In UK, each increment in quality-adjusted life year gained with SNS for FI costs $35,000

Largest burden likely from indirect costsIncreases likelihood of NH admissionLoss of productivity

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ECONOMIC IMPACT

IAS- smooth muscle, 70-85% of resting tone

Stool causes rectal distentionRectal contractionUrgency sensationRelaxation of IAS (RAIR)

EAS, PR and levator ani can be voluntarily contracted to maintain continence

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NORMAL ANORECTAL FUNCTION

Lower resting and squeeze pressures (decrease by 30-40% in pts >70 yo

Denervation of anal sphincterDecreased rectal compliance (stiffer rectum)

Decreased rectal sensationPerineal laxity

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CHANGES IN ANORECTUM WITH AGE

Fox et al, Dis Colon and Rectum, Nov 2006

1. Sphincter function2. Anorectal sensation3. Puborectalis

function4. Rectal compliance5. Colorectal motility6. Stool consistency7. Peripheral/central

innervation8. Cognition

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AT LEAST 8 FACTORS AFFECT CONTINENCE

Obtain history of co-morbid conditions (DM, UI)

Inspect for fecal matter, skin irritation, external hemorrhoids, gapping anus, lack of creases

Can identify rectal prolapse or excessive perineal descent (>3cm outward bulge)

Assess sensation and anocutenous reflexDigital rectal exam – can identify patients

with fecal impaction and overflow 04/19/23 24

INITIAL EVALUATION

Semi-formed or liquid stool stresses pelvic floor continence mechanisms more than formed stool

Harder stools may point towards overflow and/or an evacuation disorder

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STOOL CONSISTENCY IS IMPORTANT

Avoiding offending foods (Fodmaps, caffeine)Ritualizing bowel habitsImproving skin hygieneHigh fiber – 2-6 grams/d can bulk stools by

absorbing water and increase stool transit time methocellulose 100% soluble and non-fermentable

psyllium 70% soluble*fermentable fibers may cause diarrhea

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SUPPORTIVE MEASURES

“Overflow” fecal incontinence? Laxative use? Rectal impaction? Evacuation d/o

Enable evacuation with suppositoriesAnorectal testing for evacuation

disorderpelvic floor retraining as indicated

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MANAGING CONSTIPATION IN FI

Evaluate for organic cause (biopsies for microscopic colitis, ? bacterial overgrowth)

ManagementConsider eliminating fructose, lactose, caffeineLoperamide Tricyclic antidepressant (desipramine, amitryptiline)

Bile Salt agents (especially post-cholecystectomy)

Alosetron for healthy pts with IBS-D

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MANAGING DIARRHEA IN FI

Norton, et al; Gastro: 126, 1, 2004, S64 - S70

Group 1: Standard medical/nursing care (up to 6 one hr sessions of info/advice)Group 2: Same as group 1 + verbal instruction and leaflet explaining KegelsGroup 3: Same as group 2 + computer-assisted biofeedbackGroup 4: Same as group 3 + home EMG biofeedback

No significant difference between treatment groups for all improvements

For all groups median number of incontinence episodes per week from 2 to 0 (p <0.001)

BEHAVIORAL MANAGEMENT OF FI IN ADULTS

Avoid rushing to the toilet Increases abdominal wall contractionsReduces focus on pelvic floor Instead, stop and perform Kegels bf proceeding to toilet

Clean, squeeze, recleanAfter BM, clean anus, perform 2-3 Kegels, reclean

Delay BM after biofeedback therapyStart with brief periods, then increase, which improves confidence

Wean off laxatives and anti-diarrheals04/19/23 30

EXAMPLE OF BEHAVIORAL TECHNIQUES

25% of pts will improve with behavioral modification

A few small single-center studies have shown benefit of biofeedback over pelvic floor exercises

Benefit may be highest in those with urge incontinence and predominantly EAS weakness

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BIOFEEDBACK

Haymen, S, Dis Colon Rectum 2009

EAS muscles overlapped in the anterior midlineBetter outcome than end-to-end repairLong-term data shows suboptimal improvement

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OVERLAPPING SPHINCTEROPLASTY

Temperature-controlled energy to anorectal junctionProduces scarring and narrowingVariable results with no large randomized trials

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SECCA

04/19/23 34LESS COMMON TECHNIQUES

Low-amplitude electric current applied to S3 via electrode in sacral foramen

Temporary lead can be placed in office and left for 7 days or surgically for up to 14 days

Patients with >50% symptom improvement can go on to have permanent stimulator placed

Meta-analysis from 2000-2008 shows complication rate of 15% with removal in 2.7&

Newer device smaller but expensive ($40K)

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SACRAL NEUROMODULATION

Data from 67/ 120 pts available at 5-8yrsFI episodes per week from a mean of 9.1 at baseline to 1.7

at 5 years, 89% (n = 64/72) had ≥50% improvement (p < 0.0001) 36% (n = 26/72) had complete continence27/76 (35.5%) pts required a device revision, replacement, or

explant.

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SACRAL NEUROMODULATION LONG-TERM

Tjandra, Disease of Colon and Rectum, Feb 2013

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SACRAL NEUROMODULATION LONG-TERM

Tjandra, Disease of Colon and Rectum, Feb 2013

Dextranomer microsphere in hyaluronic acid (Solesta)

Randomized, study evaluating 50% improvement at 6mos71pts (52%) in Tx group 22 (31%) in sham group had 50% improvement

No difference in 3 of 4 FIQOL

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INJECTABLE BULKING AGENTS

BenefitsOffice procedure with no sedationLow complication rates w/pain being most commonAt 12 mos, 69% noted improvement (higher than 6mo improvement data)

DisadvantagesMay need 2-3 injectionsCost of $4000-$5000/ injectionNo sx or anorectal data on which pts may benefit6% fully continent at 6mo, 11% at 12 mos

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SOLESTA

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Wald A, et al. Am J Gastroenterol 2014; 109:1141–1157

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CONSTIPATION

CONSTIPATION- ROME III

Prevalence of 14% (3-30% depending on population assessed)

Cumulative incidence of 17% over 12-yr period

555,000 ER visits yearly38,000 hospitalizationsIn 2004, direct costs of $1.6 billion

EPIDEMIOLOGY

Advanced age Often results from hard stool and excessive straining

Causes may include food intake, mobility, weakening of abdominal wall and pelvic muscles, chronic illness, psychological factors, medications

Female gender (2-3X higher)Low level of educationLow level of physical activityLow socioeconomic statusNonwhite ethnicity

RISK FACTORS

* Dyssynergic defecation affects 23% of constipated pts

CONSTIPATION SUBTYPES- FUNCTIONAL DEFECATION

DISORDERS

During repeated attempts to defecate must have at least 2 of the following:

A. Evidence of impaired evacuation, based on balloon expulsion test or imaging

B1. Inappropriate contraction of the pelvic floor muscles anal sphincter or puborectalis

B2. OR < 20% relaxation of basal resting sphincter pressure by manometry, imaging, or EMG

C. Inadequate propulsive forces assessed by manometry or imaging

INITIAL EVALUATION - DIGITAL RECTAL EXAM

Resting tone Augmentation of sphincter tone with squeeze Contraction of puborectalis during squeeze Tenderness of PR may indicate levator ani syndrome Palpate anteriorly for rectocele Have pt bear down or “expel my finger”

Should note descent of PR Should note relaxation of sphincter tone

DYSSYNERGIC DEFECATION (DD)

Defined as paradoxical contraction or failure to relax the pelvic floor

Abnormal Push Maneuver with Increase in EAS Pressure

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ANORECTAL MANOMETRY

BALLOON EXPULSION TEST

Balloon tipped catheter inserted into the rectum and inflated with 50mL of H2O

Timed measurement of patient’s ability to evacuate balloon in privacy

Balloon expulsion time of >2 min is abnlAbnl study suggests obstructive defecation

etiologies include DD, Hirschsprung’s, rectal prolapse, rectocele, enterocele, strictures

BALLOON EXPULSION TEST

Concordance of failed BET and DD of 72-94%

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Wald A, Bharucha AE, Cosman BC, Whitehead WE.Am J Gastroenterol. 2014 Aug;109(8):1141-57

Sensitivity and Specificity of BET as defined by ARM

Capsule contains 24 radio-opaque markers

Patient takes 1 capsule by mouth with water on Day 0

Patient should not use laxatives, enemas or suppositories for 24hrs before or for 5 days after

X-ray on Day 5 Abnl if 20% (>5-6 markers

remain)

STANDARD SITZ-MARKER TEST

If over 80% (5 or fewer markers remain) of markers are passed by day 5, colonic transit is grossly normal

If most rings are gathered in the rectosigmoid, may have functional outlet obstruction (may need anorectal manometry with balloon expulsion or defecography)

If most rings are scattered about the colon, patient most likely has hypomotility or ‘colonic inertia’

Line A- Posterior wall of the rectal ampulla

Line B –Axis of anal canalROLE OF BARIUM DEFECOGRAPHY

Consider if ARM and BET are inconclusive or suspect pelvic organ prolapse

Dyssynergic DefecationImpaired evacuation of contrast Inadequate widening of anorectal angle

Can evaluate foranatomical causesof constipation

OTHER CAUSES OF DEFECATION D/O

Rectal Prolapse

Descending Perineum Syndrome

Rectocele

Enterocele

Lee, et al. Neurogastroenterology & Motility 25 MAR 2015

Long‐term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow‐up

Biofeedback therapy is an instrument-based behavioral learning process centered on operant conditioning

http://youtu.be/lrTxCLUDDAQ

BIOFEEDBACK VIDEO

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Pelvic Floor Disorders are common but under-recognized

Bowel disturbance (diarrhea) biggest risk factor for fecal incontinence

Initial management should include behavioral modification/biofeedback and treatment of bowel disturbance

Newer options Like Sacral Neuromodulcation offer hope from chronic sufferers from fecal incontinence (? constipation)

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CONCLUSION