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Faecal Incontinence: A Debilitating and Surprisingly Common Condition

Digestion | October 16, 2014 | Author: The Super Pharmacist

Digestion

Faecal Incontinence: A Debilitating and Surprisingly Common Condition

Faecal incontinence is usually defined as the involuntary loss of solid or liquid stool. Anal incontinence is a broader concept that includes loss of solid or liquid stool, flatus (passing gas), or mucus. The two terms are sometimes used interchangeably, and some surveys have included the loss of flatus in the definition of faecal incontinence.

Faecal incontinence is a significant cause of social embarrassment and imposes a high cost on the patient and the community. It can be physically and psychologically disabling, leading to progressive isolation and a devastating social impact.

Faecal incontinence in nursing homes has been associated with cognitive and physical impairments, both of which place a person at risk for institutionalisation. Faecal incontinence is a significant problem worldwide. Yet due to the socially stigmatising and sensitive nature of the symptoms, and the incorrect perception that little can be done to treat or minimise it, faecal incontinence is largely under reported. 

Severity of Faecal Incontinence

Severity of Faecal IncontinenceThe measurement of faecal incontinence is challenging. Because faecal incontinence is a symptom, the subjective perception of the patient must be the foundation of any evaluation of incontinence or the impact of incontinence.

The lack of a criterion standard makes testing measures for reliability and validity more difficult. Despite this, many measures are available and can be divided into three broad categories:

  • descriptive measures that do not provide summary scores 
  • severity measures that assess the frequency and type of incontinence
  • impact measures that assess the effect of incontinence on quality of life

Among others, scoring systems include the Rothenberger, Wexner, Vaizey and Fecal Incontinence Severity Index systems. The Wexner scale is judged to correlate the most closely with subjective perception by patients, and also with clinical assessment of symptom severity by investigators. Due to its simplicity, it is the most commonly used scoring system.

Risk Factors for Faecal Incontinence

The National Institute for Health and Clinical Excellence outlines the following as high risk groups for faecal incontinence:

  • Frail, older individuals
  • Patients with loose stools or diarrhoea from any cause
  • Women who have recently given birth (especially after third or fourth degree obstetric injury)
  • Patients with neurological or spinal cord disease or injury
  • Patients with severe cognitive impairment or learning disabilities
  • Patients with urinary incontinence
  • Patients with pelvic organ or rectal prolapse
  • Patients with perianal soreness, itching, or pain
  • Patients who have had colonic resection, anal surgery, or pelvic radiotherapy

Age causing faecal incontinence

Age is significantly associated with the prevalence of faecal incontinence in both men and women.  A multivariate regression analysis showed age to be a strong predictor of faecal incontinence after adjusting for the number of chronic illnesses, overall health status, and physical activity level. The mechanisms that could explain this effect of age on the prevalence of faecal incontinence could not be identified.

Diarrhoea causing faecal incontinence

Faecal incontinence has been shown to be positively correlated with diarrhoea. The relationship between diarrhoea and faecal incontinence is probably causative, as liquid stool is more difficult to control than solid stool. The symptom of urgency (having to rush to the toilet) has also been associated with faecal incontinence.

A number of diseases and conditions can cause diarrhoea and treatment depends on the suspected cause.

Common causes of diarrhoea include: 

Diarrhoea causing faecal incontinenceViruses: Viruses that can cause diarrhoea include Norwalk virus, cytomegalovirus and viral hepatitis. Rotavirus is a common cause of acute childhood diarrhoea.

Bacteria and parasites: Contaminated food or water can transmit bacteria and parasites to the body.

Diarrhoea caused by bacteria and parasites can be common when traveling in developing countries and is often called traveler's diarrhoea.

Medications: Many medications can cause diarrhoea. The most common are antibiotics. Antibiotics destroy both good and bad bacteria, which can disturb the natural balance of bacteria in the intestines. This disturbance sometimes leads to an infection with bacteria called Clostridium difficile, which also can cause diarrhoea.

Lactose intolerance: Lactose intolerance is the inability to digest and absorb the sugar found in milk and milk products. It is a common cause of abdominal cramping, bloating and diarrhoea and is caused by a deficiency of an enzyme called lactase. The body normally synthesises lactase, but its production declines with age. Three different forms of lactose intolerance exist:

  • Acquired lactase deficiency is the most common. Here, production of lactase  decreases with aging and can stop completely (physiological lactase deficiency).
  • Primary or neonatal lactase deficiency is very rare and means that there is no lactase production from birth on.
  • Secondary lactase deficiency develops as a result of gastrointestinal diseases like celiac disease or Crohn's. Secondary lactase deficiency may improve when the underlying gastrointestinal disease improves.

Diarrhoea caused by lactose intolerance can be controlled by the elimination of milk and dairy products from the diet. Lactose-free milk and lactose-free dairy products are readily available at most supermarkets and have identical nutritional value.

Chronic illness: Several studies have reported an association between poor overall health and faecal incontinence.

Urinary incontinence: Urinary incontinence is significantly associated with faecal incontinence. The association is believed to be related to the fact that both the external anal and external urethral sphincters are innervated by the sacral nerves.

Diarrhoea causing faecal incontinenceObstetric traum: Obstetric trauma is a major predisposing factor for faecal incontinence. The injury may involve either the external anal sphincter, internal anal sphincter or the pudendal nerves, or all three. Prospective studies demonstrate that nearly 35% of primiparous women have evidence of sphincter disruption following vaginal delivery, and between a third to two-thirds of women who sustain a recognised third-degree tear during delivery subsequently suffer from faecal incontinence.

Other obstetrical risk factors for both sphincter laceration and faecal incontinence are vacuum extraction, forceps delivery, prolonged second stage of labor, and large birthweight. Some studies suggest that cesarean delivery is associated with lower rates of sphincter laceration and faecal incontinence compared with vaginal delivery, but other studies find no significant difference.

Episiotomy: Episiotomy is an obstetric technique where the external sphincter is intentionally cut in the belief that this prevents uncontrolled tears of the perineum and sphincter during vaginal childbirth. This was once standard practice and is still performed in some places. However, large case series have demonstrated that episiotomy does not reduce the severity of sphincter lacerations or the risk of faecal incontinence, but instead exacerbates it. Midline episiotomies are associated with higher rates of sphincter laceration compared with mediolateral episiotomy.

Hemorrhoids: Hemorrhoids are more common in women than in men and often develop for the first time during straining with childbirth. Overall, 48–63% of patients with grade 3 or 4 hemorrhoids (requiring manual reduction) report soiling of underwear. Furthermore, surgical treatment of hemorrhoids sometimes involves a myectomy (partial excision) of the internal anal sphincter in order to reduce anal canal pressure (and, hence, reduce straining). This procedure is associated with an increased incidence of faecal incontinence. In a large case series at the Mayo Clinic, myectomy was shown to result in some degree of faecal incontinence in 45% of patients.

Obesity: Obesity is a risk factor for faecal incontinence. The mechanism for this may be that obesity increases the intra-abdominal pressure on the pelvis, rendering the continence mechanism less efficient.

Irritable bowel syndrome: Population-based studies have demonstrated an excess incidence of faecal incontinence in patients with irritable bowel syndrome.

Neurologic disorders: Many neurological disorders place patients at increased risk of faecal incontinence. Diabetes mellitus was associated with a 40% increase in the risk of faecal incontinence in one study. 

Diarrhoea causing faecal incontinenceMicrovascular complications associated with diabetes mellitus may damage the nerve supply to the rectum and pelvic floor musculature, and this is presumed to be the mechanism for the increased risk of faecal incontinence in diabetes mellitus patients. 

Other neurological diseases, including stroke, multiple sclerosis, dementia, traumatic spinal cord and brain injury have been associated with faecal incontinence. These can affect continence by interfering with sensory perception or motor function, or both. Approximately 30–50% of patients with multiple sclerosis are reported to have faecal incontinence.

Surgery for prostate cancer: Faecal incontinence has been shown to increase slightly after radical prostatectomy. 

Radiation therapy and brachytherapy for prostate cancer: Both radiation therapy and brachytherapy (the insertion of radioactive prostatic implants) appear to be risk factors for faecal urgency and faecal incontinence.

Preventing Faecal Incontinence

Prevention refers to eliminating or ameliorating risk factors before faecal incontinence develops. Modifiable risk factors for faecal incontinence include diarrhoea, obesity and surgical/obstetrical practices. Behavioral and lifestyle changes can reduce the risk of faecal incontinence due to diarrhoea and obesity.

A recent study has also demonstrated reductions in prevalence of faecal incontinence from 19% to 9% with weight loss in patients undergoing bariatric surgery. 

In the past, episiotomy was routinely carried out at delivery, based on the belief that this would control and, therefore, minimise sphincter tears. However, recent evidence demonstrates that episiotomy does not prevent sphincter laceration but, instead, tends to make it worse. The use of routine episiotomy can cause morbidity in women who would have otherwise had an intact perineum. In fact, the risk of anal sphincter injury from a non-extending midline episiotomy is triple that compared with a spontaneous laceration. On the strength of this evidence, many obstetricians have abandoned episiotomy which has resulted in a substantial reduction in the incidence of sphincter lacerations.

Treating Faecal Incontinence

Pelvic floor muscle training and/or biofeedback: 

Pelvic floor muscle exercises (also known as Kegel exercises) are intended to strengthen weak pelvic floor muscles. Biofeedback is a type of therapy where surface electrodes are placed over the pelvic floor muscles and connected to a computer. Contraction of the muscles is recorded on the display monitor.

In a 2012 study, 21 randomised (or quasi-randomised) trials involving 1525 participants were reviewed to determine the effects of biofeedback and/or pelvic floor muscle training in the treatment of adult faecal incontinence. The authors concluded that the limited number of trials together with the methodological weaknesses of many precluded a definitive assessment of the role of these modalities in the management of patients with faecal incontinence. Another recent analysis of 22 trials involving 8485 pregnant women failed to identify a clear benefit of pelvic floor muscle training either in terms of urinary or faecal incontinence. A meta-analysis of biofeedback in the treatment of faecal incontinence concluded that biofeedback yielded no greater benefit than standard care. 

Although some evidence suggests that pelvic floor muscle training has short-term effectiveness in treating urinary incontinence in older women, evidence is insufficient to support any sustained, long-term benefits of either pelvic floor muscle training or biofeedback in preventing or reversing faecal or urinary incontinence.

Dietary interventions

Certain dietary measures may alleviate or even control diarrhoea:

  • Low fibre diet
  • BRAT (banana, rice, apple, toast)
  • Avoiding excessively hot or cold fluids (these are stimulants)
  • Avoiding dairy products, high fibre foods or highly seasoned foods

Medications

Antidiarrhoeal agents, fibre supplements, and laxatives demonstrate efficacy in specific types of faecal incontinence.

Antidiarrhoeal agents: Antidiarrhoeal agents, such as loperamide hydrochloride and diphenoxylate/atropine sulphate are the mainstay of drug treatment for diarrhoea-related faecal incontinence. Placebo-controlled studies have demonstrated a reduction in the frequency of faecal incontinence, improvement in stool urgency, increase in colonic transit time as well as increase in the resting anal sphincter pressure.

Fiber supplements: One study has demonstrated that increasing dietary fiber is helpful in reducing diarrhea-associated faecal incontinence.

Laxatives: If faecal incontinence is related to constipation, with wet stool leaking out around a hard mass, enemas or suppositories can be used to stimulate stool evacuation. Laxatives can also be used for constipation-associated faecal incontinence, a condition that occurs more commonly in children and the institutionalised elderly.

Surgery: There are several surgical treatment options for faecal incontinence. Sphincteroplasty involves the reconnection of separated ends of a torn sphincter muscle. Injection of collagen or another bio-compatible bulking agent into or near the anal muscle is performed to improve closure of the anal sphincter. A colostomy or ileostomy diverts the colon to an artificial opening in the abdominal wall.

Sacral nerve stimulation: Among the experimental treatments for faecal incontinence, the most promising is sacral nerve stimulation. In this procedure, the surgeon uses a needle to insert electrodes into the sacral nerve plexus and identifies a site where stimulation causes the external anal sphincter to contract. If such a site is found, the patient is provided with a temporary stimulator for approximately 2 weeks. If the 2-week trial is successful, the stimulator can be permanently implanted. Large clinical trials have now been carried out, which demonstrate improvements in 80–90% and full continence in approximately half of patients who are implanted. There are a significant number of complications, including infections, device failures and migration of electrodes, but the overall experience has been positive.

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