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HeatherAdministrator

Reged: 12/09/02
Posts: 7322
Loc: Seattle, WA
Faecal incontinence - Many treatment options now exist
      12/16/03 12:17 PM

BMJ 2003;327:1299-1300 (6 December), doi:10.1136/bmj.327.7427.1299


Faecal incontinence - Many treatment options now exist for this embarrassing condition

Faecal incontinence, not a glamorous area of medicine, has changed markedly in its recognition and management over the past 10 years. Patients and doctors can talk about it now as the taboo is disappearing. Pathophysiology is better understood, helped by advances in imaging. Treatments are improving as they move away from invasive sphincter surgery as an early step to the use of simple pharmacological treatments, behavioural techniques, injectable biomaterials, and, when necessary, minimally invasive surgery.

Faecal incontinence affects both sexes and all age groups. Approximately 2% of the adult population have it on a frequent basis.1 The commonest cause of faecal leakage is probably degeneration of the delicate smooth muscle of the internal anal sphincter—the muscle that maintains sphincter closure.2 The commonest cause in young women is obstetric anal sphincter damage. Most sphincter damage is occult; approximately a third of first vaginal deliveries result in endosonographically identifiable structural sphincter damage; about a third of these are associated with new bowel symptoms of faecal incontinence or urgency.3 Forceps delivery is the greatest risk factor; others are a large baby, occipito-posterior position, and a prolonged second stage of labour. The same risk factors apply to the 1% of vaginal deliveries complicated by a recognised third degree tear.4

Structural damage to the sphincter can also result from surgery. This may be an unavoidable consequence of necessary treatment such as in the care of an anal fistula. Or it may result from anal dilatation, an outmoded form of treatment for chronic fissure or constipation.

In elderly people, especially those in care, faecal impaction is a common cause of leakage. Many factors contribute to this process, including constipating medications and poor mobility.5 Children with faecal impaction leak stool. Others have impaired continence after correction of congenital anorectal abnormalities.

A complete history, examination for sphincter damage or faecal impaction, and correction of predisposing factors, can lead to successful treatment in many patients. If further investigation is required anal endosonography has become the standard means of imaging the anal sphincter, and is now available in most specialist centres.6 It enables identification of structural damage and degenerative disorders of the sphincter muscles. When sepsis involves the sphincter complex, such as in complex perianal fistulas or Crohn's disease, magnetic resonance imaging provides accurate information.

Factors contributing to continence include the integrity of the sphincter muscles, the force of bowel contraction, consistency of stools, and cognitive factors. Each of these can act as a suitable target for treatment. Most commonly a combination of treatments is useful. For example, for patients with urge faecal incontinence, learning to overcome a sense of panic, sustain contraction of the sphincter, and titrate loperamide can lead to marked improvement in the symptom sometimes even when there is structural damage to the sphincter.7

Drugs that diminish the force of bowel contractions and enhance absorption of luminal colonic water can transform bowel control and the ability to function socially. Loperamide is effective in patients with symptoms of either urgency or leakage. The wide therapeutic to toxic ratio makes this a very safe drug in adults and one that should be titrated to achieve control of symptoms. If one capsule is too constipating patients can use smaller doses of the syrup formulation.

Topical application to the perianal skin is an alternative pharmacological approach. Topical phenylephrine, which increases the tone of the sphincter smooth muscle, is under development.8

Behavioural techniques have transformed the management of this condition.9 Even in patients with structural damage it is often possible to improve continence substantially, which implies that there is often an element of reversibility and that a complex combination of factors contributes to continence.7 9

A recent randomised study examined which component of behavioural treatment was most important.7 Treatment with bowel focused counselling, including advice on resisting urgency and titrating loperamide, was as effective as providing the patient with real time feedback—biofeedback—about sphincter function. The pharmacological treatment, advice, and nature of the interaction between therapist and patient seemed to be more important than the technical aspects of treatment.

In institutionalised elderly patients a combination of treatments is most likely to be fruitful, including attention to medications, regular toileting, and sometimes use of gentle laxatives.5 When non-invasive treatments have failed minimally invasive treatments can be considered. Injection of silicone biomaterial can improve leakage caused by a weak internal anal sphincter.10 Surgery should be reserved for patients with major incontinence that has failed to respond to conservative treatment and is necessary in only very few patients. However, no operation is capable of restoring the sphincter to its original finely tuned state.

An overlap repair of the sphincter is still the first line surgical treatment for major disruption of the sphincter due to obstetric causes, especially if there is loss of the perineal body. However, although the short term results are good, the long term results are less satisfactory.11

More invasive procedures include the artificial bowel sphincter or repositioning the gracilis muscle as a neo-sphincter around the anal canal.12 Both operations have a substantial learning curve, a success rate of about 50% in good hands, and are associated with considerable morbidity. Another treatment undergoing evaluation is radiofrequency ablation at the anorectal junction, a process that may induce fibrosis and prevent neurally mediated sphincter relaxations.

An alternative to sphincter surgery entails modulating the neural control of the lower bowel and sphincter. Chronic low amplitude stimulation of sacral nerves, via percutaneously inserted fine wire electrodes, is substantially less invasive than sphincter surgery and has proved successful.13

The socially disabling symptom of faecal incontinence is usually amenable to simple and inexpensive treatments. General practitioners need to be familiar with the condition, initiate treatment, or obtain help from continence advisers. Surgeons need to exhaust conservative treatments before proceeding to surgery and be realistic about the outcome of surgery. Healthcare providers need to establish multiskilled regional centres offering a range of diagnostic and treatment expertise.

Michael A Kamm, professor of gastroenterology

St Mark's Hospital, Watford Road, Harrow HA1 3UJ
--------------------------------------------------------------------------------
Competing interests: MK has acted as an adviser to Curon, Johnson and Johnson, Medtronic, and Uroplasty, and has received financial support from SLA Pharma.

References:

Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H, et al. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 2002;50: 480-4.[Abstract/Free Full Text]
Vaizey CJ, Kamm MA, Bartram CI. Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet 1997;349: 612-5.[CrossRef][ISI][Medline]
Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-11.[Abstract/Free Full Text]
Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308: 887-91.[Abstract/Free Full Text]
Potter J, Norton C, Cottenden A, eds. Bowel care in older people. Research and practice. London: Royal College of Physicians of London, 2002.
Law PJ, Kamm MA, Bartram CI. Anal endosonography in the investigation of faecal incontinence. Br J Surg 1991;78: 312-4.[ISI][Medline]
Norton C, Chelvanayagam S, Wilson-Barnett J, Redfern S, Kamm MA. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology (in press).
Cheetham, Kamm MA, Phillips RKS. Topical phenylephrine increases anal canal resting pressure in patients with faecal incontinence. Gut 2001;48: 356-9.[Abstract/Free Full Text]
Norton C, Kamm MA. Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults - a systematic review. Aliment Pharmacol Ther 2001;15: 1147-54.[CrossRef][ISI][Medline]
Kenefick NJ, Vaizey CJ, Malouf AJ, Norton CS, Marshall M, Kamm MA. Injectable silicone biomaterial for faecal incontinence due to internal anal sphincter dysfunction. Gut 2002;51: 225-8.[Abstract/Free Full Text]
Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long term results of overlapping anterior anal sphincter repair for obstetric trauma. Lancet 2000;355: 260-5.[CrossRef][ISI][Medline]
Madoff RD, Rosen HR, Baeten CG, LaFontaine LJ, Cavina E, Devesa M, et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective multicenter trial. Gastroenterology 1999;116: 549-56.[ISI][Medline]
Kenefick NJ, Vaizey CJ, Cohen RCG, Nicholls RJ, Kamm MA. Medium-term results of permanent sacral nerve stimulation for faecal incontinence. Br J Surg 2002;89: 896-901.[CrossRef][ISI][Medline]


Prevalence of faecal incontinence
Peter J Elton
bmj.com, 8 Dec 2003

http://bmj.bmjjournals.com/cgi/content/full/327/7427/1299

--------------------
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. * Symptom patterns in functional dyspepsia and irritable bowel syndrome HeatherAdministrator   11/28/04 02:34 PM
. * Obese Women Face Higher Risk of Colorectal Cancer HeatherAdministrator   11/08/04 04:48 PM
. * Obesity is Associated With Increased Risk of Gastrointestinal Symptoms HeatherAdministrator   10/24/04 07:42 PM
. * Stress Therapy Can Help Irritable Bowel HeatherAdministrator   10/24/04 07:38 PM
. * Relationship Between Colon Ischemia, Irritable Bowel Syndrome HeatherAdministrator   10/11/04 04:15 PM
. * Clinical Update on the Treatment of Constipation in Adults HeatherAdministrator   10/11/04 03:34 PM
. * Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life HeatherAdministrator   10/11/04 03:25 PM
. * What Differentiates Chronic Constipation From IBS With Constipation? HeatherAdministrator   09/26/04 03:25 PM
. * Treatment options in irritable bowel syndrome HeatherAdministrator   09/26/04 02:57 PM
. * Diagnostic approach to suspected irritable bowel syndrome HeatherAdministrator   09/12/04 03:38 PM
. * Dyssynergic Defecation: Demographics, Symptoms, Stool Patterns, and Quality of Life HeatherAdministrator   09/12/04 03:35 PM
. * Small Intestinal Bacterial Overgrowth - A Framework for Understanding IBS HeatherAdministrator   08/30/04 01:46 PM
. * New views - and some respect - for IBS HeatherAdministrator   08/30/04 01:25 PM
. * Categorization of dysmotility in patients with chronic constipation HeatherAdministrator   08/08/04 02:54 PM
. * Prevalence of IBS according to different diagnostic criteria HeatherAdministrator   08/08/04 02:50 PM
. * Irritable Bowel Can Follow Dysentery HeatherAdministrator   08/08/04 02:37 PM
. * Irritable Bowel Syndrome Remains a Difficult Condition to Manage HeatherAdministrator   07/24/04 02:09 PM
. * Intolerance to visceral distension in functional dyspepsia or irritable bowel syndrome HeatherAdministrator   07/24/04 02:17 PM
. * Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis HeatherAdministrator   07/24/04 01:42 PM
. * Irritable Bowel Syndrome Linked to High Rates of Various Surgeries HeatherAdministrator   07/11/04 02:15 PM
. * Drug-Free Ways to Treat IBS HeatherAdministrator   07/11/04 01:47 PM
. * Irritable Bowel Syndrome - An Evidence-Based Approach to Diagnosis HeatherAdministrator   06/27/04 01:14 PM
. * Biases Affect Treatment of IBS HeatherAdministrator   06/04/04 06:45 PM
. * Moms with Bowel Symptoms Take Baby to Doctor More HeatherAdministrator   05/25/04 11:53 AM
. * Natural History of Irritable Bowel Syndrome HeatherAdministrator   05/10/04 02:36 PM
. * Intestinal Gas May Contribute to IBS Symptoms HeatherAdministrator   05/10/04 02:29 PM
. * Are Your Bowels Irritable? IBS Awareness Month is Here HeatherAdministrator   04/09/04 07:11 PM
. * Heartburn May Not Reflect Gastroesophageal Reflux Disease Severity HeatherAdministrator   03/30/04 02:43 PM
. * A link between irritable bowel syndrome and fibromyalgia HeatherAdministrator   03/30/04 01:46 PM
. * Diverticular Disease: Electrophysiologic Study and a New Concept of Pathogenesis HeatherAdministrator   03/09/04 11:48 AM
. * New Syndrome Connects Gallbladder Dysfunction And Chronic Diarrhea HeatherAdministrator   03/09/04 11:45 AM
. * Researchers Pioneer Accessible, Cost-Effective Treatments for IBS HeatherAdministrator   03/08/04 06:48 PM
. * Splitting IBS: from original Rome to Rome II criteria HeatherAdministrator   02/10/04 02:35 PM
. * Utilization patterns and net direct medical cost to Medicaid of IBS HeatherAdministrator   02/10/04 02:34 PM
. * Family practitioners' attitudes and knowledge about IBS HeatherAdministrator   02/10/04 02:32 PM
. * The Effect of Somatization on Gastrointestinal and Extraintestinal Symptoms of IBS HeatherAdministrator   01/26/04 03:26 PM
. * Surgery and IBS HeatherAdministrator   01/26/04 03:21 PM
. * IBS Subgroups by Bowel Habit Predominance HeatherAdministrator   01/26/04 03:13 PM
. * Visceral perception thresholds in irritable bowel syndrome HeatherAdministrator   01/07/04 11:56 AM
. * Electric activity of the colon in irritable bowel syndrome HeatherAdministrator   01/07/04 11:52 AM
. * Irritable Bowel Syndrome's Possible Genetic Link HeatherAdministrator   01/07/04 11:40 AM
. * Intestinal gas distribution determines abdominal symptoms HeatherAdministrator   12/16/03 12:27 PM
. * Faecal incontinence - Many treatment options now exist HeatherAdministrator   12/16/03 12:17 PM
. * Abnormal Colonic Propagated Activity in Patients with Constipation HeatherAdministrator   12/16/03 12:07 PM
. * Colonic Propulsive Impairment in Intractable Slow-Transit Constipation HeatherAdministrator   12/16/03 12:03 PM
. * Overlapping upper and lower GI symptoms in IBS patients with constipation or diarrhea HeatherAdministrator   12/01/03 05:51 PM
. * Familial aggregation of irritable bowel syndrome HeatherAdministrator   12/01/03 05:49 PM
. * Outlook affects bowel disorder patients HeatherAdministrator   11/18/03 03:30 PM
. * Doctors unmoved by bowel misery HeatherAdministrator   11/18/03 03:28 PM
. * Travelers' Diarrhoea Can Trigger Irritable Bowel HeatherAdministrator   11/04/03 03:21 PM
. * Mind-Body Technique Eases Kids' Gut Pain HeatherAdministrator   10/30/03 11:17 AM
. * Molecular Alterations In Patients With Irritable Bowel Syndrome HeatherAdministrator   10/20/03 03:46 PM
. * Three in Four People With IBS Also Have Functional Dyspepsia HeatherAdministrator   10/15/03 03:28 PM
. * Infectious Gastroenteritis Linked to Irritable Bowel Syndrome HeatherAdministrator   09/30/03 02:27 PM
. * Association Between Pain Episodes & High Amplitude Pressure Waves in IBS HeatherAdministrator   09/16/03 03:54 PM
. * Constipation and its management HeatherAdministrator   09/16/03 03:41 PM
. * Contributions of suggestion, desire, and expectation to placebo effects in IBS patients HeatherAdministrator   09/16/03 03:28 PM
. * Do published guidelines for evaluation of IBS reflect practice? HeatherAdministrator   08/30/03 02:40 PM
. * Cognitive-behavioral therapy versus education and desipramine versus placebo for IBS HeatherAdministrator   08/12/03 12:54 PM
. * Distinctive features of postinfective irritable bowel syndrome HeatherAdministrator   07/28/03 03:18 PM
. * UCLA/CURE Neuroenteric Disease Program Newsletter HeatherAdministrator   07/23/03 10:38 AM
. * Bacterial Overgrowth in IBS HeatherAdministrator   07/18/03 12:15 PM
. * Diagnosis of irritable bowel syndrome. HeatherAdministrator   07/18/03 11:54 AM
. * Eradication of small intestinal bacterial overgrowth reduces symptoms of IBS HeatherAdministrator   07/18/03 11:44 AM
. * Antibiotics increase functional abdominal symptoms. HeatherAdministrator   07/18/03 11:41 AM
. * Treatment of the irritable bowel syndrome. HeatherAdministrator   07/15/03 11:02 PM
. * Extraintestinal symptoms in IBS and IBD HeatherAdministrator   07/15/03 06:21 PM
. * Postinfectious irritable bowel syndrome. HeatherAdministrator   07/15/03 06:19 PM
. * Dieting severity and GI symptoms in college women. HeatherAdministrator   07/15/03 01:13 PM
. * Functional GI disorders and eating disorders - Relevance of the association HeatherAdministrator   07/15/03 11:14 AM
. * Features of eating disorders in patients with IBS HeatherAdministrator   07/15/03 11:12 AM
. * New and Important Insights Into IBS HeatherAdministrator   07/14/03 03:24 PM
. * The Irritable Bowel Syndrome-Fibromyalgia Connection HeatherAdministrator   07/14/03 03:19 PM
. * Update on Treatment of Functional Gastrointestinal Disorders HeatherAdministrator   07/14/03 02:55 PM
. * Irritable bowel syndrome in primary care: The patients’ and doctors’ views HeatherAdministrator   07/14/03 02:43 PM
. * Inflammatory bowel disease and irritable bowel syndrome: separate or unified? HeatherAdministrator   07/14/03 02:32 PM

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