| Bowel
and anal sphincter dysfunction
Incontinence is the impaired ability to control wind or stool. Its severity
ranges from mild difficulty with wind control to severe loss of control
over liquid and formed stools. Incontinence to stool is a common problem,
with an estimated prevalence of 4 people in every 1000 rising to more
than 10 people in every 1000 above the age of 65 age. It is more common
in women and in the elderly of both sexes.
Many people
with faecal incontinence are ashamed to talk about this problem with their
doctor. They think that nothing can help them. However, many effective
treatments for faecal incontinence are available.
Bowel function and continence is controlled by three factors: anal sphincter
pressure, rectal storage capacity and rectal sensation. The anal sphincter
is a muscle that contracts to prevent stool from leaving the rectum. This
muscle is critical in maintaining continence. The rectum can stretch and
hold stool for some time after a person becomes aware that the stool is
there. This is the rectal storage capacity. Rectal sensation tells a person
that stool is in the rectum. Then the person knows that it is time to
go to the bathroom. A person also must be alert enough to notice the rectal
sensation and do something about it. He or she must also be able to move
to a toilet. If something is wrong with any of these factors, then faecal
incontinence can occur.
Muscle damage is involved in most cases of faecal incontinence. In women,
this damage commonly occurs during childbirth. It's especially likely
to happen in a difficult delivery that uses forceps and/or an episiotomy.
An episiotomy is when a cut is made to enlarge the opening to the vagina
for delivery of a baby. A young woman can often compensate for muscle
weakness. Typically, they only develop incontinence in later life when
their muscles are growing weaker and the supporting structures in the
pelvis are becoming loose. Muscle damage can also occur during anal surgery
(especially surgery for piles or deep fistulae). It may also occur in
people with inflammatory bowel disease or an abscess in the perianal area.
Damage to
the nerves that control the anal muscle or that are responsible for rectal
sensation is also a common cause of fecal incontinence. Nerve injury can
occur in the following situations:
- During
childbirth.
- With
severe and prolonged straining for stool (chronic constipation).
- With diseases
such as diabetes, spinal cord tumors and multiple sclerosis.
Incontinence
may also be caused by a reduction in the elasticity of the rectum, which
shortens the time between the sensation of the stool and the urgent need
to have a bowel movement. Surgery or radiation injury can scar and stiffen
the rectum. Inflammatory bowel disease can also make the rectum less elastic.
Because loose
stool (diarrhea) is more difficult to control than formed stool, diarrhea
is an added stress that can lead to fecal incontinence. A change in stool
consistency to a looser form often causes the problem of incontinence
to show up. If bleeding accompanies lack of bowel control, This must be
reported promptly. These symptoms may indicate inflammation within the
colon (colitis), a rectal tumor, or rectal prolapse - all conditions that
require thorough evaluation.
An initial discussion of the problem will help establish the degree of
control difficulty and its impact on your lifestyle. Many clues to the
origin of incontinence may be found in patient histories. For example,
a woman's history of past childbirths is very important. Multiple pregnancies,
large weight babies, forceps deliveries, or episiotomies may contribute
to muscle or nerve injury at the time of childbirth. In some cases, medical
illnesses and medications play a role in problems with control.
Afterwards
an examination of the anal and vaginal region is performed. It may readily
identify an obvious injury to the anal muscles. It will also identify
any weakness in the vaginal area which often are present and usually caused
by the same mechanism that lead to the anal weakness.
To obtain
an objective evidence of the extent of the weakness, additional studies
are required. These help to define the anal area more completely and use
it as a base line to monitor treatment progress. Anal manometry, is a
test where a small catheter is placed into the anus to record pressure
as patients relax and tighten the anal muscles. This test can demonstrate
how weak or strong the muscle really is. Pudendal nerve latency is another
test, which determines if the nerves that go to the anal muscles are functioning
properly. Endoanal ultrasound scan involves inserting probe within the
anal area to provide a picture of the muscles and show areas in which
the anal muscles have been injured. Finally, proctogram is another test
that may be done to look at the configuration of the rectum especially
if there is associated history of constipation.
After a careful history, physical examination and testing to determine
the cause and severity of the problem, treatment can be addressed. Mild
problems may be treated very simply with dietary changes and the use of
some constipating medications. In addition, simple home exercises that
may strengthen the anal muscles may help in mild cases.
In other cases, biofeedback can be used to help patients' sense when stool
is ready to be evacuated and help strengthen the muscles. Injuries to
the anal muscles may be repaired with surgery (sphincter repair). Diseases,
which cause inflammation in the rectum, such as colitis, may contribute
to anal control problems. Treating diseases such as colitis or rectal
prolapse may eliminate or improve symptoms of incontinence. Sometimes
a change in prescribed medications may help.
New research
is currently evaluation the use of topical ointments as well as new surgical
techniques such transposing and wrapping gracilis muscle around the anus
or insertion of artificial sphincter. In the past, patients with no hope
of regaining bowel control required a colostomy. Today, this procedure
is rarely required.
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