Faecal incontinence: diagnosis
Faecal incontinence is a debilitating condition which can be associated with a variety of causes. There are also several types of faecal incontinence with specific features and symptoms.
The treatment of faecal incontinence must therefore start from a careful diagnosis. During the initial exam, the clinician will be able to identify the causes of the problem based on the features and frequency of the bowel movements and on the patient’s general state of health.
The clinician will also be able to identify problems in the functioning of the sphincter muscles through an examination called anorectal manometry.
The clinician may also request a transanal ultrasound to better assess the anatomy and functioning of the pelvic floor. Transanal ultrasound is especially useful in patients with a history of vaginal childbirths or of previous surgery in the anorectal area.
After the examination and the diagnostic tests, the doctor will indicate the most appropriate therapy and any changes in diet or lifestyle. In fact, the treatment of faecal incontinence involves several aspects which must be addressed in synergy and evaluated case by case.
Faecal incontinence care: diet and lifestyle
Sometimes, changes in eating habits and lifestyle can help prevent or reduce the discomforts associated with faecal incontinence.
Diet and eating habits
In the case of faecal incontinence, changes in diet and eating habits can help to alleviate the symptoms for sufferers.
If faecal incontinence is related to diarrhoea, it is useful to give preference to foods which are able to absorb liquids. In particular, the intake of foods rich in fibre or of fibre dietary supplements are suitable.
Specifically, foods with a laxative or irritating effect on intestinal mucous membranes, including coffee, alcoholic beverages, spices and smoked products should be avoided or limited. Those who suffer from specific food intolerances, such as lactose and gluten, will have to eliminate foods containing these substances from their diet.
For further information on foods to avoid in case of diarrhoea, click here.
It is not only the foods that are eaten that influence bowel activity. Attention must also be paid to meal times and frequency in order to make evacuations more regular and predictable and to limit the discomforts associated with the disease.
Bowel movements are also influenced by our emotional state and by the time we spend eating. A hectic and stressful lifestyle with quickly eaten meals does not allow proper food digestion and will affect bowel regularity.
Anyone who suffers from faecal or soiling incontinence must take thorough care of his/her intimate hygiene to prevent genital infections. It is important to use specific cleaning agents for the perianal area to avoid scenarios which will leave faeces in contact with the skin for a long time.
Regular physical activity helps to tone the pelvic floor muscles. By contracting, the pelvic floor contributes to improving continence. Pelvic floor problems, in conjunction with other factors, may promote the onset of incontinence.
However please note that some sports activities, including weight lifting and improperly performed exercises, can damage the pelvic floor. Intense and sudden efforts cause an increase in abdominal pressure which, if not counterbalanced by the contraction of the pelvic muscles, can cause involuntary faecal leaks.
Bowel movement habits
It is also important to avoid too much straining during evacuation. These increased efforts can damage the muscles involved, leading to the onset of the problem or aggravating it, if it is already present. It is therefore important to keep the stools soft and moisturised and to prevent constipation.
Faecal incontinence: remedies
In cases of mild faecal incontinence, first-choice medical treatment is often conservative and may include:
The medicines used for treating faecal incontinence aim to obtain control of faecal consistency, avoiding the formation of stools which are contain too much liquid. Liquid stools are in fact more difficult for the body to retain and can cause more discomfort to those suffering from faecal incontinence.
So, in addition to dietary and lifestyle changes, the clinician may also recommend anti-diarrhoeal medications. In patients with chronic diarrhoea, these medicines can help reduce incontinence episodes, improving stool consistency.
The main side effects which can occur after taking these medications are constipation, headache, nausea, flatulence and vomiting.
Absorbent plugs or anal plugs are small synthetic plugs inserted into the anus to eliminate unintentional leaks of faeces. Anal plugs must be replaced often to prevent the onset of local infections and irritations and are not recommended in case of haemorrhoids and of anal fissures.
Biofeedback: rehabilitation of the pelvic floor
A very common conservative treatment used in the early stages of the disease is pelvic floor rehabilitation in the form of biofeedback.
Biofeedback is a form of active exercises performed in the clinic with the use of dedicated equipment. Rehabilitation of the pelvic floor, with exercises for incontinence, is recommended for patients who do not respond to other conservative therapies.
Biofeedback involves the insertion of a small probe in the anal canal and part of the rectal ampulla. The probe collects information on the pressure exerted at different points of the anal canal. These data are then converted into bars of different colours which can be seen on the monitor. The colours indicate the degree of contraction and relaxation of the muscles involved.
After having learned the exercises for an improved management of the defecation reflex, the patient can verify their correct execution by viewing the coloured bands. The whole procedure takes about 15 minutes and has no complications or contraindications.
The goal of biofeedback is to improve the sensitivity and tone of the pelvic floor. This treatment has variable benefits. Furthermore, the clinical data available to date do not allow to clearly assess its efficacy.
Biofeedback is often combined with electrotherapy, a passive muscle stimulating technique aimed at contracting the anal muscles with electrical impulses. Biofeedback and electrotherapy are often performed in sequence during the same session.
The doctor inserts an electrode into the anal canal with which he/she stimulates the fibres of the anal muscles. The treatment lasts about 10 minutes.
As with biofeedback, the results of electrotherapy are also variable and unproven. Unlike biofeedback, electrotherapy is also contraindicated in patients with pacemakers.
Faecal incontinence: surgical treatments
Should the Faecal incontinence symptoms not respond to conservative therapies or if they recur, the doctor may recommend surgery. The surgeon will choose the most appropriate operation based on the symptoms and features of the disease and on the patient’s general state of health.
There are in fact many surgical techniques for treating faecal incontinence, with different levels of effectiveness and invasiveness:
Sphincteroplasty is used to repair lacerations of the sphincter muscles. This procedure is useful for treating circumscribed traumatic lesions caused by obstetric injury or by surgery in the anorectal area.
However, this is a complex and very invasive technique, with a high risk of infections and frequent relapses. Effectiveness is also conditioned by the number and extent of lacerations and the age of the patients.
Post-anal repair is used to remedy sphincter muscle problems not caused by lacerations but by weakness of the pelvic floor and of the anal sphincters. The surgeon overlaps the pelvic floor muscles to lengthen the anal canal and sharpen the anorectal angle. The surgery aims to reduce the weakness and the lowering of the pelvic floor and of the sphincter muscles.
This operation is used increasingly less because of its limited long-term effectiveness.
Dynamic or stimulated graciloplasty
Traditional graciloplasty involves replacement or support of the sphincter muscles by placing muscle tissue taken from the thigh muscles (gracilis muscle) around the anus.
The surgeon can use traditional graciloplasty, defined as dynamic, or electrically stimulated graciloplasty. For electrically stimulated graciloplasty, transplantation of the gracilis muscle to the area around the anus is associated with implantation of an electrical stimulation device. The electrical stimulation device allows the patient to control the closure of the anus and the impulse to defecate with a constant electrical stimulation.
These interventions result in a significant improvement of the symptoms in the short and medium term and are suitable for more severe cases of incontinence.
However, graciloplasty is associated with a high percentage of complications and with lengthy recovery times. As it is an invasive and complex technique, it involves certain risks which can sometimes be very serious. Among the most common complications we have the onset of infections and pain in the treated areas, obstructed defecation and a worsening of continence in the long term.
Artificial anal sphincter
The traditional artificial anal sphincter is the replacement of the sphincter muscles by implanting a prosthesis to control the closure and the opening of the anus.
The implanted prosthesis can have different features depending on the procedure adopted. The most used procedure involves the implant of a silicone balloon and of a sleeve connected to a control port. The port allows the patient to contract and release the sphincters voluntarily by manual pressure. A less used variant involves the installation of a flexible magnetic ring around the sphincters to restore their functionality.
This procedure allows to obtain good results in controlling faecal incontinence and is also suitable for the disease’s more advanced degrees.
However, this is a very invasive technique with many complications. The most frequent side effects include: infection and malfunctioning of the control valve, a need for re-operation and removal of the prosthesis, the erosion of tissues in the implant area and difficulty in evacuation.
Transanal radiofrequency involves the use of electromagnetic energy at a controlled temperature to restore the functionality of the anal sphincters. Electromagnetic waves cause micro lesions in the tissues which, by healing, cause them to contract and promote continence.
Transanal radiofrequency is a minimally invasive surgical procedure, often performed under sedation or local anaesthesia, which allows a rapid return to normal activities. This method offers results in the short term and a significant improvement in continence and anorectal sensitivity.
However, long-term results are not proven. Moreover, clinical evidence on the efficacy of this method is still scarce. The most frequent complications are bleeding, anal pain and ulceration.
Sacral nerve stimulation (SNS)
Sacral nerve stimulation is a surgical option originally used for the treatment of urinary incontinence. This technique was later extended to faecal incontinence.
Sacral nerve stimulation is based on the electrical stimulation of the sacral nerves. This stimulation acts on the rectal sensitivity with the aim of improving the functionality of the anal sphincters.
The procedure is divided into two phases:
- test stimulation with a temporary electrode implant: of variable duration between 2 and 6 weeks, it allows to evaluate the efficacy and tolerability of the treatment before the final implantation.
- final implant of the electrode: it provides for the final implantation and customisation of the neural stimulator which can be managed directly by the patient with a remote control.
Sacral nerve stimulation has shown good results on urge incontinence in the majority of patients in the short and long term, with its efficacy documented by ample clinical evidence. This procedure is also useful for the treatment of chronic constipation and of intestinal problems due to congenital anal malformations.
However, complications such as infections, electrode displacement, frequent re-operations for overhauling or repositioning the electrode, allergies, local pain are described. This surgical technique is also associated with the discomfort of undergoing multiple procedures and of manually activating and deactivating the neural stimulator. Within the UK this procedure is only offered in certain areas.
Colostomy is used in case of the failure or inability to perform any other surgical procedure. It is a highly invasive and debilitating radical surgery.
During a colostomy operation, a part of the large intestine is forced out of the abdominal wall to allow the evacuation of stools. The opening that connects the intestine to the abdominal wall is called a stoma. If the diversion of the faeces concerns the final part of the small intestine (ileum) it is called ileostomy.
The intestine will continue to empty through the stoma on into a special bag for stool collection. This bag must obviously be emptied regularly. The patient will also have to take care of the hygiene of the area to prevent infections and irritation related to the passage of stools.
Colostomy can involve different parts of the colon. Depending on the portion concerned, a distinction is made between:
- ascending colostomy: this involves the ascending colon and is uncommon. In this part of the colon the stools are still liquid or semi-liquid and therefore very irritating to the surrounding skin.
- transverse colostomy: this involves the transverse colon in which liquid or partially formed stools are still present.
- descending colostomy: this involves the descending colon in which there are semi-solid stools.
- sigmoid colostomy: this involves the lower part of the colon which contains already formed stools since the liquids have already been absorbed in the other parts of the colon.
The intestinal stoma can also be temporary. This happens if a part of the intestine must not be used for some time, for example after surgery.
Permanent colostomy is a very invasive procedure which creates discomfort and anxiety in the patient. Those who undergo this procedure often find it difficult to adapt to the new condition. After a colostomy, the patient must undergo lengthy rehabilitation at specialised facilities.
The surgical and the post-operative procedure are also characterised by a high mortality rate and by complications which can also be serious, such as peritonitis, faecal fistulas and septicaemia.
Minimally invasive surgery: the THD GateKeeper® & THD SphinKeeper® methods
The THD GateKeeper® & THD SphinKeeper® methods are surgical techniques which allow the treatment of faecal incontinence with high efficacy and low levels of invasiveness. These techniques involve the use of self-expanding biocompatible prostheses to improve sphincter function and to correct incontinence.
For further information on the THD GateKeeper® & THD SphinKeeper® methods, click here.