MDNews - Cleveland-Akron-Canton

++++++++++++++++++++++++ + +++ + WOMEN'S HEALTH U +++ ++++++++++++++++++++++++ The Unexpected Leak: Current Treatment Options for Fecal Incontinence By Amy George, MD F E C A L I N CO N TI N E N CE (F I) is a distressing disease which significantly impacts a person's quality of life and may cause psychological and social debilitation. The true incidence of FI is unknown. Community-based studies report rates from 1 to 24 percent.1, 2 A number of etiologies are associated with development of FI, and traumatic obstetric injury and aging are the most common causes. Embarrassment causes patients to be less likely to volunteer anal incontinence symptoms; therefore, healthcare providers should specifically inquire about these symptoms. Thorough understanding of anal continence mechanisms, a directed examination, optimal diagnostic testing and step-by-step treatment are the basis of effective management. Treatment includes medical therapies to reduce stool frequency and improve stool consistency. Dietary adjustments should focus on bulking of the stool with a high-fiber diet and removing foods causing diarrhea and/or fecal urgency. Medications can be introduced as needed to slow the bowels and increase anal sphincter tone. Pelvic floor rehabilitation with biofeedback is a mainstay of non-operative treatment with variable short-term success. It can be especially helpful in patients with an intact external anal sphincter. Some centers have reported success rates as high as 70 percent.3 Surgical management should be considered in patients for whom conservative therapy has failed or patients with distinct anatomic defects (cloaca-like deformity, 32 | Cleveland/Akron/Canton MD NEWS fistula). Multiple operative options are available, some technically challenging; therefore, treatment is individualized with careful preoperative counseling and clear delineation of patient priorities and post-operative goals. Many patients with distinct external sphincter damage can be treated with anal sphincteroplasty. Short-term success rates can be as high as 85 to 92 percent,4 with 50 to 60 percent of patients experiencing sustained clinical improvement five years post-surgery.5 Creation of an anal neo-sphincter from the gracilis muscle or implantation of an artificial anal sphincter are also possibilities. These methods are fraught with complications and frequent reoperations and are therefore rarely used. Additionally, colostomy is a predictable, effective treatment alternative in patients with multiple comorbidities that preclude more aggressive or time-consuming therapy. Newer, conservative treatment options include sacral neuromodulation and anal injectable agents. The Interstim device was FDA approved for FI in 2011. Continence is achieved through stimulation of the sacral nerves that modulate function of the anal sphincter. Randomized controlled studies have shown sacral neuromodulation significantly improves outcomes in patients with FI compared with patients optimized on medical therapy.6 It is a relatively safe, reversible and effective treatment alternative. Additionally, an anal sub-mucosal injectable agent, Solesta (hyaluronic acid/dextranomer), was FDA approved I MDNEWS.COM I SEPTEMBER- OCTOBER 2013 for treatment of FI in patients who have failed conservative therapies. Although long-term studies are lacking, this alternative is another nonsurgical option. Ultimately, prevention is the best strategy with emphasis on minimizing pelvic floor trauma/stress during and after delivery. Much of FI's effects are psychological; therefore, a supportive medical team is essential. Support groups or psychological counselors may also be helpful. Patients should be counseled that FI is not part of the normal aging or postpartum process, and effective treatments are available with goals of controlling continence and improving quality of life. Dr. Amy George is a urogynecologist with Summa Physicians Inc. She practices at Summa Akron City Hospital. I References: 1. Nelson R, Norton N et al. Community-based prevalence of anal incontinence. JAMA 1995; 274:559. 2. Markland AD, Goode PS et al. Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study. J Am Geriatr Soc 2010; 58:1341. 3. Ryn AK, Morren GL et al. Long-term results of electromyographic biofeedback training for fecal incontinence. Dis Colon Rectum. 2000; 43:1262–1266. 4. Farrell SA, Gilmore D et al. Overlapping compared with end-to-end repair of third- and fourth-degree obstetric anal sphincter tears: a randomized controlled trial. Obstet Gynecol 2010; 116: 16–24 5. Kamm MA. Faecal incontinence. BMJ 1998; 316:528. 6. Tjandra JJ, Chan MK et al. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum 2008; 51:494.

• Cover