Editorial

 

Fecal incontinence, an ignored and concealed problem

 

Fecal incontinence is a symptom on which gastroenterologists are poorly informed, whereas an understanding of this complaint may allow clinicians to provide help for most patients (1,2). It is an involuntary, recurrent loss of feces through the anus (3). It is called anal incontinence when there is an unwanted release of gas, whether or not in association with fecal loss. Individuals suffering from this condition experience a deeply negative impact on their quality of life both in the physical and psychological spheres, which accounts for the increasingly greater attention they receive. The true prevalence of fecal incontinence is unknown, since those who experience it will not usually disclose this symptom. It is believed to involve approximately 5% of the general population (4,5), and almost 50% of elderly individuals in geriatric nursing homes (6,7). Its frequency is supposed to become higher in the next few years, given the population's longer life expectancy. In this issue of Revista Española de Enfermedades Digestivas, Ballester et al. (8) review the presence of anal and urinary (double) incontinence in women attending a primary care clinic for other reasons, and discuss factors related thereto. To this end they evaluate 103 women between 20 and 64 years of age with no known risk factors. They found that the prevelence of double incontinence was 9.7%, similar to that found in other studies (9) and in a Spanish study on urinary incontinence (10). Although including a moderate number of patients, this is the only study of this type ever performed in Spain, and as we just mentioned reveals that the prevalence of incontinence has been underestimated.

Fecal incontinence develops when structures or functions in the anal-rectal region become altered (fecal consistency, anatomic and neurologic integrity of anal sphincters, rectal compliance and sensitivity) (11-13). The most common causes that may impair these mechanisms include diarrhea, inapparent injury during birth, and neurologic conditions. It is a common occurrence that following years of normal continence women develop incontinence during the sixth or seventh decade of life when aging and hence pudendal nerve denervation and sphincter muscle weakness act on previous obstetric lesion (14-16). Diarrhea usually unveils, favors or aggravates some other disordered mechanism of fecal retention (2). Regarding therapeutic decision making, it is important that true diarrhea be told apart from false, overflow diarrhea. The latter is common in the elderly as a result of fecal impactation from limited physical status, which induces relaxation of the internal anal sphincter and hence potential soiling. Chronic constipation may in addition result in external anal sphincter hipotonia through pudendal nerve injury during defecation stress (17).

Elderly patients with fecal incontinence are known to also experience urinary incontinence; hence it is considered that having one type of incontinente (either fecal or urinary) is a risk factor for having the other type (18). A close association has been reported between double incontinence and vaginal delivery or chronic regional stress, but few studies have investigated factors predisposing to double incontinence in the female general population (10,19). As Ballester et al. conclude in this issue of Revista Española de Enfermedades Digestivas (8), age, number of vaginal deliveries, and overweight are associated with the presence of anal and/or urinary dysfunction. Although age and the number of vaginal deliveries have been consistently reported in the literature as risk factors for incontinence, such is not the case for overweight (20). Results obtained by these indicate suggest that overweight is an independent risk factor for both anal and urinary incontinence in women, and they suggest that greater weight may result in extremely high intraabdominal pressures, which would in turn impair the pelvic floor (21).

Symptoms and a physical examination help intuit some causal mechanisms on occasion (22); however, having recourse to other, more complex diagnostic techniques is often needed (23). Although to date no protocol has been firmly established for the assessment of anorectal conditions, techniques currently recommended for the exploration of fecal incontinence include anorectal manometry, rectal sensitivity testing, surface electromyography, and ultrasonography (4,24,25). These tests complement each other, as the etiology of fecal incontinence is usually multiple. With the information provided by these tests the mechanisms involved in continence and defecation may be better understood, and more rational therapies may be initiated (26-28). However, the fact that they are performed under non-physiologic conditions is somehow a limitation.

The information provided by these studies is essential for treatment selection; indeed, if a structural sphincteric disorder is revealed, this may be amenable to surgical treatment, whereas other etiologies may benefit from conservative therapy. Regarding the latter, any causes of diarrhea should be controlled using specific measures. Otherwise, hygienic-dietary recommendations, bulking agents, and or antidiarrheic agents such as loperamide may be indicated. The mechanism through which antidiarrheic agents act is thought to be by slowing down bowel motility and by decreasing stooling frequency, which would result in better formed feces. Aminotryptiline is a tricyclic antidepressant that has been empirically used to improve symptoms in patients with idiopathic fecal incontinence or diarrhea-predominant irritable bowel syndrome. In low doses it reduces rectal motility, most probably through an anticholinergic action (29). Besides being useful against diarrhea, loperamide increases the tonus of the internal anal sphincter (30). Phenylephrine gel is undergoing clinical trials, as it plays a role in smooth muscle vascularization and hence modulates internal anal sphincter innervation, increases sphincteric tonus, and may be useful for patients with passive fecal incontinence, who have an intact though hypotonic internal anal sphincter. Side effects are minimal, and its usefulness for structural disorders in this sphincter is being assessed (31). In case of overflow diarrhea the rectum should be lavaged using suppositories or enemas, and laxatives should be prescribed. In the elderly hygienic-dietary measures and drug therapies may help improve their status during this time of life. Biofeedback techniques attempting to strengthen the external sphincter or to improve rectal sensitivity may be associated with these measures (32). This may be result in improvement in around 75% of patients, and in healing in around 50% of cases (2,33). However, the real usefulness of this technique has not been established yet, since reported studies about it are non-controlled, and patient selection, biofeedback type and duration, and response assessment lacked homogeneous criteria. On the other hand the role played by other concurrently prescribed therapies awaits definition (33). In this sense the patient-physician relationship regarding education on useful strategies has been seen to be potentially more relevant for the improvement of fecal incontinence than exercise or biofeedback on sphincteric function (32). The fact that the etiology of fecal incontinence is often multiple makes it possible that continence be achieved by merely correcting some the involved causes. Finally, sacral nerve stimulation has shown promising preliminary results with minimal morbidity; however, few studies are available thus far to define its role in the management of fecal incontinence (34).

In view of the common occurrence of both fecal and urinary incontinence in one patient, studies on both disorders should be carried out by interdisciplinary teams (gastroenterologists, surgeons, urologists, gynecologists, physical therapists, psychologists). The therapies for fecal incontinence (biofeedback, sphincteroplasty, antidiarrheic agents, laxatives, sacral nerve stimulation) require validation from controlled randomized studies. Regarding urinary incontinence, a comparison of drug, behavioral, and surgical therapies is still due. Similarly, studies comparing combination therapies using biofeedback and surgery versus surgery alone or biofeedback alone are also needed. New drugs acting on baseline anal pressure are needed for fecal incontinence, and other drugs acting on distension hypersensitivity would be most welcome for urinary urge incontinence (35).

The incidence of incontinence may probably be significantly decreased if risk factors are identified and excluded. For instance, a number of standard obstetric practices such as unnecessary episiotomy or cesarean delivery in high-risk patients should be avoided, and women should be instructed to work up their pelvic floor before and after delivery, and educated to avoid stress during defecation. Similarly, since a number of authors - including Ballester et al. in their paper in this issue (8) - conclude that overweight is a risk factor for incontinence, it seems reasonable that preventive measures are taken against it, particularly given the fact that obesity is becoming increasingly common in the general population.

In addition, understanding and informing these patients, who may sometimes need psychological counseling, may help them get over the social impact of this improvable disabling condition, which is challenging for physicians and leaves a wide margin for further investigation.

M. T. Muñoz Yagüe

Service of Digestive Diseases. Hospital Universitario 12 de Octubre.
Madrid, Spain

 

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