Bowel Retraining for Anal Incontinence

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Anal incontinence is the involuntary loss of control of rectal contents (solid, liquid, or gas) and can be secondary to a variety of causes. Conservative measures such as dietary manipulation, pharmacologic intervention, scheduled rectal emptying, perineal exercises, and biofeedback therapy are effective in many patients who are not surgical candidates or who do not desire surgical intervention for fecal incontinence. The bowel can then be trained to effectively reestablish continence using combinations of these techniques.

The approach to patients with fecal incontinence begins with the identification of the etiology of the incontinence. Stool consistency, colonic transit, rectal sensation, rectal compliance, pudendal nerve integrity, and sphincter complex function all have a role in continence. Increased stool consistency and colonic transit can result from a number of medical illnesses and alterations in colorectal function. Those patients who do not have concomitant dysfunction of the pelvic floor are best treated with dietary manipulation and constipating agents. All patients should be encouraged to adhere to a well-balanced, high-fiber diet with adequate fluid intake. The addition of fiber to the diet aids in bulking and solidifying the stool to facilitate control in defecation. Some patients may benefit from dietary restrictions such as lactose-free or gluten-free diets.

Multiple medications are available to help slow intestinal transit (Table 12-3.2). Loperamide (Imodium) inhibits intestinal motility through direct effects in the circular smooth muscle of the bowel. It also contributes to the con tinence by solidifying stool, increasing rectal compliance, and increasing the resting pressure of the sphincter complex. Diphenoxylate hydrochloride (Lomotil) can also be added to slow intestinal transit. Opium derivatives such as tincture of opium, paregoric, and codeine are very potent in slowing colonic transit via direct effects on the colonic musculature; however, the risk of addiction makes these agents less suitable for long-term use. Cholestyramine (Questran) is effective in slowing diarrhea in patients with known alterations in bile metabolism. It also helps bulk stool and may be of benefit in patients with chronic diarrhea.

Pseudo-incontinence, or overflow incontinence, may develop in patients with fecal impaction secondary to constipation. This cause of incontinence can be elicited from physical examination and is treated by removing the impaction and implementing a bowel regimen that prevents constipation and stool stasis.

Minor incontinence from either pudendal neuropathy or sphincter defects may also respond to conservative measures. Frequently, the addition of fiber and increased stool consistency are adequate to facilitate control in these patients.

For patients who are unresponsive to dietary and phar-macologic interventions, the institution of a regular bowel regimen can reeducate the bowel to evacuate at a predictable and convenient time. Colonic irrigations or suppositories administered at the same hour each day, preferably after meals when the gastrocolic reflex may contribute, serve to retrain the bowel to empty with regularity. Patients are taught abdominal massage and positioning exercises to reinforce patterns of defecation. The goal is to promote scheduled evacuations such that the majority of the time, the rectum is empty and episodes of incontinence are minimized. If a disorder in rectal evacuation accompanies the problem of fecal incontinence, ACE through a continent colonic conduit may facilitate regularity.

Evacuation retraining can also be accomplished with the help of a continence plug. The anal plug (the Pro con device) (Figure 12-3.1) consists ofa catheter that is inserted in the rectum and held in place by a balloon. The catheter has a sensor that detects flatus and stool. The catheter is attached to a beeper that signals when the rectum is full, preventing seepage and allowing adequate time to reach a bathroom and evacuate.

Table 12-3.2. Frequently used bowel agents for fecal incontinence

Agent Type

Name

Dosage

Loperamide

Imodium

2-4mg PO b.i.d.-q.i.d.

Diphenoxylate hydrochloride

Lomotil

1-2 tabs PO t.i.d.-q.i.d.

Tincture of opium

0.3 mL PO t.i.d.-q.i.d.

Cholestyramine

Questran

2-8g PO q.d.-b.i.d.

PO, per os; b.i.d., twice a day; q.i.d

., four times a

day; t.i.d., three times a day; q.d.,

every day

Pictures Procon For Bowel
Figure 12-3.1. Procon device.

Perineal (Kegel) exercises have proven to be beneficial in the medical management of both urinary and fecal incontinence. Perineal exercises retrain the muscles of the pelvic floor by increasing muscle bulk and tone of the external anal sphincter, puborectalis, and levators. Exercises consist of contracting the muscles used to hold in bowel movements for 15 seconds at a time. This exercise is repeated 15 to 20 times a day with results seen after several weeks. In patients who are unable to perform such exercises because of physical disability, sphincter contractility and tone can be increased by electrical stimulation of the sphincter muscle using an anal canal electrode. The device applies an electrical stimulus to the anal and pelvic floor muscles causing tonic contraction for 30-minute time periods. The repetitive contractions strengthen the muscles in the same manner as perineal exercises.

Biofeedback, or operant conditioning, is an effective form of behavioral therapy for fecal incontinence. The use of biofeedback is most successful in patients with minor incontinence in whom a viable, functioning, innervated sphincter exists. Using anal EMG probes or manometry catheters, the subject is shown the results of the anal and rectal pressure changes generated during the squeeze. Exercises that contract and relax muscles of the pelvic floor are performed while the records of the muscle activity are monitored on a screen. The result is improved strengthening and efficiency of the anal sphincter,improved rectoanal coordination, and increased rectal compliance and sensation. The patient is often able to strengthen the muscles of continence and train alternate muscles to compensate for weak or defective muscles, when needed. Each session takes 1 to 2 hours and occurs at 4- to 8-week intervals for a total of four to eight sessions or until the biofeedback therapist thinks the patient has obtained maximum benefit. Short-term results include success rates of 65% to 85% in most series and are dependent on the degree of initial dysfunction and patient attendance of all sessions. Effectiveness tends to deteriorate with time requiring reinitiation of biofeedback in some patients.

Bowel retraining for anal incontinence involves phar-macologic treatment and dietary interventions to modulate diarrhea and reestablish normal colonic function. Scheduled rectal emptying minimizes the incidence of fecal incontinence. Perineal exercises in combination with biofeedback serve to retrain and strengthen the muscles of the pelvic floor to allow for anorectal coordination for controlled defecation. Patients with severe incontinence or large anatomic defects in the anal sphincters may benefit from surgery if conservative interventions do not improve fecal control.

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