Fecal incontinence: nonsurgical options: biofeedback, anal plug, dietary changes.
Changes in dietary habits, such as avoiding gaseous foods, limiting caffeine, and increasing bulk, can help, as can certain medications. In those patients with chronic diarrhea--which can cause or worsen incontinence--constipating medications like Imodium and phenylephrine can help, said Dr. Tuckson, a colorectal surgeon in private practice in Louisville, Ky.
Imodium acts on the circular smooth muscle and increases resting anal tone and sphincter contraction. Topical phenylephrine increases anal canal resting pressure, and in a small, double-blind crossover study, 6 of 12 patients treated with it experienced improvements in their incontinence while 4 of 12 had complete cessation of incontinence.
Bowel management can also be achieved in some patients with stimulated defecation, which empties the bowel, reducing the likelihood of inadvertently passing stool. Enemas or suppositories can be used for this purpose, and patients find them most effective when used 30 minutes after eating.
Biofeedback is another option for some patients. Indications for this approach include a weak but intact sphincter, intact innervation, and a motivated patient. Biofeedback is not helpful in those with sphincter disruption or complete denervation, Dr. Tuckson said at the meeting, which was sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.
When surgical treatment is warranted, options include occlusion, sphincteroplasty, neosphincter, radio-frequency energy, and fecal diversion.
Occlusion, such as with the ProCon A200 device, involves the use of an anal plug with a sensor that indicates when feces is present. The plug is removed to allow defecation and then replaced. Ideal candidates for occlusion are nursing home patients with sphincter dysfunction and neurologic deficit.
Indications for sphincteroplasty include sphincter disruption, intact innervation, and adequate sphincter mass.
Contraindications include neuropathy and loss of sphincter mass. But the corresponding benefits are questionable.
In a study of 71 patients, only 14% were totally continent at the 69-month follow-up, while 54% remained incontinent for solid stool. Slightly better results were seen in a study of 86 patients: nearly half were completely continent at 40-month follow-up, but 35% remained incontinent for gas and 18% were incontinent for feces.
The Acticon Neosphincter is another device that has been gaining popularity for surgical treatment of fecal incontinence. This pump-based implantable system is indicated in patients who have neuropathy, sphincter deficit, or sphincter loss. Use of the device is contraindicated in patients with poor mental status, diarrhea, constipation, pelvic radiation, or perineal sepsis. Although infection has been a problem with neosphincter placement in the past, it is becoming less so as experience with it increases, Dr. Tuckson noted.
Another newer treatment is radio-frequency energy delivery to the anal canal, known as the Secca procedure. This involves submucosal electrode placement, submucosal burn, and mucosal irrigation, which work together to induce collagen contraction, focal wound healing, remodeling, and reduction in tissue compliance. It is indicated mainly for internal anal sphincter injury.
Fecal diversion is also a treatment option. It's not something patients come in asking for, but it "beats the devil out of having a perineal colostomy," Dr. Tuckson commented.
Patients should be told that fecal diversion with colostomy is not a failure, but a means for providing them with the ability to carry on with a good quality of life, he said.
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|Publication:||Internal Medicine News|
|Date:||Feb 1, 2004|
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