Accidental Bowel Leakage: Prevalent, Underreported, but Treatable
Shafik Sidani, MD
, Virginia Hospital Center Physician Group-Colorectal Surgery
, received his medical degree from the American University of Beirut. He did a two-year post-doctoral research fellowship in gastrointestinal physiology at Yale University, where he was the recipient of multiple grant awards for his research. He completed his general surgery internship at Yale New Haven Hospital, followed by residency at Georgetown University Hospital. He then completed fellowship training in colon and rectal surgery at the University of Minnesota. He is an Associate Fellow of the American College of Surgery and a member of the American Society of Colon and Rectal Surgery.
In a national survey of women age 45 and older, one in five had at least one episode of bowel leakage in the previous year, with 40% of this group reporting a severe negative impact on their quality of life (see Box). Yet, few said they sought medical care or even volunteered information about the condition to a physician.
An Underreported Condition
For this reason, Shafik Sidani, MD, Virginia Hospital Center Physician Group-Colorectal Surgery, recommends that PCPs, gynecologists, gastroenterologists, and colon & rectal surgeons screen for fecal incontinence through a patient intake form or during a health maintenance visit. As a way to frame the conversation, he noted the majority of respondents in the survey mentioned above preferred the term “accidental bowel leakage” to “fecal incontinence.”
Risk factors include a previous vaginal delivery or obstetrical injury; other factors include urinary incontinence, bowel disorders, stroke, nervous system disorders, or a history of pelvic radiation. Women age 55 and older are most likely to have the condition. Although younger women can have bowel leakage immediately after obstetrical sphincter injury, the majority of those affected occur years later as muscles atrophy. Men are less frequently affected.
Looser stools are harder to control, so the PCP’s first line of treatment is to try to thicken stool consistency when appropriate.
If this does not help, a specialist can further evaluate the patient with anorectal physiology testing, endoanal ultrasound, and defecography.
Sacral Nerve Stimulation
Until recently, options for treatment were few, Dr. Sidani explained. A sphincter repair, done primarily for young women with recent obstetrical injury, shows good short-term results but less so in the long term. The artificial bowel sphincter has been on and off the market, with a relatively high risk of complications. Injectible bulking agents and radiofrequency treatment of the anal canal can help with minor incontinence, while a colostomy is a dramatic step appropriate only in certain situations.
But in 2011, the FDA approved sacral nerve stimulation (SNS) for fecal incontinence. Dr. Sidani trained at the University of Minnesota, one of the nation’s most renowned pelvic floor centers that helped pioneer this minimally invasive outpatient procedure for fecal incontinence. He said SNS can be life-changing: 90% of patients have at least a 50% improvement, and up to 40% report complete continence.
In the first of two stages, the surgeon implants the lead of the device; if it works for the patient, the surgeon implants a permanent stimulator in the buttocks two weeks later. “Having the test phase is a great option. There is nothing to lose,” he said. “I’ve seen SNS work on patients with sphincter defects, certain spinal anomalies, radiation injuries, and some nervous system disorders.”
The patient learns to do basic programming, and the specialist performs more complex programming and changes the device every 3–5 years when the battery is depleted. There are limitations to getting an MRI in the presence of the device. Therefore, patients requiring MRIs may not be appropriate candidates for this particular treatment.
Prevalence and Terminology Preferences
While adults of all ages can be affected, researchers at University of California San Diego focused on 6,800 women over age 45 via an Internet-based questionnaire about fecal incontinence. As reported in the International Journal of Clinical Practice (“Accidental Bowel Leakage in the Mature Women’s Health Study,” November 2012), about one in five (18.8%) reported at least one incident in the previous year. Among these women, 97% said they were bothered by the condition, and 71% said they preferred the term “accidental bowel leakage” (ABL) to “fecal incontinence.” Only 29% spoke to a physician about their ABL, the majority of whom did so to their primary care physician. The authors recommended incorporating questions regarding ABL or bowel or bladder disorders into routine screening to aid in identifying “silent sufferers.”