Incontinence and constipation: pelvic floor disorders of gastrointestinal motility and urodynamics.

Abstract

Approximately 13 million people suffer from urinary incontinence, and 6 million from fecal incontinence.1,2 Approximately 12% of the patients with fecal incontinence have stress urinary incontinence.3 Most of these patients have learned to live with their problem. Most of them use some form of diapers to maintain a satisfactory social life. The problem is so widespread that so-called complementary or alternative medicine providers have begun to use biofeedback mechanisms to treat these patients with a varied degree of success. These patients represent a wide variety of diagnoses and a wide range of severity. It behooves us to better understand these disorders so that patients may be advised correctly. To do so we must learn the diagnostic and therapeutic techniques involved so that we can deliver them in our offices and laboratories. In a series of three articles, Satish Rao carefully described the manometric evaluation of constipation, the manometric evaluation of fecal incontinence, and the technical aspects of biofeedback therapy for defecation disorders. All three articles were published as reviews in our merged journal, The Gastroenterologist.4-6 After a routine history and physical examination, and flexible sigmoidoscopy, the diagnosis of fecal incontinence should be evaluated by several tests that include either anorectal manometry, electromyographic evaluation, and/or rectal and anal sphincter sensitivity testing.7 Once sphincter dysfunction secondary to either obstetrical trauma, or to surgical trauma or fecal incontinence caused by diabetes or of idiopathic origin is identified,7 these patients become candidates for biofeedback therapy. There is a clear crossover between patients suffering from fecal and urinary incontinence. Snooks and colleagues note that neuropathy or nerve injury can cause disorders of either urination or defecation.8,9 Thorpe and colleagues studied 17 constipated women with urinary symptoms and 13 women with idiopathic fecal incontinence and urinary symptoms. They used anorectal manometry, balloon proctometography, measurement of the anorectal angle, and video-urodynamics to evaluate the patients. Their pelvic floor physiology studies showed that the fecal incontinent women with urinary symptoms had significantly greater anorectal angles and a higher grade of genuine stress incontinence than the constipated controls that indicated a weakened pelvic floor in this group of women. They stress that doubly incontinent women had greater severity of urinary incontinence and that this should be considered before corrective surgery is considered. It becomes clear from this study that there is an overlap between urinary and fecal incontinence symptomatology. It is also clear that we need more studies to evaluate subgroups of patients with these disorders. The degrees of incontinence and "rectal and urinary malfunction" after ileo-rectal anastomosis and after all forms of prostatectomy are poorly understood. Which patients will be helped by biofeedback treatment is also poorly understood. It is clear that some of these patients can be helped, and physicians should identify those subgroups that will benefit from treatment when there is nerve injury and/or pelvic floor muscle weakness. Enck reviewed biofeedback studies of fecal incontinence between 1974 and 1990.10 In the 13 publications, there were 322 patients evaluated. The treatment efficacy in most of the studies was done by assessing the reduction in the number of incontinent events. More than 75% of the patients reached the standard goal. However, most of the studies used diaries to evaluate the severity of posttreatment incontinence. It is difficult to evaluate the degree of success, although they concluded that between 50% and 90% of the patients were significantly improved by biofeedback treatment. In Rao's most recent publication,6 he evaluated 14 studies of biofeedback treatment in obstructive defecation between 1988 and 1997 with a total of 276 patients evaluated. Unfortunately, only 2 of those studies used manometry in their outcome assessment and relied, as Enck noted, on diaries. This analysis of the studies shows that symptomatic improvement ranged from 44% to 100%. The analysis of both Enck and Rao points out that we must have better standardized criteria for outcome evaluation. It is now clear that both incontinence and constipation can be caused by altered colonic and anorectal motility. Incontinence appears to be easier defined, but constipation caused by obstructive defecation may account for as much as 30% to 50% of chronic constipated patients.6 This is referred to as either pelvic floor dyssynergi or anismus. Biofeedback therapy attempts to correct one or more of the following: impaired rectal contraction, paradoxical anal contraction, absent or inadequate anal relaxation, or impaired rectal sensation. The landmark observations of Whitehead and Shuster11 and Wald12 have led us to this point in time to where biofeedback therapy is rapidly becoming available through many sources to patients. It behooves gastroenterologists to understand this area of anorectal and urinary pathophysiology because it appears to affect up to 1 in 11 people in our population. Since biofeedback is safe and may improve quality of life in anywhere from 50% to 90% of patients suffering from various forms of incontinence and constipation, we should make this treatment available to our patients. Martin H. Floch, M.D. John Dowd, D.O. Gastroenterology Section, Department of Medicine, Norwalk Hospital/Yale University School of Medicine, Norwalk, Connecticut