Constipation
Normal bowel habits vary from individual to individual. Having normal bowel movements is defined as having between three bowel movements a day and three bowel movements per week. If you have more than three bowels per day, this is considered diarrhea, and if you have less than three bowel movements per week, this is considered constipation.
Constipation can be best defined as either the slow transit of stool through the colon or the difficult evacuation of stool from the rectum. The slow transit of stool translates to infrequent bowel movements whereas difficult evacuation normally translates to excessive straining in order to have a bowel movement.
Most slow transit constipation is caused either by medications that a patient is taking or the poor intake of fluid and fiber. These can easily be remedied with simple solutions such as over the counter fiber supplements and over the counter stool softeners along with increasing the amount of water a person takes in during the course of the day. Rarely, however, constipation can be indicative of underlying conditions such as polyps and cancers and, therefore, where appropriate, colonoscopy is recommended.
There is a disease termed “colonic inertia” (or Slow Transit Constipation) that is an actual physical condition of the colon itself. The colon is made up of three layers and in between these layers are nerve cells that stimulate the colon to move stool forward. If there is a lack of nerve endings or a decrease in the number of nerve endings, then the colon cannot propel stool towards the rectum and therefore, in this small subset of patients, a surgical removal of the colon is the only cure for this problem. This can be done laparoscopically but only if all other options have been exhausted. A simple radiologic study can be performed that will accurately diagnose this condition.
If constipation is coupled with abdominal pain, this may be part of irritable bowel syndrome. In this group of individuals who have abdominal pain that is relieved by the moving of the bowels and who have changes in their lifestyle and quality of life because of constipation, there are some pharmacologic therapies that may help in addition to the supplements named before.
Difficult evacuation is a much more complex problem. This usually is a problem related to the pelvic floor or to the rectum and this requires specialized testing in order to determine what the underlying cause is. Again, significant straining or decrease in the width of the stool can be indicative of a polyp or cancer and should be evaluated first with colonoscopy. Often times significant straining to evacuate is a simple disorder of the muscles of the pelvic floor, where coordination of these muscles is abnormal and, therefore, moving your bowels is difficult. Other causes for significant straining include rectocele, which is a pouching of the rectum into the vagina. This is best diagnosed if aiding evacuation by supporting the rectocele is noted. This includes pressing the rectocele back into the rectum through the vagina during evacuation or pressing between the rectum and the vagina in order to aid evacuation. A symptomatic rectocele can be readily repaired surgically to fix this problem.
Other conditions that can cause obstructed defecation or difficult evacuation include rectal prolapse where the rectum comes out of the anus or internal rectal prolapse (internal intussusception) as well as nonemptying rectocele. These are best treated surgically. Full thickness rectal prolapse outside of the anus can be treated either laparoscopically by suspending the rectum back into the pelvis or through the rectum where the excess bowel is excised from below. For internal intussusception and nonemptying rectocele, a STARR (Stapled Trans-Anal Rectal Resection) procedure excises the excess prolapsing and redundant rectum transanally to restore both normal anatomy and normal physiology to the rectum.
The work up for constipation includes colonoscopy, radiologic studies and pelvic floor studies. Once an accurate diagnosis can be made, a treatment plan can be formulated that will improve the patient's bowel habits and therefore quality of life.
Fecal Incontinence
Fecal incontinence is defined as the inability to hold solid, liquid or gas from the rectum. This effects up to 10% of the general population and is especially common in senior citizens and people living in assisted-living and nursing homes. In the younger patient, this often is secondary to trauma to the anus, but in the older patients it is a much more complex problem.
For young patients with fecal incontinence this usually, in women, is caused by childbirth injury. The risk factors include multiple children, episiotomy, tear, prolonged pushing, and children of larger size. This may not be immediately evident after delivery, but may show up decades later as part of a more significant pelvic floor problem. Other traumatic injuries to the anus that can cause fecal incontinence include treatments for other anorectal conditions such as hemorrhoidectomies and procedures for anal fissure. Care should be taken in performing these procedures so as not to precipitate incontinence in patients at risk.
As women age, the level of estrogen begins to diminish and once menopause has set, is essentially absent. Estrogen builds up the pelvic floor and after menopause when the muscles of the pelvic floor begin to thin out, incontinence often shows up much later in life despite its origins at the time of childbirth.
Rare conditions that can cause incontinence include neurological conditions such as multiple sclerosis, spinal cord injury, and metastatic disease and this may be the first presentation of any of these conditions and, therefore, require a high index of suspicion.
The work up for fecal incontinence includes specialized testing of the pelvic floor that we perform here in the office. This allows us to measure the function of the muscles of the pelvic floor, the muscles of the anal canal and the function of the nerves that stimulate these muscles. In addition, when a sphincter defect is suspected, endoanal ultrasound is performed to identify a gap in the muscle that can readily be repaired surgically.
Other therapies for incontinence are either currently available or in study that may be offered in select circumstances. This includes the artifical bowel sphincter, sacral nerve stimulation, and the injection of particles to increase the bulk of the anal canal and prevent leakage. However, most incontinence will not need surgery. The majority of patients with fecal incontinence can be managed with appropriate bowel regimens, medications and specialized physical therapy that will train patients to use muscles not otherwise used in the maintenance of continence.
The biggest impediment to the treatment of fecal incontinence is the patient who is embarrassed or afraid to discuss this with their doctor. Be assured this is a much more common problem than is generally known and much time has been put into the diagnosis and treatment of fecal incontinence to improve quality of life.