Good deal. So I get the sexiest topics of the whole meeting. Stop the leakage and unplug the clog. So we're going to talk about fecal incontinence first. And then we're going to talk about constipation. And the ideal situation is you don't want to over-treat fecal incontinence so you get constipation. You don't want to over-treat constipation so you get fecal incontinence. You've got to find that middle of the road thing. So today we're going to appreciate the anatomy and physiology that's related to fecal incontinence. It's important to understand the process of continence so that you can troubleshoot with respect to diagnosing fecal incontinence. We're going to review the evaluation and workup of fecal incontinence and discuss evidence-based medical management of FI. So as many of you know, fecal incontinence is the accidental passing of solid or liquid stool or mucus from the rectum. And probably a more common term is anal incontinence, which includes loss of flattus with or without the loss of liquid solid stool. And I think this is just an important point for you to appreciate because most of the literature on rectal incontinence is with respect to fecal incontinence. In fact, we've tried to do trials with fecal incontinence. And sometimes prevalence rates are so low it's difficult to study. But if you use a more inclusive term, anal incontinence, you'll see that's much more prevalent in the community. So just like with urinary incontinence, there are various classifications of fecal incontinence, including urgent CFI, where there's a strong desire to defecate. Incontinence occurs despite the effort to retain stool. And you're going to see some similarities between conservative management for the bladder, as we see for the bowel, as you'll see for the bowel. Passive incontinence is a lack of awareness of need to defecate prior to the incontinence episode. And then fecal seepage is the leakage of stool after a normal evacuation, usually presenting a staining of the undergarments. And more recently, there's a little bit of increase in seeing a different phenotype of fecal incontinence, stress fecal incontinence. So with cough and sneeze, she also loses stool. So prevalence rates vary from 1% to 20%. These rates vary most likely because of the definition used, whether they're having fecal incontinence once every three months, once a month, once a week. It depends on the population studied. We see different prevalence rates in women 25 years of age compared to those 80 years of age. And the data collections methods that are used. Women that are filling out these questionnaires in the privacy of their own home may be a little more honest than when there's a face-to-face interview with someone. But a systematic review by Sharma et al, where the definition of FI is greater than or equal to one time a month, shows that prevalence rates somewhere between 8% and 12% in the community-dwelling woman. And this was data from NHANES, where almost 2,000 women. This was done through the Pelvic Floor Disorders Network, where almost 2,000 women were interviewed in their homes and underwent an examination in a mobile trailer. So subjective and objective evaluations. About 25% of these women had sun pelvic floor symptom. With respect to FI, you saw prevalence rates that are low, less than 5% overall, in women aged 20 to 29. 10% in the next age group of 40 to 59. 60 to 79, you see about a 14% prevalence rate. And hitting the age of 80 and above, prevalence rates were typically greater than 20%. So as noted, it's very important to understand how continence works so that you can treat incontinence. And fecal continence is maintained by a coordination of a functioning anal sphincter complex, intact sensation and reflexes of the anorectum, rectal compliance, the ability of the rectum to distend without increases in pressure, and conscious control of defecation. Additional factors which I would argue are probably the primary things you should be looking at is stool consistency and volume. And the whole goal of treating fecal incontinence is, number one, to keep the stool formed, and number two, keep the rectum empty. You can do that. You're not going to have fecal incontinence. So the presence of fecal matter in the rectum is usually normally first perceived at about 50 cc's. And this kind of stimulates what's called the rectoanal inhibitory reflex. And the sampling goes on. So think about when you're in the store, you start to get a little urgency in the bowel. You're kind of figuring out, is this a liquid stool, solid stool, is it gas? So the IAS, the internal anal sphincter, relaxes briefly in response to this distention. It allows for sampling. Oh yeah, I can pass this. Oh no, I can't pass this. I've got to wait and get into the bathroom. And the external anal sphincter reflexively contracts. As the rectum, as the rectal volume, increases to about 300 cc's, that's when a woman will start getting a strong urge to have a bowel movement. So I'm going to briefly review the anatomy of the anal sphincter complex and how it relates to fecal incontinence. So we have the puborectalis, which acts as a sling. And it typically is in a contracted state with increases in intra-abdominal pressure, decreasing the anal rectal angle so that stool doesn't pass. And it actually actively responds to increases in intra-abdominal pressure. Thankfully, because if we had to walk around consciously tightening our sphincter, that would be a full-time job. It relaxes during defecation, or should. It maintains continence of solid stool. And it's innervated by direct somatic efferent nerves of the sacral plexus. We then have the internal anal sphincter, which is a slow-twitch smooth muscle. It is derived from the inner circular muscle layer of the rectum. And it confers up to 85% of resting tone. So it's a very important part of the continence mechanism. It helps maintain continence of both liquid stool and gas. And dysfunction in the internal anal sphincter results in passive leakage. So it makes sense. If it's conferring up to 80% of control of continence and there's some denervation going on, passive incontinence can occur. And it's innervated by the superior rectal and inferior hypogastric plexus. The external anal sphincter, which many of us are aware of through obstetric, through our colleagues, is a striated muscle with slow-twitch and fast-twitch fibers, conferring the other amount of resting tone, 20% to 30%. It can actually contract a double resting tone. What we see as a normal resting tone, probably a low normal, is about 40 millimeters of mercury. When you're doing anal rectal manometries, you want to see that double to at least above 100 millimeters of mercury. It helps maintain continence of liquid stool and gas. And dysfunction results in a fecal urgency. The muscle's trying to contract. She's trying to contract it. But that urgency drives things and sometimes can result in leakage. And as you know, the external anal sphincter is innervated by the pudendal nerve. If we think of the anal area itself, oops, backwards, which we all do very frequently, I'm sure. Where is this? The anal canal goes from the dentate line down to the anal verge, usually three to five centimeters in length or so. And the canal also has some vascular cushions, which are expansions of the vascular tissue within the mucosa. And these also can contribute to the continence mechanism. So the etiology of fecal incontinence is quite complex and includes a lot of different potential players. There are the anal sphincter complex itself, which we all kind of primarily target. There could be an anal sphincter injury. There could be an intact external anal muscle, but there could be denervation of the muscle. You've got to think about whether she's had an anal rectal surgery or prolapse surgery or hemorrhoidal surgery. And then there can be primary neuropathies, diabetes, MS, spinal cord injury, stroke. All these things can impact the fecal continence mechanism. Rectal compliance is very important. If she has any kind of inflammatory bowel disease or that, the compliance of the rectum may not be able to suit what she needs. She needs to expand, just like the bladder. You expand without increases in pressure. And if she has a problem with that, stool may not be able to be maintained in the rectum. And then there are issues of conscious control of defecation and, as I stated primarily, diarrhea. Stool consistency is very important to treat. And diarrhea is a big player for many patients. So just as with UI, there are short validated measures with which to evaluate your patients. One that is used quite often in research is the Vasey-St. Marks, or the St. Marks, as well as the FIQOL. It's a very simple questionnaire. They bring it with them when they come to see you for their problem. You can take a quick look and see that the order of magnitude of the problem and its impact on quality of life. So really important to use one of these validated measures. And there's lots of short ones that don't take a lot of time. On evaluation, physical examination, it's very important to inspect for anal patulence. Make sure there's no loss of perineal body. Take a look for a dovetail sign, which is somewhat suggestive of an external anal sphincter tear. You want to evaluate for any posterior compartment prolapse. So looking for rectoceles, looking for rectovaginal fistulas. And usually, history will tell you if you're going to go that route. You'll want to ask her if she has any sensation of something passing through the rectum when she has a bowel movement. And DRE's digital rectal exam is very important to do. Make sure she can isolate, and with pushing, that she can relax. So we're not going to go into the testing modalities that exist. But it's just like with the treating of a constipation. You're going to try evidence-based empiric treatments first. But if those don't work, then you want to take the toolbox out and think about doing some diagnostic testing, including the pointers. Oh, there we go. Endoanal ultrasonography, anal rectal manometry, where you can really get some very helpful data. Deficography. More and more, I've done increasingly MRI deficographies, and especially in terms of refractory FI. And you can find other types of organic mechanisms that may be impacting her fecal continence. So I've kind of made that change there. Other testing, a balloon expulsion test, EMG, pudendal nerve terminal motor latencies. We don't do those anymore. Certainly, if there are any red flags or warning signs, you want to get a colonoscopy done. In terms of treatment of fecal incontinence, there's a lack of high-quality trials, although in the past five years, we've had one big trial looking at conservative approach to managing FI. And we need more good level one data. This is a nice algorithm for you. You're going to see all of us will present these algorithms. You'll get these slides at the end, so you'll be able to have the algorithms. This one was put together by Heidi Brown. It's in the Green Journal, 2020. And it goes through after you say hi, you get to know each other, assess for red flags, and kind of gives you the basic premise for an empiric treatment for the condition. So are the stools too loose? Are they too firm? It suggests the use of fiber. Does she have difficulty emptying? Is she able to relax her pelvic floor? Maybe pelvic floor therapy with biofeedback will be helpful. She can consider the use of vaginal bowel control inserts or anal plugs, and certainly the advanced therapies I'm going to go into, but I think you're going to see later in the course. So conservative management, first line, few exceptions, includes behavioral modifications. This means there'll be changes to diet, that type of thing, pharmacotherapy, and pelvic floor muscle therapy with or without biofeedback. So behavioral therapies include dietary considerations, take a look at medications, ritualize bowel habits by potentially promoting the gastrocolic reflex, coffee in the morning, bowel movement in an hour or so. And you want to keep the stool consistency around a Bristol stool scale score of about four and keep the rectum empty. So pharmacotherapies, fiber supplementation, kind of under that umbrella. There are different types of fiber. There's good data with psyllium as a fiber to use for women with fecal incontinence. Helps bind up the stool and make it more solid. And then antidiarrheals such as a loperamide, which is preferred over lamodal. There are decreased side effects. Loperamide's over the counter. I would just say always start low and go slow. Pelvic floor muscle therapy, there's no real consensus on what kind of regimen to follow. However, it is effective in many women. And it helps alleviate FI symptoms by improving rectal sensitivity, sphincter strength, and coordination of the continence mechanisms. So we did do a trial in the Pelvic Floor Disorders Network. This came out in Lancet Gastro in 2019. It was a randomized trial, factorial design, of women with monthly fecal incontinence. And they were randomized in a factorial fashion. So they were either randomized to loperamide or placebo, so active med versus placebo, and to anal exercises with biofeedback versus an NIDDK educational pamphlet. And the primary outcome was change in St. Mark's score from baseline to 24 weeks. So a woman could get the full treatment. She could be on loperamide and get biofeedback, or she could be on placebo and education and then in between. So she could be in four groups. We thought, this is the full strength patient's going to do the best. And to our surprise, we found no difference among these various treatments. And all the treatment approaches were higher than the MID of the St. Mark's score. So what this told us, we were kind of like, oh, bummed out at first. But really, what it tells us is good education with intention to empiric therapy, which this education included, can really help these patients. So a really important study. So there are devices. There's an anal insert plug. There are data that support its use. The biggest side effect of the plug was the hard plastic is really irritated to the anal mucosa. So a lot of women didn't like that. The vaginal bowel control system, the life study, which I was involved with, 86% of these patients had a 50% or greater decrease in fecal incontinence episodes. And if successfully fit, women were very happy with this. So there are various surgical approaches to the management of FI, which I am not charged to cover today. So there are some future directions, including a study of the use of vasus lateralis muscle cell injections into the anal sphincter. I'm on the DSMB for that. It's a pretty exciting study. OK, buckle your belt. Let's talk about constipation. So we're going to look at fairly similar types of topics in constipation as we did in fecal incontinence. So again, in order to understand the problem of constipation, we need to know normal bowel habits. And these are data from the NHANES study. Almost 5,000 people were asked about their bowel movement frequency. And what we found is that a bowel movement frequency was essentially between 3 and 21 per week. So this upholds the common metric of a normal frequency, three bowel movements a week to up to three bowel movements a day being considered normal. Another interesting part of the study was that stool consistency seemed to be a little different between males and females, whether that impacts on treatment of constipation or not. That was just a very interesting finding as well. So worldwide prevalence rates of chronic constipation are not well understood, probably for the same reasons as fecal incontinence. Population, definition used, that type of thing. But in general, chronic idiopathic constipation ranges from 1% to 15%. In the general population, the prevalence rates approximately 20%, although it can range anywhere from 2% to 27%, again, depending on the definition used. In a large multinational survey, the prevalence of Rome type IV functional constipation was about 8%. And interestingly, constipation is twice as common in women compared to men. And we'll take a look at some reasons why that may occur. So the normal pathology of colon motility is determined by high-resolution colonic manometry. shows that circular muscle contractions slowly mix and propel and tear at content. We're using short phase contractions, which do not really result in a lot of propulsion. They're low amplitude, long phase contractions, a little bit higher amplitude, a little more propulsive action, and then the giant migrating colonic contractions. These occur about 10 times per day. The pressure's quite high, up to 120 millimeters of mercury can occur 10 times per day and actively propel the colonic contents. So innervation is its own type of intrinsic innervation, the enteric nervous system, and it has about 400,000 to 600,000 type neurons that are present in the muscle layers as well as the lining of the GI tract and extends from the esophagus down to the anus. So it's own innervation type process. So the physiology of defecation, we've gone through that before when we looked at fecal incontinence. It's fecal loading of an otherwise empty rectum, distention of stretch receptors, relaxation of the IAS, contraction of the EAS, sampling of the contents. If she's in a socially acceptable situation, external anal sphincter relaxes, anorectal angle opens up, and she's able to have a bowel movement in theory. So you all are well aware of the Bristol stool form scales. What we aim for here are typically type 4 Bristol stool type. So what is constipation? Constipation is the complaint that bowel movements are infrequent and or incomplete and or there is a need for frequent straining or manual assistance in order to defecate. Or there's an unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or defecation that is both infrequent as well as difficult. So the Rome 4 criteria for functional constipation, a woman should have greater than or equal to two of these six type symptoms. And you can read them yourselves. Must have both that she doesn't have loose stools and does not meet the Rome 4 criteria for irritable bowel symptom syndrome C, which is constipation, which is delineated from regular constipation by the fact that a woman with IBSC has pain. And that's where the difference comes in. So just as in UI and FI, constipation can be classified into different types. Primary constipation is due to disordered regulation of colonic and anal rectal neuromuscular function, as well as brain, gut, neuroenteric function. And using symptom-based criteria, international experts have classified primary constipation into dyssynergic defecation, slow transit constipation, normal transit constipation should be here. And they also, as a primary cause, includes irritable bowel syndrome C. But we're not going to discuss that today. And certainly, there are, as you can imagine, secondary causes of constipation. Usually, these secondary causes are very modifiable. They just have to be found. So what do patients mean by constipation? They come in stating, almost half of them, that their stools are hard. Or they can't have a bowel movement. Or they can't complete a bowel movement. They feel a blockage sensation. They have to splint to have a bowel movement. They feel bloating and distention. And they have less than three bowel movements a week. So what do providers mean by constipation? Usually, less. We kind of hold on to the definitions, less than three bowel movements per week, based on 95% lower confidence limit from the NHANES data that you saw. But reports of bowel movement frequency are notoriously unreliable. So really, in this case, it's very helpful for a patient to do a bowel diary so you can get a handle on this, and for her to get a handle on this. She may actually find she has three a week. So important to delineate. So this is just FYI. This is not my final version of the talk. But we're going to talk about the various types of primary constipation, including pelvic floor dysfunction, normal transit constipation constipation, as well as slow transit constipation. So in terms of normal transit constipation, some of these patients have increased rectal compliance, have rectal hyposensitivity. So what came first? Again, kind of a chicken and egg situation. Otherwise, they have a totally normal colon and rectal physiology. And as we usually treat constipation with empiric therapy, these patients don't need a big workup. Any of these patients need a big workup right off the bat, because you're going to treat them all empirically. In slow transit constipation, it usually occurs in young women. Onset is usually very young. They have less than one bowel movement a week. They may have a little more abdominal pain, but mainly bloating and malaise. These symptoms, they've tried fiber. They've tried every osmotic laxative, both non-stimulant and stimulant. And what they found is that basically, it's a chronic situation. And this is the type of patient who typically fails empiric therapy or comes in having tried empiric therapy. You will want to do an evaluation on her. So slow transit constipation occurs because of disturbed autonomic neurovisceral refluxes. And this is known because a stimuli such as a balloon distension originating in the left colon can actually propagate to the rectum where the IAS relaxes. So you can artificially stimulate propulsion. And she can have a bowel movement. But in general, these patients have a higher sympathetic tone, so slowing bowel movement propulsion, a low parasympathetic tone, so those two go hand in hand, and they have also a disturbed coloanal coordination. So risk factors for chronic constipation include age, being female, not eating a lot of fiber. Fiber is critically important. Many people are at 10 grams a day. Slowly increase them to 25 grams a day. They may be on medications that are slowing down the bowel. They may have intrinsic neurologic conditions. So why in women greater than men, it's really unclear, although there are data that show that transit times may be prolonged in a woman's luteal phase. So the idea of maybe there's an overexpression of progestin receptors. This affects colon smooth muscle contraction. So there may be some of this going on. But there's also biopsy type data from these women that show it might be an inherent muscle problem. There are lots of medical conditions associated with chronic constipation. Drugs, we're going to look at it a second. But mechanical obstruction type conditions, such as colon cancer, strictures, rectoceles, metabolic conditions, myopathies, neuropathies, and other conditions. So you've got to get a checklist or something in your mind to go through these as you're thinking about your patient as she's presenting her history. A lot of meds that are associated with constipation. Probably the biggest ones we all see are opioids. But there are very many others that are associated with constipation. So defecatory disorders is also a very important thing to be aware of. There may be an inadequate coordination of the abdominal rectal and pelvic floor muscle. So instead of relaxation of the external anal sphincter, the puborectalis muscle, there may be a dysnergic response and a contraction. So the anal rectal angle doesn't open up and she's not able to relax and defecate. So this is really something to understand as well. Usually you can kind of get an idea about that on a pelvic exam. In many of these women, you try empiric therapy if they haven't already tried it, but then get them to a pelvic floor PT. So defecatory disorders can reflect rectoceles, descending peroneal syndrome, rectal hyposensitivity, and rectal prolapse, which you need to look for on physical exam. And these are the common clinical clues. Where they tell you they have prolonged straining, assumption of unusual positions. I had a dream about that last night. That was frightening. Support of the peroneum, inability to expel enema fluid. You get the story here. So we have a case. This is a woman who presents, 55-year-old. States that she's had constipation her whole life. And physical exam was essentially unremarkable. This is someone who's going to walk in your office. So her constipation symptoms started when she was younger. So a real chronic constipation patient. And she may have some pelvic dysfunction as well. So she definitely needs a good history and physical exam. So everything that we talked about before on how to evaluate the patient, you go through with her. Do a dietary history. Why are you here today if you've had this for 25 years? And are there warning signs? You want to rule that out in a new patient like this that comes to see you. So you want to do a good physical exam, just as we do with fecal incontinence. You want to do a perianal inspection, check sacral innervation, peroneal inspection, assess for impaction, any type of obstructive type things that may occur. You want to get an idea of her baseline basal sphincter tone. Have her contract, have her push. When she pushes, that should relax. And check for levator tenderness as well. So again, as with FI, don't rush her to the lab. Not everybody needs testing right off the bat. You'll see in some of these algorithms that you'll get that sometimes testing is warranted because they've already failed an empiric treatment. But testing can be helpful. If you need to exclude a structural disorder or symptoms are refractory to empiric treatment. So what does this testing involve? It may involve some labs, especially checking thyroid. It may involve anal rectal manometry, a balloon expulsion test, colon transit, a MR deficography, or a barium enema deficography. So it may involve any or none of these right off the bat. OK, I'm going to go through that. Oh, one thing I think is very interesting, if you're thinking that it is a slow transit, a SITS marker study is very helpful. It's easy to do. She has to be off all her stimulants. And she takes a capsule of the SITS markers. Five days later, gets a flattened upright. And if she has slow transit constipation, she'll have greater than 20% of those markers left after five days. So kind of the treatment, empiric treatment of a chronic constipation patient, non-pharmacologic treatment first, osmotic laxative, stimulant laxatives. If she's refractory to that, you're thinking anal rectal manometry, balloon expulsion test. If equivocal, you're thinking deficography. You may try pharmacologic therapy before you do this. It kind of depends on the patient. And the thing we want to avoid is a total abdominal colectomy for sure. So these are going to be in the slides. These are very nice summary of how to treat these patients, starting with the initial patient, history and physical. Are there alarm features? No. Education, high fiber, ineffective, goes on and shows a nice algorithm on where to treat. This is summary one for American gastroenterology. Summary two is that you know it's a primary constipation or you know it's a secondary constipation and you work down those lines. There are some overlaps in these two algorithms, but they adhere to the common principles of managing constipation. So reassurance, lifestyle changes, if expelling trouble, you can always do a squatty potty. That may help her. What that does is help reflexively relax the pelvic floor. Review meds, consider psychologic factors, and fiber and increase fluid intake for sure. So this is in the slides, obviously. We go through various types of laxative, bulkings, osmotic, stimulants, lubricants, and then serotonergic agents, such meds that you know, pro-secretary agents. This is all in the slides and can help you. There are good data for fiber supplements, especially with psyllium. It's very helpful for normal transit constipation. I found it a little helpful as well for slow transit constipation, but it doesn't change colonic transit time. Osmotic agents, as seen in the slide before, things like polyethylene glycol, Miralax, magnesium, lactulose. The stimulant laxative work by increasing motility and intestinal secretion. It's a dose-dependent effect. Ken, this is where, when I started off, if they're taking the meds too high, they can go from constipation to FI. So you have to find that right middle of the road dose if they are responsive to these medications. Stool softeners can work for some patients. However, a few randomized controlled trials really show benefit with stool softeners. And in fact, I think stool softeners make the stool pasty and make it harder to evacuate for some patients. Enemas and suppositories can help some patients, although you have to be very careful that you don't injure the rectal wall, which can cause problems in and of itself. And then there are some suppositories which are a little less invasive than enemas. Lots of meds. So here, this gives you the pathophysiology of how these meds work. The amitiza and linzess, these are all in the slide deck. Basically, they all increase propulsion of the bowel in order to help pass stool. So lots and lots of meds. Most of these have pretty good data beside them. So take a look at meds if indicated in the algorithm. So you've got a slow transit constipation. What do you do when medications fail? A very nice algorithm here. The thing with these failure of empiric and even individualized treatment, depending on type of constipation, the lower get a little tight in terms of you start thinking about the surgical options. Partial colectomy, ileo, reanastomosis, all these types of things that should be far down the path. If she has a defecatory disorder and what if biofeedback fails, again, a very nice algorithm to follow, which brings in more testing. But again, those bottom line considerations involve surgery. There are other kinds of treatments, including botulinum toxin, but there's not a lot of good data there. And then others, including sacral nerve stimulation. I don't think we have that approval yet in the US for S&M. This is mind boggling to me, a vibrating capsule. Take a capsule, feel it vibrate through your colorectal tract. Acupuncture, there are some data for acupuncture, just as with bladder pain. Surgeries include total abdominal colectomy with iliorectal anastomosis. Involves chronic, can involve a cecostomy with integrated enemas. That's making a connection between the bowel and the abdominal wall for stool to come out. MACE is a Malone integrated colonic enema. STAR procedures are thought, you guys know what those are, that's thought to help in terms of optimizing anorectal angle. And then certainly, if there's an evident large rectocele, you're going to want to fix that. When to refer to GI? I think we manage the majority of these patients. And the whole intent of this talk is so you can manage these patients. There's evidence-based, there's good algorithms that you can use with these patients. However, to my mind, if there are new unexplained change in bowel habits, persistent narrow stool caliber, bleeding, anything a little funky, a family history of colorectal cancer, Lynch syndrome, get them into the GI doc or partner with them in terms of managing these patients. So two tough problems, two kind of complementary problems, a lot of similarities between the two in terms of approaches to treatment. Chronic constipation is common, especially in women. Most patients can be managed without partnering with a gastroenterologist. But if you don't manage them, send them to your gastro or send them to a urogyne who does manage them. A therapeutic approach can be very organized and very evidence-based. Know when to refer. When you're reaching a point when they are refractory to treatment, you want to think about diagnostic testing. So in this 40 minutes, we looked at the etiology of fecal incontinence and constipation and often can be multifactorial. Rarely will single treatment guarantee perfect outcomes. We know this. We know this from UI. We know it's true in FI and constipation. Behavioral modifications, pelvic or muscle training are first line, with or without medical management. And new innovations are really needed because these are areas that really impact women's quality of life. So thank you.

fecal incontinence

constipation

gastrointestinal issues

diagnostic evaluations

treatment strategies

colonic motility

biofeedback

evidence-based approaches