it a minute for the folks to stroll in here virtually and we'll get started. Welcome, everyone. I'd like to welcome everyone tonight to the Ogg Virogynecology webinar series. I'm Pam Fairchild. I'll be moderating today's webinar. Today's webinar is entitled Accidental Bowel Leakage, an Update on Evaluation and Treatment. Our speaker today, Dr. Candice Parker Autry, is an assistant professor at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina. She received her medical degree at Wake Forest School of Medicine and completed residency in obstetrics and gynecology at the Hospital of the University of Pennsylvania. She then went on to fellowship in FPMRS at the University of Alabama and has special clinical and research interests in geriatric medicine, focusing on dual incontinence, including the evaluation and management of accidental bowel leakage. We're excited to have Dr. Parker Autry speak with us today. I'm going to do a few housekeeping reminders. The presentation is going to be around 45 minutes. The last 15 minutes will be dedicated to questions and question and answer. To claim your C&E credit, you have to log into the Ogg e-learning portal and complete the evaluation following completion of the webinar. The webinar is recorded and is live streamed. The recording will be available in the Ogg e-learning portal after completion of today's session. Please use the question and answer feature of the Zoom webinar to ask any of the speaker questions. We will answer them at the end of the presentation. Use the chat feature if you have any technical issues. The Ogg staff is going to be monitoring the chat and can assist at any point. Without further ado, let's get started. Thank you so much, Dr. Fairchild, for that introduction. Our objectives today are to review the physiology of anorectal continence with a focus on anorectal complex anatomy and neuromuscular function. We are going to do a case-based review of the evaluation of bowel incontinence as well as an evidence-based review of treatment options and algorithms. The rectum and anus are the terminal portions of the GI tract. The rectum is 12 to 15 centimeters long and the anus is approximately 2 to 4 centimeters long. Women have a slightly shorter anal canal than men with a mean length of 4 centimeters and is on average 5 centimeters in men. Besides this, the anorectal function or the canal are similar between both sexes. The rectum contains three distinct semilunar recosal folds that you can see here, which help to maintain its capacitance. The rectum can accommodate up to 300 cc without any significant increase in interlunar pressure. Beyond that volume, however, the interlunar pressure increases and this results in a sensation to feel like you have to defecate. Retrograde colonic cyclic motor patterns have been hypothesized as a rectocyclic break that can limit the feeling of the rectum. The wall of the rectum also has functioning continence. From its inner to outer layers, it has mucosal surface, a submucosal layer, and a muscular and cirrhosis layer. The muscularis layer has smooth muscle layers that includes a network of intrinsic neurons. Recall that the epithelium changes from columnar epithelium in the rectal wall to the squamous epithelium at the dentate line or pectineal line located at the mid-portion of the anal canal. This is approximately two centimeters from the anal verge. The anoderm is the squamous epithelial portion of the anal canal and it has numerous sensory nerves that allow for what we call sampling function of the anus. This refers to the tactile and nociceptive signals that determines the composition of a bolus that is pushed into the anal canal to distinguish between solid, liquid, or gas contents. When we think about the anatomy of the bowel incontinence mechanism, the enteric nervous system is very important. The physiology of colorectal function is dependent on properly functioning enteric nervous system, which is an independent component of the nervous system. This controls peristalsis through intrinsic enteric nerve plexi within the muscularis of the bowel wall, and conditions that affect this enteric nervous system result in megarectomy. For example, we've heard of Hirschsprung disease, which is a congenital incomplete migration of neuronal crest cells. There's also Chagas disease, which is a tropical parasitic infection that impacts the ganglionic cells in this area. With less nitric oxide producing neurons, the internal anal sphincter does not relax to accommodate for a defecation, resulting in ballooning of the rectal wall. The enteric nervous system is also responsible for most bowel actions. In the small intestine, peristalsis uses sequential and synchronous contractions to repel food and waste to the large intestine. However, downstream functional obstructions result in increased pressure in the lumen of the bowel to move contents forward. So constipation is a form of this obstruction, or this functional obstruction. And thus, we have often, we have constipated patients with quote-unquote diarrhea, because the lumen of the colon is attempting to move the fecal bolus forward by contracting with greater force. But this doesn't result in solid stool moving forward, but with liquid stool moving past the solid stool through a continent rectum and anus. Once waste passes through the ileocecal valve into the large intestine, peristalsis is replaced by this bidirectional contractions, mostly antegrade in the colon towards the rectum using mass movements that are massive propagating waves that are controlled by sophisticated enteric nervous system, as well as socially disciplined system. The other function of the large intestine is to absorb water, of course. Colonic transit time is dependent on the contents of the stool, and water absorption is really critical to this. The rectal neural activity behaves similarly to the colon, with less antegrade contractions compared to retrograde contractions. But this bidirectional function of propulsion allows for the storage nature of the rectum to allow for socially appropriate defecation. The pelvic floor and the anal sphincters are also important anatomic components of the bowel continence mechanism. As a reminder, the pelvic floor is composed of the later ani, the pubococcygeus, ileococcygeus, and puborectalis muscles that you see here. The puborectalis muscle originates from the pubic arch. It leaps posteriorly behind the rectum and then travels back to the pubic arch, therefore forming a sling around the anal rectum. This angle, which is typically between 80 to 110 degrees at rest, becomes less than 80 degrees during voluntary relaxation, and greater than 80 degrees during voluntary squeeze. This helps to maintain continence by forming an anatomic barrier against the discharge of stool. Dysfunction of the later ani muscle appears to have a strong association with the severity of incontinence. The internal and external, the internal anal sphincter is a thickened circular smooth muscle layer innervated by the enteric nervous system. It's tonically contracted and accounts for 80 to 85 percent of the anal canal resting pressure, so that's very important to incontinence. The internal anal sphincter relaxes transiently in response to rectal distension, a reflex known as the anal rectal inhibitory reflex, and this is thought to permit the sampling of the rectal contents by sensory receptors in the anal canal, thereby helping to distinguish between solid or liquid stool or gas. It does not appear to be essential for continence, however, this anal rectal inhibitory complex, as people who have things like ilioanal anastomosis are able to still be continent. The external anal sphincter and the puborectalis muscles represent the voluntary component of the anal rectal continence mechanism, since these are composed of striated muscle with somatic innervation. Despite their independent innervation, the external anal sphincter and puborectalis muscle functions as a unit. Contraction of the external anal sphincter normally doubles the pressure in the anal canal, although this pressure cannot be sustained for more than a few minutes. A spinal reflex causes the external anal sphincter to contract, transiting increases in inter-abdominal pressure, such as coughing, lifting, and thereby helping to maintain continence. So, in summary, the processes involved in normal defecation are complex. They involve a sequence of events that are initiated by the entry of stool into the rectum. Progressive rectal distension leads to reflex relaxation of the internal anal sphincter. The urge to defecate increases as stool continues to enter the rectum from the sigmoid colon. When defecation is desired and appropriate, the anal rectal angle is voluntarily straightened, which is facilitated by squatting or sitting, and abdominal pressure is increased. This results in descent of the pelvic floor, contraction of the rectum, and inhibition of the external anal sphincters, thereby allowing for evacuation of the rectal contents. Continence depends upon a number of factors, including cognitive function, stool volume and consistency, colonic transit, rectal distensibility, anal sphincter function, anal rectal sensation, and anal rectal reflexes. Within the anal rectum, the anal sphincter complex serves as an anatomic barrier that helps preserve continence, including the rectum, the internal anal sphincter, the external anal sphincter, and the puborectalis muscle. So on the contrary, the loss of continence can result from dysfunction of the anal sphincters, abnormal rectal compliance, decreased rectal sensation, altered stool consistency, or a combination of any of these abnormalities. Incontinence is usually multifactorial since abnormalities often coexist. Malimpairment of any one of these mechanisms will usually not cause incontinence, since the other mechanisms for maintaining continence can usually compensate. But patients with urgent continence often have weakness of the external anal sphincters, as well as decreased rectal capacity and rectal hypersensitivity. And patients with passive buccal incontinence often have weakness of the internal anal sphincter. When we consider dysfunction in the bowel continence mechanism, anal sphincter dysfunction is very important. When we have weakness of the anal sphincter, this may be due to traumatic or atraumatic causes. Atraumatic causes of anal sphincter weakness include neurologic disorders such as diabetes, spinal cord injury, or infiltrative disorders like systemic sclerosis. Decreased anal sphincter pressures can result from anal trauma, such as after childbirth or surgery on the anal sphincter, or surrounding structures like hemorrhoidectomy, treatment of anal fissure or fistula. It's uncommon, but there have been reports that anal sphincter weakness becomes a predominant and long-lasting feature after treatment of anal fissures with Botox injections. Anal sphincter lacerations or trauma to the pudendal nerve during vaginal delivery may also result in fecal incontinence. Oasis injuries are recognized in 0.5 to 9% of all vaginal deliveries, but studies show that 30 to 40% of women may have injury to the anal sphincters after vaginal delivery depending on their parity. Fecal incontinence symptoms may present immediately or years afterwards. Risk factors for fecal incontinence after vaginal delivery include use of forceps for assisted vaginal delivery, a higher birth weight infant, long secondary stage of labor, the occipital posterior position of the fetus, and increased maternal age. 50% of women who have primary reconstruction of the anal sphincter after an oasis injury will have some disruption incontinence, but it's mostly with gas. However, all anal sphincter tears do not result in fecal incontinence as mentioned before. A systematic review that included more than 100 patients who underwent endoanal ultrasound after vaginal delivery estimated that anal sphincter defects were detected in 27% of pre-maternal women, but only 29% of women with an anal sphincter defect were symptomatic. In a population-based study, fecal urgency rather than obstetric sphincter injury appeared to be the main risk factor for the presence of fecal incontinence in women after vaginal delivery. So that's an important symptom to screen for in your patients. If you've had a patient who is at risk for having an anal sphincter defect or an oasis injury, it's important to ask them about this fecal urgency symptom. Rectal sensation is also a potential dysfunction of the bowel continence mechanism. Hyposensitivity may be detected in patients with fecal incontinence or constipation. A number of conditions are associated with impaired rectal sensation, including diabetes, Parkinson's disease, and spinal cord injury. Patients with diabetes can also have reduced internal anal sphincter resting pressure, which may result in incontinence. Diarrhea, secondary to autonomic neuropathies, may also contribute to fecal incontinence in these patients. Increased rectal compliance may also be a dysfunction that leads to fecal incontinence. With decreased rectal compliance, this can lead to increased frequency and urgency of bowel movements because the ability of the rectum to store fecal matter is reduced. This can lead to fecal incontinence even if a sphincter function is normal and intact. Disorders associated with this decreased rectal compliance can include ulcerative proctitis, radiation proctitis, or history of pelvic radiation, and proctectomy. We have to consider the potential for ultra stool consistency as a contributor for fecal incontinence symptoms. Chronic constipation and fecal impaction may result in this propulsion of liquid stools that I mentioned earlier into the rectum. It can also result in inhibition of the internal anal sphincter that sampling reflects. In the setting of this inhibited anal sphincter incontinence, liquid stools may occur around impacted solid stools, defining overflow incontinence. This may result from impaired cognitive function for some patients, immobility, rectal hyposensitivity, or inadequate intake of fluids. In research-rich settings that we work in mostly, the common causes of this abnormal stool consistency are irritable bowel syndrome, inflammatory bowel disease, malabsorption syndromes, such as lactose intolerance or celiac disease, and chronic infections, particularly in patients who are immunocompromised. All of these conditions can result in chronic diarrhea. Diarrhea is usually characterized as frequent loose stools of small to moderate volume. Stools generally occur during waking hours, most often in the morning or after meals. Most bowel movements are preceded by extreme urgency and may be followed by a feeling of incomplete evacuation. Incontinence of liquid stool may occur during periods of disease activity, for example with IBS or inflammation. Approximately one-half of all patients with IBS complain of a mucus discharge with stools as well. Symptoms of IBS often correlate with episodes of psychological stress. Functional diarrhea is characterized by a recurrent passage of loose or watery stools, and patients should not meet the criteria for IBS. They don't have preceding pain or bloating or any of those characteristics. When patients with inflammatory bowel disease primarily refers to ulcerative colitis or Crohn's disease, they also may have this chronic or episodic diarrhea. Malabsorption syndromes like lactose intolerance, celiac disease, or small bowel intestinal overgrowth are also common causes of chronic diarrhea. These are cases that I typically refer to gastroenterologists to diagnose and to manage. It's important to consider some alarm symptoms for our patients. For those with chronic diarrhea who are older than 50 years, who have melanoma, rectal bleeding, abdominal rectal pain, associated weight loss, fever, systemic symptoms, anemia, or family history of any kind of colorectal cancer, you'll be immediately referred to a gastroenterologist. For women, the absence or weakness of posterior compartment support results in erectile. We're all familiar with that. This can be associated with enlarged genital hiatus and an attenuated perinatal body. Some women with these characteristics also experience bowel incontinence associated with erectile as you can see in pictures A and B. This demonstrates the occasional women who we may see with an acquired absence of the perinatal body. Even in this case, while the pubertalis muscle maintains normal tone, there's almost no consistency and she has normal stool consistency, she may remain incontinent. Incontinence begins when these components of the continence mechanism are compromised. Last, we have rectal prolapse. This causes a dilation of the anorectal canal, attenuation of anal sphincters, and sensible fecal incontinence of solid stool. Next, we'll move on to the clinical evaluation and treatments to include the interview, examination, and treatment algorithm. When we consider the life cycle of women, it's difficult to know where management or treatment of fecal incontinence may fit in. Currently, most of the women that we see are presenting with fecal incontinence or bowel accident symptoms 10 to 15 years beyond menopause. Screening for fecal incontinence is important because individuals do not discuss these symptoms with their healthcare providers, even with us as your gynecologist. Evaluation of patients with fecal incontinence begins with an assessment of bowel function. This, of course, is a standard component of our interview. For any type of incontinence, including urinary incontinence as a presence of constipation or fecal incontinence, may prove to play a role in their urinary incontinence symptoms, the overactive bladder, or recurrent UTI. I typically include a bowel history where I'm assessing frequency of continent bowel movements, the stool consistency, and I often refer to this Bristol stool chart in my interview, as well as the presence of fecal urgency, that key characteristic or preceding symptom for fecal incontinence. I also discuss defecatory dysfunction, specifically asking about straining, incomplete bowel emptying, or needing to splint to evacuate. The history, when I talk to my patients about fecal incontinence, I'm using that term because we're speaking to each other as colleagues. However, when I'm talking to patients and I teach my trainees this as well, we're always referring to it as accidental bowel leakage, as this has been shown to be a more friendly term, more patient-centered term, to refer to their symptoms. But in our interview, we want to make sure we assess for the duration and the frequency of their accidents. I often ask patients, I say, do you have to rush to the restroom when you have to have a bowel movement? And a follow up question is, I say, well, do you ever have not make it to a restroom and have an accident? And typically, some patients that opens up, you know, a segue into as an opportunity to discuss their fecal incontinence symptoms in a way that's not, that's benign and not saying, do you have fecal incontinence? Within that setting, I like to discuss whether the leakage is happening during the day or the night, whether it's associated with physical activities or stress, coughing, laughing, sneezing, exercise, whether there's insensible or sensible loss. I always characterize what types of stools are being lost, solid, liquid or gas, any precipitating events like abdominal pain. Are they having diarrhea, frequent stools or any medications? I also like to ensure that we're not missing any kind of potential neurologic conditions. Of course, we're going to ask about prior perineal lacerations and their obstetric history. I also like to determine whether there's any concern for any transanal masses like hemorrhoids or rectum collapse. I basically ask, does tissue come outside of the rectum or knees? So I wanted to kind of orient our talk today with a patient of mine that I would love your help with. She's a 37-year-old female with a history of brittle type 1 diabetes that has led to significant cardiac disease. She's already had an MI by this age and she's a chronic smoker. She's presenting with recurrent fecal incontinence. In review of her EMR, she's a G2P2. She had what she thought described as a potential forceps-assisted vaginal delivery of a nine-pound infant with a third and fourth degree laceration and onset of fecal incontinence approximately four years later in the setting of constipation. In 2016, she underwent an overlapping external anal sphincteroplasty with placation of her rectum muscularis as well as perineurophy with a urethane colorectal case. On post-update number 11, unfortunately, she presented with poorly controlled blood sugars, hypoglycemic, and had a complete wound breakdown for repair, and she was treated for a superficial wound infection. She eventually healed well from that, but of course has this persistent cloacal defect. She represented to our clinic five years later with complaint of persistent fecal incontinence and a desire for treatment. She's currently struggling with diarrhea, now taking three Imodium per day. That's type four to six stools every one to two days. She does have alternating constipation. She has fecal urgency and incontinence multiple times per week. She also has stress-generating incontinence symptoms. On our evaluation, she is sexually active. She's not having any recurrent ETIs. She consumes a very low-fiber diet, and we talked about her obstetric risk factors. The next part of the evaluation includes a physical examination. In the physical examination, it's important to focus on the abdominal exam, of course, but we're going to focus on the pelvic exam. The evaluation of the external anatomy is important. You want to look at the skin for evidence of dermatitis. Look at the perineal body for length and substance. Look at the anal verge for stool smearing. You want to look for prolapsing hemorrhoids. You want to look for perianal reflexes and test for sensation. I basically just used a Q-tip to do that. The absence of anal cutaneous reflexes may indicate nerve damage and interrupted spinal arcs. You want to assess for disrupted posterior or apical vaginal support, so do a Q-exam. I think it's important to perform a bimanual examination to detect pelvic masses, as well as to assess pelvic floor tone and function. Hypotonicity of the pelvic floor can definitely sometimes be a reflection of overflow incontinence, so that's why that's important. A digital rectal exam, of course, is a key component for our evaluation. With this, we rule out anal masses, assess for resting anal tone. With bearing down and squeeze, we can assess their anal rectal angle and its appropriate functioning of the pubic rectalis muscle. We're also able to do an assessment of the anal sphincter complex and its function. Our patient, on a physical examination, had glucose urea. On pelvic exam, she had intact reflexes, an absent perianal body with scarring at the hymenal ring. Her anal examination revealed large dovetail sign of internal anal sphincter, no hemorrhoids. A digital exam of the rectum revealed absent baseline anal tone. There was no palpable internal or external anal sphincter anteriorly. She had weak pubic rectalis contraction. It's important to understand that there are no ancillary studies that are necessary prior to initiating first-line therapy. However, in our patients with chronic diarrhea, there are some laboratory studies that may be important, metabolic studies, for example. You may want to consider sending stool studies. In our patients who have those risk factors or who are older than 40 years, some gastroenterologists do recommend considering colon cancer risk assessment. In other investigations, I typically recommend it only if the symptoms are refractory. For the rest of the talk, I'm going to refer to these evidence-based guidelines that are produced by the American Society for Colon and Rectal Surgeons, the National Institute for Health and Care Excellence, as well as the International Consonant Society. The number one thing you want to do in our patients with bowel accidents is to obtain objective evaluation of bowel habits through a bowel diary and or questionnaire assessment. This allows for a self-directed evaluation of the patient's habits by using a diary or repeated questionnaires. It can often help patients identify and eventually avoid any kind of triggering or aggravating factors in their daily routine. These habits may be difficult to detect during the short span of an interview, so this is something I typically would send my patients home with. And listed here are just some standardized questionnaires that I hope that we all are familiar with and you can integrate into your practice. I strongly recommend that their first-line therapy should include dietary or medical management, suboptimal stool consistency, and excessive motility play key roles in aggravating fecal incontinence. So, you know, you want to consider Medicaid medical therapy first. And this can include fiber supplements, things like lapiramide or imodium, colostaramine, depending on their history. And those are listed here. Studies have shown that incorporation of a bowel diary into your treatment algorithm can decrease fecal incontinence symptoms in 20 to 50 percent of patients because it helps them to identify some triggering behaviors, such as excessive intake of caffeine or sugary foods and drinks that may stimulate more frequent loose bowel movements. It also helps to structure formal counseling around fluid management and bowel routines with follow-up visits. With optimization of stool consistency, I typically give my patients a dispersal stool chart, and if patients are following within a type 1 through type 3 range, I typically counsel them to increase their water as well as insoluble fibers, and with a goal of getting 35 to 40 grams in a day, and that's done very gradually over at least four weeks. With those who have more loose stools or diarrhea, I do increase fiber, but it's soluble fiber in that case, with similar targets for fiber intake. Catepeptic, colostaramine, antidiarrheal agents like lopuramide and TCA are all to decrease excessive GI motility. And I would start some of these agents, but if it's primarily diarrhea, these are patients that I would refer to gastroenterologist at the factory. And considering medical management, Dr. Marklin and colleagues did a RCT, double-blind crossover RCT, comparing lopuramide versus psyllium for reducing FI episodes in 80 community-dwelling men and women, and they were able to find that both medications reduced fecal incontinence without any significant differences between them, except for lopuramide, of course, had higher risk of thyroid from constipation. So both of these agents can be used very safely. We must consider patients who may be having malabsorption, diarrhea, and urgency. And this may be associated with eating foods high in fermentable oligodietes or monosaccharides and polioids or the FODMAP foods, because these can cause symptoms of diarrhea and urgency. So this is a retrospective chart review that reported on the experiences of 65 men and women with fecal incontinence, mostly with loose stools who were in the Michigan bowel control program. And they underwent formal dietary teaching on the low FODMAP diet, and 65% reported reduction of fecal incontinence symptoms. This is definitely something to consider in those with malabsorption. Considering our patients with abnormal GI motility, this is a secondary data analysis of a nurse's health study that revealed that higher physical activity levels were associated with lower risk of fecal incontinence symptoms, potentially due to this role of increasing physical function and neuromuscular health and anorectal continence. So maintaining good skeletal muscle health and function we think is important for our continence, especially in older adults. And another study that looked at potentially targeting GI motility, this is a secondary data analysis of older adults with fecal incontinence symptoms. And it shows that their symptoms may worsen with moderate to vigorous physical exercise or activities in comparison to light intensity physical activity. So while we are encouraging our patients to stay physically active, those with fecal incontinence may want to stay away from high impact exercises and choose to strengthen their muscles in an alternative way. Another component of our first line therapy is promoting bowel movements with rectal emptying. Bowel management programs to aid in rectal evacuation are useful in appropriately selected patients. Emptying the rectum by use of enemas or suppositories at convenient times results in a reduction of rectal stool volume and may be helpful to mitigate these fecal incontinence symptoms in this patient population. This measure may be particularly helpful in patients with underlying primary constipation with overflow incontinence, if that's what you think is going on, or in patients who are secondarily constipated because of other medications. In the setting that conservative therapy options fail to improve symptoms, what should we do next? Well, this is when I think our anorectal testing is important. Anorectal physiology testing consists of a number of simple minimally invasive test elements, like measuring the resting squeeze pressure of the anal sphincter, determining the length of the high pressure zone and pressure profile of the anal canal, as well as assessing for anorectal sensation capacity and rectal compliance. And this is all done really simply with anorectal manometry. The findings do not consistently correlate with the severity of fecal incontinence symptoms or the prediction of outcomes at this point, but they may influence our management decisions to select an individualized treatment strategy. And that's how I typically integrate it. This is an example of what a read for anorectal manometry may look like, where you obtain the resting and squeeze pressures. You can see that here. There are normal cutoffs for all of these things. And this is based on normal normative data that's been performed for women and men, and these are different. You're also able to determine sensation, you're able to test for the recto-anal inhibitory reflex to confirm neurologic function as well. When we think about defecation, the balloon expulsion test is a test of simulated evacuation in which the balloon tip of a catheter, the same one that we use for anorectal manometry, is filled with air or water, typically about 50 cc's, or sometimes to the volume of sensation, they're sitting on the toilet and they evacuate. And the time required for the patient to evacuate is typically measured. We typically allow for no more than five minutes for this test. This test has a high specificity for detecting dyssynergia. So we have EMG leads that are on the pelvic floor in the anal sphincter, and we're able to watch to see what's happening with evacuation. If dyssynergia is defined by this paradoxical contraction or failure to relax of the pelvic floor, you're going to see upregulation of those muscles on the EMG. EMG expulsion time of greater than two minutes is definitely abnormal. In our observations, we are seeing this happening in more patients with rectoceles, as well as those with dyssynergic anal sphincter function. Ultrasound is a sensitive tool in the evaluation of patients with sphincter incontinence, especially when there's a history of vaginal delivery or anorectal surgery. Ultrasound can reliably identify internal and external sphincter defects that may be associated with sphincter dysfunction. The presence of a sphincter defect alone is not sufficient to predict a functional deficit of force. Other imaging modalities, such as MRI, have also shown substantial intra-observable variability, and they can be alternatives if you don't have access to endoanal ultrasound. This is just a picture of the puborectalis muscle that you can see here. You can see the internal anal sphincter and the inside to external anal sphincter here. Other testing, like pudendal nerve terminal motor latency, as well as endoscopic evaluations, are variable. For pudendal nerve conduction studies, it's controversial in terms of its use in evaluation and management of patients with sphincter incontinence. I think if you're really suspicious that there is a significant defect in the nerve function, that's something that you can potentially identify as a sensory impairment or absence of the rare and anorectal manometry. I haven't personally performed this test. Endoscopic evaluation is performed in patients who meet general screening guidelines that we talked about before, like diarrhea, bleeding, or obstructive symptoms. We have effective management strategies for our patients with bowel accidents, so it's important for us not to just put them into PETs. Let's talk about them. Biofeedback therapy or biofeedback training, also known as anorectal biofeedback, is non-invasive. It's considered a first-line treatment option for patients with sphincter incontinence that have not responded to simple dietary modifications or medications. Patients can be taught to contract their pelvic floor muscles with or without balloon assistance. The goal of this therapy is to improve sensation, coordination, and strength, although supportive counseling and practical advice regarding diet, bowel habits, and skin care remain important. This is an additive therapy to those things. Biofeedback therapy also improves rectal sensation and may enhance coordination between the perception of rectal distension and external sphincter contraction in patients with reduced rectal sensation. Studies have shown that six biweekly sessions of anorectal biofeedback have been shown to be superior to pelvic floor exercise alone in patients who did not respond to education or first-line therapy, where 77% reported adequate relief and 66% were completely continent. These numbers have been persistent in both non-randomized as well as randomized controlled trials. I'm hoping that after this talk, everybody looks for a pelvic floor physical therapist who's trained in anorectal biofeedback and integrates this into their practice. So coronary modulation, what we're all familiar with, is thought to modulate rectal sensation by activating or deactivating clinically mediated receptors, stimulating the afferent pathway and changing brain activity relevant to the continence mechanism of the anus and rectum. It's been consistently shown to result in reduction in frequency of fecal incontinence episodes. Pooled analysis of all studies to date indicates that 79% of patients experience at least a greater than 50% improvement in their weekly FI episodes. And that's short-term, like three to 12 months. Long-term results are also good, 84% after 36 months. The presence of an anal sphincter injury may not impact the outcome of sacral neuromodulation. There's a systematic review of 10 studies with 119 patients that showed an average decrease of Wexner incontinence scores from 16.5 to 3.8 in the setting of a sphincter defect. The success has been reported in patients with defects up to 120 degrees. So this table highlights some of the indications and advantages of sacral neuromodulation therapy that I think most of us are going to be familiar with. The studies have, in terms of the use in women with non-sphincter defects, I thought it was important to mention that these studies were retrospective of short-term follow-up. And some of them were deemed poor quality because we just don't have a lot of data. Potential side effects to sacral neuromodulation that's important to consider is implant site pain, paresthesia, or other abnormal simulations. And infection rate is typically 3% reported. There also have been some studies that have investigated post-generative nerve stimulation for this indication as well. I do recall that it also targets L4-S3 nerve roots and has been shown to reduce fecal incontinence episodes by more than 50% in 52 to 83% in observational studies. And in random mass control trials, it has demonstrated 66% reduction in symptoms at the completion of 12 weeks of therapy. We don't have a lot of long-term efficacy data for post-generative nerve stimulation in this population. Patients who experience fecal incontinence in conjunction with or as a result of anatomic defects like retrovascular fistula, rectal or hemorrhoidal prolapse, fistula in anal, or cloacal-like deformities of the anal sphincter should have those defects corrected first. That's our 1C recommendation because this step may frequently improve or eliminate the incontinence that they have. We don't have any data currently to support correction of rectocele primarily for the management of fecal incontinence symptoms. But my clinical experience suggests that this approach is effective when performed with perineurophy. And we here at Wake Forest have recently completed a retrospective cohort study and currently doing that data analysis to support this hypothesis. We plan to present that data at the 2023 AUGS and ICS meetings. So the anal string to repair. Well, I know this is controversial. So disruption of the normal circumferential anatomy of the anal sphincter muscle may diminish the effect of its contraction because of the shortening of the muscle would not translate into adequate narrowing of the anal canal. Ideally, restoring sphincter integrity will result in a dynamically adaptable outlet resistance. And that's why we have an indication of 1B with moderate quality evidence to perform sphincteroplasties when disruptions are identified. The goal of the sphincter repair is to reconstruct the anatomy and anal sphincter muscles, both internal and external are recommended with either end-to-end or an overlapping approach. There are significant variability in the techniques performed and those published to include approach, the suture materials used, inclusion of internal anal sphincter application or repair routinely. But the data does say that 70 to 80% of women will have immediate symptom improvement. However, the question is long-term efficacy. And this is very variable defined. This is very variably defined and limited by mostly retrospective studies that have been conducted. So I liked this paper by Glasgow where they looked at long-term outcomes of anal sphincter repair for fecal incontinence as a systematic review. Because a flaw in the appropriate integration of sphincteroplasty into our clinical algorithms is that the studies have not used uniform criteria to define success. So most of them have defined success as complete continence. Whereas we know that complete continence in our patients is often not achievable. So in looking at the data that Glasgow and colleagues presented, they, in this chart, you can see patients with good outcomes zero to 100%, over zero to 140 months. And if we apply the standard interpretation of successful treatments for fecal incontinence as 50% improvement or greater, you can see in this red box that the majority of the studies have long-term efficacy of greater than 50%. So I think if we reinterpret our data with this outcome, then the sphincteroplasty is gonna perform as well as stegoneuromodulation or other therapies. And this pilot study investigating long-term efficacy of sphincteroplasty with perineuroreconstruction for treatment of fecal incontinence. The authors observed that in 20 women, 102% were continent of solid stool and 90% were continent of liquid stool at three years. Other agents like bulking agents. These are biocompatible bulking agents that are injected into the anal canal and they may help decrease episodes of passive fecal incontinence. They have, this is a weak recommendation based on pretty poor long-term efficacy that's documented. So short-term, 52% have had improvement of ABL symptoms at 12 months, but in long-term, 21% have significant symptoms. So this is typically something that I integrate for my patients who have refractory fecal incontinence or prior radiation therapy, those who have really wide syndrome defects that would never be able to placate. So Lesta is the FDA approved bulking agent that's used transangularly that I have experience with. In this prospective cohort with refractory FI symptoms, they had 82% success rate at 12 months that likely decreased significantly long-term. I'm gonna mention some other therapies really briefly. These are therapies that we can consider. I think these are mostly done in the hands of colorectal surgeons. I'll be interested to know how many of you all have experienced with this, but radiofrequency ablation is something to know about. This was adapted from treatment of GERD disease, FDA approved in 2002. This basically uses thermal control delivery of radiofrequency energy to the anal canal and thought to trigger tissue remodeling. Artificial anal sphincter is also something that we have some experience with here at Wake Forest. We were doing some NIH sponsored studies in this. The recommendation is that this is used for severe refractory incontinence and a systematic review found that 59% of devices were still functional at five years, but they have a significant complication profile. So it's not something that we're averagely seeing or used. Bowel diversion. So this, the creation of a colostomy is an excellent surgical option for patients who have failed other therapies or do not wish to pursue other therapies for fetal incontinence. And it's been shown that patients are able to resume normal activities and have a significant improvement in their quality of life if they get here. So lastly, we'll just summarize really quickly. This is a nice paper that summarized the ICS NICE and ASCRS guidelines. So patients who are without defects in terms of the use of sacroineuromodulation, ICS recommends to use in patients without anal sphincter defects or those that are less than 120 degrees or second line of sphincter plasty fails. NICE guidelines suggest to use it when sphincter surgery is deemed inappropriate. And in ASCRS, the American Society of Colorectal Surgeons recommends first line surgical option for fetal incontinence with or without sphincter defects. We think about sphincter repair indications. ICS recommends this in symptomatic patients as a first option if lesion is between 120 and 180 degrees. NICE recommends full length EAS defect that is 90 degrees or greater. And ASCRS recommends this in symptomatic patients with defined defect in the external anal sphincter. For bulking agents or gracilla plasty or artificial bowel sphincter, these are all gonna be kind of third line, fourth line options with the criteria that are listed here as well as PTNS and other treatment modalities. So in summary, fetal incontinence is prevalent equally among women with aging. As providers, we must screen patients for these symptoms, especially in the setting of other pelvic floor disorders. The diagnosis of fetal incontinence is made clinically and first line therapy should be initiated at their first visit prior to any procedure-based evaluation to target food consistency, GM motility and malabsorption if present. For refractory symptoms, anorectal manometry with balloon expulsion tests and or plus or minus endoanal ultrasound may be helpful to identify anatomic, motor and sensory function defects in the rectum, anus and anorectal unit, as well as to guide therapy. Clotting diarrhea is a common cause of bowel incontinence and if refractory would require gastroenterology workup. In management, algorithm two can involve the anorectal biofeedback therapy, which should be first line, synchroneuromodulation, surgical repair of any anatomic defects. Less effective strategies may include the celesta, or I'm sorry, bulking, radiofrequency ablation or use of an artificial endo-sphincter. And clostomy should be discussed or considered for extreme refractory cases. So let's consider our patient, TM, who's a 37-year-old female with Brtotype 1 diabetes. She's a smoker, history of MI, who has beguiling incontinence with solid and loose stools, a known sphincter defect, failed prior sphincter repair, who desires resolution of her symptoms. She's presently with diarrhea, alternating with constipation. Thank you. Great, thank you so much. I'd like to invite our attendees to provide their potential answers there. There's a few questions not related to our case. So if someone wants to answer a case question, that would be great. And then we'll address these others in just a moment. We can address those, it's up to you all. Okay, great. So the first question is actually about the Eclipse. And I was gonna ask you the same question. So what experience do you have with that? What success have you seen if you're using it? Yeah, so I personally don't have a lot of experience with Eclipse. However, my partner, Katherine Matthews does, and I'm pretty sure she's somewhere out there. The recommendations, I can kind of go back to that slide. So Eclipse is a vaginal bowel control system. I think in the hands of clinicians who have a lot of experience with fitting Eclipse, there's a patient population with a certain vaginal length and certain fecal incontinence symptoms that I think it performed well in. I think we struggle to integrate Eclipse into our clinical algorithm due to coverage issues in terms of insurance. But we still have access to it. I think that if you have access to it, just like some of these other therapies, it can be a good option if you're able to successfully fit it. And Katherine, do you? I think that's totally true, Candice. We have had it up here in Michigan, and coverage is the issue. Like it's virtually impossible. They say it's covered now and we've not had success. It's been very frustrating. The next question is, could you please discuss the anal sling? The anal sling. Yes, this puborectal sling is also a therapy. I felt like it was more popular as a fellow. So 2013, 2010, 2013 area, you will probably have more experience. I think a lot of the studies were done up there, but- They were, yeah. So it was a Boston Scientific product and it got FDA approval. The initial studies were actually quite favorable. Unfortunately, Boston Scientific then said, we're out of the mesh game. And so it never really went to market outside of studies, but the studies looked pretty good. So if somebody has an innovative bone and they want to go like buy that already FDA approved post-anal sling, they might make some money. The next question is, great talk. Do you anticipate there will be a shift from IPG to PTNS with newer technology like the eCoin or remote technology? That's a great question. I think that PTNS, in terms of how we integrate it into our algorithm, just like in urinary incontinence, doesn't outperform other modalities at this point. So, but I do think that potentially if we're able to have an implantable device, maybe some patients may opt for that instead of formal sigmoid neuromodulation therapy. So I think that that's, it's a great opportunity to do some further research and maybe be able to find a specific phenotype of women with fecal incontinence that this may perform really well in. Great. And the next talk is actually about ongoing research and specifically regenerative therapies. Any thoughts about that or where we might be going in the future? Yeah, we're actually doing a study here looking at the use of muscle derived cells with injection along the pattern of the anal sphincter in patients who have anal sphincter defects. You know, I think that, hopefully what translated in this talk is there's such a complexity to having bowel leakage symptoms in women. And, you know, I think that just like these other therapies that are listed here, I think that regenerative therapies, you know, are going to pop up on this list. And become potentially more favorable for some women to avoid implants or major surgery. You know, one of the things that's complex is that, you know, in order for muscle to regenerate, you know, sometimes it requires nerve stimulation and other things, other components. So it's hard to know at this point, it's pretty early in the technology development, but it has been shown to be effective in some populations and other types of conditions. So we're hopeful that we are going to kind of do the first line kind of safety profile study here at Wake. And hopefully that can continue to grow in terms of injecting muscle on the anal sphincter for primary treatment for fecal incontinence. That's great. Really exciting, interesting stuff for a very challenging disease. Someone did want to take a stab at our case, it looks like. And their first question was, is her diabetes controlled? Which I think is an excellent thought about our patient here. Yes, her A1C is seven at this point. That's pretty good. I honestly think, you know, my question is if you've done an endoanal ultrasound, how large is her defect? It looks cloacal, but I mean, how wide is that? So I have not actually done an ultrasound for this patient yet. So my next steps are to do an inter-rectal evaluation. So I would do an inter-rectal manometry with an endoanal ultrasound to characterize her defect. Do you think that would change? How would that help you in managing her in particular if her defects looks like it's going to be pretty wide? I think, you know, with a failed prior sphincteroplasty, I would be hesitant to go after a sphincteroplasty again, just because I think you've probably already done some damage with scarring and just this muscle's been denervated for so long. What are you really going to bring together? And if it's, oh, did we lose? No, I just said no. Okay, good. I was like, it's gone. And so I would just, I would probably consider neuromodulation for her as a next step. If she's really optimized on medical treatment as far as her diet and, you know, fiber and physical therapy, that would probably be my next step. Especially with a well-controlled diabetes. What are you thinking? I agree with you. Any other thoughts? I had one question actually that I was hoping you could address. One thing that I really struggle with in clinical practice is for people that have fecal incontinence in the setting of cognitive impairment, which can be very challenging to teach. And I wonder if you have any kind of pearls to offer people in that setting. Your best, what I like to do is I like to partner with caregivers. I think that's really important to the care of anybody with any kind of pelvic floor dysfunction or probably any other condition as well as cognitive impairments. You know, these are patients who it's difficult, you know, they're, it's nice. And that we can integrate medical management with whoever's distributing their medications. And we're able to, I typically also schedule toileting for these patients because sometimes I just, you know, awaiting this spontaneous urge to defecate may not be something that they're aware of. So along with their bowel regimen, toileting either first thing in the morning or before bedtime, whatever's, you know, most useful is something that I often integrate. And then some, our answer to that case did indeed populate another question, which is someone is wondering what the efficacy of tickle neuromodulation would be for fecal incontinence in patients who have a cloacal defect, such as this woman here. Yeah, so the studies that have been published, there's some that have been published that looked at defects that were less than 120 degrees though, to show that there was still significant efficacy in patients who have tickle neuromodulation. Yeah, that's why I was saying get the endoanal ultrasound actually. Right, yeah. So, but I do think just to your point, Pamela, that because you've tried a center deep repair before and the repair broke down because of her lifestyle in terms of fully controlled diabetes, continuing to smoke, some noncompliance in terms of healing. I think that repeating that and hoping for a different outcome probably wouldn't be the first step. So I think we can do tickle neuromodulation, see how she does with that. And, you know, one of her issues is that she wants anatomic restoration, even if it doesn't mean that it reflects normal anal function. You know, she- That's an excellent point, because I think that is a factor for many women. Yes, so she's willing to undergo that repair to have anatomic restoration of her anatomy, but in terms of primarily treating her fetal incontinence symptoms, I think that the next best step would be evaluation and then consideration of synchronous neuromodulation. Yeah. The other question we have about this particular case is would you consider irritable bowel syndrome and would you consider a GI consult for this patient? That's a great question. So she doesn't really have any symptoms that are preexisting for fetal incontinence episodes. She is, however, under the care of a gastroenterologist for her long history of chronic diarrhea constipation. And then one last question here, which it says, I know this is a bit out of scope, but I'm curious what your recommendations are for neurogenic bladder and bowel patients. Do you have any specific regimen that you recommend for someone with neurogenic bowel? Yes. So anal stimulation is really helpful for those patients. So we kind of talked briefly about increasing GI motility with rectal stimulants, so suppositories or enemas and things like that. Those can be helpful. So you want to kind of stimulate the anus and the rectum, and you also want to make sure they have a bowel reg or something that's stimulating them orally, so laxatives and most of those patients are going to have constipation, so insoluble fibers. And the thing about fiber that's really important I know to understand is that there has to be this gradual increased titration of the fiber. Everybody's not made equal. So some women may need 20 grams or another may need 40 grams, and that's going to be very variable. So I do this titration every week with increasing the amount of fiber that they're supplementing with, along with oral laxatives in order to get those patients to a point where they're having more regular bowel movements, and that's typically done over four to five weeks. Great. So one just comment from our participants, and this says there is a code for Eclipse and access is improving. And I would encourage participants to kind of investigate their own insurance and their state because access should be improving. I think it's kind of, it's variable at this point, but it's definitely a device we should be considering and trying to get access to in treating this patient population. Well, thank you so much, Dr. Parker Autry on behalf of Oggs for speaking with us today for this excellent webinar. We will be having an upcoming webinar with Dr. Amy Park on medicine and social media. That'll be on May 17th. We're skipping April, but we encourage you to register for that if necessary. And thanks again so much. Everyone have a great night. Thank you all. Take care. Thank you.

webinar

evaluation

treatment options

accidental bowel leakage

physiology of anorectal continence

bowel incontinence

dietary and medical management

anorectal manometry

anatomical defects

individualized treatment approach