GI Issues in Women

Educational Objectives

The goal of this program is to improve the care of women with inflammatory bowel disease (IBD) and fecal inconti­nence. After hearing and assimilating this program, the clinician will be better able to:

1.   Discuss the effect of IBD on body image in women.

2.   Counsel patients about the impact of IBD on fertility and pregnancy.

3.   Explain the relationship between IBD and bone health.

4.   Assess patients with fecal incontinence.

5.   Integrate a tiered approach to managing patients with fecal incontinence.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgments

Dr. Strader was recorded at Women’s Health Issues for Primary Care Providers, sponsored by the University of Vermont College of Medicine, and held May 7-9, 2008, in Burlington, VT. Dr. Lunsford was recorded at Women’s Health Update 2008, sponsored by the Mayo Clinic Scottsdale, and held April 17-19, 2008, in Scottsdale, AZ. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this pro­gram.

Inflammatory Bowel Disease in Women

  Doris B. Strader, MD, Associate Professor of Medicine, Department of Medicine/Gastroenterology, University of Vermont College of Medicine, Burlington

Body image: more women than men with inflammatory bowel disease (IBD) report concerns about attractiveness, in­timacy, and sexual performance; issues affecting body image  —  lone-liness; self-consciousness; dyspareunia; de­creased libido; diarrhea; fistulae; perineal scarring or deformity; surgical scarring or ostomies; side effects from medications (particularly corticosteroids; eg, weight gain, mood swings, difficulty sleeping, vaginal dryness); is­sues of childbearing, sexual health, and body image often overlooked, but should be addressed

Menarche: IBD first peaks in teenage years to early 20s; second peak in 50- to 60-yr age range; disease often present some time before diagnosis; onset of menses may be delayed in girls diagnosed before or during puberty (often sec­ondary to inflammation (particularly with Crohn’s disease [CD]); CD can occur anywhere along digestive tract, from mouth to anus, whereas ulcerative colitis (UC) affects only colon; inflammation associated with CD may re­sult in nutritional deficiencies leading to abnormalities in menstrual cycle; malnourishment rare in UC; menstrual cycle  —  can affect symptoms of IBD; symptoms increase during premenstrual or menstrual phase; range from mi­nor gastrointestinal (GI) problems (eg, cramping, occasional diarrhea) to severe flares (eg, cramping, diarrhea, bleeding, and weight loss); diarrhea and constipation most common complaints in women with IBD; study looking at symptoms during menses  —  diarrhea significantly increased in women with UC, compared to control group; sim­ilar pattern among women with CD and irritable bowel syndrome (IBS); elimination of menses with injectable con­traceptives (eg, medroxyprogesterone acetate [eg, Depo-Provera]) or ovarian suppression with gonadotropin-releasing hormone analogue may improve IBD sym-ptoms; oophorectomy not recommended, except for gyneco­logic reason

Fertility: fertility rates in women with IBD same as those in general population; previously, fertility believed to be af­fected because early studies did not take into account voluntary decrease in childbearing among women with IBD; active CD can reduce fertility; inflammation in ileum can lead to scarring in fallopian tubes and ovaries; perineal disease may cause dyspareunia (which can decrease fertility); pyrexia, abdominal pain, diarrhea, malnutrition, and weight loss can decrease fertility; surgical resection most common reason for decreased fertility; ileal pouch-anal anastomosis (IPAA) appropriate only for UC (UC curable, CD incurable); can worsen inflammation (stricture often occurs) when performed in women with CD; study suggests 38% infertility among women with IBD; no medica­tion used to treat IBD shown to impair fertility in women (however, sulfasalazine decreases sperm count in men); good control of IBD best method to maintain fertility; contraception  —  no standard guidelines; small studies link oral contraceptives (OCs) with increasing flares or worsening of disease in patients with CD, but not in those with UC; OCs recommended; barrier methods acceptable (2 methods of barrier contraception recommended); intrauter­ine devices not recommended (can contribute to confusion surrounding symptoms)

Pregnancy: can proceed normally if IBD well controlled before conception or, if pregnancy unplanned, symptoms treated immediately; no increased risk for spontaneous abortion, stillbirth, or congenital abnormality; active IBD at conception likely to continue throughout pregnancy; risk higher with CD than with UC; data show incidence of pre­term birth (<37 wk) »2 times higher in women with CD, compared to controls; data show »4.5-fold increased risk for preterm birth among women with UC who do not smoke, compared to almost normal risk in women who do smoke; unknown component (not nicotine) in cigarettes presumably protective only in UC, not CD; rate of IBD re­lapse not increased if disease quiescent at time of conception; 70% of women with active IBD at conception have continued or worsening disease; occasional reports of pregnancy improving disease activity or resulting in clinical remission, usually in first trimester; IBD (not active therapy) greatest risk to pregnancy; encourage patients to dis­cuss plans for conceiving; during pregnancy, patient can remain on medication being used to control disease, unless drug category D or X; category B medications  —  mesalamine or balsalazide (5-aminosalicylic acid compounds) first-line medications for mild disease; can be used throughout pregnancy; corticosteroids can be used for flares in pregnancy; infliximab (Remicade) safe during pregnancy; new medications  —  adalimumab (Humira) or certoli­zumab (Cimzia); no data about safety in pregnancy; metronidazole (eg, Flagyl) and loperamide safe in pregnancy; category C medications  —  insufficient data; olsalazine (form of mesalamine) not recommended; use ciprofloxacin, cyclosporine, or diphenoxylate if possible; category D  —  6-mercaptopurine (6-MP) and azathioprine; switch pa­tient to other agent if she wants to conceive; category X  —  methotrexate and thalidomide; delivery  —  no effect of IBD on indications for cesarean delivery for obstetric reasons; vaginal delivery can worsen active perianal CD; data show 18% of women with CD developed perianal disease after vaginal delivery involving extensive episiotomy; if CD active at time of delivery, infliximab and corticosteroids used to prevent perianal fistula; breast-feeding  —mesalamine, sulfasalazine, and corticosteroids safe to use while patient breast-feeding; limited data with 6-MP and infliximab (no data showing harm); methotrexate, thalidomide, cyclosporine, ciprofloxacin, metronidazole, and loperamide not recommended

Osteoporosis: meta-analysis showed osteopenia in 30% to almost 80% of patients with IBD, and osteoporosis in »5% to 42%; data show more profound effect with CD (difficulties with absorption of calcium and vitamin D); risk factors  —  low body mass index (BMI); poor calcium intake or lactase deficiency; reduced exercise; tobacco smok­ing; poor calcium and magnesium absorption; CD “patchy” disease (can occur in different areas of small intestine with different nutrients malabsorbed, depending on area affected); malnutrition, ileal resection, inflammatory cyto­kines, estrogen deficiency, and corticosteroids contribute to low bone mass; cortico-steroids  —  bone loss dependent on dosage and duration of therapy; taper dosage when discontinuing; lowering dosage too quickly causes recur­rence of flares, not tapering fast enough causes side effects; 5% to 15% bone loss per year with high dose (40 mg/day); most rapid in first 6 mo; low-dose corticosteroids (£10 mg/day) associated with reduced bone mineral density in men and postmenopausal women; monitor serum 25-hydroxyvitamin D levels in all patients; low levels of vitamin D associated with increase in inflammatory cytokines; prevention  —  calcium supplements, 1.2 to 1.3 g daily in adults (separated doses); vitamin D, 400 to 1000 IU daily; weight-bearing activities (performed regularly); eliminate smoking or excessive use of alcohol; hormone replacement therapy (in deficient women), unless contra­indicated; bone densitometry  —  recommended with prolonged steroid use (>3 mo consecutive, recurrent doses of corticosteroids), evidence of low trauma or fragility fracture, and in patients who are postmenopausal or exhibit hy­pogonadism; T score of -1  —  basic prevention (eg, calcium, vitamin D, exercise, smoking cessation, and minimiza­tion of corticosteroids); T score between -2.5 and -1  —  prevention and repeat bone densitometry every 2 yr; consider therapy with bisphosphonates; T score of -2.5  —  screen for other causes and refer to bone specialist

Fecal Incontinence  

Tisha N. Lunsford, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Scott­sdale, Scottsdale, AZ

General considerations: fecal incontinence part of group of clinical disorders; often multiple areas of dysfunction within pelvic floor; concurrent disorders (eg, vulvodynia, interstitial cystitis) may accompany fecal incontinence; often, treatment aimed at concurrent disorders within pelvic floor; patients may suffer in silence or turn to support groups on Internet; health care providers usually do not ask patients about incontinence; quality of life severely im­paired

Epidemiology: affects 2% of adult population, women more than men; second leading cause of nursing home place­ment in United States; direct health care costs  —  difficult to determine because disorder may be concurrent with urinary incontinence; care of incontinent adults in nursing homes costs $7 billion annually

Clinical assessment: majority of patients seen clinically have functional fecal incontinence; no obvious distinction between organic and functional anorectal disorder; causal relationship may be unclear; organic lesions may be in­fluenced by behavioral adaptations; patient may have several structural or functional disorders which may not ex­plain symptoms; Rome III diagnostic criteria for functional fecal incontinence  —  incontinence not solely explained by damaged sphincter or damaged nerves (neuropathy from diabetes, spinal cord, or sacral nerve lesions); passive incontinence  —  discharge of fecal matter when patient unaware; can be caused by sphincter weakness or impaired neurologic capabilities; urge incontinence  —  patient aware of need to have bowel movement, but cannot control urge; often associated with sphincter weakness or decreased compliance of rectal vault because of surgery, inflam­mation, or radiation; fecal seepage  —  discharge of 1 to 2 tablespoons of soft stool usually after normal bowel move­ment; evaluating degree of disability  —  bowel health diary or Cleveland Clinic fecal incontinence score helpful in determining severity of patient impairment

Pathophysiology: clinical features alone insufficient to define pathophysiology; 4 basic components (sensory, motor, structural, and cognitive/behavioral) comprise mechanism of continence; patient with abnormality in one compo­nent may learn to compensate, resulting in control of incontinence; patient with cognitive/behavioral abnormality may have fecal retention and impaction, with subsequent overflow and impairment of sphincter muscles; sphincter dysfunction most common cause of incontinence; pudendal neuropathy from obstetric trauma or surgery second cause; impaired sensation and altered compliance third and fourth causes; pathophysiology determined from medi­cal history by experienced interviewer; anal sphincter disruption or weakness  —  can suggest history of obstetric trauma (specifically use of forceps), anorectal surgery or manipulation, history of irradiation, or neurologic dis­eases (eg, multiple sclerosis, diabetes); pudendal neuropathy  —  usually involves history of obstetric trauma; im­paired rectal sensation  —  often overlooked; can occur with chronic constipation; decreased sensation seen on anorectal manometry; can lead to fecal retention and overflow; impaired rectal accommodation can occur with his­tory of ischemia or IBD or history of irradiation; incomplete evacuation  —  with fecal retention in obstructive or dyssynergic defecation

Diagnosis: many patients complain about diarrhea; important to determine whether fecal incontinence independent of deranged bowel habit; ask about onset and precipitating events, duration, severity, and timing; hyperawareness of bathroom locations usually clue to urge incontinence; soiling of undergarments clue to passive incontinence; nor­mal bowel movement followed by soiling of undergarment characteristic of anal seepage; coexisting problems if patient has sensory problem or paresthesia of lower extremities or neurologic or sacral issues; concurrent urinary incontinence may indicate pelvic floor dysfunction; obtain obstetric history; determine medications used; consider dietary triggers (eg, caffeine); fructose or lactose intolerance can lead to increased rapid transit in colon and fecal intolerance; digital rectal examination (DRE)  —  positive predictive value fairly low (even when performed by ex­perienced coloproctologist); signs of fecal matter or skin excoriation clue to prolonged soiling; prolapse and pro­lapsed hemorrhoids may be forcing stool onto patient’s undergarment (patient may not have true fecal incontinence); neuronal injury suggested by impaired anal wink; accuracy of DRE limited, but procedure worth­while; endoscopic evaluation  —  warranted with new onset of deranged bowel habit or new onset of fecal inconti­nence; stool studies  —  assess for infection; metabolic evaluation and breath testing  —  assess for bacterial overgrowth or carbohydrate intolerance if diarrhea predominant bowel habit; anorectal manometry, with or without balloon expulsion testing  —  assess rectoanal reflexes, coordination of pelvic floor and anal canal, rectal compli­ance, sensation, resting pressure of anal canal (congruent with internal anal sphincter pressure), and squeeze pres­sures; endoanal ultrasonography (US) and pudendal nerve terminal motor latency not useful; magnetic resonance imaging (MRI) may be of value in future for patients with dyssynergic defecation

Management: tiered approach; begin with lifestyle and dietary modification; surgical intervention not automatic op­tion for patient with sphincter tear; fiber supplementation; 2 capsules of methylcellulose (Citrucel; less gas-produc­ing than psyllium [Metamucil]) with sips of water »2 times daily (up to 3 times per day) produces bulking effect; introduce fiber slowly; limit caffeine (however, can be useful in morning to stimulate bowel movement); Kegel ex­ercises; tap-water enemas used to exert control over time of defecation safe and effective in clearing out rectal vault; saline enema (eg, Fleet) not recommended (irritating to colonic mucosa)

Pharmacologic therapy: loperamide (eg, Imodium)  —  does not cross blood-brain barrier; safe to use prophylacti­cally; 1 to 2 tablets (8 tablets/ day); diphenoxylate plus atropine (eg, Lomotil)  —  more side effects; cholestyramine  —  2 to 6 g; interferes with absorption of other medications; use either 1 hr before or 2 hr after other medications; colestipol (pill form of cholestyramine); amitriptyline  —  some evidence of ability to improve sphinc­ter resting pressures; option for patient with concurrent chronic pain in pelvic floor; use at low doses; oxybutynin  —  option with concurrent urinary incontinence; Calmoseptine ointment  —  effective treatment for perianal excoriation

Other treatment options: biofeedback  —  safe and effective; may be no better than counseling and education alone; surgery  —  reserved for patients in whom medical management failed; overlapping sphincter repair most common and most successful procedure (most supporting evidence); dynamic graciloplasty not associated with good treat­ment outcomes; neo-sphincter implantation associated with explan-tation and infection; antegrade continence en­ema procedure reserved for patient with cerebral palsy or multiple sclerosis; colostomy rarely used (should not be perceived as failure); sphincter bulking, electrical stimulation, sacral nerve stimulation (speaker describes as prom­ising), and anal plugs future options

Evidence supporting treatment options: level 2 evidence for loperamide and diphenoxylate plus atropine, but good recommendation; level 3 evidence for amitriptyline; level of evidence poor for cholestyramine, but recommenda­tion good because product benign; level 1 evidence to support biofeedback as moderately successful intervention; sphincteroplasty only surgical procedure recommended; sacral nerve stimulation level B recommendation

Editor’s Notes

Crohn’s & Colitis Foundation of America: www.ccfa.org

Colitis Foundation: www.colitisfoundation.net

United Ostomy Association of America, Inc.: www.uoaa.org

Pelvic Floor Disorders Network: www.pfdnetwork.org

National Association for Continence: www.nafc.org

Suggested Reading

Bharucha AE et al: Functional anorectal disorders. Gastroenterology 130:1510, 2006; Crowell MD et al: Impact of anal inconti­nence on psychosocial function and health-related quality of life. Dig Dis Sci 52:1627, 2007; Dubinsky M et al: Management of the pregnant IBD patient. Inflamm Bowel Dis Jul 14, 2008 [Epub ahead of print]; Maunder R et al: Influence of sex and disease on illness-related concerns in inflammatory bowel disease. Can J Gastroenterol 13:723, 1999; Rodriguez-Bores L et al: Basic and clinical aspects of osteoporosis in inflammatory bowel disease. World J Gastroenterol 13:6156, 2007; Scarlett Y: Medical management of fecal incontinence. Gastroenterology 126(1 Suppl 1):S55, 2004; Vroom F et al: Prescribing of sulfasalazine, aza­thioprine and methotrexate round pregnancy—a descriptive study. Pharmacoepidemiol Drug Saf 17:52, 2008.