HIDDEN PROBLEMS
| ANAL INCONTINENCE: WHY DOES IT OCCUR, AND HOW CAN WE TREAT IT ?—Rebecca G. Rogers, MD, Associate
Professor, and Director of Urogynecology, Division of Urogynecology and Pelvic Floor Disorders, Department of
Obstetrics and Gynecology, University of New Mexico Health Sciences Center School of Medicine, Albuquerque
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| General considerations: definition—involuntary loss of flatus, loose or formed stool; socially debilitating;
prevalence—2% to 10% in community dwellers; higher in nursing home patients; patients reluctant to report symptoms;
50% of patients with chronic diarrhea have problems with continence; medication or food can cause loose stools or
irritate anal passage; chronic constipation can result in large bolus of stool with liquid stool seeping around it (analogous
to retention with overflow problem in urinary incontinence); ideal stool—2 cm diameter; time to expel single solid
sphere inversely proportional to its diameter; causes—diarrhea, constipation with impaction, irritable bowel syndrome
(IBS) or inflammatory bowel disease, decreased mobility, decreased cognitive function, psychiatric disorders, constipating
medications, and obstetric injury
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| Anatomy of anal sphincter complex: rectum—hollow tube extending up canal 10 to 12 cm; anus—distal portion includes
anal sphincter; complex complicated interaction of sphincters; external anal sphincter—striated muscle; extends
2 to 3 cm up anal canal; under voluntary control; in close proximity to puborectalis muscle; responsible for squeeze tone;
internal anal sphincter—smooth muscle; overlaps and extends up anal canal next to external anal sphincter; under involuntary
control; responsible for 70% to 80% of resting tone of complex; endovascular rectal cushions—
hemorrhoidal tissue; vascular tissue of anal mucosa; prevent seepage; located inside internal sphincter; removal may lead
to anal incontinence; circuitry—S2, S3, and S4 responsible for pudendal and enteric nervous system; mixed nerves carrying
motor and sensory information; pudendal block decreases sensation in perianal skin and decreases strength of external
anal sphincter and some contractile reflexes; rectoanal reflexes—distention causes rectum to relax; increasing
distention causes anal sphincter to contract; more voluntary control; complex can be damaged by childbirth, chronic
straining with constipation, trauma, and aging; puborectalis muscle—part of levator ani; precise role in anal continence
unclear; with disruption of anal sphincter complex, patient can still maintain continence; anorectal angle may play role;
mechanics of stool passage—stool delivered to rectum; nerve endings sense urge to defecate; defecation occurs when
internal anal sphincter relaxes and external anal sphincter contracts; with more sensation and if time appropriate, puborectalis
relaxes and bowel movement occurs; more causes of incontinence—decreased mobility, decreased cognitive
function, psychiatric disorders, and medications
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| Treatment: behavioral therapy, physical therapy, medications, and surgery; behavioral therapy—address problem of diarrhea;
increased dietary fiber and fluid first-line therapy; 25 to 30 g of fiber daily recommended (most Americans consume
≈10 to 12 g daily); daily recommended fluid intake 64 oz; counsel patient to increase fiber intake slowly over
months; address diarrhea with constipating anticholinergic agents, eg, diphenoxylate atropine (Lomotil), loperamide (Imodium);
Lomotil increases anal sphincter tone and decreases colonic mobility; Imodium decreases colonic mobility and
allows patient to engage in daily activities, but enema may be necessary for patient to have bowel movement; surgical
intervention—sphincteroplasty mainstay of surgical treatment; speaker counsels patient that surgery cannot cure anal incontinence,
can only improve it; important to offer nonsurgical management before considering surgery; speaker emphasizes
avoidance of episiotomy and operative delivery to reduce chance of anal sphincter damage
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| HOW TO TREAT CONSTIPATION AND OTHER COMMON DEFECATORY DYSFUNCTIONS —Dee E. Fenner,
MD, Harold A. Furlong Professor of Women’s Health and Associate Professor of Obstetrics and Gynecology, Department
of Obstetrics and Gynecology, University of Michigan Health System, Women’s Hospital, Ann Arbor, Michigan
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| General considerations: constipation and defecation disorders 3 times more common in women than men; affects one
third of women >60 yr of age; associated annual cost $400 million; most people believe good digestive health requires daily
bowel movement; physicians surveyed reported normal range 3 to 21 bowel movements weekly; important that patient
clarify problem, eg, frequency of bowel movements, straining, hard stools; Rome II criteria for constipation—must
have 2 of following symptoms in past 12 mo; straining with >25% of defecations, hard or lumpy stools, feeling of incomplete
evacuation, sensation of anorectal obstruction, and use of manual maneuvers to assist defecation; pain differentiating
factor between chronic constipation and IBS
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| Defining problem: “do you get the urge to defecate?” important question; if patient response “yes, but stool never gets
down to rectum”, likely transit problem; colonic peristalsis likely not occurring; if patient response is that stool is in rectum,
but unable to pass, problem likely associated with defecation mechanism, eg, rectocele, spastic puborectalis; poor
prognosis if patient responds that she is unaware that stool in rectum, likely patient has decreased sensation in rectum (rectum
does not signal need for defecation to brain); gastrocolic reflex—occurs with peristalsis in small and large intestine;
useful signal in training patient about when to have effective elimination; compliance of rectal reservoir affected by radiation
and scleroderma; diabetes, aging, and constant straining during bowel movements can result in altered peripheral
nerve function and sensation; possible to restore sampling reflex with biofeedback
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| History and physical examination: ask patient about what is normal in her family for bowel movements; ask about medications
used, diet, and fluid intake; ask whether stool being manually removed or whether she is splinting or pushing on
perineum or vagina in order to defecate; ask about frequency of bowel movements, sense of urgency to defecate, and urinary
function (concomitant with bladder function); ask about use of laxatives, ie, type, length of time used, how often;
ask about use of anticholinergic medications; treatment strategy difficult if patient has overactive bladder and constipation;
antidepressants, calcium channel blockers, and iron supplements can slow gastrointestinal (GI) tract and make defecation
difficult; ask about history of physical or sexual abuse and depression (in some studies, 40% of women who
present with complaint of constipation and defecation disorders have positive history); perform neurologic assessment;
evaluate anal tone and squeeze; check for rectocele; guaiac test for occult blood; assess for pain with hemorrhoids or impacted
stool; consider psychiatric screening
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| Diagnostic tests: transit study—consider if patient does not respond to dietary and behavioral modification; measures colonic
transit time; if normal, focus on whether patient able to relax pelvic floor and determine presence of rectocele or enterocele;
colectomy considered with abnormal result (drastic step); patient swallows capsules containing radiopaque
markers; normal colonic transit time if patient passes 80% of markers; defecography—used to rule out rectal prolapse,
rectocele, enterocele, or rectoanal intussusception; patient drinks barium and barium infused in vagina and bladder; patient
sits on radiolucent toilet while fluoroscopic images taken; anorectal angle can be evaluated; beneficial for patient
who fails surgery; anal manometry—some benefit, especially in testing for sensation and strength of anal muscle; manometry
not as beneficial as manual rectal examination; puborectalis electromyogram—rarely used
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| Counseling issues: patient must think of chronic constipation as chronic disease; regular meals should be eaten at predictable
times to promote gastrocolic reflex; high-fiber breakfast; choose best time of day to have bowel movement; exercise
stimulates appetite and promotes overall well-being; some data show it increases GI motility, but no data it promotes
peristalsis postoperatively; defecation mechanics—lean forward to increase hip flexion; relax body and rectum; wiping
anus may initiate peristaltic wave; sit on toilet same time every day; diet—add fiber slowly, 25 to 30 g daily; 8 oz of water
for every 10 g of fiber; fluids should be caffeine-free; food and defecation diary useful in motivating and educating
patient
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| Laxatives: bulk laxatives—psyllium (eg, Metamucil, Fiberall); degraded by bacteria; can increase bloating and flatus; not
recommended; Fibercon and Konsyl synthetic; not broken down by bacteria, resulting in less bloating and flatus; osmotic
laxatives—monobasic sodium phosphate and dibasic sodium phosphate (Fleet Phospho-Soda), magnesium citrate, milk
of magnesia; poorly absorbed sugars—polyethylene glycol solution (MiraLax); stimulants—senna not recommended;
associated with stretching and discoloration of colon wall; contained in over-the-counter (OTC) and health food products;
data show colon returns to normal within 1 yr of stopping senna-containing product; stool softeners—no data supporting
use, even postoperatively; no data showing they improve stool frequency or change consistency of stool; mineral oil—
effective, but seepage possible with long-term use; tegaserod—serotonin-4 receptor agonist; induces peristalsis; ≈30%
increase in stool frequency; approved only for short-term use and for constipation-predominant IBS; associated with bloating
and pain; can induce diarrhea and headaches
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| Biofeedback: myofascial release therapy; 65% to 70% success rate; should be encouraged for defecation disorders; primarily
involves sensory training; poor prognosis for patient with perineal descent; obstructed defecation may require trigger
point injections along with myofascial release therapy
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| PELVIC FLOOR DISORDERS AND SEXUAL FUNCTION —Dr. Rogers
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| General considerations: triad of urinary and anal incontinence and pelvic organ prolapse; large study showed significant
impact on arousal disorders and sexual pain disorders in women with urinary tract symptoms; recent study of women
scheduled for hysterectomy showed those with urinary incontinence less likely to be sexually active and more likely to
complain of low libido, vaginal dryness, or dyspareunia; prolapse not associated with sexual complaints; early studies of
sexual function in women with pelvic floor disorders concentrated on measurements of vaginal anatomy after surgical intervention;
study design poor, ie, nonvalidated questionnaires, evaluator was surgeon
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| Urinary incontinence during intercourse: studies show incidence ≈12%; no partners complained; urge incontinence associated
with more sexual dysfunction than stress incontinence
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| Neurobiology of sexual function: link between incontinence and depression purported; depression common among incontinent
patients; may be biochemical reason for incontinence (study showed increases in serotonin (5-hyroxytryptamine
[5-HT]) lead to increases in complaints of urge incontinence)
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| Surgery: counsel patient that correcting anatomy does not always result in improved function; “anatomy does not equal
function”; Burch retropubic urethropexy—gold standard surgery for incontinence; usually performed as open case, but
can be done laparoscopically; sling procedure—tissue taken from abdominal wall and sutured under urethra to abdominal
wall; provides support to urethra; tension-free vaginal tape (TVT)—midurethral sling; polypropylene mesh placed
under urethra through retropubic space into abdominal wall through 3 small incisions; multicenter trial showed surgery
improves coital incontinence; debatable whether overall sexual function improved; no changes in postoperative reports of
pain or partner dysfunction, regardless of prolapse severity, menopausal status, anticholinergic use, posterior repair, hysterectomy,
castration, or Burch retropubic urethropexy; many patients in speaker’s study postoperatively afraid of harming
repair or harming partner, or partner afraid of harming them; patient’s anatomic defect corrected, but sexual
functioning not enhanced due to lack of counseling
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| Nonsurgical management: no data on pharmacologic intervention or pessary therapy; data show improved desire and decreased
dyspareunia with physical therapy; physical therapy cornerstone therapy for patients with pelvic floor disorders
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| Sexual functioning and prolapse: higher grades of prolapse (stage 3 or 4) associated with more complaints of sexual
functioning than lower grades (prolapse still inside introitus); vaginal anatomy not associated with complaints of dyspareunia,
vaginal dryness, or sexual dysfunction; vaginal anatomy probably not significant concern when looking at sexual
functioning postoperatively; patient reports of difficulty with intercourse with vaginal length <7 cm; abdominal
procedure results in longer vaginal length than vaginal procedure; reports of vaginal tightness with posterior colporrhaphy;
1 in 5 patients undergoing sacrospinous ligament suspension complained of dysfunction postoperatively, and 17%
complained of constricted vagina; 69% of patients undergoing sacrocolpopexy afraid vagina too narrow after procedure,
22% complained of new-onset dyspareunia, and 41% of decreased libido and coital events; high rates of dyspareunia,
vaginal tightness, or sexual dysfunction in patients undergoing posterior colporrhaphy; patient with posterior compartment
repair performed in conjunction with incontinence procedure at highest risk for postoperative dyspareunia; proceed
with caution when operating in posterior compartment; mesh, porcine, or cadaveric tissue—no evidence that outcome
improved anatomically or functionally; ≈20% of women complained of new-onset dyspareunia when mesh placed in anterior
compartment and 63% with posterior compartment placement; use not recommended
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| Conclusion: no data looking at anal incontinence and sexual functioning in women; pelvic floor disorders and sexual functioning
common in women; more studies needed using validated questionnaires to evaluate outcome of surgical interventions;
speaker counsels patients that it is safe to resume sexual activity after prolapse repair; posterior compartment repair
should be avoided, especially with Burch retropubic urethropexy
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Educational Objectives
| The goal of this program is to educate the listener about identification, evaluation, and treatment of women who have defecation
disorders and pelvic organ prolapse. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Discuss the mechanics of the normal passage of stool.
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| 2. Make treatment recommendations for the patient with defecatory dysfunction.
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| 3. List the diagnostic criteria for constipation and determine possible cause of patient’s constipation.
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| 4. Discuss the impact of pelvic floor disorders on sexual functioning.
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| 5. Counsel patients with pelvic organ prolapse about the effect of surgery for this condition on sexual functioning.
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Discussed on This Program
Docusate calcium (dioctyl calcium sulfosuccinate) [DC Softgels, Stool Softener, Surfak Liquigels]
Docusate sodium (dioctyl sodium sulfosuccinate; DSS) [several trade names]
Loperamide HCl [Diar-aid Caplets, Imodium, Imodium A-D Caplets, Kaopectate II Caplets, K-Pek II, Maalox Anti-
Diarrheal Caplets, Neo-Diaral, Pepto Diarrhea Control]
Monobasic sodium phosphate and dibasic sodium phosphate [Fleet Phospho-soda]
Magnesium citrate solution
Milk of magnesia [Concentrated Phillips’ Milk of Magnesia, Phillips’ Chewable, Phillips’ Milk of Magnesia]
Polyethylene glycol solution [MiraLax]
Psyllium (several trade names)
Sennosides [Agoral, Black-Draught, ex·lax,·ex·lax Chocolated, Fletcher’s Castoria, Lax-Pills, Maximum Relief ex·lax,
Senexon, Senna-Gen, Senokot, SenokotXTRA]
Tegaserod maleate [Zelnorm]
Suggested Reading
Abramov Y et al: Risk factors for female anal incontinence: new insight through the Evanston-Northwestern Twin Sisters
Study. Obstet Gynecol 106(4):726, 2005; Baessler K et al: Severe mesh complications following intravaginal sliplasty. Obstet
Gynecol 106(4):713, 2005; Bradley CS: Vaginal wall descensus and pelvic symptoms in older women. Obstet Gynecol
106(4):759, 2005; Cherry K: Effective biofeedback treatment in patients with slow-transit constipation. Nat Clin
Pract Gastroenterol Hepatol 2(10):439, 2005; Dietz HP et al: Levator trauma after vaginal delivery. Obstet Gynecol
106(4):707, 2005; Fenner DE et al: Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in
an obstetrics unit in the United States. Am J Obstet Gynecol 189(6):1543:2003; Handa VL et al: Sexual function among
women with urinary incontinence and pelvic organ prolapse. Am J Obstet Gynecol 191(3):2004; Rogers RG et al: Sexual
function after surgery for stress urinary incontinence and/or pelvic organ prolapse: a multicenter prospective study. Am J Obstet
Gynecol 191(1):206, 2004; Tack J et al: A randomized controlled trial assessing the efficacy and safety of repeated tegaserod
therapy in women with irritable bowel syndrome with constipation (IBS-C). Gut (Epub ahead of print), 2005; Talley
NJ: Definitions, epidemiology, and impact of chronic constipation. Rev Gastroenterol Disord Suppl 2:S3-S10, 2004
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Fenner has received a research grant from Pfizer Inc. Dr. Rogers has consulted for Pfizer Inc. and received research
grants from Pfizer Inc. and Wyeth.
Drs. Rogers and Fenner were recorded at Treating the Hidden Problems of Urinary Incontinence, Anal Incontinence,
and Pelvic Organ Prolapse: What Every Practitioner Needs to Know, sponsored by the University of New Mexico
Health Sciences Center School of Medicine and held on August 19, 2005, in Albuquerque, New Mexico. Dr. Rogers was also
recorded at Women’s Sexual Health, sponsored by the University of California, Los Angeles Female Sexual Medicine Center
and held on April 2-4, 2005, in Beverly Hills, California. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
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