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In the final installment of this two-part series on pelvic floor disorders, For The Record provides an overview of rectal disorders, from constipation to rectal prolapse.

There are some topics people naturally shy away from discussing. Among those is anything to do with a person eliminating waste—specifically, defecation, constipation, or fecal incontinence (FI). But when any one of these topics becomes an issue, it can leave a person in pain, embarrassed, and oftentimes, isolated.

FI, in particular, can be a debilitating disorder that can render a person homebound. In recent years, there has not been much discussion about FI, but it is becoming apparent that at least 7% of women suffer from it, according to a recent study conducted at the University of Washington School of Medicine that was published in the American Journal of Obstetrics and Gynecology (AJOG).

Constipation and FI are but two of the many disabilities that fall under the category of rectal pelvic floor disorders (PFDs).

Rectal PFDs
The rectum and colon are a complicated set of muscles and tissues. Any damage sustained by the rectum or anus can impair their function and lead to a series of problems called rectal PFDs. “Women suffer from PFDs more than men due to the trauma childbirth causes to the female anatomy,” says Joshua A. Katz, MD, a colorectal surgeon at the George Washington University School of Medicine in Washington, D.C.

PFDs affecting the rectum include constipation, FI, rectoceles, and rectal prolapse. “Although the female body is very resilient, any damage that may have occurred during pregnancy and delivery may not become apparent until much later when the woman begins to suffer from constipation or one of the other PFDs,” Katz says.

Additionally, people who are taking psychotropic drugs, have lost sensation in their anus due to trauma or neurological damage, or use excessive straining are also at risk of developing a PFD, according to Katz. The disorders can range from chronic constipation to the more severe rectal prolapse.

Diagnosing and Treating Constipation
According to the International Foundation for Functional Gastrointestinal Disorders, Inc. (IFFGD) Web site, as many as 42 million Americans, or 15% of the population, suffer from constipation. However, Katz differentiates between constipation and regularity. “We have all heard about the need to have a bowel movement daily to maintain regularity, but that is a myth; what is regular for one individual is not the same for someone else. If you normally go every three days then, for you, that is regular. Constipation only becomes an issue when your body deviates from that schedule and the stool becomes impacted,” he explains.

Occasional bouts of constipation are normal and can be caused by numerous factors, including lack of fiber, decreased fluid intake, and lack of exercise. By addressing each or one of these issues or by taking an over-the-counter laxative, the symptoms are generally relieved, according to the IFFGD.

When constipation turns from being an occasional occurrence to a chronic ailment is when most people will consult their physicians, says IFFGD Vice President William F. Norton. “As with other disorders of the colon, such as FI, the inability to pass stool or incontinence are oftentimes a symptom of a larger issue,” says Norton.

Katz agrees. “Any trauma sustained to the anus can cause problems at a later date. Certain medications, such as psychotropic drugs, can increase a person’s risk of incontinence because their faculties may be impaired. Other issues could be neurological problems that distort the communication between the brain and the colon,” he says.

Tests and Other Options for Chronic Constipation
If the constipation does not respond to a change in diet, laxatives, or pharmacological treatment, further testing is necessary, says Katz. To investigate the causes and extent of the disorder, tests such as a colonic marker study can be used. In a colonic marker study, the patient ingests a capsule containing 24 small study markers, which are then visible on an x-ray. If more than five markers remain in the abdomen, the transit time is prolonged and the patient will require further testing, explains Katz.

A defecography test—an x-ray during defecation—is performed to determine whether the rectum and anus are functioning properly. “Although not the nicest test, it can be very effective in determining if the patient’s rectum, anus, and sphincter muscles are working properly,” says Katz. The defecography test can also be useful in diagnosing a rectoceles, which is a protrusion of the colon through the vaginal wall.

Another test Katz recommends is the anorectal manometry to measure the resting and squeezing anal sphincter pressures, rectal sensation and compliance, and sphincter response. This test can also help determine whether there was some trauma to the rectum that has impaired its ability to function properly.

In addition to those tests, the patient can try behavioral therapy such as bowel retraining or biofeedback. In bowel retraining, the patient attempts to retrain his or her body to become “regular,” says Katz. The patient will go to the bathroom at the same time every day, generally following breakfast with coffee. With biofeedback, the patient will work with a therapist to modify or change abnormal body functions, such as straining, to more normal patterns, according to the IFFGD.

In 2002, Novartis introduced tegaserod maleate as a pharmacological option for treating chronic constipation. In most patients, there is a lack of serotonin, which works to keep the muscles of the intestines moving freely, according to the Novartis Web site. Tegaserod works by acting like serotonin and encourages the digestive system and muscles of the intestines to function as they should and helps relieve symptoms that have lasted six months or longer, according to the Web site.

For the most severe cases of chronic constipation, surgery may be a last resort. The most important factor to consider before going forth with surgery is the patient. “If the patient is an 85-year-old woman living in a nursing home, I would be disinclined to perform the surgery because this is a difficult surgery,” Katz says.

However, if the patient lacks the ability to relax the anal sphincter following defecation, other issues such as Hirschsprung’s disease could be the culprit. If that’s the case, Katz says surgical removal of a portion of the colorectum can fix the problem.

The Taboo Topic Affecting Thousands
Through consumer-directed advertising, urinary incontinence (UI) is becoming a mainstream topic of discussion between patient and doctor. But, as Norton is quick to point out, “never once is the word incontinence used in the commercial.” He attributes this to the level of discomfort people have with discussing such a basic bodily function. “This is at the detriment of the public because no one is talking about incontinence, especially FI. People are embarrassed to talk to their doctors about it and doctors seem to be embarrassed to ask about it,” he says.

According to a recent study published in the AJOG, 7% of U.S. women are affected by FI each year. However, the IFFGD estimates that 2% to 7% of the population is affected by FI. Despite the numbers, it appears that a significant portion of the population is suffering from this disorder and there is still limited conversation between the patient and the doctor, says Dee E. Fenner, MD, a gynecologist and clinical researcher on UI, FI, and pelvic organ prolapse at the University of Michigan Health System in Ann Arbor and coauthor of the study published in the AJOG.

Diagnosing FI
FI is generally defined as “the inability to defer the passage of stool or gas to an appropriate time and place,” according to literature written by Katz and his colleagues. Because of the inability to control the bowels, the person may be limited in his or her professional or personal life out of fear of an episode. “Fear of another episode happening will either prompt the person to see his or her doctor for some sort of solution or force the person into seclusion,” says Katz.

“Passing stool is dependent on the person’s ability to contract and release the muscles of the sphincter,” explains Katz. For someone with FI, the internal and external muscles of the sphincter are important, but the person must also have a compliant and functioning rectum with the proper sensation to maintain continence, he adds.

As with constipation, FI is often a symptom of a neurological disorder such as spinal injuries, diabetic neuropathy, multiple sclerosis, or some other larger issue. It is often caused by damage to the anus from vaginal child birth or other trauma; anorectal surgery; spine or pelvic trauma; radiation and chemotherapy; diabetes mellitus; tumors of the colon, rectum, pelvis, and spine; or inflammatory bowel disease such as ulcerative colitis or Crohn’s disease, say Katz and his colleagues.

To determine FI’s underlying problem, it is important that the patient undergo a complete medical history and careful physical examination, Katz explains. Oftentimes tests such as a colonoscopy, anorectal manometry, anal ultrasound, or pudendal nerve terminal motor latency studies may be necessary to diagnose FI.

Management and Treatment
The first step in managing FI is to adjust the patient’s diet. Drinking four to six glasses of water every day; limiting spicy and fried foods, alcohol, caffeine, leafy green vegetables, milk, and ice cream; and eating regular meals at the same time each day help the person have some control over his or her bowels. “The control will be in the form of predictability but it can empower the patient,” explains Katz.

If controlling diet alone is not effective, the use of “stimulated defecation” can provide relief. By using an antidiarrheal medication to slow down the bowel movement and using enemas or suppositories to stimulate a movement, the patient will also have greater control. Another option could be pelvic floor rehabilitation to improve the function of the anal sphincter and increase sensation to weakened muscles and nerves, says Katz.

The last option—one for which most FI patients are not candidates—is surgery. FI is only cured with the colostomy or ileostomy procedures, which is the removal of the rectum and a portion of the intestines to create a stoma—an opening in the abdomen—for the stool to pass. Other surgical options include sphincteroplasty to repair a direct muscle defect; placement of an artificial bowel sphincter, which is an implanted inflatable donut placed around the anal muscles; and sacral nerve stimulation, which involves placing electrodes in the spine to stimulate the spinal nerves.

Prolapsed Rectum and Rectoceles
Rectoceles primarily affect women, although they have been known to occur in men. If the muscular wall and the connective tissue of the rectum weaken, the rectum can drop down and protrude into the back wall of the vagina, forming a rectocele, explains Beth Julian-Wang, MD, an obstetrician/gynecologist at Huntington Hospital in Pasadena, Calif. A rectocele can make having a bowel movement difficult and may cause a sensation of constipation, which can lead to further straining and weakening of the muscular wall. A rectocele, like the other rectal PFDs, is caused by trauma to the anus such as tearing during vaginal birth or having an episiotomy, according to the American Society of Colon and Rectal Surgeons (ASCRS).

“A prolapsed rectum is essentially the turning out of the rectum which in some cases can protrude through the anus,” says Katz. Rectal prolapse is often caused by the weakening of the anal sphincter muscle and may be associated with some FI. The prolapsed organ can also be caused by excessive straining to have a bowel movement or other injury to the sphincter muscle. “The symptoms of a prolapsed rectum are not unlike a hemorrhoid but a prolapsed rectum involves a portion of the bowel higher up in the rectum rather than at the anus,” according to the ASCRS.

To treat a rectocele, a bowel management program can be effective, as can the use of a pessary to support the pelvic organs, says Julian-Wang. Straining should be avoided if a rectocele is present, she adds. For the prolapsed organ, surgery is the most effective course. The age and physical condition of the patient will dictate which surgical procedure the physician will employ but they all include some form of suturing the rectum to the surrounding tissues, says Katz.

— Kim M. Norton is a freelance writer/journalist.

Resources:
American Society of Colon & Rectal Surgeons
www.fascrs.org

International Foundation for Functional Gastrointestinal Disorders
www.IFFGD.org

The Merck Manual — Rectal Prolapse
www.merck.com/mmhe/sec09/ch130/ch130h.html

Articles accessed:
http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=18

http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=19

Melville JL, Fan MY, Newton K, et al. Fecal incontinence in US women: A population-based study. Am J Obstetr Gynecol. 2005;193(6):2071-2076.

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