Life is full of embarrassing moments. Who among us hasn’t suffered the mild mortification of unknowingly walking around with toilet paper trailing from a shoe? Or an unzipped fly? How many of us know what it’s like to emerge from an underwater dive only to discover that part of our bathing suit didn’t emerge with us? And while these cringe-causing moments leave us red in the face, they usually end up as sources of amusement – not lasting, life-altering burdens.
Unless we have firsthand experience, can any of us truly understand the pain and embarrassment of something like bowel incontinence? Most of us can’t even say “bowel” or “fecal incontinence” without wincing, let alone fathom what it would be like to actually have it. Adding insult to injury is the fact that –as the Journal of the American Medical Association reported, puts it: “Silence masks the prevalence of fecal incontinence,” making it very difficult to pin down accurate estimates of sufferers.
Bowel or fecal incontinence, is a symptom of a condition or disease resulting in the inability to control bowel movements. It occurs when rectal and anal muscles and nerves are damaged as a result of such conditions and diseases as: complications during childbirth, inflammatory bowel disease, irritable bowel syndrome, pelvic surgery, neurological disorders, nerve or muscle damage, spinal trauma and radiation therapy in the pelvic area to treat cancer. It strikes in a full range of degrees, from the leakage of small amounts of fecal matter when passing gas, to complete loss of bowel and rectal control.
While bowel incontinence is not technically life-threatening, it certainly is life-altering, having a devastating impact on sufferer’s live. In addition to attacking one’s quality of life, it severely impairs one’s activities both in and away from home, and restricts – if not completely halts – one’s ability to travel. “In addition to all the physical and logistical issues that patients have to deal with regarding bowel incontinence, perhaps the most disturbing aspects are how negatively this affects emotional and mental health and most of all – self esteem,” said Joshua I. S. Bleier, MD, assistant professor of Clinical Surgery in Penn’s Division of Colon and Rectal Surgery at Pennsylvania Hospital. “There is such a social stigma attached to bowel incontinence. It causes social isolation and confines patients to their homes.”
It also costs money.
In addition to the mounting cost of sanitary products and treatment of depression, there are more serious societal costs. “In young patients, more severe cases of bowel incontinence can result in the loss of employment and increased dependence upon welfare,” said Dr. Bleier. “As for our elderly patients, there is the high cost of residential care as incontinence is the most common reason for 40 to 50 percent of all nursing home admissions.”
There is now new hope for patients who experience chronic fecal incontinence and whom have failed or are not candidates for conventional therapies – sacral nerve stimulation (SNS) – a minimally invasive treatment option which may help them regain complete bowel control.
For some patients, fecal incontinence may be due to weakening or discoordination of the muscles of the pelvic floor. In most patients – the majority of whom are women in the 50s or 60s – there is also a component of prior anal sphincter injury, usually during childbirth. Stimulation of the sacral nerves – which control the bladder, anal and urinary sphincters and pelvic floor – via electrode leads placed into the lowest part of the spinal column, may help regulate the malfunctioning muscles. Similar to a pacemaker for the heart, the stimulator discharges mild electrical pulses to restore normal function to the pelvic floor and help patients regain bowel control. “Sacral nerve stimulation works in more than 75 percent of potential patients, and when it works it is profoundly life-changing,” says Dr. Bleier.
The first step in sacral nerve stimulation treatment is a test phase, which does not require implantation of the permanent device, to determine if the process will work. Only if the test is successful, can then the small permanent pacer be confidently implanted. It is placed with the help of fluoroscopy, or a “live,” moving x-ray. Conversely, if the test phase is not successful, unnecessary implantation of the device is avoided. “Both procedures are very safe and cause minimal, if any, discomfort,” said Dr. Bleier.
Prior to approval of SNS, many patients with old sphincter defects had no other options but to undergo sphincter repair, which while initially effective, does not usually work long-term, and is a difficult operation to recover from. Incredibly, SNS works, even in those patients with sphincter defects, and is becoming first-line treatment, when conservative measures have failed. This technology is truly changing our paradigm of treatment for fecal incontinence.
FDA-approved to treat bowel incontinence in April of 2011, sacral nerve stimulation is also being used to successfully to treat sufferers of an overactive bladder. Lily Arya, MD, MS, chief of Penn’s Division of Urogynecology and Pelvic Reconstructive Surgery, and Ariana Smith, MD, director of Pelvic Medicine and Reconstructive Surgery, have been treating female patients with urge incontinence with sacral nerve stimulation at both the Hospital of the University of Pennsylvania and Pennsylvania Hospital.
“Sadly, incontinence is a common problem with profound social and economic impact,” added Dr. Bleier. “Sacral nerve stimulation is a promising new modality helping us effectively treat more patients than ever before. Our main challenge now is to let these silent sufferers know that now there is something out there that can help them get their lives back. They shouldn't have to suffer and be embarrassed and alone any more."