(March 27, 2008 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a medical condition.
On a recent trip to Atlanta, we caught up with Dr. Niall Galloway, MD, FRCS, a Urologist at the Emory Clinic, and an Associate Professor of Urology at Emory University. As Director of the Emory Continence Center, Dr. Galloway's clinical research covers a broad range of continence issues.
We asked Dr. Galloway what he would do if he had a family member with bowel control issues.
Dr. Galloway: Well, fecal incontinence is the name that doctors give to patients who have problems controlling the bowel, and typically controlling gas is less of a problem than controlling the stool or the bowel movement. This is a very common problem, and more than 10% of the patients that we see who come to a bladder control clinic are also going to have bowel control issues as well. There are many paradoxes associated with leakage, and of course the first thing that we tend to think of when patients have problems with bowel control is to do with muscle weakness. It’s about “why can’t the patient manage to hold this in?” But, in effect, under perfect healthy conditions, the bowel should be emptied by nerves and muscles. And those nerves and muscles function in a way that effectively allows the whole train to leave the station, so that after a bowel movement most patients are empty. For the patient who has problems with bowel control, typically the first thing they have is a little bit of constipation, that they don’t quite empty as well as they should, and one could think of the bowel a little bit like a weapon; when it’s loaded, it’s dangerous. And here we have a situation where when the patient begins to have problems with leakage, the first thing that they tend to do is to say “how can I go to the pharmacy and use medicines to help me from not having this diarrhea or this leakage?” and in reality, that is typically exactly the wrong way to go.
How should my doctor approach this issue?
Dr. Galloway: I think the first thing is we should recognize that fecal incontinence is truly just a symptom, and that symptom can be a reflection of a number of different sorts of problems. Oftentimes, this is associated with problems with nerves and muscles, so patients who have an inability to sense the structures in the pelvic floor will have a much greater risk of problems like fecal incontinence, patients who have muscle weakness and difficulty with coordination. But oftentimes, simple things like life events, such as childbirth, can cause damage to the pelvic floor or the anal sphincter. Some patients are left after childbirth with an opening, called a fistula, between the bowel and the vagina, which means that the continence mechanism cannot protect against leakage. There are many kinds of surgeries that are done for problems like cancer, radiation treatments that may be given in the pelvis that can have a profound effect on bowel function and can drive patients towards problems with fecal incontinence.
How do you distinguish categories of fecal incontinence?
Dr. Galloway: Well, I think the first thing to do is to distinguish whether or not this is leakage because of failure of the pelvic muscles and the anal sphincter to hold, or whether it’s a problem that has to do with emptying. And in many ways this is very similar to situations that we see with the bladder where oftentimes patients who don’t empty their bladder present with leakage, and this is a very common pattern. If the patient doesn’t empty well, then typically that patient will have other clinical signs. Those signs include abdominal distention, so the tummy will be bigger than it should be, there may be pain or discomfort and that pain is often on the right side and often in to the low back, and sometimes radiates into the legs or even the feet. And I think that clearly if the patient is having problems with fecal leakage, and they have also noticed that their tummy is getting bigger, then it’s very likely that this is a problem of failure to empty, rather than a problem of muscle weakness.
If I had a family member suffering from fecal incontinence…
Dr. Galloway: Well, I think if I had a family member with fecal incontinence, the first thing that I would do would be to make sure that they understand that this is part of a physical problem, that this is not a reflection of mental incompetence, because oftentimes in our society, we have associated incontinence with incompetence, and that is just not true. If the patient is noticing abdominal distention or pain or discomfort in the pelvis, then we must get the bowel emptying better, and that can be done with simple measures: over-the-counter medication such as magnesium, but it can also be done using changes in diet that might include prunes and prune juice, that might include flax seed, for example, which is a wonderful, natural lubricant that helps the bowel to move better. Some patients prefer, particularly if there’s a sensory deficit, to use a trigger, such as a suppository, that can be placed into the bowel in order to stimulate the bowel to empty. And these approaches, typically, can be used very safely on a daily basis. The other things that are so important have to do with maintaining an adequate intake of water, because when we become dehydrated, the body takes fluid from the only place it can, which is the colon, and that makes the bowel more dry, more stiff, and more difficult. So, an adequate intake of water, a good diet, typically rich in high fiber, and walking exercise. These things are all important.