Fecal incontinence in the elderly patient

REVIEWS

Fecal Incontinence in the Elderly Patient Syed H. Tariq, MD, John E. Morley, MB, BCh, Charlene M. Prather, MD Fecal incontinence is an underreported problem in the general population; it is especially common in elderly persons (aged ⱖ65 years) residing in the community or in long-term care settings. It affects more women than men during younger years, but this differential narrows with age. Physiological changes such as sphincter muscle and sensory abnormalities in the anorectal region contribute to this problem, as do factors such as dementia, physical disability, and fecal impaction. Treatment with biofeedback is feasible in many elderly patients. Those with

advanced dementia or physical disability may benefit from a bowel habit training program. Selected patients may require surgical sphincter repair. Minimally invasive techniques such as radiofrequency energy application offer promising future treatment options. The purpose of this review is to provide current information on fecal incontinence and its management in the elderly. Am J Med. 2003;115:217–227. ©2003 by Excerpta Medica Inc.

F

PREVALENCE

ecal incontinence, defined as the involuntary passage of stool through the anus, affects 3% to 21% of community-dwelling older persons aged ⱖ65 years (1–3) and more than 50% of nursing home residents (4). It can occur in healthy people during an acute event such as diarrhea when the volume of stool overwhelms the rectal reservoir. Patients with fecal incontinence experience anxiety, embarrassment, and social isolation (5,6), which may lead to underreporting of the problem, thus placing the onus on the physician to ask about anorectal problems and to encourage patients to seek treatment. We reviewed the available literature on fecal incontinence, focusing on the clinical evaluation and management of this condition in elderly persons.

METHODS Using MEDLINE we identified English-language journal articles and reviews published from 1966 to December 2002. The key words included anus, anal sphincter, fecal incontinence, elderly, epidemiology, prevalence, pelvic floor disorders, anorectal manometry, therapeutic interventions, anal ultrasound, biofeedback, and surgery. Special attention was given to data regarding persons aged ⱖ65 years.

The prevalence of fecal incontinence in the general population in Wisconsin is 2.2% (7), which may be a conservative estimate because persons residing in nursing homes were excluded in this study. Nonetheless, applying this estimate to the U.S. population would indicate that more than 6 million persons residing in the community have fecal incontinence. Among persons aged ⱖ65 years, the frequency of fecal incontinence ranges from 3.7% to 27% (2,3,8,9). In younger persons, the condition is more common in women than in men, but this differential narrows with age. By the age of 70 years, men experience fecal incontinence as often as do women (3,10). An even higher prevalence is found in nursing homes, where more than 50% of long-term care residents are affected (4). Eighty percent of patients hospitalized with dementia experience fecal incontinence (11). Double incontinence (fecal and urinary incontinence) is 12 times more common than fecal incontinence alone, with 50% to 70% of patients with urinary incontinence also suffering from fecal incontinence (7,12), and is the second most common cause of institutionalization in the elderly (13,14).

IMPACT AND IMPORTANCE From the Divisions of Geriatric Medicine (SHT, JEM) and Gastroenterology (CMP), Department of Internal Medicine, Saint Louis University School of Medicine; and Division of Geriatrics, GRECC Saint Louis Veterans Administration Medical Center (SHT, JEM), Saint Louis, Missouri. Requests for reprints should be addressed to Syed H. Tariq, MD, Division of Geriatric Medicine, Department of Internal Medicine, Saint Louis University School of Medicine, 1402 S. Grand, M-238, Saint Louis, Missouri 63104, or [email protected]. Manuscript submitted September 10, 2002, and accepted in revised form April 23, 2003. © 2003 by Excerpta Medica Inc. All rights reserved.

In the long-term care setting, fecal incontinence is more than an inconvenience to the persons affected and their caregivers, it is also a marker for poor overall health and increased mortality (4). Incontinent nursing home residents experience more urinary tract infections and pressure ulcers (15). Fecal incontinence has also been associated with increased mortality among elderly persons living at home (16). The additional health expenditure is in excess of $9000 per patient-year of incontinence (15). 0002-9343/03/$–see front matter 217 doi:10.1016/S0002-9343(03)00327-9

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Figure 1. Illustration of the anal canal and rectum.

ANATOMY AND PHYSIOLOGY OF THE ANAL CANAL A combination of muscles (internal anal sphincter, external anal sphincter, and puborectalis) and anal cushions make up the high-pressure zone of the anal sphincter that surrounds the anal canal (Figure 1) (17–19). The internal anal sphincter emanates from the distal inner circular muscle layer of the rectum and is identified as a 2- to 3-mm thick band of muscle on ultrasound (Figure 2). It is tonically contracted at rest, preventing the involuntary

loss of stool and gas. Internal anal sphincter thickness increases with age (20,21), from 2.4 to 2.7 mm in persons younger than 55 years to 2.8 to 3.4 mm in those who are older (22). This change in thickness is associated with increased echogenicity of the internal sphincter (23), which has been suggested to be a compensatory change for maintaining continence (20). However, this hypothesis has been difficult to demonstrate as the age-related changes in anal sphincter pressures are modest in healthy persons and some studies have reported no change in resting anal sphincter pressures (24,25). Increased connective tissue or sclerosis of the internal anal sphincter, which also occurs with aging, may be a more likely explanation for the sonographic finding (26). The external anal sphincter is an elliptical cylinder of striated muscle surrounding the inner smooth muscle and terminating distal to the internal anal sphincter (Figure 1). It contributes about 20% to the resting tone of the anal sphincter (27). Along with the puborectalis, the external anal sphincter provides voluntary control of continence in response to stimuli such as increased intraabdominal pressure that occurs with coughing, rectal distention, and anal dilatation (18,28). Voluntary anal sphincter pressures decrease with age and are lower in women than in men (29). Like skeletal muscle reduction elsewhere in the body, pronounced thinning of the external anal sphincter occurs with aging, possibly contributing to this reduction in pressure (20).

RISK FACTORS AND CAUSES OF FECAL INCONTINENCE A variety of medical conditions are associated with fecal incontinence in the elderly (Table 1) (30). Most etiologies

Figure 2. Anal ultrasound. Note the hyperechoic external anal sphincter muscle and the hypoechoic internal anal sphincter. 218

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Table 1. Etiology of Fecal Incontinence

of 8% to 15% (38 – 40). Altered cognition is commonly associated with fecal incontinence (4). Although commonly seen together, the mechanisms involved in urinary and fecal incontinence have been poorly explored, especially in the elderly. In addition to aging, changes affecting the perineal musculature, cognition, mobility, medication use, and overall functional capacity are likely to affect the development of double incontinence. Sex-specific contributing factors include prostate cancer and child bearing.

Fecal impaction (usually associated with reduced rectal sensation) Loss of normal continence mechanism Local neuronal damage (e.g., pudendal nerve) Impaired neurological control Spinal reflex arc Autonomic control Central inhibition Anorectal trauma/sphincter disruption Birth trauma Anal dilatation Anal surgery Problems overwhelming normal continence mechanism Diarrhea/colitis Poor access to toileting facilities Laxatives Radiation Psychological and behavioral problems Severe depression Dementia Delirium Physical functional impairment Hemiparesis Arthritis Gait instability Neoplasm (rare)

EVALUATION OF FECAL INCONTINENCE Goals when evaluating fecal incontinence include establishing the severity of incontinence, understanding the pathophysiology, and directing the patient to appropriate therapy.

History

are associated with alterations in the muscular or neural control of the anus and rectum. Risk factors for fecal incontinence include a prior history of urinary incontinence, the presence of neurological or psychiatric disease, poor mobility, age ⬎70 years, and dementia (7,31). Fecal impaction, possibly the most common predisposing condition, is found in up to 42% of elderly patients admitted to geriatric units (31). These patients often have chronic constipation resulting in incontinence from leakage around the large fecal impaction (32). The problem is compounded by decreased rectal sensation, which allows accumulation of stool in the rectum (33). Fecal incontinence may also result from excessive use of laxatives overwhelming the sphincter mechanism with an increased volume of loose stool. In patients with diabetes mellitus, the condition results from autonomic neuropathy and is exacerbated in the presence of diabetic diarrhea (34). Pelvic neuropathy may result from prolonged straining and birth trauma. Although anal sphincter disruption occurs frequently with vaginal delivery, it remains a risk factor for the development of incontinence even in the elderly patient (35). Anal surgery, such as hemorrhoidectomy, anal fissure repair, and anal dilatation, may disrupt the sphincter muscles, resulting in impaired continence (36,37). Patients with total internal sphincterotomy have a 40% risk of fecal incontinence, whereas partial sphincterotomy is associated with a risk

Patients rarely volunteer information about incontinence (6). This information is best elicited through specific questioning about bowel habit and continence. This is especially important in patients with chronic diarrhea, fecal urgency, constipation, diabetes mellitus, urinary incontinence, recurrent urinary tract infections, or neuromuscular disease. It is helpful to identify when and under what circumstances (e.g., after surgery or a stroke) the symptoms first occurred. Physicians should note the timing of incontinence as compared with periods of continence, bowel movement frequency, stool consistency, stool volume, nocturnal symptoms, and the relation to certain foods or meals. It should also be determined whether the patient has an awareness of the passage of stool or gas, fullness in the rectum, or warning symptoms such as abdominal cramps and urgency. Inquiries about the home environment and any barriers to bathroom facilities are also helpful. A history of prior operations in the anorectal region should be noted, including hemorrhoidectomy, sphincterotomy, fistulectomy, prostatectomy, colon resection, and anal dilatation. Likewise, a previous history of radiation treatment for prostate or cervical carcinoma may point towards radiation changes contributing to the incontinence through effects on the sphincter or altered rectal compliance. Colitis of any cause may result in loose stools that overwhelm continence mechanisms. In the elderly patient with a history of recent antibiotic use or institutionalization, the coexistence of Clostridium difficile diarrhea should be considered. Colonic ischemia, ulcerative colitis, and proctitis are also found in elderly persons, who can present with diarrhea and incontinence, in addition to rectal bleeding. Obstetrical injury, even at a young age, may result in subsequent incontinence. An altered bowel habit (diarrhea or constipation) of any cause increases the risk of fecal incontinence (3).

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Several components of the neurological history warrant attention. A cerebrovascular accident may limit the patient’s physical ability to use the toileting facility. New onset of fecal incontinence may also indicate spinal cord compression, especially when observed with other neurologic symptoms. Although dementia can be suspected based on the patient’s history and the Mini-Mental Status Examination, eliciting additional information from family members may be necessary in patients with dementia (41). Chronic medical conditions such as diabetes may cause neuropathy. Conditions affecting skeletal muscle strength and thereby limiting mobility can also contribute to altered bowel function. A thorough review of prescription and over-thecounter medicine and supplements may sometimes explain an altered bowel habit. Medications that cause diarrhea include magnesium-containing antacids and poorly absorbed sugars such as sorbitol and mannitol (used in dietetic products). Sorbitol is also frequently used as a base in elixirs. The use of cathartics may contribute to diarrhea and incontinence. Similarly, a medication that causes constipation may worsen incontinence through overflow mechanisms.

Physical Examination The physical examination helps to identify the pathophysiology of fecal incontinence and guides the ordering of tests for further evaluation (42). The neurological examination includes assessment of mobility, motor strength, and sensory testing. The “anal wink” is elicited by stroking the skin lateral to the anal canal and observing the contraction. Absence of this reflex suggests marked neural damage. Anal gaping can be seen when the buttocks are parted in patients with paraplegia (43). The perineum should be inspected for dermatitis, hemorrhoids, fistula, surgical scars, skin tags, rectal prolapse, soiling, and ballooning of the perineum (suggesting weakness of the pelvic floor). Following inspection, the digital rectal examination should be performed. Physicians should note the baseline sphincter tone, squeeze pressure, any asymmetry of the sphincter on squeeze (especially anteriorly), and the amount and character of the stool (e.g., hard and ball-like or soft). The positive predictive value of a digital examination is 67% for detecting decreased anal tone when compared with anal manometry (44). Patients with high or normal sphincter tone may also be incontinent, especially those with large rectal volumes or altered rectal sensation. Sphincter tone may be normal in patients with lesions of spinal cord or cauda equina, but gaping is observed when pressure is applied to any part of the anorectal ring. Examination of healthy elderly persons typically reveals lower anal canal pressures (45).

TREATMENT

Diagnostic Tests A number of tests are available that provide data on colonic and anorectal function (46). In the elderly, the first 220

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priority is to exclude fecal impaction. Even in the absence of stool in the rectal vault, there may be higher impaction. In patients at risk, a plain abdominal radiograph is required to exclude high impaction. Flexible sigmoidoscopy is used to examine the colorectal mucosa for evidence of colitis, neoplasia, colonic ischemia, laxative abuse, and other structural abnormalities. Patients with a history of colorectal neoplasia, a family history of colon cancer, or iron deficiency anemia should undergo colonoscopy. Colonoscopy should also be considered in those who have never undergone colon cancer screening. Anorectal manometry provides comprehensive information on anorectal function, quantifying anal sphincter tone and assessing anorectal sensory responses, the rectoanal inhibitory reflex, and rectal compliance (47). Manometry either provides new information or confirms the suspected diagnosis in patients with fecal incontinence (48). A finding of lower rectal compliance may point to fecal incontinence from increased stress on the continence mechanism as the stool is received in the rectum (i.e., a stiff rectum does not accommodate the stool bolus and results in overflow) (49). Electromyography measures the neuromuscular integrity between the distal portion of the pudendal nerve and the anal sphincter muscle (50). Electromyography correlates well with anorectal manometry, but its use in the routine assessment of fecal incontinence is controversial (46,51). Anal ultrasound defines the internal and external anal sphincters (52). It can be used to identify isolated sphincter defects, which are present in about two thirds of incontinent patients (53,54). Ultrasonographic findings correlate with both surgical and electromyographic findings (55,56). Magnetic resonance imaging, which is used to evaluate sphincter defects, provides higher spatial resolution and better contrast for lesion characterization as compared with ultrasound (57). However, given the added expense and need for special coils, the clinical relevance of the improved resolution is debatable. Defecating proctography, which involves inserting a barium paste in the rectum, is used to evaluate the defecation dynamics of the anorectum through images taken at rest and during defecation. Although helpful in identifying internal intussusception, it is rarely used in routine evaluation because it may be difficult for the incontinent patient to hold the contrast material to allow an adequate examination. It may sometimes, however, be helpful in the preoperative assessment. Nonetheless, not all patients require all tests. An algorithm outlining a possible management strategy is shown in Figure 3.

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The type of treatment depends on the underlying etiology and severity of the incontinence. Patients with mental

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Figure 3. Algorithm for the evaluation and treatment of fecal incontinence.

impairment such as dementia may simply need to be directed to the toilet or reminded of such use. Physical limitations and obstacles in the environment need to be addressed if they contribute to incontinence.

Conservative Therapy Habit training involves a regular schedule for defecation, usually after breakfast and often incorporating the use of supplemental fiber. Patients with overflow incontinence may benefit from the addition of regularly scheduled enemas or laxatives, especially when defecation is delayed for more than 2 or 3 days. Habit training has been found to be effective in patients with overflow incontinence

(58). Indeed, prompted voiding has been shown to increase the number of continent bowel movements and reduce the number of incontinent bowel movements (58). The use of enemas or suppositories may be problematic in patients with low anal sphincter pressures who are unable to hold the inserted material. The use of enemas does not add to the effects of oral laxatives in the treatment of nursing home patients (59). Sphincter training exercises (Kegel exercises) alone do not increase the number of continent episodes (60). Antidiarrheals such as loperamide are helpful when the stool is loose (61). In a double-blind crossover study of 30 patients receiving

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Table 2. Selected Studies of Biofeedback Therapy

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First Author (Reference)

Number

Age Range in Years (Mean)

Control Group

25

17–76

Yes Randomized

Whitehead (60)

18

65–92 (73)

Yes Randomized

Guillemot (67)

Strength Sensory Coordination Strength Sensory Coordination Strength

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24 39–72 (60) 16 BF 8 control Loening-Baucke (68) 17 35–84 (64) 8 BF 9 medical therapy Macleod (69) 50 25–76 (55)

Yes Not randomized Patients chose therapy Yes Strength Not randomized Sensory Coordination No Strength

Rao (70)

22

15–78 (50)

No

Goldenberg (71) Wald (63)

12 17

12–78 10–79 (48)

No No

Sangwan (72)

28

30–74 (52.9)

No

Glia (73)

26

32–82 (median, 61) No

Chiarioni (74)

14

24–75 (49)

No

Cerulli (75)

50

5–97 (46)

No

Berti Riboli (76)

21

14–84 (60)

No

Patankar (77)

72

34–87 (70)

No

Strength Sensory Coordination Strength Strength Sensory Coordination Strength Sensory Strength Sensory Strength

Outcome Measure

Improvement

Follow-up in Months (Mean)

Stool diary

77% BF 42% sham

24

Diary ⱖ75% improvement

77% 50% 42% 75% 19%

Post BF 6 12 6 24–36 (30)

Stool diary ⱖ75% improvement

50%* 38%*

3 12

ⱖ90% decrease in FI frequency Diary/VAS FI severity scale

72%

12

ⱖ75% ⫽ 53% ⱖ50% ⫽ 100%

12

Clinical score

Not described Interview Questionnaire ⱖ75% improvement Manometry Excellent/good results FI questionnaire ⱖ50% reduction in FI Diary cards ⱖ75% reduction FI Monthly interview ⫻ 5 Then every 3 months ⱖ90% reduction FI

Strength Sensory Coordination Strength ⱖ90% reduction FI Sensory Coordination Strength Questionnaire ⱖ75% improvement Subjective satisfaction

83% 71%

3–24 2–38 (15)

75%

4–47 (21)

64%

12–48 (21)

75%

3–21 (15)

72%

4–108 (32)

86%

1.5 or 3

85%

Not stated

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Miner (66)

Biofeedback Modality

Table 2. Selected Studies of Biofeedback Therapy—Continued First Author (Reference)

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Age Range in Years (Mean)

Rieger (36)

30

29–85 (median, 68)

No

Strength

Ryn (78)

37

22–82 (median, 61)

No

Strength

Buser (79)

13

13–66

No

14–82 (median, 49)

No

Strength Sensory Coordination Strength Sensory Coordination Strength Coordination Strength Sensory Coordination

Norton (80)

100

Control Group

Ko (81)

25

31–82 (63)

No

Leroi (82)

27

29–74 (53)

No

* Unchanged from controls. BF ⫽ biofeedback; FI ⫽ fecal incontinence; VAS ⫽ visual analog scale.

Biofeedback Modality

Outcome Measure VAS Incontinence score ⬎80% improved ⫽ cure Any improvement FI score Subject rating VAS Manometry Resolution of FI

Improvement 27% 23% 23% 67% 59% good/very good 41% some improvement 92%

Bowel diary Symptom questionnaire

43% (cure) 24% (improvement)

Symptom improvement No. of FI episodes Clinical improvement Good vs. poor

92% 30%

Follow-up in Months (Mean) 1.5 6 12 12–59 (44)

16–30

End of BF

7 Not reported

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loperamide, codeine, or diphenoxylate for 4 weeks, loperamide and codeine were more effective in reducing fecal incontinence as compared with diphenoxylate (62). Diphenoxylate and codeine, however, have more adverse effects on the central nervous system than does loperamide and are best avoided in elderly patients. Biofeedback is a nonsurgical, noninvasive, and relatively inexpensive method of treating fecal incontinence on an outpatient basis (63). Engel et al (64) were among the first to describe biofeedback for fecal incontinence using the Schuster balloon system. Biofeedback improves the strength of the external sphincter and anorectal sensation (60), thus providing immediate and long-term improvement of fecal incontinence (65). Training involves teaching the patient to recognize small volumes of rectal distension and to contract the external anal sphincter while simultaneously keeping intra-abdominal pressure low. This is accomplished by measuring anal canal pressure, showing this on a visual display to the patient, and providing verbal feedback. A number of studies have been conducted to determine the effectiveness of biofeedback therapy (Table 2). Better results are observed with motivated, mentally capable patients. Patients should also have some degree of rectal sensation and be able to contract the external anal sphincter (83). In a comparison of active sensory biofeedback with sham retraining (66), biofeedback reduced the number of incontinent episodes from five to one per week, whereas the sham group showed no change from baseline. This improvement lasted more than 2 years in the 73% of patients who were available for follow-up. In another study of 13 elderly patients (including those with dementia or depression or who were wheelchair dependent) who were incontinent despite initial treatment for fecal impaction (60), biofeedback improved sphincter strength and reduced incontinence episodes by more than 75%. A review of biofeedback studies by Enck et al showed improved continence in 13 of 14 studies (84). More recently, Norton and Kamm reviewed 46 studies involving the use of biofeedback for fecal incontinence in 1364 patients, about 75% of whom were female (85). They found that only two studies were randomized (60,66) and only four studies included a control group (60,66 – 68). Most studies involved relatively small numbers of subjects, had varying duration of follow-up, and defined treatment success differently (Table 2). Despite these differences, improvement in continence was observed in at least 50% of patients. Specific details regarding age-related responses to biofeedback are lacking (85); most studies included patients in a broad range of ages and only one study has focused on the elderly (60).

Surgical Therapy Surgical intervention is considered when more conservative measures have failed in patients with severe 224

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incontinence and identifiable anatomic defects. Although surgery is recommended mostly in younger patients, appropriately selected elderly patients fare as well with surgical intervention (86). There are three surgical approaches to sphincter repair: direct apposition, overlapping anterior sphincteroplasty, and plication procedures. In the setting of an isolated sphincter defect, surgical repair is very successful (87) and anterior sphincteroplasty is among the most effective operations (88). Fleshman et al (89) reported a 96% improvement in anal function with anterior sphincter repair in women aged 22 to 75 years. There have, however, been reports of patients continuing to experience incontinence or developing new bowel problems postoperatively (88,90). In patients with severe fecal incontinence in whom standard therapy is not effective, muscle transposition may be considered. Techniques include graciloplasty, dynamic graciloplasty, and gluteus maximus transposition. Newer techniques have been developed for the treatment of fecal incontinence in patients who do not respond to conventional therapy, such as implantation of an artificial anal sphincter (91), as well as injection of glutaraldehyde cross-linked collagen, a simple and welltolerated procedure, in patients who have a surgically uncorrectable problem such as internal sphincter dysfunction (92). Sacral nerve stimulation (93) and the application of radiofrequency energy to the sphincter (94) have been shown to improve fecal continence in selected patients. Few of these procedures, however, have been studied in the elderly, and none have been subject to adequate randomized controlled trials. Nevertheless, when all other procedures have failed, a diverting colostomy is usually the surgical procedure of choice for severe fecal incontinence (95).

CONCLUSION Fecal incontinence is a common problem in the elderly and is a leading reason for nursing home placement. Patients and their caregivers must be questioned specifically about the presence and severity of fecal incontinence as they may be embarrassed to admit their problem and unaware that effective treatment exists. All patients should undergo an initial medical evaluation that includes the exclusion of fecal impaction. Cognitively impaired patients benefit most from habit training, whereas select elderly patients may benefit from biofeedback and surgical intervention. Future studies are needed to identify which patients will obtain the most benefit from these interventions and to determine the most cost-effective evaluation and treatment regimens for an aging population.

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94. Takahashi T, Garcia-Osogobio S, Valdovinos MA, et al. Radiofrequency energy delivery to the muscle of the anal canal for the treatment of fecal incontinence. Dis Colon Rectum. 2002;45:915– 922. 95. Oliveira L, Reissman P, Nogueras J, Wexner SD. Laparoscopic creation of stomas. Surg Endosc. 1997;11:19 –23.

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