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Guest Editorial JANUARY 2007

Minimally Invasive Outpatient Treatment of Bowel Incontinence: A New Procedure for the Gynecologist

Stephen Grochmal, MD

Just a few years ago, gynecologists began to expand their “pelvic focus” to include disorders of the bladder, providing earlier
intervention with appropriate pharmacotherapy or surgery. Included in this “expanded focus” should also be a consideration of diseases of the rectum or anal canal. Gynecologists need a heightened level of awareness, as bowel (fecal) incontinence (BI) is both overlooked by physicians and underreported by patients.1,2

Because up to 20% of women have dual urinary incontinence/BI,3 physicians should routinely inquire about both bladder and bowel function. Although these disorders are considered by some OB/GYNs to be outside the “pelvic paradigm,” we are in a unique position to identify, diagnose, and either treat such conditions or make a referral, providing relief for women who have suffered in silence for years.

Bowel incontinence, as I prefer to designate the condition, is defined as the unintentional passing of stool in an inappropriate place or time, more than two times a month. It has a significant impact on quality of life, leading to social isolation, poor self-image, and sexual dysfunction. Prevalence varies from 2% to 21%, with a suggested rate of one in 41 people—ie, approximately 7 million people in the United States.4-6 There is no distinct difference between men and women in BI prevalence, but women are eight times more likely to have BI than men in age-controlled groups.4

One major cause of BI in women is tearing of the anal sphincter during vaginal childbirth, leading to fecal and flatal incontinence after up to 18% of all vaginal deliveries.7 Women with such tears have twice the risk of BI compared with women who do not have tears. Even after the tear is repaired, 29% to 53% of women continue to report incontinence of flatus and 5% to 10% of women have incontinence of stool 3 to 6 months postrepair.8-10 There are many predisposing factors in women, including menopause, pelvic floor disorders, obesity, abdominal hysterectomy secondary to descending perineum syndrome, and possibly cesarean delivery.

Several methods of BI treatment have been described, but none is optimal. Pharmacotherapy, biofeedback training, and anterior sphincteroplasty are the common approaches. Improved surgical interventions include dynamic gracilloplasty, artificial bowel sphincter, and sacral nerve stimulation. However, these techniques require specialized training, may not be available in the United States, have high complication rates, or only produce satisfactory results in a selected subgroup of BI patients. Foreign-body implants have been associated with significant postprocedure extrusions. Lastly, these advanced techniques are only offered in a few high-level centers to patients with severe BI.

However, one minimally invasive procedure has successfully passed clinical trials in the United States and is presently utilized by many colorectal surgeons—the Secca procedure, which uses radio-frequency energy for anal remodeling. Studies demonstrate significant improvement in both incontinence severity and quality of life, with good long-term implications.11,12 The procedure delivers precise, temperature-
controlled radio-frequency energy to the anal sphincter complex and anorectal junction, strengthening the sphincter muscles and improving anorectal coordination. The thermal energy triggers collagen contraction, leading over time to collagen deposition and tissue remodeling to enhance barrier function. This procedure is essentially noninvasive, requires only sedation and local anesthesia, has a low complication rate, and can be performed in the outpatient or office setting. It is well tolerated,13 almost painless, confers no foreign-body risks, and does not preclude future treatment options. Finally, the training required is minimal.

Nevertheless, it is highly un-likely that a woman will consult a colorectal surgeon on her own. Rather, she is much more likely to disclose BI to her OB/GYN—with whom she already has a rapport regarding intimate subjects. So, as with bladder disorders, OB/GYNs would be well advised to initiate discussions of BI during routine annual examinations—especially now that less invasive, outpatient procedures are available to treat this condition. If OB/GYNs do not wish to offer the Secca technique, they can make referrals to colorectal surgeons who perform it, avoiding “turf wars” and promoting a win-win situation for everyone involved.

Bowel incontinence remains an area of unmet need. Gyne-cologists are in a unique posi-tion to offer a solution to these women, providing the “missing link” to assist patients in obtaining treatment.

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Stephen Grochmal, MD, is Associate Clinical Professor Department of Obstetrics and Gynecology (Adjunct Faculty) Howard University College of Medicine, Washington, DC Private Practitioner, Minimally Invasive Gynecologic Surgery Ridgewood, New Jersey

References

1. Leigh R, Turnberg LA. Faecal incon-tinence: the unvoiced symptom. Lancet. 1982;1(8285):1349-1351.
2. Kwon C, Sand PK. Fecal incon-tinence. J Pelvic Med Surg. 2004; 10:161-167.
3. Jackson SL, Weber AM, Hull TL, Mitchinson AR, Walters MD. Fecal incontinence in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 1997;89(3):423-427.
4. Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA. 1995;274(7):559-561.
5. Walter S, Hallbook O, Gotthard R, Bergmark M, Sjodahl R. A population-based study on bowel habits in a Swedish community: prevalence of faecal incontinence and constipation. Scand J Gastro-enterol. 2002;37(8):911-916.
6. Melville JL, Fan MY, Newton K, Fenner D. Fecal incontinence in US women: a population-based study. Am J Obstet Gynecol. 2005;193(6):2071-2076.
7. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol. 2003;189(6):1543-1549.
8. Fitzpatrick M, Behan M, O°Connell PR, O°Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol. 2000;183(5): 1220-1224.
9. Haadem K, Dahlstrom JA, Lingman G. Anal sphincter function after delivery: a prospective study in women with sphincter rupture and controls. Eur J Obstet Gynecol Reprod Biol. 1990;35(1):7-13.
10. Haadem K, Ohrlander S, Lingman G. Long-term ailments due to anal sphincter rupture caused by delivery—a hidden problem. Eur J Obstet Gynecol Reprod Biol. 1988;27(1):27-33.
11. Efron JE, Corman ML, Fleshman J, et al. Safety and effectiveness of temperature-controlled radio-frequency energy delivery to the anal canal (Secca procedure) for the treatment of fecal incontinence. Dis Colon Rectum. 2003;46(12): 1606-1618.
12. Takahashi T, Garcia-Osogobio S, Valdovinos MA, Belmonte C, Barreto C, Velasco L. Extended two-year results of radio-frequency energy delivery for the treatment of fecal incontinence (the Secca procedure). Dis Colon Rectum. 2003;46(6):711-715.
13. Takahashi T, Garcia-Osogobio S, Valdovinos MA, et al. Radio-frequency energy delivery to the anal canal for the treatment of fecal incontinence. Dis Colon Rectum. 2002;45(7):915-922.

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