The involuntary loss of bowel motion is disabling and embarrassing for those affected. It can have devastating consequences on an individual’s quality of life. There are two broad categories which, more often than not, can occur together – soiling and loss of faecal material without the patient being aware (passive incontinence) or the inability to defer defecation leading to an incontinence episode (urgency). Mr Andrew Clarke specialises in bowel issues and offers bowel incontinence treatment.
About Bowel Incontinence
Severity of symptoms can vary but the condition is common and becomes more prevalent with increasing age. Childbirth is often causal and patients with a history of multiple births and obstetric trauma are more susceptible. Bowel incontinence treatment is usually one of escalation until symptomatic improvement is achieved and the majority of patients do not require surgery or indeed investigation.
Conservative therapies including dietary manipulations and stool thickening agents often suffice. In the event that these measures fail then pelvic floor assessment through X-ray, ultra-sound or pressure studies is used to guide to the most appropriate surgical treatment. Pathways are highly individualised and appropriately tailored to a patient’s requirement and circumstance. Operations are not necessarily major procedures, indeed with modern key-hole operations or electrical stimulation techniques for example, much is performed as a day-case or one night in hospital.
Please note that any change in bowel habit, stool consistency or rectal bleeding may indicate a pathology within the bowel including cancer and it is common for patients to be offered a test to be sure all is clear before embarking on any treatment of their incontinence.
The pelvic floor muscles and structures within it are controlled by the nervous system. A complex pathway of nerves both instruct activity, for example passing urine (motor) and receive information, for example when the bladder is full (sensory). These processes are controlled by both reflexes within the pelvis and by higher centres in the brain. Sacral neuromodulation is a day case procedure that involves placing fine wires adjacent to the very lower nerves that can modulate these pathways.
What is sacral neuromodulation?
In the pelvis are muscles and valves (sphincters) that impart control on the bladder and bowel functions. These not only receive instructions from the brain but report back to it, for example when the bowel or bladder is full. If this communication system fails then faecal or bladder incontinence may ensue. Sacral neuromodulation (SNS) is a procedure which can help improve such situation.
When might SNS be considered the appropriate bowel incontinence treatment?
Various disorders can affect the pelvic floor:
- Bowel leakage from weakness in anal sphincter (passive)
- Urgency and frequency leading to faecal incontinence
- Urinary problems, overactive bladder, interstitial cystitis
First line treatment nearly always involves non-surgical methods. Simple dietary and lifestyle advice may be all that is required. Physiotherapists can dramatically improve symptoms with pelvic floor muscle training and toileting advice. However if the problem persists despite such treatment then SNS may be considered appropriate.
How does this bowel incontinence treatment work?
The technique simply involves a wire inserted in to the very lower back attached to an implanted device about the size of a watch. Once in place it stimulates, with varying degrees of intensity, the appropriate nerves in the pelvic area thus helping to restore coordination between the brain and this area of the body.
Will it work for you?
The likely efficacy of the device can be tested using a two stage technique:
1. The trial phase. A small soft wire is placed within a nerve root low down in the sacral area of the back. This is away from the main spinal cord and cannot damage important nerves. The patient has an external controller to activate the stimulator and will test its efficacy over the trial period which is usually two weeks. There is no implantable material other than the wire and all the equipment is external. If this temporary device works then the patient is put forward for the permanent implant.
2. For the permanent implant the procedure is repeated using a fully implantable wire and stimulating device. This is subsequently programmed to maximise its efficacy.
Both procedures require a general anaesthetic, but are all performed on a day case basis.
How effective is it expected to be?
In a study carried out by the National Institute for Clinical Excellence (NICE) involving a series of tests complete continence was achieved for between 41 and 75% of those tested and 75-100% experienced a decrease of 50% or more in the number of incontinence episodes. Patients also reported a general improvement in their quality-of-life scores.
Using a mobile phone is not affected in any way.
During the temporary assessment a bath must be avoided, but a patient can shower after 48 hours.
There are no such restrictions for the permanent device.
During the test phase you will have to restrict your physical activities due to the risk of the electrode moving from its initial position.
With the permanent implant there are normally no restrictions to physical activities. You should avoid activities that involve sudden, excessive or repetitive bending, twisting, bouncing or stretching soon after the surgery. These movements could damage or move the electrode wire making it less effective
During the test phase it is recommended that you avoid sexual intercourse in case the electrode moves from the correct position. With the permanent implant sexual activity is not restricted.