This week in Share Mayflowers, we are highlighting Bladder and Bowel Health. I had the privilege of discussing this topic with Lieba Savitt, a Nurse Practitioner who specializes in pelvic and colorectal health at Massachusetts General Hospital in Boston, MA. Here is an overview of what she had share.
Most often, the patients that Ms. Savitt sees in her practice include those with pelvic pain (specifically rectal pain), constipation, fecal incontinence, and rectal prolapse. In her clinical experience, many of these patients are eager to “fix” the problem, or problems, they may be having. Because of this, she spends a lot of time educating patients to help them understand the different disease processes. In addition, she discusses how developing regular bowel habits can help lead to consistent bowel movements, as well as improve fecal incontinence and constipation.
We also discussed the potential interventions, both conservative and surgical, for the different colorectal problems that women may experience. For example, if someone comes into her office with symptoms of constipation and fecal incontinence, fiber supplementation is typically used as a first-line treatment approach. If this treatment approach is unsuccessful, further treatment varies depending on the underlying issues. Patients coming in with rectal prolapse, for instance, generally need surgical intervention, because if left uncorrected, the rectal prolapse can stretch out the anal sphincter and lead to fecal incontinence. When this occurs, it becomes more difficult to treat in the future, even with surgery.
Fecal incontinence in particular is addressed through a combination of dietary and medication management. If they are having fecal incontinence due to loose stool, Imodium and anti-diarrheal medications to bulk the stool can be given. If patients are coming in with more formed and hard stools, however, the treatment depends more on context. Fecal incontinence of this type can sometimes be related to a decrease in anal sphincter pressure and women are examined to determine if there is any damage to the anal sphincter muscle, which often happens during childbirth. Many women seek care in years after the trauma to their pelvic floor. They may not have been aware of the injury at the time and then come in seeking help for fecal incontinence many years after giving birth to their last child. Depending on the severity of incontinence, a surgical sphincter repair may be recommended. If the sphincter is intact but its tone is low, she often recommends biofeedback to strengthen the pelvic floor muscles. A sacral nerve stimulator is also an option to help with fecal incontinence. In limited circumstances, there is also an option involving surgical implantation of an artificial bowel sphincter, a procedure not performed regularly due to the risks involved. When fecal incontinence is related high anal sphincter tone and decreased rectal compliance (where the rectum doesn’t stretch very easily), patients often have symptoms of constipation and then have symptoms of overflow or urgent fecal incontinence. In these situations, enemas to empty out their rectum are useful, as well as physical therapy if the inside of rectum is very tight (which can often cause pain) or biofeedback for sensation retraining.
If women are coming in with symptoms of constipation, this is often due to a combination of an increase in rectal capacity and rectum not contracting well combined with not having good urges to defecate. They may also have tight rectum tone causing the anus to not open well to allow stool to come out. These are the pelvic floor type constipation issues. She also sees patients with constipation issues related to problems such as Irritable Bowel Syndrome and slow transit constipation where the colon is slow at moving stool through. In these cases, she recommends using fiber and laxatives as a first line treatment. Biofeedback and physical therapy to train pelvic muscles to relax are other recommendations. In addition, bowel training can be very helpful in the treatment of constipation. During bowel training, she recommends patients go to bathroom at a regular time everyday, eat something before they try to go to bathroom to increase the gastrocolic reflex (the reflex responsible for the urge to defecate following a meal), sit in appropriate position to defecate, and wait for urge from body. This training also includes educating patients on how to best use enemas.
In some circumstances, patients may experience an internal intussusception (or prolapse), where their rectal walls fold in on each other. Ms. Savitt has similar recommendations to treat this problem including dietary changes such as fiber supplementation. If dietary changes do not solve this problem, surgery is also an option. In addition, patients may present with rectoceles (a herniation of rectum into vaginal wall) with the possibility that stool can get trapped in the herniated space. A surgical repair of the rectocele may be recommended.
If patients present with complaints of rectal pain, a major focus is figuring out the source of the pain. This source may be an anal fissure (a split in the tissue wall/lining) that reopens every time they defecate, causing a very sharp pain. Treatment options for fissures include medications and potentially surgical intervention. If that is not the cause, tight pelvic floor muscles are often to blame for complaints of pain the pelvic area and pelvic floor physical therapy is frequently the recommended avenue of treatment. It is important to note, though, that she wants to first rule out any neoplasms developing as a result of rectal or colon cancer because sometimes these symptoms are first signs and this is why she wants to make sure patients have up to date colonoscopies before proceeding with treatment.
Ms. Savitt also mentions that many of the people she sees assume that these problems are only happening to them. As much as people don’t talk about urine incontinence, the reservation about talking about fecal incontinence is even greater even though there are opportunities to improve things with treatment with patients often keeping these problems undercover for many years. She also says it is important to note that these problems are not a normal part of aging and don’t only happen with older people (she sees people as young as 16 years old). She also cites a plethora of misinformation, leading many women to self restrict their diets in ways that may be contributing to the problem. This is why it is so important to educate patients about what constipation is about and where coming it is coming from as well as what fecal continence is about and where it is coming from.
I asked Ms. Savitt about changes she would like to see in women’s health in the near future and she responded by saying that women’s health care providers are making strides in the treatment of fecal incontinence but that they still don’t have 100% effective treatments. Even the treatments they have now are not optimal and long term effects don’t seem to always hold, which is very frustrating because fecal incontinence can be so debilitating and isolating. In light of this, she thinks it would be great to do more research on treatment interventions for fecal incontinence. She also spends a lot of time looking at the interplay between bowel and bladder issues - often times health care providers are focusing on bowel OR bladder and not taking a comprehensive look at it even though when you take a closer look, many patients with bowel problems also have bladder problems. She sees many women with urinary incontinence who also have fecal incontinence, or have rectal prolapse and vaginal prolapse, or have experienced constipation and urinary incontinence. Because there is such an interplay between the two systems, she believes it is really important to really look at this comprehensively and to treat the pelvis a holistic manner. To do so, it is important that colorectal and urogynecology specialists be increasingly more comprehensive and collaborative in their treatment.
Lieba Savitt, NP, is a nurse practitioner in the Pelvic Floor Disorders Service at Massachusetts General Hospital.