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Treatments

The treatment suggested will depend on the cause of the faecal incontinence, how severe the problem is, and how bothered you are by the symptoms. This is not a problem that you must be treated for, it is up to you. Some people are happy just to have had things checked out and to be reassured that there is no sign of serious disease or illness. Most are understandably anxious to get rid of the problem.

It is up to you to discuss the possible options with your doctor or nurse, and together come to a decision as to which treatment to try first. It is important that you do not simply accept a treatment because it is possible, and your doctor or nurse will discuss with you the advantages, and possible disadvantages, of whatever is suggested. Only you can decide whether, for instance, your problem is bothering you enough to go through an operation.

Some people will be treated by their own doctor, district nurse of continence advisor. In other cases treatment is best supervised by the hospital.

Self help

This section contains information on exercises, bowel retraining, diet, skin care and other things that you can do to help yourself.

Drug treatment

This section contains information on medications that may help.

Biofeedback

This sections describes the programme of supervised exercises and bowel retraining that is available in some specialised clinics.

Surgery

This section contains information on operations that are possible for some people with faecal incontinence.

TREATMENTS - SURGERY 

Do I need an operation?

For some problems that cause faecal incontinence it is possible to do an operation. For other problems there is no operation which can help. The anorectal physiology tests and anal ultrasound tests will determine if an operation is likely to help in your case. This will never be something that you MUST have done, it is your choice whether or not to have an operation if one is suggested.

1. Anterior anal sphincter repair

If the external sphincter is damaged, and this damage can be seen very clearly and located accurately with the anal ultrasound test, surgical repair may be suggested. The results of sphincter repair operation are usually good, with 4 out of 5 (80%) of people reporting a satisfactory outcome after 2 years, although the longer term results are probably less good. This is the best treatment currently available for this particular problem, although one in five is not helped. /patient-information-leaflets

2. Other operations

Post-anal repair - Where the sphincter muscle is not actually brokem, but the whole pelvic floor is generally weak and sagging, the surgeon may suggest post-anal repair. This is done via an incision behind the anus and the muscles are tightened up to give more support. About one in four patients have good bowel control in the long term after this operation.

Rectal prolapse - Where the tests and examination have found that you have a rectal prolapse, this can be repaired and the rectum fixed back in place. your surgeon will discuss with you whether it will be better to so this repair through the anus (without any external incision - Delormes procedure see patient leaflet on /patient-information-leaflets, or through an incision in your abdomen - (abdominal rectopexy)/patient-information-leaflets.

Other operations for faecal incontinence may sometimes be suggested in some curcumstances.

For patient swith more extensive sphincter damage, or when previous surgery has failed, or for those who were born with little or no anal sphincter, it is possible to construct a new sphincter. Only people with very severe faecal incontinence, who cannot lead a normal life because of it, are likely to suitable for this at present.

Artificial bowel sphincter

An artificial bowel sphincter made from medical silicone has been developed and implanted. The artificial sphincter is an inflatable cuff which is implanted around the anus to keep it closed. when you want to open your bowels there is a small pump which you press to let the cuff down and allow stool to pass out of the anus. This is only available in very specialised hospitals. We do not know yet how successful this is likely to be in the long term.

Dynamic Graciloplasty

An alternative operation is called the dynamic graciloplasty. the surgeon takes the gracillis leg muscle from the inner thigh and wraps it around the anus to form a new sphincter. Results are best if this si combined with implantation of a small electrical stimulator which stimulates the muscle to keep it closed at all times except when you want to empty the bowel. Again, this is only done in specialist centres and it is too early to know what the long tern results will be.

Sacral Nerve Stimulation

It is possible ti implant a small electrical stimulator to stimulate the nerves that are at the bottom of the spine and help the sphincter muscles to work. This has been used for many years for bladder problems and more recently has been used for the bowel. At the moment this is quite new and it is not certain which people are the most likely to be helped and if the effects will last for many years. It is not likely to help if the sphincter muscles are very damaged. The technology is the same as a heart pacemaker. A small battery operated stimulator is under the skin (usually in the buttock or the abdomen), with wires that stimulate the nerves at the base of the spine. Usually, temporary stimulation is tried for 2-3 weeks to see if it helps before proceeding to a permanent implant. For more information on the technology see the Medtronic website.

The ACE operation (Antegrade Continence Enema) /patient-information-leaflets

some people who have both constipation and faecal incontinence benefit from the ACE operation. The operation creates a small stoma into the right side of the bowel to allow you to wash out the bowel (usually while sitting on the toilet). This si most commonly used for people with major nerve problems such as spina bifida.

Will I need a bag?

For a few people with severe bowel leakage, which has failed to improve in spite of all attempts at treatment, the decision to have a stoma (colostomy) may be a positive one which enables a return to normal life style. While this decision is obviously a major one, and only to be taken after extensive discussion and counselling with a stoma care nurse, some people prefer a stoma to uncontrolled bowel leakage.

A stoma operation brings the end of the bowel out onto the wall of your abdomen, so that you can wear a bag to collect the stools. The modern bags are small and discrete and contain any smells, so that you can carry on with your life without worrying about having an accident. Other people would not be aware that you have a bag.

Many peole find the idea of a stoma or bag very frightening. It is important to understand that this will never be something that you must have done for incontinence, it will always be your choice and decision. If a stoma has been suggested for you, make sure that you see a stoma nurse, who will give you alot more information and answer any questions that you may have. Or visit the colostomy association for further details www.colostomyassociation.org.uk/.

TREATMENTS - BIOFEEDBACK

Sphincter training

Sometimes a course of biofeedback therapy will be suggested. This involves using a computer or machine to show your muscles are working and how well you can co-ordinate the use of these muscles with a full bowel and to teach you how to improve your control. Biofeedback may also involve other exercises, depending upon the problem you are having. Sometimes the anal sphincter muscles do not relax properly when you attempt to empty the bowel and so the rectum is not emptied completely. Biofeedback can help to teach you to use the correct muscles to empty the bowel effectively. This is usually only available in very specialised centres. Often you will be seen over a period of a few weeks to a few months and there will be plenty of time to discuss your problem and for you to learn how the bowel should work, and what has gone wrong in your particular case.

As long as the spincter muscles and nerves are not too severly damaged, biofeedback usually benefits half to three-quarters of people who try it. This is not a "quick fix" and you will need to work hard at the exercises to make them effective.

Electrical stimulation

Electrical stimulation can be used to make muscles stronger. There is very little research on this in faecal incontinence and so it should not be used without advice from a health professional. Small home stimulators can be obtained, but generally should only b eused after full investigation of symptoms.

TREATMENTS - DRUG THERAPY

Sometimes medicines are used in treating incontinence. They work by solidifying liquid or soft stool or making the bowel squeeze less strongly. Obviously, if diarrhoea is present, treating this should lessen frequency and urgency and make incontinence less likely. If you are opening your bowels more than once a day and have soft or losse stool, your doctor may suggest some medicine to slow down the bowel.

Where the internal sphincte is weak, the stool can be made firmer by use of a drug such as loperamide (also called imodium), codeine phosphate or lomotil. These drugs may control the passive seepage of loose stool. the dose needs to be individually decided, as it si difficult to predict a dose that will be effective, but not cause constiaption. Some people find one of these drugs does not help but that another works well, or that a low dose combination is best. The only way to tell which may help you is by trial and error.

These drugs are designed to slow down the passage of stool through the colon, so that more water can be absorbed and the stool becomes firmer and so less likely to leak. It is usually best to take these medicines immediately after opening the bowels and if possible before food rather than after a meal. They usually act quite quickly and last just a few hours, so you need to take the tablets at the time when you need them. There is little point taking a tablet at night if your main problem is in the morning. If the tablets work too well for you and cause constiaption, lopermaide is also available as a syrup, whcih can enable you to have half or even a quarter of the usual dose.

What is loperamide?

How to take loperamide (imodium)

Loperamide is one of a group of drugs called anti-diarrhoeals. These drugs are designed to thicken your stools and so to reduce diarrhoea. It will also firm up slightly soft stools.

How does it work?

Loperamide works by slowing down the passage of food through the gut and encouraging more uptake by the body of water from the waste in the lower bowel. The longer food takes to pass through the gut the more time there is for water to be absorbed from it through the gut wall. The stools that are then produced are thicker and firmer.

What dose do I take?

A suggested starting dose of loperamide will have been discussed with you. People vary a lot in their response to loperamide. It sometimes needs some experimentation to find the dose that will control your bowels without constipating you. The more you take the firmer your stools should become. If you take more than you need you may feel constipated. If you do not take enough your stools will remain loose or soft. It is usual to start on a low dose and build it up slowly over a few days so that you can judge how you body is responding.

Loperamide comes in capsules / tablets or as a syrup. As the syrup is often used for children it can only be obtained on prescription in this country.

Amount you take Actual dose of loperamide

1 capsule / tablet 2 milligrams

1 teaspoon (5ml) 1 milligram

1 half teaspoon (2.5ml) Half a milligram

It is best to take loperamide half an hour before a meal. This will help to slow down the usual gut activity that is stimulated by eating. Most people find that the bowel is most active in the morning and so loperamide will help most if taken before breakfast. The medicine starts to work within half an hour of taking it and is effective for eight to 12 hours. This means that doses taken after lunch are not likely to help much if all your problems are in the morning. However, a dose last thing at night may help with early morning frequency. Loperamide is a very safe drug which is not addictive. It can be taken in doses of up to eight capsules (16 milligrams) per day over long periods of time. Do not take more than 16 milligrams per day without medical advice.

People in whom passive leakage is a mjor problem may even choose to slow the bowel down so far that there are no bowel actions without the help of suppositories or an enema to empty the bowel once every few days. This is not ideal, but at least it can give you control back.

There is a new cream in development which is designed to raise the muscles pressure in the anus. This seems to be most helpful for people with a small amount of seepage and should be generally avaialble soon.

If the stools are very loose, especially if there seems to a alot of mucus, medication such as Fybogel, Movicol or Regulan can help to mop up the excess fluid in the colon and prodice more formed stools. Methyl-cellulose tablets also help some people.

Other medicines will be useful to some people with faecal incontinence. Where the underlying problem is constipation with impaction (a blockage of hard stool in the colon), a laxative may be helpful to prevent the problem from coming back once the impaction has been cleared. Some ,edicines are helpful to some people with irritable bowel syndrome and some of the diseases that can cause diarrhoea can be kept under control by specific drugs.

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