Centers & Programs News

Anorectal Physiology Laboratory (ARP)

Overcoming Anal Incontinence
New hope for patients

Daniel Feingold, MD Biofeedback data helps the patient isolate and then strengthen the proper muscles to regain control.

Most people are blissfully unaware of their pelvic floor and anal sphincter muscles—as long as they're working normally. These muscles provide valuable support for the rectum and the bladder, as well as the female reproductive organs. When they weaken, however, individuals may suffer from an embarrassing condition called anal incontinence. Symptoms range from the occasional involuntary passing of gas to daily fecal soiling. In extreme cases, people are afraid to leave their homes for fearing of having an accident.

"These patients are often afraid to confide in their spouses or their doctors," says Daniel Feingold, MD, Assistant Professor of Surgery at Columbia University College of Physicians and Surgeons. "Yet many can be helped by relatively simple therapies, and the majority will not require surgery."

Relief is now only a phone call away, at NewYork-Presbyterian/Columbia's Anorectal Physiology Laboratory (ARP Lab), a state-of-the-art center, and one of only a few in metropolitan New York to offer a full complement of diagnostic and therapeutic tools for anorectal disorders.

"Indirectly, we know that age-related incontinence is a major problem because of the amount of money spent on diapers and pads by the elderly every year," says Dr. Feingold. Population studies also show that between five and ten percent of American men and women over the age of 60 have some degree of incontinence, and as baby boomers age, the number of people in this category will increase.

The reassuring news is that anal incontinence can frequently be controlled with dietary modifications, pelvic floor exercises, antispasmodic medications, and binding agents like Imodium®. Eighty to ninety percent of these patients can be helped with these methods, according to Dr. Feingold.

"At the ARP Lab, we see a number of patients who think they have anal incontinence but who are actually suffering from Irritable Bowel Syndrome (IBS) or other gastrointestinal disorders," he adds. "They have abdominal cramping and difficult to control diarrhea, and they are worried that they'll need an operation to correct it. They are greatly relieved to find out that their problems can be addressed with medication, nutrition, and lifestyle changes."

Patients who do have anal incontinence and do not respond to medication or lifestyle changes, may benefit from biofeedback therapy, a retraining program that strengthens the pelvic floor muscles. Biofeedback is a non-invasive approach that teaches patients how to sense the presence of stool or gas, and retrains their muscles to function properly. A dedicated biofeedback nurse or physician guides the patient through these exercises over the course of six to eight weekly sessions.

The ideal biofeedback patient is self-motivated, like the middle-aged woman who said, "I'll do whatever it takes to get better. At this point, I can't go on vacation or go see my daughter graduate from college and I'm afraid to go out with my friends." This kind of patient wants very much to resume her usual activities, notes Dr. Feingold, "Biofeedback improves function about 50 percent of the time, depending upon the patients' condition and level of commitment."

If biofeedback fails, the individual may then be a candidate for the Secca procedure that applies radiofrequency energy to the sphincter muscles. By creating a small lesion on the anal muscles, Secca causes the tissue to contract. This increases the tone of the anal muscles and can help more than half of these patients regain control. "Those with age-related incontinence can get long-lasting benefits from a single treatment," says Dr. Feingold, "and there is a very low risk of side effects."

The Secca procedure is performed as an outpatient procedure and requires only light sedation. "There is very little postprocedure discomfort. It takes less than an hour and is fairly non-invasive. Patients recover quickly and return to their normal activities," Dr. Feingold reports. To find out if a patient is a candidate for biofeedback or has an anatomic defect requiring surgery, the ARP Lab may perform one or more of the following diagnostic tests:

• Transrectal ultrasound, a special type of ultrasound that provides anatomical images of the anal sphincter muscles
• Nerve conduction studies that determine whether nerve problems may be contributing to fecal incontinence
• Manometry, a test that measures the amount of pressure the sphincter muscles can exert

These tests are not required for all patients. "However, they can provide valuable information for the physician, helping us to identify individuals who may be treated with biofeedback, Secca, or surgical correction of the sphincter muscles," Dr. Feingold says.

Which people are most likely to benefit from surgery? First, younger women with obstetrical injuries. "Of millions of births each year in the United States, only a small percentage of women have tears from episiotomies or forceps injuries resulting in incontinence. Those who do may need corrective surgery," Dr. Feingold explains.

Second, surgery may help individuals who have had previous operations for either hemorrhoids or anal fistulas and now have weakened muscles. Patients in this category have a short-term response rate of 80 percent after corrective surgery. Yet five or ten years later, some may require a second procedure. "We think this may be related to nerve injuries," Dr. Feingold says, "but more research is needed to help us understand these cases."

Many patients treated in the ARP Lab end up with a new lease on life. "People can be reserved and embarrassed when they first come to see us," notes Dr. Feingold. "They may think there's no one to turn to and there's nothing that will help. I explain that the ARP Lab exists specifically for them."

For more information about the ARP Lab, contact the Section of Colorectal Surgery at 212.342.1155