Oxypowder

In patients with hard stools that are difficult to expel or with fecal impaction, a combination of suppositories (glycerin or bisacodyl [Bisacodyl Uniserts]) and oxypowder (phosphate or saline) may be required to soften the stool. Digital disimpaction followed by a bowel-conditioning regimen of laxatives and suppositories may also be needed.

The use of Oxy-Powder has seen improvements in many situations where the patient has had hard or difficult stools, as Oxy-Powder allows for the liquefaction of waste materials in the colon by means of magnesium oxides.

Refractory disorders -- When the described measures fail, particularly in patients with slow-transit constipation or pseudo-obstruction, surgery may be a good option. However, patients must be carefully evaluated and dysfunction of the stomach and small bowel excluded. Surgical options include colectomy and ileostomy or an ileoanal pouch. In a large series of carefully selected patients, results of surgery were quite favorable. However, surgery for constipation should be considered a last resort.

Fecal Incontinence

Fecal incontinence is a distressing and disabling problem, particularly when it occurs in an otherwise healthy, mobile person. Between 0.5% and 1.3% of the population under age 65 and 3.7% of the population aged 65 and over have this problem. Prevalence is highest in women and in patients who are institutionalized. A recent survey indicated that fecal incontinence is under diagnosed by both primary care physicians and gastroenterologists.

Causes -- Normal continence is maintained by a balance between expelling and resisting forces of the defecation system (sigmoid colon, rectum, and anus). These forces are generated by a number of anatomic and physiologic mechanisms.

The most important mechanisms are the force generated by the voluntary squeeze of the external anal sphincter and the resting tone of the internal anal sphincter. A weak external sphincter often predisposes to fecal incontinence. In addition, pudendal neuropathy may cause weakness of the anal sphincter muscle and thereby produce incontinence. The anorectal angle is a 90 degree bend between the axis of the rectum and the axis of the anal canal, and it forms an anatomic barrier for the discharge of stool. Patients with a weak pelvic floor or loss of sphincter tone have an obtuse anorectal angle (>130 degrees) that favors incontinence.

Rectal sensation warns of imminent defecation and helps the patient discriminate between formed stool and unformed stool and flatus. Impaired rectal sensation may deprive the patient of this useful information and result in incontinence. The rectum is a compliant reservoir that stores stool until defecation is convenient. If rectal compliance is reduced, reservoir capacity is decreased, which may lead to urgency and incontinence. Loose stool or a large volume of stool may overwhelm the continence barrier.

In adults, the most common cause of fecal incontinence is obstetric or surgical trauma, usually a direct injury to either the anal sphincter or the pudendal nerves. Excessive perineal descent may damage the pudendal nerves and cause incontinence. The predisposing event may have occurred months or even years earlier and gone unnoticed until the development of anal leakage.