The toilet taboo

Lack of bowel control is a growing phenomenon, but it remains largely ‘unmentionable’ not only among those suffering in silence but also among general practitioners.

By JUDY SIEGEL-ITZKOVICH
Toilets [Illustrative] (photo credit: REUTERS)
Toilets [Illustrative]
(photo credit: REUTERS)
The “Asher Yatzar” blessing that religious Jews make every time they leave the bathroom might seem comical to some, but in fact it’s quite a gift when one’s gastroenterological and urological systems function as intended. A growing number of people – and not only the elderly – can’t take this for granted.
Enuresis, the inability to control urination, is trouble enough, although there are ways to deal with it. But fecal incontinence (FI) – when the stools leak unexpectedly from the rectum and anus – is an even more embarrassing condition that few patients mention to their doctors.
Many individuals hide at home and give up on social life due to FI, get depressed and even keep the “secret” from their family.
Here too, most sufferers can get at least some relief or even a cure, with anything from biofeedback and pelvic floor exercises to medications, disposable plugs and surgery. The only visible sign of the problem are the TV ads for adult diapers and the space they take up in the pharmacies.
The impetus for this article on an “unspeakable” subject was a letter from an octogenarian with bowel incontinence and a rectal prolapse.
“The mother of a friend had what she delicately described as ‘problems,’” the letter read, “She stopped going out and was becoming increasingly depressed and withdrawn. After a bit of gentle probing, I found out that at 83, she had the same problem as I do. I was able to call her, reassure her that she was neither unique nor alone and to give her some tips on managing.”
We are all living longer, said the octogenarian, “and my proctologist tells me this is becoming quite a common problem among the elderly.
After all, not so many years ago, at our age we would have been confined to geriatric institution and wearing nappies. There is treatment for many, but there is a hard core of patients who are found to be untreatable and are told to ‘live with it,’ of which, unfortunately, I am one.
“However, there is still a great amount of personal shame and humiliation involved. I suppose it is due to ingrained childhood training, but whether you are four years old or 84, there is an inbuilt tendency to whimper ‘Sorry, Mummy.’ In fact, the psychological effects can be more devastating than the actual physical inconvenience, which with a bit of ingenuity and practice can be managed.”
When this reporter asked a major general hospital in the central region for an expert on FI, after a few days the spokeswoman came back to say it had none.
But Jerusalem’s Shaare Zedek Medical Center does have at least one – gastroenterologist and proctologist Dr. Joseph Lysy – who was highly recommended by a leading general practitioner for an interview.
“There is so much taboo about the subject, and it really hasn’t been talked or written about,” said Lysy in his ground-floor office. “It is also underreported by doctors. And patients usually don’t think it’s legitimate to raise the matter. They feel ashamed and guilty and lose their self-confidence.
But our department gives lots of lectures in our auditorium about fecal incontinence to family doctors from the four health funds.”
He added that FI is not a subject of lectures in medical schools, and it’s a problem that few family physicians approach their patients about.
The Jerusalem-born Lysy, who studied medicine at the University and did his specialty at St. Marks Hopsital in Middlesex, England, worked for 25 years as a gastroenterologist at the Hadassah University Medical Center in Jerusalem’s Ein Kerem and switched to SZMC along with Prof. Eran Goldin, who became head of the gastroenterology division, and several other colleagues three years ago.
“The condition affects between two percent and 6% of the population, and younger people with neurological diseases such multiple sclerosis or spinal injuries or older people with Parkinson’s disease, as well as muscular disorders are affected. However, it is most common among the elderly. Many are sent by their families to live in geriatric institutions because of this lack of control, so as many as 40% of residents in these facilities may suffer from FI,” said Lysy.
The family doctor has to be proactive about this problem, he continued, because with the aging of the population, the prevalence is growing. “When fecal incontinence is combined with pressure sores, it becomes even more complicated,” he added, “and about 30% of those with enuresis also suffer from FI.”
“There is an internal sphincter, whose contraction and relaxation are involuntary, and an external sphincter that is voluntary to prevent unplanned defection and flatus [the passage of gas].” The condition of weakness or damage to the sphincters is more common in women – about 60% of the cases – and this is due largely to tears in the anal sphincter or the back of the vagina during childbirth. One in three women who give birth vaginally suffer some sphincter damage. It is even more likely if the infant is very large or needs the help of forceps to be born. Usually, this damage is nobody’s fault; it occurs because the anus and vagina are so close and it is easy for the anal sphincters to suffer internal tears or get stretched.
The Shaare Zedek doctor said these problems are not really connected to episiotomies (sewing up of the entrance to the birth canal as a result of a rupture during childbirth). But many women who give birth to larger babies or have a small pelvis can end up with a tear in the anal sphincter. “If this happens, a gynecologist or a surgeon who knows how to sew the tear should do this immediately.”
As his hospital is in Jerusalem, where the average number of babies per mother is high, and performs the largest number of deliveries (around 20,000) annually, midwives and obstetricians see a lot of sphincter injuries.
“If a woman had one as a result of her first delivery, the risk is much higher in [later] births. At Shaare Zedek, the woman with a sphincter problem is invited with her husband to consult with me or a urogenital specialist or colorectal surgeon to discuss the implications on future deliveries. Some are advised to have a cesarean section for the next delivery, but others may have enough functional reserves and can have a normal delivery again. It’s a joint decision. The ultra-Orthodox or Orthodox sometimes consult their rabbis about this as well. Most accept our medical recommendations.
“Ultrasound is used to identify the problem. Sewing up the tear is a must, because it dramatically reduces the number of sphincter problems later. Many women,” he said, “don’t connect the delivery with incontinence decades later.”
Yet FI is not a problem that begins only in young women; younger men can also suffer, as can older men with peripheral damage to nerves and radiation to the pelvic area to treat prostate cancer.
Another high-risk group is haredi men who force themselves to have a bowel movement before they recite their prayers, thinking this spiritual task should be accomplished with a “clean body.” In some cases, this habit involves obsessive/compulsive behavior. Lysy said the forcing of defecation can cause serious weakness of the sphincters, as well as permanent damage.
Lysy noted that other possible causes of damage to the sphincter are damage from rectal surgery for anal fissures, fistulas or hemorrhoids.
Repeated straining over decades can eventually lead to muscle weakness around the anus, leading to rectal prolapse or weakness of the anal sphincter.
The more serious cases involve patients with a rectal prolapse, in which part of the rectum or its lining drop down through the anus and protrude from the body. Some people with bowel diseases like Crohn’s disease or ulcerative colitis may have difficulty controlling the sphincters when their condition flares up.
Ironically, both severe diarrhea and the opposite condition, constipation, can lead to FI. In the first, the individual can’t get to the toilet in time. In the second, the bowel becomes so packed with stool that small pieces break off without being felt and leak out. Those with such problems should avoid consuming caffeine beverages, dairy products and spicy, fatty or greasy foods. Fecal incontinence is also commonly present in patients with the later stages of dementia, including Alzheimer’s disease.
Proctologists have a number of important tests to diagnose the problems, beginning with the digital rectal (simple insertion of a gloved and lubricated finger or long cotton swab) to test reflexes, Lysy said.
Another is the balloon expulsion test, in which a small latex bag is inserted into the rectum and filled with water. The patient is instructed to go to the toilet and expel the balloon, and the doctor measures how long it takes to accomplish this.
Taking more than 60 seconds may lead to FI.
Other low-tech techniques are inserting a narrow, flexible tube to measure the tightness of the sphincters or search the last two-thirds of the colon for signs of inflammation, scar tissue or tumors. Higher-tech tests include x-rays while having a bowel movement (on a special toilet), ultrasounds of sphincters and the colon, colonoscopies, anal electromyography using electrodes to test nerve damage, and even MRIs.
As for treatments, there are conservative ones such as consuming fibers such as psyllium that can ease both diarrhea and constipation. Sufferers are advised to eat at set times so bowel movements are more regular.
The Paula technique is sometimes helpful for strengthening the sphincters, said Lysy; other options are biofeedback and the same pelvic floor exercises that young women do after giving birth. Adult diapers are always an option, but they are usually very harmful to the ego and self confidence.
There are also prescription drugs such as a low-dose antidepressant that help to control defecation. An anal plug, which is inserted like a tampon with a small balloon, can help people when they are away from home, even though “it is not suitable for everyone, because it is not very comfortable.”
The next option in surgery, either transabdominal, laparoscopic (keyhole) or from the rectum.
“It may not be complicated, and lots of patients gain from it,” said Lysy, but it is more difficult when it has to be repeated, especially in the elderly. Sacral nerve stimulation, which has been used for enuresis, is being tested for fecal incontinence as well, but it is not covered in the basket of health services and costs as much as NIS 80,000. Some private insurance companies offer it.
The most extreme option is a colostomy, in which the healthy end of the large intestine or colon is diverted by being pulled through an incision in the anterior abdominal wall and sewn into place. This opening, called a stoma, is an alternative channel for feces to exit the body. Asked if he is shy about telling strangers what he does for a living, Lysy concludes with a wink: “I remember an aunt who asked me about this. I’m not at all ashamed. I am proud to be a proctologist and deal with supposedly unmentionable subjects as rectums. I am able to help a lot of patients.”