An SGH study published in 2014 showed that approximately 4.7 per cent of our adult population suffer from bowel incontinence.
I met Madam L two years ago at an outreach programme for pelvic floor disorders. The 64-year-old retired teacher, who was accompanied by her husband, had told me meekly: “Doc, I think I need help.”
I was surprised by her candour and willingness to seek help for her bowel incontinence – a medical condition that remains taboo to this day in many societies, including Singapore.
A Singapore General Hospital (SGH) study published in 2014 showed that approximately 4.7 per cent of the adult population – or some 200,000 individuals – may have this condition.
This is a staggering number, yet it may be an underestimate as the incidence is often even higher among the elderly staying in care facilities like nursing homes.
The same study also showed that women are three times more likely to be affected by bowel incontinence, with childbirth-related injuries being the main cause.
In fact, those over 50 years old are five times more vulnerable. Men are not spared from the condition.
The causes of bowel incontinence that are common to both genders include injury to the muscles and nerves around the anal region that controls continence, surgical treatment for benign conditions like piles and fistula, as well as surgery and radiotherapy for colorectal, gynaecological and urological cancers.
Madam L, who has three children, has lived with bowel incontinence for more than 20 years. She recalls that the birth of her youngest child was difficult – a prolonged labour that required forceps assistance.
Women who experience these traumatic events are vulnerable to injuries in the birth canal which can manifest many years later, especially after menopause, as that is when muscle strength deteriorates due to ageing.
In recent years, the condition had became more intolerable for Madam L. She had to rush to the toilet the moment she felt the urge to defecate and often had less than 10 seconds to reach the toilet before an “accident” occurred.
She recalled the countless times these incidents occurred when she was outside and the embarrassment they had caused her. Eventually, she stopped going on family holidays and avoided meeting friends entirely. For an outgoing woman, this was truly devastating.
Despite having a supportive family and accommodating friends who understood her difficulties, it still took her a long while to summon the courage to seek medical attention.
This is a familiar story, as many choose to suffer in silence. It is sad, though unsurprising, to know that people would rather forsake their quality of life than to admit to having incontinence or seek treatment for it.
Most people are told that this is part of ageing and they therefore resign themselves to a life of uncomfortable rashes and diapers.
It is not surprising that bowel incontinence is often associated with social isolation and depression.
WAYS TO FIX ‘LEAKS’
Yet the vast majority of patients can have their condition managed by conventional non-surgical treatments.
Dietary adjustments and medication can improve stool consistency, while doing pelvic floor strengthening exercises will boost muscle strength and coordination, which helps to hold stools in when the urge arrives, until there is an appropriate time to defecate.
Up to 50 per cent of our patients with bowel incontinence often complain of urinary incontinence as well.
The SGH Pelvic Floor Disorders Service, set up in 2008, is a collaboration among colorectal surgeons, urologists and gynaecologists, providing individualised treatment for patients, based on their symptoms and severity.
Patients are considered for surgery only when conventional treatments fail to work or if the injuries are severe at the start, such as those related to traumatic childbirth or surgery.
Fortunately, much progress has been made in recent years and patients can now undergo the most advanced therapy methods.
In Madam L’s case, detailed tests showed that the nerves controlling continence had weakened, likely due to damage during childbirth. She underwent the entire regimen of non-surgical treatment for more than a year, but found that her problem had not improved significantly.
She wanted better results and, after much consideration, agreed to a treatment known as sacral nerve stimulation.
This involves inserting a needle into the lower back to deliver a low electrical charge from a pacemaker to stimulate the nerves controlling the bowels. Doing so augments the function of the anal muscle, hence improving continence.
Madam L had to go through a two-week testing phase to make sure the treatment would work for her.
A portable external battery about the size of a pager was used for this initial phase. When she was found to be responding well and had fewer “accidents”, a permanent stimulator (slightly larger than a 50-cent coin) was implanted underneath the skin of the buttocks.
I am happy to report that after the successful procedure and an uneventful recovery, she has seen an improvement in her symptoms. She could hold the urge to move her bowels for much longer than before.
Recently, she was confident enough to travel again and is enjoying the freedom she had lost for over a decade. She told me that had she known the treatment was this easy, she would have sought help earlier and would not have needed to live with the “handicap” for so long.