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Can you describe how you do your rectal examination in someone with
incontinence?
The digital rectal examination is a very important aspect of the physical exami-
nation in a patient with incontinence. Here is a description of the full rectal
examination:
1. Ask the patient to lie in the left lateral position.
2. Inspect the perineum and external anus by spreading the buttocks after donning
a pair of gloves, to look for any dermatitis, scarring, skin tags, hemorrhoids,
rectal prolapse, stulas, or ssures.
3. Stroke the skin around the anus using a Q-tip to assess the anocutaneous reex.
When the reex is acting normally, sensory stimulation of the skin around the
anus leads to anal sphincter contraction (anal wink). A normal anocutaneous
reex indicates an intact sacral reex arc and pudendal nerve innervation of the
external anal sphincter.
4. Ask the patient to strain to evaluate the presence of perineal descent, prolapsed
hemorrhoids, and rectal prolapse.
5. Assess the resting tone by gently inserting your index nger into the anal
canal. This is best measured after waiting a few seconds to allow for accom-
modation. The resting tone is predominantly attributable to the internal anal
sphincter. A reduced tone may indicate weakness of the internal anal sphincter,
while the presence of increased tone may contribute to difculty with
defecation.
6. Have the patient perform a voluntary anal squeeze to evaluate the external anal
sphincter tone. Reduced anal squeeze pressure may suggest weakness of the
external anal sphincter.
7. Palpate the posterior rectal wall to evaluate for any pain. If this is present, it sug-
gests puborectalis muscle tenderness.
8. Have the patient strain and try to push your nger out. Normally, the anal sphinc-
ter should relax associated with perineal descent while bearing down. If the
sphincter muscles seem to tighten and there is no perineal descent, this may sug-
gest dyssynergic defecation.
What are the causes of anal incontinence we are most likely to encounter?
Fecal incontinence may be caused by altered bowel habits and a variety of condi-
tions that affect the ability of the rectum and anus to hold stool. Causes of fecal
incontinence may include diarrhea, fecal impaction, obstetric or surgical sphincter
muscle injuries, pelvic oor injury, neuropathy resulting from diabetes or stroke,
spinal cord injuries, and some inammatory conditions [1].
What evaluations would you do? Would you do anorectal manometry? If so,
is it high resolution? Would you do an MRI? An endoscopic ultrasound? A bal-
loon expulsion test? A colonoscopy?
If incontinence occurs in the setting of constipation or diarrhea, we have to man-
age the bowel disturbance rst. We usually begin with an abdominal X-ray to evalu-
ate stool burden.
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If diarrhea is a concern, the work-up often includes a colonoscopy, with random
biopsies to assess for microscopic colitis.
If fecal incontinence persists despite managing bowel disturbance, the next step is
to perform anorectal manometry with assessment of rectal sensation and a rectal bal-
loon expulsion test. We prefer to do high-resolution manometry, which is a novel,
solid-state manometric system, which provides more accurate resolution of intralu-
minal pressure and greater anatomical detail compared to water-perfused manometric
systems. The balloon expulsion test is a simple test to screen for a defecation disorder.
If a weak anal sphincter is identied during anorectal manometry, further evalu-
ation with endoanal ultrasound or MRI can be considered to evaluate for muscle
damage, especially when surgery is being considered. EMG can also be considered,
depending on center availability.
MRI is superior for visualizing external sphincter defects, atrophy, and patulous
anal canal. This should only be ordered if there are concerns about defects.
How do you like to manage patients like this?
We would rst treat underlying causes such as constipation or diarrhea. For
patients with fecal impaction with an overow component, I would start a bowel
regimen with a ber supplement (psyllium) and a daily laxative program. For
patients with diarrhea, we would initially start with dietary modications, such as
eliminating foods with articial sweeteners (e.g., lactose, fructose, and sorbitol),
spicy food, and caffeine-containing beverages. We will observe for any improve-
ment in bowel habits and stool leakage. Anti-diarrheal agents, such as loperamide
(non-prescription) or Lomotil (prescription), can be used to reduce loose stool.
Loperamide is usually taken 30min before meals or after each loose stool. The
maximal dosage is 16mg/day. Studies have shown that loperamide can also improve
incontinence by increasing resting anal tone [2]. Other medications such as bile acid
binders can be used in patients with IBS-D or post-cholecystectomy diarrhea.
Are there any surgical options you might recommend?
If the above measures have failed, then surgical options can be considered. I
would initially recommend a sacral nerve stimulator, in which the nerves that sup-
ply the rectum and anal sphincters can be activated by a stimulator [3]. In selected
patients, injection of bulking agents into the anal sphincter is another approach that
may improve the anal seal [3]. A surgical sphincteroplasty can be considered in
women with a sphincter defect resulting from vaginal delivery [3]. However, long-
term outcomes with this procedure are mixed, with about 50% of patients having
recurrence of symptoms [4]. In severe cases of incontinence that are debilitating and
signicantly affecting quality of life, a colostomy can be considered.
Can you describe the process of sending patients for sacral nerve stimulation?
Sacral nerve stimulation can be considered in all patients who fail conservative
management. This is a two-stage procedure. First, a temporary nerve stimulator is
attached and used for 2weeks. Patients whose symptoms respond to the temporary
nerve stimulator are then sent for permanent subcutaneous implantation of the
device. There is about 80% therapeutic success and 40% complete continence at
3-year follow-up [5, 6].
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Do you have any experience with biofeedback therapy?
This is the mainstay of treatment for patients who fail medical treatment. Pelvic
biofeedback training by combining pelvic oor exercises and visual feedback from
anal manometry or surface EMG can strengthen anal sphincters and improve rectal
sensation. For patients having fecal incontinence due to dyssynergic defecation,
biofeedback therapy, using a different technique, can improve the coordination
between abdominal muscles and the pelvic oor and subsequently improve rectal
emptying. Satisfaction has been reported in up to 70% of patients in prior studies [7].
Are there any particular areas you are personally researching in anal
incontinence?
We have been researching the ability to exercise the external sphincter and
puborectalis muscles beyond simple Kegel exercises with added resistance training
via an exerciser balloon in the anal canal. We rst evaluated the ability of the mus-
cles to fatigue more with added resistance [8]. Muscle overload and subsequent
neuromuscular fatigue are necessary requirements for any successful strength train-
ing as shown in rehabilitative exercises [9, 10]. We then assessed the ability to
strengthen the muscles using pre- and post-anorectal manometry after 6weeks of
resistance training in patients suffering from fecal incontinence. Our preliminary
results have shown improvement of symptoms and sphincter muscle contractility
demonstrated as an increased anal resting and squeeze pressure after 6weeks of
resistance training [11].
Case 2 A 75-year-old woman has occasional “accidents” where she is unaware
that she is having a bowel movement until she smells stool in her panties, or feels
wetness.
What are some possible etiologies for this?
This patient has passive fecal incontinence. Passive incontinence can occur in the
setting of neuropathy resulting in loss of rectal sensation and weakness of the inter-
nal anal sphincter. This may be seen in systemic illnesses such as diabetes. It can
also be seen in patients with spinal cord injury, stretch injury, or obstetric trauma.
What might the rectal examination show?
Rectal examination might show poor resting sphincter tone.
What would you be looking for on a neurologic examination, and what other
systems might be involved?
Neurologic examination may reveal decreased perianal pin-prick sensation,
lower extremity weakness if related to an underlying spinal cord injury, or reduced
sensation in the setting of neuropathy. The urinary system may also be involved
with incontinence.
What ndings would you expect on anorectal manometry?
Anorectal manometry may reveal reduced rectal sensation and/or resting sphinc-
ter tone. Squeeze pressure could be normal or reduced.
How would you manage this patient’s problems?
Management would be different based on the cause of symptoms. In most cases,
we recommend increasing stool consistency by adding ber supplements and
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having scheduled bowel movements. Enemas or suppositories may be helpful in
scheduling bowel movements.
We would also recommend biofeedback for rectal hyposensitivity if some degree
of rectal sensation is still preserved. Biofeedback is usually not effective for isolated
internal anal sphincter weakness; in which case, we might consider a bulking agent
(such as dextranomer injection) and/or sacral nerve stimulation.
In some patients, the Eclipse system (in which a vaginal balloon compresses the
rectum) or Renew insert (in which an anal plug is worn) can be considered on a PRN
basis to reduce fecal leakage.
Case 3 A 64-year-old woman has problems moving her bowels and will go several
days without a bowel movement. In spite of difculties with constipation, she has
occasional episodes where liquid stools pass of their own volition. She has minimal
warning but then feels the stool in her panties or down the side of her legs. Prior
screening colonoscopy, 5years earlier, was negative. There is abdominal fullness
on the examination, presumably due to increased stool. On the rectal examination,
there is adequate sphincter tone and some stool in the vault, although not a large
rectal impaction.
How would you recommend managing this situation?
It appears the patient has constipation with overow diarrhea. We would rst
recommend an abdominal X-ray to assess the stool burden. After conrming
increased stool, we would recommend a bowel regimen to regulate the bowel move-
ments. We often recommend starting with a colon purge followed by a daily bowel
regimen.
How do you respond when patients complain that the laxatives are only
worsening their incontinence?
You are less likely to have this problem if you start out with a colon purge,
attempting to get the colon cleaned out initially. In these patients, the incontinence
is likely related to fecal retention/impaction, and once you correct this, you’ve cor-
rected their incontinence. We would follow this with a daily laxative regimen. We
also encourage patients to consume adequate daily ber (25–30g/day for adults).
We encourage them to include psyllium in their daily bowel regimen. We might also
do anorectal manometry to evaluate the defecatory disorder.
Will you ever use a full colon lavage, like 2 or 4 liters of Golytely?
We do usually recommend a colon purge before starting a daily bowel regimen.
If choosing Golytely for the colon purge, we will start with 2 liters rst. If the
patient does not feel adequately emptied after the half dose of Golytely, we will then
advise the patient to complete the second half. Alternatively, a colon purge using a
bottle of MiraLAX or magnesium citrate is also an option if the patient is unable to
obtain or tolerate the Golytely.
Case 4 A 67-year-old man has had a stroke with left-sided weakness. He tries to
schedule his bowel movements once a day in the morning and is successful about
half the time. Recently, he has had episodes of rectal incontinence.
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What are some possible explanations for this?
There are multiple possible reasons for his altered bowel habits and inconti-
nence. His immobility can be associated with reduced GI motility and incomplete
evacuation/stool retention, which may subsequently result in overow incontinence.
Since he is post-stroke, his neurologic decit may be associated with reduced rectal
sensation and decreased sphincter strength, which may also contribute to his
incontinence.
What might you nd on the rectal examination?
We may feel the retained stool in the rectum. He may have reduced perianal
sensation and reduced anal sphincter tone.
How would you manage his problems?
We will recommend a colon purge if the patient is able to cooperate. We will
recommend a routine bowel regimen including adequate daily ber intake and add-
ing a laxative if his stool is hard (Bristol 1 or 2). We will recommend a scheduled
bowel movement using a suppository or enema in the morning if the patient does
not have a spontaneous bowel movement. If his symptoms do not show signicant
improvement with the bowel regimen, we will obtain anorectal manometry to fur-
ther evaluate anorectal function.
Case 5 A 54-year-old female psychotherapist is embarrassed because of occa-
sional episodes where she has stool involuntarily soiling her pants. Her bowel
movements seem normal, and she feels like she is totally emptying her rectum with
each bowel movement. Afterward, she tries to clean herself very well. In spite of
that, as the day goes on, she notices stool soiling her underpants almost every day.
What are some possible explanations for this?
This patient has anal seepage, which is dened as staining or streaking of under-
wear. Anal seepage can occur if the rectum is not fully emptied after a bowel move-
ment, something which is seen in dyssynergic defecation, rectocele, radiation
therapy, and with prolapsed hemorrhoids. It responds to different treatments as
compared to fecal incontinence.
Are there dietary or behavioral precautions she could take?
She should maintain a high-ber diet to help bulk up her stool. We recommend
avoiding excessive wiping after defecation and using alcohol-free wipes. We will
advise the patient to place a cotton ball at the anus to act as an occasional wick.
Some women may benet from a splinting technique during defecation, particularly
if a rectocele is present. The splinting technique involves placing a nger in the
vagina to push against the rectum to help stool to empty.
Are there medications that might be helpful?
Anal suppositories can be tried to help with emptying the rectum. Patients with
hemorrhoids can try topical steroids to shrink the hemorrhoids and reduce the
irritation.
Are there any other sorts of intervention?
Patients with dyssynergic defecation may benet from pelvic biofeedback
retraining. Patients with a rectocele may need surgical consultation.
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References
1. Menees SB, Almario CV, Spiegel BMR, Chey WD. Prevalence of and factors associ-
ated with fecal incontinence: results from a population-based survey. Gastroenterology.
2018;154(6):1672–81 e3.
2. Read M, Read NW, Barber DC, Duthie HL.Effects of loperamide on anal sphincter function
in patients complaining of chronic diarrhea with fecal incontinence and urgency. Dig Dis Sci.
1982;27(9):807–14.
3. Whitehead WE, Rao SS, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton
FA. Treatment of fecal incontinence: state of the science summary for the National
Institute of Diabetes and Digestive and Kidney Diseases workshop. Am J Gastroenterol.
2015;110(1):138–46.
4. Glasgow SC, Lowry AC.Long-term outcomes of anal sphincter repair for fecal incontinence:
a systematic review. Dis Colon Rectum. 2012;55(4):482–90.
5. Meurette G, Siproudhis L, Leroi AM, Damon H, Urs Josef Keller D, Faucheron JL, French
Faecal Registry Study Group. Sacral neuromodulation with the InterStim™ system for faecal
incontinence: results from a prospective French multicentre observational study. Color Dis.
2021;23(6):1463–73.
6. Rao SS.Current and emerging treatment options for fecal incontinence. J Clin Gastroenterol.
2014;48(9):752–64.
7. Norton C, Cody JD.Biofeedback and/or sphincter exercises for the treatment of faecal incon-
tinence in adults. Cochrane Database Syst Rev. 2012;7:CD002111.
8. Mei L, Patel K, Lehal N, Kern MK, Benjamin A, Sanvanson P, Shaker R.Fatigability of the
external anal sphincter muscles using a novel strength training resistance exercise device. Am
J Physiol Gastrointest Liver Physiol. 2021;320(4):G609–16.
9. Marques A, Stothers L, Macnab A.The status of pelvic oor muscle training for women. Can
Urol Assoc J. 2010;4(6):419–24.
10. Johnson VY.How the principles of exercise physiology inuence pelvic oor muscle training.
J Wound Ostomy Continence Nurs. 2001;28(3):150–5.
11. Patel KML, Lehal N, Benjamin A, Sanvanson P, Kern M, Shaker R.External anal sphincter
strength training exercise using a novel continence muscles resistance exerciser device results
in improved anal sphincter contractility in patients with fecal incontinence. Gastroenterology.
2020;158(6):S-388.
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Switzerland AG 2023
W. H. Sobin et al. (eds.), Managing Complex Cases in Gastroenterology,
https://doi.org/10.1007/978-3-031-48949-5_19
Chapter 19
Diverticulitis
WilliamBerger, KeelyBrowning, andW.HarleySobin
Case 1 A 54-year-old man presents to the ER with LLQ pain of 6-h duration. He
has a temp. of 99, WBC is 14,000, and CRP is 30. A CT scan is performed that
reveals mild uncomplicated diverticulitis.
How would you manage this patient? Would you consider treating without
antibiotics?
Browning: Treatment considerations for uncomplicated diverticulitis include
antibiotics and patient disposition. Hospitalization should be considered for patients
who cannot tolerate oral intake, have a fever, or have excessive vomiting. Outpatient
management includes bowel rest, liquid diet, and oral antibiotics [1].
The AGA recommends consideration of liquid diet for patient comfort, but evi-
dence suggests it is not necessary, and if patients would like to advance their diet,
they should be allowed to. However, if they are unable to tolerate advancing the diet
in 3–5days, they should be re-evaluated [2]. The two most common antibiotic regi-
mens are quinolone with metronidazole or amoxicillin-clavulanate for 4–10days [1].
However, several studies have shown that antibiotics do not always accelerate
recovery, nor prevent complications or recurrence. Due to this, the AGA recom-
mends antibiotics be used selectively for patients with uncomplicated diverticulitis,
including those who have comorbidities, frailty, immunocompromised state,
refractory vomiting, CRP >140mg/L, WBC >15× 10
9
cells/L, or who have CT
ndings of a uid collection or longer segment of inammation on CT [2]. Patients
W. Berger · W. H. Sobin (*)
Division of Gastroenterology and Hepatology, Medical College of Wisconsin,
Milwaukee, WI, USA
e-mail: wberger@mcw.edu; hsobin@mcw.edu
K. Browning
Madison Medical Afliates, Milwaukee, WI, USA
e-mail: Keely.browning@ascension-external.org
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130
with uncomplicated diverticulitis without comorbidities do not necessarily require
antibiotics [1, 2].
Berger: I would only briey consider treating without antibiotics. I know that the
new literature is supposed to show that there’s no difference, but when I have some-
thing that looks like a bacterial infection, I usually do start antibiotics and patients
seem to respond. When antibiotics aren’t started, the process seems to go off and on
for a longer period of time before it resolves itself. I have a preference for using
metronidazole, partly to avoid pseudomembranous colitis. Along with metronida-
zole, I use cipro. I am not a fan of Augmentin because of cases of pseudomembra-
nous colitis that I’ve encountered using that.
I give the patient a follow-up call after 5days, and if they’re not better, I will give
them a longer course of antibiotics or occasionally switch to a different antibiotic.
If they’re still not improving, I usually choose to do some more imaging.
What if you’re dealing with a patient who has had repeated episodes of
diverticulitis treated with antibiotics as an outpatient, but hates taking the
antibiotics because of adverse symptoms, and comes in now with one more
typical recurrence (mild, uncomplicated). Would you consider managing with-
out antibiotics?
Sobin: I have had a few cases like this where a patient had repeated mild episodes
that we reexively treated with antibiotics. After a couple of times, the patient
started pleading to skip antibiotics after another bout of diverticulitis, because of
severe intolerance. These were mild cases, and because the literature supports with-
holding antibiotics in cases like this, I managed the cases without antibiotics and the
patients did ne.
Berger: No. Actually, if this is a patient who is in his 40s, 50s, or 60s, I would
give antibiotics and suggest elective surgery after resolution of the acute episode.
There is something focally wrong with that colon, and this person will be ghting
this problem for the rest of his life. They just need that sigmoid in a bucket. Now if
they’re 85, the risk of surgery will far exceed any potential benet, but no, I would
rarely pass on giving antibiotics for recurrent/chronic diverticulitis to cool it down
so we can get on with the appropriate therapy.
Case 2 A 48-year-old man presents with an episode of sigmoid diverticulitis and is
started on outpatient metronidazole and ciprooxacin. However, after a week of
antibiotics he still complains of pain and so a second 7-day course is administered.
After 2weeks, he returns to his doctor’s ofce with ongoing LLQ pain and low-
grade fevers to 100.5. Because his WBC is 18,000 and CRP is 75, a CT is ordered.
The CT shows ongoing inammation in the sigmoid. How would you manage this?
Browning: Diverticulitis is the most common complication of diverticulosis.
Prior estimates suggested that diverticulitis occurred in 10–25% of patients, but
more recent studies suggest that the incidence is much lower, about 4% based on
population studies [1].
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Smoldering diverticulitis is a complication of acute diverticulitis where patients
have continued abdominal pain with the presence of inammation on imaging in
spite of treatment with antibiotics [1, 2]. Based on systemic signs of inammation
like fever and elevated inammatory markers, I would start IV antibiotics.
Berger: I would start IV antibiotics to cool things down. Now, we do IV antibiot-
ics at home, and I think that’s a very reasonable thing to try in an appropriate patient.
I would also call a surgeon because this patient is going to have trouble again.
As I get older and more experienced, my threshold for operating on these patients
becomes lower, but it is a balanced calculation, having to do with how old they are
and how many comorbid health conditions they have. This is weighed against how
severe, recurrent, and symptomatic the diverticulitis is.
However, on balance, I’m tipping a little bit more toward surgery. For one thing,
the complications using laparoscopic or robotic surgery are so much less, and the
recovery so much better than the old open surgical techniques.
Sobin: I agree. I would also bring the patient in for IV antibiotics and consult a
surgeon.
Case 3 A 45-year-old patient presents with his third episode of sigmoid diverticu-
litis in 12months. He has been on a high-ber diet and remains in good general
condition.
Would you recommend elective surgery at this point? If not, when?
Berger: After three episodes, you can be pretty sure they’re going to have more,
particularly at this young age. If you know you’re going to end up having surgery,
the earlier you have it done the better. You’re healthier, and your nutrition’s going to
be better. You don’t have to wait for complications of the disease. Everything just
works better with earlier surgery if you know you’re going to need it eventually. If
you wait until you’re older, you get less benet out of it and are much more likely
to have complications.
Three is generally my magic number for recommending diverticulitis in the
younger patient, not the 84years old.
There was a recent report in JAMA surgery [3], where they followed a group of
patients who had a sigmoid resection vs conservative therapy for recurrent compli-
cated, persistent, or painful diverticulitis. Mortality and complications of surgery
were virtually nil. The quality-of-life assessment after 2years was much better in
those who had a sigmoid resection. It is interesting, though, that those with elective
sigmoid resection still had a 10–18% risk of recurrent diverticulitis.
Now, in the conservative management group, about 20% ended up needing sur-
gery anyway, but they had a much higher complication rate than the group that had
elective surgery.
Browning: Due to recent data showing that there were fewer deaths and colosto-
mies and better cost-effectiveness if surgical resection was delayed until the fourth
episode rather than the second, both the American Society of Colon and Rectal
Surgeons (ASCRS) and the AGA recommend a case-by-case basis for elective
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surgical resection. These factors include immune status, severity of diverticulitis,
patient preference, patient age, and operative risk [2]. For example, young patients
with diverticulitis tend to have more severe disease and fewer complications follow-
ing surgical resection and therefore may be considered for earlier surgical resection
[1]. In this case, I would refer to a surgeon given multiple episodes in a relatively
short time and relatively good health of the patient.
If you had a 30years old who had their rst episode of sigmoid diverticulitis,
would you recommend surgery?
Berger: Oh, no, because the rst incident is a one-off, and the second is a coinci-
dence, but three is a pattern. By the time you hit three, you’ll know what you’re in for.
Sobin: I agree. I would hold off on surgery after the rst episode. I might recom-
mend surgery after the second, if it is a severe attack, otherwise, probably after
the third.
How do you advise your patients on a way to avoid recurrent diverticulitis?
Any dietary or physical activity suggestions?
Browning: Diverticulosis is very common, and it is estimated that 2/3 of adults
will have diverticula by the ninth decade of life [1]. Most people are asymptomatic,
and thus, the prevalence of diverticulosis may be underestimated. The etiology of
diverticula is debated. Traditionally, diverticula were thought to form from low-ber
diets leading to smaller caliber stools and constipation. This causes higher intralu-
minal pressures leading to herniation of colonic mucosa and submucosa [4].
Diverticula typically form between the taenia coli, which are the three bands of
longitudinal bers of the colon. Diverticula form along the sites of penetration of
the vasa recta. Circular muscle layers thicken and taeniae shorten, causing the colon
to appear thickened with luminal narrowing [1]. Evidence for this can be seen when
people immigrate to regions with a Western diet, they develop a higher incidence of
diverticula [4]. Most diverticula in the western hemisphere are actually pseudodi-
verticula, as the herniation only reaches the submucosa. In Asian countries, diver-
ticula tend to be in the right colon and can be true diverticula involving all layers of
the colonic wall [1].
Other known risk factors include smoking, alcohol, vitamin D deciency, high
red meat diet, physical inactivity, obesity, and genetic factors. Non-steroidal anti-
inammatory drugs (NSAIDs), steroids, hormone replacement therapy, and opiates
increase risk of diverticula and diverticulitis, while calcium channel blockers and
statins were found to be protective [1, 5].
Traditionally, it was recommended that patients with a history of diverticulitis
should avoid nuts and seeds. However, studies have shown that there is no increased
risk of diverticulitis and nuts and seeds may actually lower the risk. The AGA does
not recommend a particular diet [2]. Unfortunately, there is no strong evidence to
suggest medications to prevent recurrence of diverticulitis, and risk of diverticulitis
is largely due to genetic factors. Although dietary changes are debated, due to
absence of side effects, I would propose that this patient stick to a high-ber diet or
consider daily Metamucil. I would counsel him to avoid NSAIDs if possible,
encourage regular exercise, and continue cessation from smoking.
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