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6.12.3 Trans-Anal Electrical Stimulation Therapy
Electrical stimulation is another second-line management modality that has been
proposed for the rehabilitation of fecal and urinary incontinence. It was reported
that pelvic oor electrical stimulation achieves a cure rate of 30–60% and an
improvement rate of 74% in those with stress urinary incontinence (SUI) [91].
However, for fecal incontinence, success is lower [5]. Electrical stimulation can be
delivered to the pelvic oor and sphincters in many different forms, including via
surface electrodes or intrarectal probes.
One of the postulated mechanisms of electrical stimulation in urinary inconti-
nence is that it increases the level of transforming growth factor-β1 (TGF-β1),
which is a pleiotropic cytokine that plays important roles in many physiological and
pathological processes [92]. It has unique and widespread actions in the remodeling
of the extracellular matrix and is critical for tissue integrity. Recent studies have
reported that the TGF-β1 pathway is activated, and expression of collagens I and III
is signicantly decreased in stress urinary incontinence [93]. Electrical stimulation
therapy potentially causes T-type calcium channels to open and subsequently acti-
vates a TGF-β1-protein pathway. This encourages collagen deposition, which
restores tissues’ tensile strength and mechanical stability as well as pelvic tissue
structure and function, producing a therapeutic effect for stress urinary incontinence
[94]. These effects also related to pelvic tissue when working on coordination of
anal sphincter activity and working to isolate a contraction of the anal sphincter [95].
The goal of electrical stimulation is to enhance the strength and/or endurance of
striated muscle contraction; the target is typically the external anal sphincter in the
case of fecal incontinence. Another goal is for patients with decreased kinesthetic
awareness to become more cognizant of where their pelvic oor muscles are in
space and what it feels like when the muscles and sphincter are contracting.
Electrical stimulation has been shown to transform fast-twitch muscle bers to
slow-twitch muscle bers, which is thought to help with improving endurance [96].
It also increases capillary density, allowing more blood ow to the oxidative slow-
twitch bers [97].
Norton etal. [98] compared daily anal electrical stimulation of two different
frequencies—35Hz versus 1Hz—and there were no differences between the groups
in terms of any outcome measures, and 63% of patients who completed treatment
felt that electrical stimulation had improved their symptoms at least somewhat.
Box 6.4 (continued)
For pelvic oor rehabilitation purposes, the most common types of bio-
feedback use electromyography (EMG) and biofeedback therapy. However,
other forms of pelvic oor biofeedback include the use of ultrasound (either
intrarectal, intravaginal, or perineal), rectal balloons, digital guidance (the use
of an intrarectal/intravaginal nger or hand placed on the perineum), and ano-
rectal manometry [89, 90].
6 Management ofFecal Incontinence inCommunity-Living Adults
114
They speculated that improvements in both groups were possibly related to improved
rectal sensation rather than direct muscle strengthening, or alternatively, a pla-
cebo effect.
Healy etal. [99] randomized 48 patients to endo-anal electrical stimulation with
a home unit versus endo-anal electrical stimulation plus augmented biofeedback
under supervision of a physical therapist. Both groups improved in terms of conti-
nence scores, manometric pressure readings in post-treatment, and quality of life.
However, this study had no control group. A “triple therapy” approach using
medium frequency electrical stimulation (3000Hz, 500mV) via a plug electrode
and EMG biofeedback twice per day has had better results, reducing anal inconti-
nence compared to EMG biofeedback alone. The protocol, however, may be com-
plex and intensive for some patients to follow or sustain. More research is needed to
further ascertain the most efcacious treatment protocols [100].
Box 6.5 Examples of Electrical Stimulation Protocols
• Treatment modalities will certainly vary locally, nationally, and glob-
ally. A protocol used by a medical center in Hong Kong, China uses an
intravaginal electrical probe to deliver stimulation to the pelvic oor
for patients with urinary or double incontinence. The protocol consists
of two 20-min sessions per week over a 6-week period. The electrical
parameters used in all sessions were a frequency of 30–60Hz; pulse
time of 500μs, with continuous stimulation; and the intensity varied
according to each patient’s tolerability. All patients receive a combina-
tion of intravaginal electro- stimulation and home pelvic oor muscle
exercise, which was taught by the urology advanced practice nurse.
Results from that center on intravaginal electro-stimulation showed
that it was especially effective for poor responders to pelvic oor exer-
cise monotherapy [83]. In addition, the actual number of pads used
showed a signicant decline [83].
• Another center in Canada uses a different protocol of 6 weekly treat-
ments with biofeedback and electrical stimulation. Most of the litera-
ture will cite between 8 and 12 weekly treatments. This can be
time-intensive, and the advanced practice nurses at this center have
found 6 weekly treatments sufce as long as the patient is committed
and is compliant with practicing their pelvic oor exercise routine
between appointments. For the electrical stimulation therapy, this cen-
ter uses a protocol of 50Hz for stress incontinence with a pulse width
of 1.0ms, ramping of 20%, and a biphasic wave. The optimal protocol
for electrical stimulation has not been established.
S. Eustice and D. Z. Bliss
115
6.12.4 Extracorporeal Magnetic Innervation
The initial clinical application of extracorporeal magnetic innervation technology
was for the treatment of urinary incontinence. Pulsed magnetic technology has been
developed for pelvic oor therapy. The magnetic eld generator (therapy head) is
contained in the middle of the chair seat of the neocontrol system using an external
power unit (Neotonus, Inc., Marietta, Ga). The output of the power unit consists of
magnetic pulses, and the amplitude can be adjusted by the advanced practice nurse.
It is the amplitude that determines the volume of the eld needed to generate stimu-
lation strong enough to induce a nerve impulse. This application relies on the basic
principle of physics that a changing magnetic eld will induce a ow of electrons
within the eld, triggering a nerve stimulation [101]. Although this technology has
not been exposed to randomized controlled study designs to treat fecal incontinence
alone, evidence is emerging on its effectiveness. Brusciano etal. [102] investigated
30 patients (26 were female) on the reduction of liquid and solid fecal leakage.
Incontinence severity and quality of life scores improved for 24 and 27 of the
patients, respectively.
A pilot study by an advanced practice nurse in Pamela Youde Nethersole Eastern
Hospital, Hong Kong, China, using extracellular matrix therapy for the treatment
of double incontinence observed positive results [103]. Patients who had a modi-
ed Oxford score grade 0–1 and failed pelvic oor muscle training for 6months
were treated with extracorporeal magnetic innervation therapy. Ten adult female
patients (age range from 44 to 77years) were studied. Patients were seated fully
clothed in a neocontrol chair. Each treatment session lasted for 20min and was
conducted twice a week for 6weeks. The frequency of the pulsed magnetic eld
was 5Hz, intermittently for 10min, followed by a rest period of 1–5min and a
second treatment at 50Hz intermittently for 10min. The treatment intervals were
intermittent (5s on and 5s off) to avoid muscle fatigue. Validated quality of life
surveys was used (e.g., UDI-6 IIQ-7, FIQOL) at the beginning of treatment and
again at 3months. A 3-day bladder diary was used to assess frequency, urgency,
urge incontinence, bladder capacity, and uid intake. The number of pads used was
also counted.
The results [103] showed a signication decrease in both fecal and urinary incon-
tinence per day; the pad used decreased from 2.8 to 1.4 (p<0.05). The mean UDI-6
score decreased from 2.5 to 1.5 (p<0.05); the mean IIQ-7 score decreased from 4.5
to 5.5 (p<0.05). The FIQOL subscale scores improved. Limitations of the study
were the small sample size and lack of random assignment to a control or compari-
son group and self-reported measures. There were no complications or adverse
events during or after the treatment. Long-term follow-up and randomized con-
trolled studies are crucial to properly evaluate the efcacy of this treatment for fecal
incontinence. The comfort and non-invasiveness of extracorporeal magnetic inner-
vation technology could be a compelling option for selected patients..
6 Management ofFecal Incontinence inCommunity-Living Adults
116
Overall, emerging evidence has been considered, and current recommendations
are to offer pelvic oor muscle training as a rst-line intervention, with biofeedback
as an adjunct in the second-line intervention [5]. The position of electrical stimula-
tion has not been conrmed, and therefore recommendation is uncertain until fur-
ther investigation.
6.13 Devices andProducts forContainment
ofFecal Incontinence
Fecal incontinence may not be resolved with conservative or surgical treatment, and
some individuals may need to rely on containment products and devices. Several
containment devices offer options for preventing leakage from the rectum. These
devices include anal plugs, anal inserts, and vaginal bowel devices. However, indi-
vidual needs vary, requiring sensitive and optimal product selection. Yet, there are
inadequate decision-making tools to assist with maximizing comfort, skin health,
effectiveness, and sustainability [104]. Devises and products currently available,
include anal plugs, inserts and absorbent hygiene pads.
The anal plug and anal insert function are similar but have different designs. The
anal plug is made of soft foam-like material which is inserted in a partially col-
lapsed state into the rectum and then expands like a tampon (see Fig.6.2). Once
inside the rectum, the anal plug blocks the passage of feces around it. It is removed
by using the “string” that is securely attached to the plug or pushed out during def-
ecation. Anal plugs come in different sizes and designs. Because of the materials
used in the plug, it is not ushable, which can make its use difcult for male patients,
as male public toilet stalls do not have sanitary bins for their discrete disposal.
The anal insert has a spindle shape with a top and bottom disk and an applicator
for insertion into the rectum (see Fig.6.2). The top disk is inserted into the rectum
to seal the outlet to the anus and is available in two diameters. The bottom disk
remains outside the anus to avoid displacement into the rectum and facilitates easier
Fig. 6.2 Anal plug (left image) and anal insert (right image). (Printed with permission from the
International Continence Society; Source: Continence Product Advisor https://www.continence-
productadvisor.org)
S. Eustice and D. Z. Bliss
117
Fig. 6.3 Vaginal bowel
device. (Reprinted with
permission from the
International Continence
Society; Source: Cottenden
etal. [108])
manual removal. The anal insert is made of soft silicone, is single-use, and can be
expelled with a bowel movement. It should not be ushed down a toilet for disposal.
Anal plugs and inserts have been shown to be effective in preventing leakage and
are usually used on an as-needed basis [48, 105, 106]. Reviews by the Cochrane
group [105] and the International Consultation on Incontinence [5] suggested that
anal plugs can be uncomfortable and therefore difcult to tolerate. Therefore, anal
plugs are recommended to be placed at the upper end of the anal canal to reduce
discomfort. Educating the patient on how to position and use these devices (building
up the time of inter-rectal use of these plugs gradually) may help improve tolerance.
Although Fox etal. stated that “Anal plugs are a last resort” [107], anal plugs can be
useful in a selected group of people either as a substitute for other forms of manage-
ment or as an adjuvant treatment option. Some individuals may need time to adjust
to this device like a young woman getting used to wearing a tampon vaginally.
A vaginal bowl device uses a different approach than the plug and insert for
occluding the rectum. It is inserted into the vagina after which its balloon is inated
by the patient using an external hand pump. The inated balloon presses against the
adjacent wall of the rectum to prevent feces from leaking out of the rectum (see
Fig.6.3). The insert is then deated for removal. An insert lasts about 1 year [48].
The vaginal bowel device seems to be well tolerated by many women [109].
Adverse effects are cramping, discomfort, urinary incontinence, and vaginal spot-
ting [109]. A clinician needs to t the patient with the correct size of the insert for
comfort and effectiveness.
6.13.1 Absorbent Products
Absorbent products are a part of the management plan for fecal incontinence. They
are useful as an adjunct to other therapeutic options or as an option when intractable
incontinence continues despite active treatment modalities. Body-worn absorbent
6 Management ofFecal Incontinence inCommunity-Living Adults
118
products can promote socialization in public, assist in protecting skin integrity, and
maintain a person’s dignity. An individual’s preference should always be considered.
There are a variety of absorbent products available, differing in design, shape,
size, and degrees of absorbency (see Chap. 15 for more information). Some are
body-worn products, while others are pads for bedding and furnishings [48, 110].
Body-worn products are available in disposable and washable versions. Styles range
from full briefs to thin, small products that line underpants. Many patients “mix and
match” different body-worn absorbent products to meet their needs, depending on
whether they are worn during the day or night and the degree of their leakage [48].
Most absorbent products are designed for urinary incontinence. An exception is
a small insert that can be placed between the buttocks against the anus to absorb
small leakages of feces [48, 111]. Unfortunately, there are few absorbent products
designed specically for fecal incontinence, and many of the characteristics of those
for urinary incontinence are not optimal for fecal incontinence, due to the solids
present in feces. Community-living individuals with fecal incontinence identied
needed improvements for absorbent products including being made of materials
that can protect skin from more solid/softer feces or particulate irritants in liquid
feces and that are ushable, better/more absorption toward the back without increas-
ing bulkiness, better control of odor, capability of placing them on or taking them
off without removing outer pants, and better protection against larger leaks [112].
Many patients with fecal incontinence need advice for selecting among the many
types of absorbent products available from the advanced practice nurse (see Box
6.5). An interactive continence products advisor website is available to assist
advanced practice nurses as well as patients in reviewing the features and selecting
absorbent or containment products [113]. In many countries, the costs of many of
these absorbent products are not covered by many governmental programs or pri-
vate insurance policies for those living in the community with fecal incontinence.
These out-of-pocket costs of absorbent products add to the burden and stress for
patients and their families. Case studies illustrating conservative management of
fecal incontinence in community-living adults by the advanced practice nurse are
described in Boxes 6.6 and 6.7. Overall, the evidence base for product selection is
scant, especially when considering skin integrity [114]. Further research is neces-
sary to guide practice realistically and compassionately. Until then, the advanced
practice nurse must keep pace with best clinical practice.
6.13.2 Management Recommendations Regarding Devices
andProducts forContainment
• Recommend use of containment or absorbent products as needed to support
other conservative management approaches and facilitate public/social activities.
• Review options for styles, sizes, and levels of absorption of absorptive products.
• Teach patients how to use an anal, plug, insert, or a vaginal bowel device if they
opt to use one of these devices.
S. Eustice and D. Z. Bliss
119
• Make follow-up appointments to assess patients’ ability to use them, satisfaction,
effectiveness, and complications.
• Refer patients interested in a vaginal bowel device to an appropriate healthcare
practitioner for a prescription and tting as needed.
• Explain to patients the lack of healthcare insurance coverage for these products.
Boxes 6.6 and 6.7 present two case studies illustrating conservative management
of fecal incontinence by an advanced practice nurse.
Box 6.6 Case Study 1
Focused Assessment
Mr. Langer is a 42-year-old single male who presents with complaints of
fecal incontinence for the past few months. He had a hemorrhoidectomy sev-
eral months ago, which he said reduced the amount of his leakage but did not
eliminate it. He says he leaks small amounts of loose feces a few days per
week. He is unsure why or specically when he leaks. He really has not paid
attention to the consistency of his usual stools, but thinks they are soft. He
does not report excessive urgency. Physical examination showed he had a
weak contraction of his external anal sphincter and a weak pelvic oor con-
traction of 2/5 on the modied Oxford scale and poor endurance of 3 s. There
was some mildly diminished sensory awareness.
His perianal area was dark pink, and Mr. Langer said he had some discom-
fort there. He does not use absorbent pads and says he really does not know
much about them. He complained about staining his trousers.
He has hypertension controlled with medication and takes cholesterol-low-
ering medication. Sometimes he takes an over-the-counter antacid for “stomach
stress” related to his job. He does not follow a special diet, but his diet recall
seems low in ber and high in processed, convenience foods, as he does not
have a lot of time or interest in cooking for himself. He drinks several cups of
regular coffee/day and has a drink or beer every 2–3days after work. He says he
sometimes had rectal gas. He usually avoids spicy hot foods, which cause him
to have abdominal discomfort and diarrhea, but will, on occasion, eat spicy
chicken wings, which he likes. His work as a computer software programmer is
sedentary and very busy, so he does not get much exercise.
Treatment Plan
The advanced practice nurse developed a treatment plan with the patient.
She taught him pelvic oor muscle exercises and asked that he start a home
routine of exercises daily: perform 3–4 sets of contractions and relaxation
three times a day, one set lying, one set sitting, and the third set standing.
(continued)
6 Management ofFecal Incontinence inCommunity-Living Adults
120
Box 6.6 (continued)
The advanced practice nurse determined his antacid contained magnesium,
which can cause loose stools and suggested an alternative other counter ant-
acid without magnesium. He was recommended to take loperamide up to
8mg per day as needed.
She asked Mr. Langer to record a Bowel Diary and a diet record of foods
and drinks for 7days in a row for the same days. She explained the diaries and
said they will review the records together at his next visit to assess his bowel
and leakage pattern and to see if there are any foods/drinks (other than spicy
foods) that seem to be associated with worsened symptoms. She recom-
mended Mr. Langer start taking a daily supplement of psyllium ber at the
starting dose recommended on the supplement.
The advanced practice nurse reviewed the importance of timely cleansing
and drying of the perianal area and suggested a skin protectant for him to use.
She reviewed a chart of various types and sizes of absorbent products and
made some recommendations for him to try. She scheduled a follow-up visit
with Mr. Langer in 4weeks to review his status.
Box 6.7 Case Study 2
Focused Assessment
Mrs. Peterson is a 70-year-old married female with a history of fecal
incontinence for several years. She says she does not feel like she completely
empties her bowels and leaks several times a day. When she was younger, she
had some constipation and still takes a stool softener. She wears absorbent
menstrual pads or pantiliners.
She started reducing her activities outside the home. She stopped accom-
panying her husband when he goes shopping for groceries or a walk. She
discontinued her exercise class for seniors that she had previously enjoyed.
This has started to make her feel down as she would often socialize with some
of the other women after the class. She worries that she will start to put on
weight and has started reducing her diet intake. She is very anxious that she
will have an “accident” of fecal leakage in public. She often has urgency, and
with her feelings of anxiety, she does not always have time to make it to the
toilet on the second oor of her home.
Mrs. Peterson had 5 children all by vaginal birth (two with large birth
weight).
Treatment Plan
The advanced practice nurse provided a list of foods high in dietary ber
and recommended Mrs. Peterson add these to her diet intake and drink 2–2.3L
of water/day. After 3weeks, she is asked to complete a diet and uid intake
(continued)
S. Eustice and D. Z. Bliss
121
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