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What is Anal Incontinence?

Anal Incontinence is defined as the complaint of involuntary loss of liquid or solid stool or the involuntary loss of gas.

It is supposedly an underreported condition because of its stigmatizing nature. It occurs in approximately 50% of women at long-term follow-up after anal sphincter injuries (Gommesen et al., 2019; Haylen et al., 2010; Damon et al., 2006; Cotterill, 2008).

Ruptures During Labor and Delivery

The connection between perineal ruptures during labor and deliver and their association with postpartum anal incontinence was studied by Gommesen et al., (2019). Ruptures, or tearing, during labor and delivery can occur to the vaginal canal, perineum, and can tear into the anal canal. The degree at which one tears describes the severity of the rupture.

The Degrees of Rupture (Sultan, 1999)

  • Labial ruptures are isolated to the labia.
  • First-degree ruptures are defined as injury to perineal skin and/or vaginal mucosa.
  • Second-degree ruptures are defined as injury to the perineum, including perineal muscles but not the anal sphincter.
  • Third-degree ruptures are defined as injury to the perineum involving the anal sphincter complex, divided into the following categories:
    • grade 3a ruptures, with less than 50% of EAS thickness torn;
    • grade 3b ruptures, including more than 50% of EAS thickness torn
    • grade 3c ruptures, including both EAS and IAS torn
    • Fourth-degree ruptures are defined as an injury to the perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa.

Risk Factors for Ruptures

Age

Women sustaining third to fourth-degree ruptures tend to be older (> 26 years old) than women sustaining second-degree ruptures and women sustaining no/labia/first-degree ruptures (Gommesen, 2019).

Bigger Babies and Longer Labor

Higher rupture degree was observed with babies with higher birthweight and larger head circumference, longer second stage of labor, and longer active birth (Gommesen, 2019).

Instrument-Assisted Delivery

Deliveries utilizing instruments were more prevalent among both women with second degree (15%) and third- or fourth degree ruptures (34%) compared to women with no/labia/first-degree ruptures (3%) (Gommesen, 2019).

Anal Incontinence Postpartum is Tied to Grade 3-4 Ruptures

About 50% of AI cases after vaginal delivery can be related to anal sphincter injuries.

Sustaining ruptures of degree 3c or 4 increase the risk of AI more than 4-fold.

Time Postpartum

6 Months Postpartum Anal incontinence at 6 months postpartum has been reported to be as high as 49% among first-time deliveries (Gommesen, 2019).

One Year Postpartum
Anal incontinence at 1year postpartum is reported at 19% (Gommesen, 2019).

Additional Risk Factors


Obesity

Gommesen et al. found that study participants who were obese with a BMI greater than 29.9 were at a higher risk of sustaining degree 3c-4 ruptures and had higher prevalence of anal incontinence. Gommesen et al., report the risk of AI increases by 8% per 1-unit increase in BMI.

Smoking and BMI seemed to be independent risk factors. The risk for AI in smokers compared to nonsmokers more than doubled (BMI of >29.9) compared to women with a BMI of 29.9. Furthermore, the risk of AI increased by 8% per 1-unit increase in BMI.

How Can Pelvic Floor Therapy Help Anal Incontinece?

The primary goal of pelvic floor rehabilitation in the management of anal incontinence is to strengthen the pelvic floor and anal sphincter muscles and to make sure they are coordinated and functioning. With increased muscle tone, endurance, and coordination, one should see a positive change in function in continence and function. Additional goals may include Additional goals include increasing muscle awareness, improving rectal sensitivity, and treating any tissue dysfunction that may be getting in the way of optimal pelvic floor muscle performance.

Pelvic floor therapy can provide clients with more control. In fact, according to Scott (2014), between 50 to 80% of clients who receive pelvic floor therapy for fecal incontinence gain function improvements.

What does pelvic floor therapy look like for anal incontinence?

The treatment modalities you will receive in pelvic floor therapy depend on your body and the issues present.

Some of the modalities used at Femina Physical Therapy for the treatment of fecal incontinence can include (but are not limited to):

  • Bowel management education and retraining including lifestyle modifications like optimal fluid intake and dietary fiber intake
  • Therapeutic exercise to strengthen the pelvic floor
  • Biofeedback training with intra-rectal balloon catheters
  • Electrical stimulation using the InTone MV device
  • Manual therapy to treat connective tissue dysfunction and myofascial trigger points
  • Visceral mobilization (gentle massage techniques that loosen internal adhesions and restore movement to the organs including the intestine, bladder, uterus, and ovaries) to improve motility and GI organ function
  • Internal pelvic manual therapy to treat sensitive tissues, muscle spasms, trigger points, and muscle guarding that can cause pain with bowel movements
  • Training in self treatment techniques including abdominal lymphatic massage
  • Neuromuscular re-education and autogenic relaxation to reduce chronic muscle over-activity and improve parasympathetic nervous system function, including digestion

If you've experienced a perineal tear, contact our office to make an appointment today.

Resources

Gommesen, D., Nohr, E. A., Qvist, N., & Rasch, V. (2019). Obstetric perineal ruptures —risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study. American Journal of Obstetrics and Gynecology. doi:10.1016/j.ajog.2019.08.026

Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29: 4–20.

Damon H, Guye O, Seigneurin A, et al. Prevalence of anal incontinence in adults and impact on quality-of-life. Gastroenterol Clin Biol 2006;30:37–43.

Cotterill N, Norton C, Avery KN, Abrams P, Donovan JL. A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Dis Colon Rectum 2008;51:82–7.

Sultan AH. Editorial: Obstetrical perineal injury and anal incontinence. AVMA Med Legal J 1999;5:193–6.

Scott, K. M. (2014). Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence. Clinics in Colon and Rectal Surgery, 27(3), 99–105. https://doi.org/10.1055/s-0034-1384662
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174224/

What Our Patients Have to Say

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Testimonial by Jackie W.

I was in multiple car accidents a decade ago, and I have been to many physical therapists through the years without success. They found the root of my lower back pain problems and after nearly a decade of barely being able to walk I finally can again without pain. They are also the best pelvic floor pts and the only ones who found the connection between my pelvic floor and lower back problems. If you need help with physical pain, they are your answer.

-- Jackie W., 1/19/17 via Yelp!

Testimonial by Rosanna R., age 35

Heather has affected my life in the MOST POSITIVE way and I am forever grateful. My husband refers to her as the "sex doctor" so you can only imagine how happy he is with my therapy outcome.

After the birth of my son I suffered from "Vaginismus", however, at the time I just thought I was broken. My "broken vagina" affected me physically but it was an emotional struggle as well. Many women in my life also suffered with pain from sex after their babies were born so I knew I wasn't alone. They told me they "just got used to it" but I couldn't see myself living that way.

Sex wasn't just painful, it was literally impossible - IT DIDNT FIT!

Read more: Testimonial by Rosanna R.,...

Testimonial by Fritzette H.

I went to Heather after the birth of my third child. It was lucky, really, that I was referred to her, because my doctor had referred me to a surgeon for a possible hysterectomy or pelvic wall rebuild. Thankfully, I went to Heather before undergoing either surgery, she was able to fix the problem. She has studied extensively in women's health--even written a book about it--and was able to diagnose my problem, suggest a course of treatment (6 weeks), and then follow through with said treatment. By the end, as she said, I was as good as gold. Boy, was it worth it! Though uncomfortable to talk about, much less write about, it is worth getting the word out there. If you have painful intercourse, especially after birth or other trauma, the treatment may be as simple as Physical Therapy (with Heather, of course). I highly recommend her.

-- Fritzette H., 3/24/16 via Yelp!

Testimonial by R.D., age 38

"I had a severe tear during childbirth that was not stitched together correctly and therefore healed poorly. Even after having a surgery a year later to remove the scar tissue, I was still having pain, and no one could explain why -- there was no overt 'reason' to explain the pain. I had tried other 'specialists' and even saw another physical therapist who had me do hip / leg stretches -- what a joke! I was about to give up and just 'live with it' until thankfully I kept searching online and found Heather.

Read more: Testimonial by R.D., age 38

Testimonial by M.N., age 28

A personal journey and testimonial from one of my patients:

I was diagnosed with vaginismus 4 years ago. I never heard of such medical condition until after I got married. At first my husband and I didn't know what to do, we didn't know what the issues were or how to overcome it. Being born and raised in Armenia and being Christian I wasn't that open about talking to sex with others and so it wasn't easy to seek help. But eventually I went to an Ob-Gyn and luckily she knew about the medical condition (not many doctors know). She referred me to a physical therapist and I couldn't believe it and thought it's something I can handle myself. I ordered a kit from vaginismus.com and started practicing with dilators. There was some small progress but wasn't much helpful.

Read more: Testimonial by M.N., age 28

Testimonial by Amanda W.

Heather's unique physical therapy program literally changed my life! After years of struggling with vaginismus, a condition that made it impossible for me to have intercourse and very difficult to use tampons without pain, a gynecologist referred me to Heather. I was nervous for my first appointment, but Heather's professional and friendly demeanor put me at ease. She did a great job explaining each technique she was using to help my muscles relax. Heather uses a combination of internal and external stretches and exercises to relax the pelvic floor and build muscle strength. Her specially developed home program helped me quickly recover from an issue that seemed insurmountable before meeting Heather. She was optimistic about my progress and incredibly encouraging. Less than 6 months after my first session, I was able to have pain-free sex for the first time in my life! If you are suffering from vaginismus or any other pelvic floor issues, I highly recommend making an appointment with Heather and reading her book!

-- Amanda W., 2/15/16 via Yelp!

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