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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/

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Who gets vaginal dryness?

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What Our Patients Have to Say

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Testimonial by Julie T.

Femina PT (née Fusion Wellness & Physical Therapy) has honestly changed my life. Before receiving treatment at Femina, I was going doctor to doctor to try and find the answer to my pelvic pain. It has taken me YEARS to find someone that can help fix this. It wasn't until my gynecologist recommended your clinic that I finally felt relief. My pelvic pain is almost gone, and granted I still have a lot more to work on with Laureen (my PT), my original problem is nearly cured. I am so grateful to her.

What is even better is she gave me practical exercises to do at home that were not tedious and provided instant (and lasting) relief. Although I mainly work with Laureen, my interaction with the owner (Heather) has been great. She is very generous, kind, and committed to her business.

It hurts to know there are women out there suffering who will never know or have the opportunity to work with women like Laureen and Heather because this issue is hardly talked about and this field is so rare. I hope more doctors and physical therapists see the value in this work and can relieve more woman of their pain.

-- Julie T., 12/4/16 via Yelp!

Testimonial by M.M.

My husband and I were married for 5 years and unable to have intercourse, but I never knew why. After numerous awful experiences at doctor’s offices (where many doctors told me I “just needed to relax”), a surgery that didn’t fix the problem, and a year of owning dilators that didn’t get me anywhere, someone finally referred me to Heather for Physical Therapy. I finally had answers and information from someone who knew exactly what I was dealing with!

Read more: Testimonial by M.M.

Testimonial by Lauren B.

Femina PT (née Fusion Wellness & Physical Therapy) has been such an answer to prayer, i'm so glad I found them! I've been struggling with vaginismus my whole life, but didn't have a name for it until about 6 or 7 months ago. Even once I did have a name for it though, I didn't know where to begin in getting help. My OB/GYN had me get a set of dilators, but I couldn't even insert the smallest one by myself. Most times I tried I just ended up frustrated and in tears. I felt really alone, like I was broken and didn't have the energy to keep trying. When I got engaged a few months ago though, I realized I needed to get answers so i wasn't dreading my honeymoon.

Read more: Testimonial by Lauren B.

Testimonial by Ann V.

I wish i could give this place 10 stars!! 
I have been suffering from vaginismus for 5 years and never found the cure to it. I had seen an ob/gyn and he diagnosed me with vaginismus and told me i needed a surgery to cure my condition, which i refused to do. He also referred me to a PT that he works with, i had given them multiple calls and they never responded back to me, so i started searching yelp for another PT. I am SO HAPPY I found Heather's office! I was working with Laureen, and with her guidance and techniques i was able to be cured from vaginismus in only 2 1/2 short months!!! I couldn't believe how quickly their program worked for me! I am forever grateful and thankful from Heather, and Laureen! They are the absolute best at what they do!

Read more: Testimonial by Ann V.

Testimonial by S.B.

As someone who suffered the debilitating physical and emotional effects of vaginismus (as well as a complicated history of back injuries) for more than 15 years, I thought a "normal" life was just a fantasy. Then I found Heather.

Read more: Testimonial by S.B.

Testimonial by T.H.

I started seeing Heather in October 2014. For more than two years, I had been suffering from painful urinary tract infection type symptoms after my bartholins gland surgery which included constant burning and urinary frequency sensation that led to more and more painful intercourse. I had made multiple visits to internist, obgyn and urologist's offices, went through a range of treatment with UTI and bladder frequency medication that included antibiotics, vesicare, estrogen cream, but nothing worked.

Read more: Testimonial by T.H.

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