A syndrome is simply a group of symptoms. In irritable bowel syndrome the patient's bowel (large intestine or part of the digestive system that makes and stores stool) does not function properly and this results in a chronic relapsing pattern of crampy abdominal pain, bloating, gas, diarrhea or constipation. Symptoms suggesting IBS are present in up to 80% of women with chronic pelvic pain.
The cause of irritable bowel syndrome is not known. It is a "functional disorder," which means that there are no anatomical or biochemical abnormalities that explain the symptoms. It is commonly believed that the nerves and muscles of the bowel are unusually sensitive so that during or shortly following a meal the muscles of the bowel begin to contract strongly to cause cramps, pain and diarrhea. Events or conditions that increase the risk of IBS attacks include stress, certain hormonal conditions (may be related to particular times during the menstrual cycle), endometriosis, and exercise. It is this author's belief that endometriosis may cause or trigger a very high percentage of the symptoms associated with irritable bowel syndrome since (anecdotally) many women in our practice at the NJ Center for Fertility and Reproductive Medicine have experienced complete relief of their IBS symptoms immediately following ultrapulse laser surgery for endometriosis.
The diagnostic evaluation of irritable bowel syndrome includes (1) bloodwork for a complete blood count with differential, sedimentation rate, c reactive protein, and chemistry profile; (2) stool specimens for ova and parasites (looking for Giardia and other parasites) as well as blood and Clostridium difficile toxins (if there has been any antibiotic exposure within the last 8 weeks); and (3) assessment of the bowel structurally with either colonoscopy or radiological testing. Irritable bowel syndrome is a diagnosis of exclusion, meaning that IBS is diagnosed when none of the tests suggest a recognized disease of the bowel.
The treatment of IBS is directed at the relief of symptoms since no specific disease is identified. Symptom complexes that may be treated include:
- Abdominal pain, gas or bloating. Abdominal pain and cramping is generally treated with anti-spasmodic medications (such as Bentyl) to minimize muscle contractions. It is sometimes necessary to use higher doses of these medications, which may result in a greater incidence of side effects. Since the symptoms often occur with a meal, the medications are usually taken just prior to eating. Gas and bloating are often treated with galactosidase (such as Beano) or simethicone (such as Gas X).
- Constipation. Initial treatment generally includes a high fiber diet and psyllium. Brief courses of a stool softener or an osmotic laxative (that works by drawing water into the bowel) can be considered with a physician. Stimulant laxatives are usually not used. Prokinetic medications (which stimulate movement or transit through the bowel) like Cisapride (Propulsid) may be considered although research has not found a significant improvement with this type of medication.
- Diarrhea. A change in diet should be considered since it is often helpful, including an increase in soluble fiber, reduction in fats, and smaller meals. Loperamide (Imodium) is also commonly used to reduce or slow down movement through the intestines and Imodium is now available over the counter (it does not require a prescription). Care should be exercised with Imodium since IBS women often have an exaggerated response and a single dose can result in constipation.
It is important to manage irritable bowel syndrome with a physician when medications become involved. Surgical management has historically focused on hysterectomy, however, it is emphasized that this should be a "last resort" type of option for women with chronic pelvic pain and symptoms of IBS and should only be considered (for this indication) once all other types of management have failed. Anecdotally, the author has found in his own practice that surgical management of endometriosis in women with chronic pelvic pain and IBS often seems to relieve the IBS symptoms as well as their chronic pelvic pain.