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Colorectal Center for Functional Bowel Disorders

Don't Suffer in Silence

We can help.

Colorectal Center for Functional Bowel Disorders Overview

Bowel problems aren’t as uncommon as you might think.

In fact, millions of Americans suffer from a wide range of bowel problems: loss of bowel control, constipation, hemorrhoids, and abdominal or anal discomfort or pain, just to name a few. Yet, many people often don’t seek help because they’re too embarrassed or aren’t sure where to turn.

The good news, however, is that effective treatments may be available. Cleveland Clinic's Colorectal Center for Functional Bowel Disorders has the most experienced group of specialists in the region. Cleveland Clinic is one of only four programs in the country to be named a Center of Excellence: Continence Care for Women by the National Association for Continence (NAFC). U.S. News & World Report’s “America’s Best Hospitals” survey has ranked our digestive disease services as #2 in the nation every year since 2003 and #1 in Ohio since 1990.

Using state-of-the-art diagnostics and decades of experience, we determine the cause of patients’ problems and then tailor the most appropriate treatment. You can rely on our success in both diagnosing and treating a full spectrum of bowel disorders.

Don’t wait. You don’t have to let your bowel problems control your life.

At Cleveland Clinic's Colorectal Center for Functional Bowel Disorders, we’ve designed our services so that all of the specialists you may need – including colorectal surgeons, gastroenterologists, gynecologists, urologists, urogynecologists, and physical therapists – work together to help you regain control of your bowel issues. One call puts you in touch with our multidisciplinary team, led by a group of female physicians, who are dedicated to compassionately working with you o find the most effective treatments for your problems.

Don't Suffer in Silence

We can help. Bowel problems aren’t as uncommon as you might think.

In fact, millions of Americans suffer from a wide range of bowel problems: loss of bowel control, constipation, hemorrhoids, discomfort or pain – just to name a few. Yet, many people often don’t seek help because they’re too embarrassed or aren’t sure where to turn.

The good news, however, is that effective treatments are available. Cleveland Clinic's Colorectal Center for Functional Bowel Disorders has the most experienced group of specialists in the region. U.S. News & World Report’s “America’s Best Hospitals” survey has ranked our digestive disease services as #2 in the nation every year since 2003 and #1 in Ohio since 1990.

Diagnostic Technology

A thorough evaluation and accurate diagnosis are critical to receiving the most appropriate treatment. At Cleveland Clinic's Colorectal Center for Functional Bowel Disorders, we offer the best diagnostic tests available, including:

  • Anorectal manometry – Assesses the strength of the sphincter muscles.
  • Electromyography (EMG) – Determines if the anal sphincter muscles and nerves function normally.
  • Pudendal nerve terminal motor latency – Uses electrical impulses to measure the function of the pudendal nerves, which may be injured in patients with incontinence, constipation or rectal prolapse (rectum falling out of place).
  • Endoanal ultrasound – Provides 2-D and 3-D, real-time images to evaluate the anatomy of the anal sphincter muscles and surrounding tissue
  • Defecating proctogram – Radiographically evaluates the function and anatomy of the pelvic organs during defecation.
  • Colon Transit Study – Estimates the time for fecal matter to travel through the colon. X-rays are taken to follow the passage of markers that are swallowed in pill form.
  • Smart Pill – Measures transit time throughout the entire intestinal tract via a swallowed pill.
  • Dynamic magnetic resonance imaging (MRI) – Uses a series of MRI images to look at pelvic structures during simulated evacuation.

Common conditions treated at Cleveland Clinic’s Colorectal Center for Functional Bowel Disorders include:

Anal Fissure

An anal fissure is a small, non-healing tear or cut in the skin lining the anus. Common symptoms of an anal fissure include anal pain, especially with bowel movements, and/or bleeding. Fissures are usually caused by a hard bowel movement or by diarrhea.

Treatment options:
  • Medications – Medical treatment is focused on softening the stools with fiber and stool softeners. Prescription medications are used to promote healing of the fissure.
  • Botox injection – In some cases, injecting Botox into the anal sphincter allows for healing of the anal fissure.
  • Surgery – Some anal fissures require surgery, most frequently a lateral sphincterotomy, in which the internal sphincter muscle is divided in order to permit healing of the tear.
Anal Fistula

When an abscess develops from an anal gland, an anal fistula-- a small tunnel--can form from the gland to the skin outside the anus. Certain conditions, such as colitis or other inflammations of the intestine, can make people more prone to these infections. Common symptoms include drainage, perianal irritation or pain, and swelling.

Treatment options:
  • Fistulotomy – The fistula tract (tunnel) is surgically opened, allowing it to heal.
  • Advancement flap repair – In this surgical option for more complex fistulas, a flap of the rectal tissue is used to seal the internal opening.
  • Seton insertion / cutting seton – For deeper fistulas, a seton is used to gently cut through the tunnel to allow the tissue to heal.
  • Anal fistula plug – A biologic implant is inserted into the fistula tract, allowing the fistula to heal naturally.
  • LIFT (ligation of intersphincteric fistula tract) – This newer procedure involves dividing the fistula tract, which then permits both the internal and external opening to heal.
Chronic constipation and difficult defecation

Constipation is considered chronic when you have three or fewer bowel movements per week. Other common symptoms in constipated patients include straining, hard stools, and a feeling of incomplete evacuation. In some cases, constipation is related to difficult evacuation, which may be caused by rectal prolapse, paradoxical contraction (non-relaxation) of the pelvic floor muscles, sigmoidocele enterocele (when the sigmoid colon or pelvic floor weaken and drop),and rectocele, in which the wall between the rectum and vagina weakens.

Dietary changes and exercise as well as over-the-counter medications can frequently help. Patients may benefit from treatment with biofeedback or, in extreme cases, require surgery.

Some causes of evacuatory dysfunction include rectal prolapse, paradoxical contraction (non-relaxation) of the pelvic floor muscles, sigmoidocele enterocele (when the sigmoid colon or pelvic floor weaken and drop),and rectocele, in which the wall between the rectum and vagina weakens.

Evaluation by a Colorectal Center for Functional Bowel Disorders physician specialist is needed to determine the appropriate treatments, among which are:

Treatment options:
  • Medications – Fiber supplements, stool softeners and laxatives are often recommended.
  • Pelvic floor retraining – Physical therapists specializing in the pelvic floor teach methods to strengthen and coordinate the pelvic floor muscles, as well as to heighten the awareness of the sensation related to the rectum filling with stool.Electrical stimulation is also offered.
  • Botox injection – For patients with non-relaxation of the pelvic floor muscles, Botox injection into those muscles is an option to improve emptying ability.
  • STARR procedure – This minimally-invasive surgical procedure, which leaves no visible scars, removes excess tissue in the rectum to allow for more effective emptying.
  • Surgery for rectal prolapse – Various procedures for rectal prolapse return the rectum to its original position and anchor it in place.
  • Pelvic floor repair – This surgery restores the pelvic floor, which supports the bladder, bowel and uterus.
Fecal incontinence

Fecal incontinence refers to an inability to hold on to or control liquid or solid stool. Sometimes simple changes in diet or adjustments in medications can cure incontinence. Often treatment involves a combination of therapies.

Treatment options:
  • Medications – Anti-diarrheal drugs, or others medications, may be used to decrease bowel movement frequency or reduce the water content of the stool.
  • Pelvic floor retraining – Physical therapists specializing in the pelvic floor teach methods to strengthen and coordinate the pelvic floor muscles, as well as to heighten the awareness of the sensation related to the rectum filling with stool.
  • Sphincter repair (sphincteroplasty) – A damaged or weakened anal sphincter muscle can often be surgically repaired.
  • Sacral nerve stimulation (InterStim) – This procedure improves continence by using an implantable device to modulate the nerves to the anorectum.
  • Injectable biomaterials (Solesta) – In the office, this biomaterial is injected into the anal canal to bulk up the anal sphincter muscles.
  • Artificial bowel sphincter – This device is inserted around the anus to replace a damaged sphincter.
  • Newer treatments are currently under research protocols.
Hemorrhoids

Although internal hemorrhoids—a normal part of our anatomy--are present in everyone, it is only when these blood vessels that line the anal canal cause symptoms such as anal pain, rectal bleeding, anal itching, anal drainage, or hemorrhoidal prolapse (protrusion) that you may need treatment. The exact cause of hemorrhoid problems is not known, but contributing factors include aging, chronic constipation or diarrhea, pregnancy, prolonged sitting on the toilet, and straining during bowel movements.

Treatment options:
  • Hemorrhoid banding – This procedure, done in our specialists’ offices, involves the placement of small rubber bands around the base of the internal hemorrhoid.The rubber bands cut off the blood flow to the hemorrhoidal tissue
  • Sclerotherapy – A hardening chemical is injected into the hemorrhoid complex in order to create scaring of the inflamed tissue, reducing the blood flow to the hemorrhoids.
  • Stapled hemorrhoidopexy (PPH) – This minimally-invasive surgery uses a stapling device to reposition and secure the prolapsed hemorrhoids in place.
  • Doppler-guided hemorrhoidal artery ligation – Using a special probe containing a Doppler device, the arteries to the internal hemorrhoids are identified and then tied off.
  • Excisional hemorrhoidectomy – This surgical procedure removes the internal hemorrhoidal tissue.
Pelvic Floor Dysfunction

Pelvic floor dysfunction occurs when you are unable to effectively coordinate the muscles in your pelvic floor to have an easy bowel movements. People with pelvic floor dysfunction contract (tighten) these muscles rather than relax them. Because of this, they have difficulty with bowel movements: a feeling of incomplete emptying, straining, or the need for measures to assist in emptying (for example, enemas or using a finger to pull out stool).

Treatment options:
  • Biofeedback – The most common treatment for pelvic floor dysfunction is biofeedback, done with the help of a physical therapist.Physical therapists may take several approaches to biofeedback. These include using special sensors and video to monitor the pelvic floor muscles as the patient attempts to relax or contract them. .
  • Medication – In some cases, your physician may prescribe a low-dose muscle relaxant to deal with pelvic floor dysfunction.
  • Relaxation techniques – Your physician or physical therapist may recommend relaxation techniques such as warm baths, yoga, and exercises.
  • Surgery – If your physician determines that your pelvic floor dysfunction is the result of a rectal prolapse or rectocele, surgery may be necessary.
Rectal Prolapse

Rectal prolapse occurs when the rectum (the last section of the large intestine) falls from its normal position within the pelvic area. (The word "prolapse" means a falling down or slipping of a body part from its usual position.)

Treatment options:
  • Abdominal surgery – The rectum may be secured into its normal position (rectopexy) via an open or laparoscopic abdominal surgery. In some cases, this surgery is combined with removal of a portion of the colon (sigmoidectomy).
  • Rectal (perineal) surgery – These procedures are performed via the anus, not requiring any incisions in the abdomen.
Rectovaginal fistula

This is a type of anal fistula in which an abnormal passageway develops between the rectum and vagina. A rectovaginal fistula can occur in women after trauma during childbirth, from surgery or from inflammatory conditions.

Treatment options:
  • Advancement flap repair – In this surgical procedure the rectal lining is used to cover the internal opening in the anus.
  • Rectovaginal plug – A biologic material can be implanted to close the fistula.
  • Episioproctotomy – The anal sphincter muscle is used to reinforce a repaired opening.
  • Abdominal repair – Reconstructive surgery via the abdomen may be needed to close the fistula in some cases.
Additional treatment options

Many non-surgical treatment options are available through the offices of the Colorectal Center for Functional Bowel Disorders:

  • Electro-galvanic stimulation – This treatment for pelvic pain and levator ani syndrome uses electric stimulation to reprogram tense and stiff muscles to make them relax , thus reducing pain.
  • Trigger point injections – Injections are used to inactivate trigger points, or hypersensitive bundles in muscle tissue, to alleviate pain.
  • Biofeedback – Used to improve strength and coordination of the anus and pelvic floor muscles.
  • Pelvic floor relaxation – A method of relaxing the tense and shortened muscles in the pelvis to alleviate pelvic pain and non-relaxing sphincters.
  • Acupuncture – This form of pain management uses needles inserted at precise acupuncture points elsewhere on the body to manage pelvic pain and non-relaxing sphincters.

Cleveland Clinic's Colorectal Center for Functional Bowel Disorders also has a research group that is actively working to improve treatment options for our patients. This means that qualifying patients benefit from having access to clinical trials. These research studies not only provide treatments otherwise unavailable, but they also help us expand our overall understanding of bowel disorders.

Related Information

We want to make your appointment with us as comfortable as possible. As your visit approaches, we understand you'll have questions. That's why we've put together information that will give you an overview of what to expect when you come to us.

What to Expect During Your Visit to the Pelvic Floor Clinic in the Exam Room

  • After checking in at the front desk, you will meet the members of our team. This may include nurses, medical student or fellows and colorectal staff. Each one may ask you questions about your medical history and present condition.
  • Be prepared with your list of medication, prior surgeries, colonoscopy reports and imaging (for example, X-ray or cat scans) related to your condition.
  • You will undergo a physical examination. This may include anal, rectal and genital examinations. To examine the anus internally, a short cylindrical instrument may be gently inserted into the anal canal. When indicated, a vaginal examination may be required. For this examination, no patient preparation is needed.
  • At the conclusion of your visit, you and your doctor will establish a plan of care.
  • Before you leave, make sure that you have a clear understanding of your treatment and follow-up care.

Download this list as a PDF

Before You Leave

  • Make sure you are satisfied with your doctor's plan of testing and treatment.
  • Make sure your questions are answered.
  • Have a means of communicating with your doctor/nurse (visiting card/phone number).
  • Do you have a follow-up scheduled?
  • If you are not satisfied with your instruction, please talk to the doctor/nurse before you leave.
  • Please complete all questionnaires that you are asked to fill.

Health Assessment

When you schedule an appointment with a DDI physician, you will also be scheduled for a 20 minute Health Assessment appointment. This is to gather important information from you before seeing the physician. It is important that you arrive for this appointment on time so that gathering this information does not interfere with your physician appointment. The following information provides more detail on what and why we collect during the Health Assessment appointment:

Health Status Questionnaire

You will be asked to complete a health status questionnaire using a wireless computer tablet while sitting in the waiting room. The questionnaire will ask how you feel about the quality of your life and quality of your health.

Many of the questions are used by healthcare providers across the country and have been shown to be effective in understanding patients’ opinions of their own health.

By completing this questionnaire every time you see your doctor, you will be able to assess the changes in your perception of your own health. It also enables your doctor to see your responses over time to understand if your treatment is working as intended.

While some of the questions may seem irrelevant or intrusive, it is important for you to answer the entire survey so we have a thorough understanding of how all our patients are doing as a result of their treatment plan. Future patients may benefit from understanding if specific treatments work more effectively at improving quality of life.

Cleveland Clinic’s mission is to improve the health of all patients and therefore is committed to reporting a variety of statistics that demonstrate improvement in health outcomes. Your responses will help Cleveland Clinic provide a comprehensive view of our efforts.

HealthQuest Questionnaire

If you are a new patient scheduled to see a surgeon, you will be asked to complete a questionnaire called HealthQuest using a computer workstation in the DDI waiting room. This questionnaire asks about your cardiovascular and respiratory health as well as your history of other health conditions and past surgeries. This information will help your anesthesiologist develop a plan for your surgery ensuring that anesthesia is administered to you in the safest, most comfortable way.

Demographic and Insurance Information

We want to ensure that we have the most up to date information on your address, telephone number, date of birth, emergency contact and health insurance. We may ask you to verify this information.

Thank you for your cooperation and understanding of the numerous questions we ask and the variety of methods used to collect this information. Our goal is to provide you with the most effective care so we thank you for choosing Cleveland Clinic’s Digestive Diseases Institute to partner with you in improving your health.

Download this information as a PDF

Brooke Gurland, MD
  • Dr. Brooke Gurland is a staff physician in the Digestive Disease Institute and sees patients at Cleveland Clinic's Colorectal Center for Functional Bowel Disorders.
  • Dr. Gurland received her medical degree from Hahnemann University Medical College, Philadelphia. She completed her residency at Mount Sinai School of Medicine, New York, N.Y. and her fellowship at Cleveland Clinic Florida.
  • Her clinical and research interests include rectal prolapse, fecal incontinence, constipation and rectal vaginal fistula, robotic and laparoscopic surgery and patient reported outcomes.
Tracy L. Hull, MD
  • Dr. Tracy Hull is a staff physician in the Digestive Disease Institute and sees patients at Cleveland Clinic's Colorectal Center for Functional Bowel Disorders.
  • Dr. Hull received her medical degree from The Ohio State University College of Medicine and Public Health in Columbus, OH. She completed her residency at State University New York Health Science Institute at Syracuse in Syracuse, NY and her fellowship at Cleveland Clinic.
  • Her clinical and research interests include fecal incontinence, colon and rectal cancer, ulcerative colitis, Crohn’s disease, diverticulitis and rectal prolapse.
Ursula Szmulowicz, MD
  • Dr. Ursula Szmulowicz is a staff physician in the Digestive Disease Institute and sees patients at Cleveland Clinic's Colorectal Center for Functional Bowel Disorders.
  • Dr. Szmulowicz received her medical degree from New York University School of Medicine in New York, NY. She completed her residency at Indiana University Medical Center in Indianapolis, IN and her fellowship at Greater Baltimore Medical Center, Baltimore, MD.
Michael A. Valente, DO
  • Dr. Michael A. Valente is a staff physician in the Digestive Disease Institute and sees patients at Cleveland Clinic's Colorectal Center for Functional Bowel Disorders.
  • Dr. Valente received his medical degree from Ohio University College of Osteopathic Medicine in Athens, OH. He completed his residency at Akron City Hospital in Akron, OH and his fellowship at Grant Medical Center, Columbus, OH.
Massarat Zutshi, MD
  • Dr. Massarat Zutshi is a staff physician in the Digestive Disease Institute and sees patients at Cleveland Clinic's Colorectal Center for Functional Bowel Disorders.
  • Dr. Zutshi received her medical degree from Grant Medical College, University of Bombay, Bombay, India. She completed her fellowship at Cleveland Clinic.
  • Her clinical and research interests include pelvic floor dysfunction, rectal prolapse, fecal incontinence, constipation and anorectal disorders.

Cleveland Clinic offers a Multidisciplinary Pelvic Floor clinic staffed by a colorectal surgeon and uro-gynecologist for same-day evaluation by both specialists. In appropriate patients, we offer multidisciplinary surgery to address all pelvic floor issues, eliminating the patient’s need for multiple procedures. The majority of our patients seen in the clinic are managed surgically.

The Colorectal Center for Functional Bowel Disorders saw 701 new patients from January 2010 through November 2011. The majority of new patients were seen for management of constipation or fecal incontinence.

Call 866.289.3427 to make an appointment with any of our experts at Cleveland Clinic’s Colorectal Center for Functional Bowel Disorders.

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This information is provided by Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

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