Assessment of Fecal Incontinence
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Assessment of Fecal Incontinence
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Why should we be interested?
• Common problem• Can be iatrogenic• Results of surgery frequently imperfect• Can have an adverse effect on quality of
life• Significant cost for the Society
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Common medical problem that is under-reported to physicians
Second leading cause of nursing home placement
3% of women who give birth by vaginal delivery will develop Some degree of FI
Introduction
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Incidence and prevalence
Perry et al, 2002. Prevalence of faecal incontinence in adults aged 40 years or more living in the community
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Background: definition• Faecal incontinence is defined as
involuntary loss of faeces• Commonly classified according to:
– character of leakage– symptom– presumed primary underlying cause
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Diagnosis
• HISTORY
• EXAMINATION
• INVESTIGATION
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History
• LISTEN to what is being said
• LISTEN to the problem
• LISTEN to the effect on their life
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• Define incontinence: flatus vs. stool (liquid vs. solid) • Characterize frequency, duration, severity• Soiling?...fistula, prolapse, hemorrhoids • Urgency? ..... decreased rectal compliance • Medications: laxatives, antibiotics, pancreatic enzyme • Past surgical history: ano-rectal, obstetric
Initial evaluation History
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Examination of the anus• Skin tags, fissures, fistulas• Descent• Gape• Strain• Length and angle• Muscle bulk• Voluntary contraction
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The specific questions
• Defaecation• Consistency• Urgency• Frequency• Leakage
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Pathophysiology and Etiology
Partial incontinence – loss of control to flatus and minor soiling
Major incontinence – frequent and regular deficiency in the ability to control stool of normal consistency
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Normal Continence
External sphincter: - Somatic innervation - 15% continence
Internal sphincter: - Visceral innervation - 85% continence
Secondary Musclesof continencePrimary Muscles
of continence
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External Anal Sphincter
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Fecal Incontinencephysiologic factors
stool consistency rectal and anal sensation
rectal compliancepelvic floor function
can lead to a defective continence mechanism
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Fecal Incontinence Altered stool consistency
Inflammatory bowel diseaseInfectious diarrheaLaxative abuseRadiation enteritisShort bowel syndromeMalabsorption syndrome
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Fecal IncontinenceInadequate rectal compliance
Inflammatory bowel diseaseAbsent rectal reservoir (ileoanal, low ant. resection)Rectal neoplasmsRadiation TherapyCollagen vascular disease (scleroderma, amyloidosis, dermatomyositis)
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Fecal Incontinence Inadequate rectal sensation
Dementia, CVA, MS, brain or spinal cord injury/neoplasm, sensory neuropathy
Diabetes – multifactorial, impaired rectal sensation is important
Overflow incontinenceFecal impaction – leading cause of incontinence in institutionalized elderly patients
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Fecal IncontinenceDescending perineal syndrome
Constant straining during defecation
Traction neuropathy of the nerves
Denervation of puborectalis and EAS
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The reflex responsiveness of the anal region
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Fecal incontinence associated with spinal cord injury
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Fecal IncontinenceSphincter defect (Internal and/or External)
Traumatic
Obstetric injury prolonged difficult labor (forceps
application) episiotomy complications
Anorectal surgery anal fistula surgery (most common)
hemorrhoidectomy
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Incidence of Perineal Trauma
• 90% of incontinent women with an obstetric history have a sphincter defect (Burnett, S.J. BJS 1991)
• Women with 30/40 tear
– 74% Symptomatic– 59% Incontinent of Gas– 90% Sphincter Defect (Goffeng, A.R. Act.OGS 1998)
• 35% of Primiparous women will have a sphincter defect after delivery (13% symptomatic) (Sultan, A.H. NEJM 1993)
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Childbirth & Fecal Incontinence
• 549 prospective fecal urgencyvag 7.3% vsCS 3.1% Chaliha 99 Obstet Gyn
259 consecutive women delivered single unit31 elective CS no FIPrimaparous delivered vaginally 13% FI
Abromowitz Dis Colon Rectum 2000
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Incontinence after birth
MacLennan and collegues, BJOG 2000
No births
Caesareansection
Vaginal delivery
Instrumental delivery
Stress 11% 33% 41% 44%
Urge 4% 10% 19% 20%
Faecal 2% 4% 5% 11%
How often do these problems occur?
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The Mechanism Of Obstetric Injury
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Obstetric InjuryMechanisms
Rectovaginal septum - rectocoele
Ischaemic injury - fistula
Sphincter complex - incontinence
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Investigations
FunctionAno-rectal
ManometryAno-rectal
Electrophysiology
StructureEndoanal Ultrasound Magnetic Resonance
ImagingDefecography
MorphologyEndoscopy
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Anorectal manometry
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Anorectal manometry
Measurement of both resting and voluntary sphincter squeeze pressure
Incontinent patients – low resting and voluntary squeeze pressure
Estimate threshold for rectal sensation/compliance, recto-anal inhibitory reflex
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Anorectal manometry in fecal incontinence
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Anal Endosonography
An ultrasound probe is placed in the anal canal or transvaginally to detect sphincter injuries and to evaluate pelvic floor structures
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Normal anatomy as viewed by anal endosonography
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Normal anatomy as viewed by anal endosonography
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Faecal IncontinenceStructural Defect
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Electrophysiologic testsEMG – needle electrodes into the superficial portion of the external sphincter or puborectalis muscle – myoelectric activit
Pudendal nerve terminal motor latency – measures the delay between the application of an electrical stimulus and external sphincter muscle response. Prolonged – pudendal neuropathy
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SPHINCTEROPLASTYPNTML & Neuropathy
Is PNTML reliable in predicting poor outcome ?
• difficult to quantify neuropathy• cut-off value• value of unilateral prolonged latency
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Defecography
Evacuation is monitored with flouroscopy
Assessment of the anorectal angle at rest and during defecation
Excessive perineal descent, failure of the puborectalis muscle to relax, rectocele and internal intususception
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Summary• Listen to the story• Ask the questions• Examine the bottom• Do the tests• Fit the jigsaw together• Consider the alternatives for treatment