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Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment
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Faecal Incontinence Causes, Diagnosis, & Contemporary Treatment

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  • 1. Faecal Incontinence Causes, Diagnosis, & Contemporary Treatment Mr Darren TONKIN Colorectal Surgeon Adelaide SA
  • 2. Faecal Incontinence
    • “ Recurrent uncontrolled passage of faecal material in an individual with a developmental age of at least 4 years”
    Whitehead et al. Functional disorders of the anus and rectum. Gut 1999; 45 (Suppl II): II55–9  
  • 3. Normal Continence
    • Defaecation is complex
    • Interaction of anal function & sensation
        • Rectal compliance
        • Sphincter function
        • Anorectal sensation
        • Stool consistency
        • Stool volume
        • Colonic transit
        • Mental alertness
  • 4. Incontinence - Types
    • Sensory
        • Patient not aware of it
        • Neuropathic, rectal prolapse
    • Motor
        • Patient aware, but cannot prevent
    • Urgency
        • Radiation, IBD
        • Poor reservoir
    • Soiling
        • Anal scarring, IPAA, impaction
  • 5. Functional
    • Impaired Rectal Reservoir
        • Ulcerative colitis / Crohn’s disease
        • Radiation
    • Reduced Rectal Reservoir
        • Low colorectal anastomosis or c oloanal anastomosis
    • Diarrhoea
    • Overflow
  • 6. Sphincter Defect
    • Congenital
        • Imperforate anus
    • Trauma
        • Obstetric
        • Fistulotomy
        • Haemorrhoidectomy
        • Sphincterotomy
        • Anal stretch
    • Disease
        • Fistula in ano
        • Tumour
        • Rectal prolapse
  • 7. Trauma !
  • 8. Obstetric Injury
    • Sphincter injury on EUS
        • 35% primips
        • 44% multips
        • Up to 80% after forceps
    • Pudendal neuropathy
    • May be asymptomatic
    • Worsens with time
    ANZJS, 1999; 69: 172-7
  • 9.
    • Neurological
      • Pudendal neuropathy
      • Diabetes
      • Degenerative
      • Spinal cord injury
    • Idiopathic
  • 10. Assessment - History
    • Details of incontinence
      • Frequency
      • Nature - Solid, Liquid & Gas
      • Distinguish between Passive, Urgency and Post Defaecatory Soiling
      • Social impact
    • Associated symptoms – blood, mucus etc
    • Previous anorectal trauma
    • Previous surgery
    • Obstetric history (N o VD’s, weight, prolonged 2 nd stage, episiotomy, tear, forceps)
    • Comorbidities (eg DM)
    • Comprehensive drug history (incl OTC, caffeine)
    • Continence Scores
  • 11. Cleveland Clinic Scoring System 4 3 2 1 0 LIFESTYLE ALTERATION 4 3 2 1 0 USE OF PAD 4 3 2 1 0 FLATUS 4 3 2 1 0 LIQUIDS 4 3 2 1 0 SOLIDS ALWAYS USUALLY SOMETIMES RARELY NEVER
  • 12. Examination
    • Underwear, pads
    • General physical
    • Perineal deformity, scars
    • Perineal descent
    • Prolapse
    • Digital rectal exam
    • Resting + squeeze pressure
    • RV septum
    • Perineal sensation
  • 13. Investigations
    • Colonoscopy
    • Manometry
    • EUS
    • PNTML
    • MRI
  • 14. Endoanal US Normal Anterior defect IAS & EAS
  • 15. MRI
    • Multi-planar capability
    • Higher inherent contrast resolution than EUS
    • Not operator dependent
    • More expensive
    • IAS hyperintense, EAS hypointense
    • Good for EAS atrophy
  • 16. MRI Normal Anterior defect IAS & EAS
  • 17. Manometry
    • Sphincter
        • Resting pressure (>40mmHg)
        • Squeeze pressure (>100 mmHg)
        • Functional anal canal length (M 4-5cm, F 3-4cm)
        • Sphincter asymmetry
    • Rectal balloon
        • Sensation
        • Compliance
        • Capacity
        • RAIR
  • 18. Conservative Management
    • Alter stool consistency (bulking agents, loperamide)
    • Treatment of cause (IBD, IBS)
    • Sphincter exercises
    • Biofeedback (70% improvement in symptoms & QoL)
    • Enema programme
    • Topical phenylephrine
  • 19. Stop straining Stronger squeeze Longer duration Am J Gastro 2000; 95(8): 1873-80 Biofeedback
  • 20. Topical Phenylephrine
    • Selective  -1 agonist
    • Increase resting sphincter tone
    • Apply t o internal & external anal area
    • 20% gel twice daily
    • Improved continence & QoL
    • Colorectal Disease 2003; 5(Supp 1): 11
  • 21. Surgery Options
    • Sphincter repair
    • Injectable agents
    • Sacral nerve stimulation
    • Dynamic graciloplasty
    • Artificial sphincter
    • Stoma
    • ACE
  • 22. Anterior Sphincter Repair
    • EAS defect
    • Overlapping vs direct apposition
    • 80% improved
    • Function deteriorates with time
    Hull et al. DCR 2002; 45: 345-8
  • 23. Injectable Agents
    • IAS pathology
    • Silicone biomaterial (eg PTQ)
    • Submucosal vs intersphincteric
    • Approx 50 to 70% gain >50% improvement
    • Better results if US used
    Tjandra et al. DCR 2004.
  • 24. Injectable Agents
  • 25. Sacral Nerve Stimulation
    • Originally described for urological use
    • Weak but intact sphincter
    • Mechanism poorly understood
    • 2 stage
      • PNE – trial electrode 2/52, diary
      • Permanent implant
    • Good results – up to 90% report improvement
  • 26. SNS
  • 27. Dynamic Graciloplasty
    • First described 1988
    • Severe sphincter injury, congenital malformations
    • Convert fast-twitch muscle to slow twitch
    • Variable results (35 to 85% continence)
    • Congenital malformations do worse
    • Complications in 50% (30% infection)
  • 28. Dynamic Graciloplasty
  • 29. Artificial Bowel Sphincter
    • Adapted from urological use in 1987
    • Good results with successful implant
    • High complications rates
      • Infection (up to 50%)
      • Erosion
      • Pain
      • Obstructed defaecation
    • Revision (up to 70%)
    • Explantation (30%)
  • 30. Artificial Bowel Sphincter
    • Not recommended for routine use
    • Only in cases of severe sphincter injury, malformation or loss.
  • 31. Stoma
    • Not without complications
      • Parastomal hernia
      • Mucus leakage
      • Diversion colitis
  • 32. Faecal Incontinence Non-operative treatment Success Failure Investigate ESD Direct repair Neurogenic ISD Injectable Injectable Sacral nerve Gracilis / Artificial Stoma
  • 33. Conclusion
    • Faecal incontinence infrequently requires surgery
    • Injectable bulking agents and sacral nerve stimulation are likely to be the most applicable treatments in the future.
    • Stoma formation is an effective option, but can be avoided in the majority.

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