Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment

Faecal Incontinence Causes, Diagnosis, & Contemporary Treatment Mr Darren TONKIN Colorectal Surgeon Adelaide SA

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

Normal Continence
Defaecation is complex
Interaction of anal function & sensation
Rectal compliance
Sphincter function
Anorectal sensation
Stool consistency
Stool volume
Colonic transit
Mental alertness

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

Functional
Impaired Rectal Reservoir
Ulcerative colitis / Crohn’s disease
Radiation
Reduced Rectal Reservoir
Low colorectal anastomosis or c oloanal anastomosis
Diarrhoea
Overflow

Sphincter Defect
Congenital
Imperforate anus
Trauma
Obstetric
Fistulotomy
Haemorrhoidectomy
Sphincterotomy
Anal stretch
Disease
Fistula in ano
Tumour
Rectal prolapse

Trauma !

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

Neurological
Pudendal neuropathy
Diabetes
Degenerative
Spinal cord injury
Idiopathic

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

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

Examination
Underwear, pads
General physical
Perineal deformity, scars
Perineal descent
Prolapse
Digital rectal exam
Resting + squeeze pressure
RV septum
Perineal sensation

Investigations
Colonoscopy
Manometry
EUS
PNTML
MRI

Endoanal US Normal Anterior defect IAS & EAS

MRI
Multi-planar capability
Higher inherent contrast resolution than EUS
Not operator dependent
More expensive
IAS hyperintense, EAS hypointense
Good for EAS atrophy

MRI Normal Anterior defect IAS & EAS

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

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

Stop straining Stronger squeeze Longer duration Am J Gastro 2000; 95(8): 1873-80 Biofeedback

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

Surgery Options
Sphincter repair
Injectable agents
Sacral nerve stimulation
Dynamic graciloplasty
Artificial sphincter
Stoma
ACE

Anterior Sphincter Repair
EAS defect
Overlapping vs direct apposition
80% improved
Function deteriorates with time
Hull et al. DCR 2002; 45: 345-8

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.

Injectable Agents

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

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)

Dynamic Graciloplasty

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%)

Artificial Bowel Sphincter
Not recommended for routine use
Only in cases of severe sphincter injury, malformation or loss.

Stoma
Not without complications
Parastomal hernia
Mucus leakage
Diversion colitis

Faecal Incontinence Non-operative treatment Success Failure Investigate ESD Direct repair Neurogenic ISD Injectable Injectable Sacral nerve Gracilis / Artificial Stoma

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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Faecal IncontinenceCauses, Diagnosis, & Contemporary Treatment

by ensteve on Apr 21, 2009

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