Lecture notes for medical students

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5. This will be an ACTIVE LEARNING SESSION x
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6. Good for self study also.
7. See notes for bibliography.

2. Faecal Incontinence

3. Faecal Incontinence
• “Recurrent uncontrolled passage of faecal
material in an individual with a
developmental age of at least 4 years”

4. Normal Continence

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

6. Incontinence - Types

7. 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

8. Functional

9. Functional
• Impaired Rectal Reservoir
• Ulcerative colitis / Crohn’s disease
• Radiation
• Reduced Rectal Reservoir
• Low colorectal anastomosis or coloanal
anastomosis
• Diarrhoea
• Overflow

10. Sphincter Defect

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

12. Obstetric Injury

13. Obstetric Injury
•Sphincter injury on
EUS
• 35% primips
• 44% multips
• Up to 80% after
forceps
•
•Pudendal neuropathy
•May be
asymptomatic
•Worsens with time

14.  Neurological
 Pudendal neuropathy
 Diabetes
 Degenerative
 Spinal cord injury
 Idiopathic

15. Investigations

16. Investigations
 Colonoscopy
 Manometry
 EUS
 PNTML
 MRI

17. Conservative Management

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. Biofeedback

20. • Stop straining
• Stronger squeeze
• Longer duration
Biofeedback

21. Topical Phenylephrine

22. Topical Phenylephrine
• Selective -1 agonist
• Increase resting sphincter tone
• Apply to internal & external anal area
• 20% gel twice daily
• Improved continence & QoL

23. Surgery Options

24. Surgery Options
 Sphincter repair
 Injectable agents
 Sacral nerve stimulation
 Dynamic graciloplasty
 Artificial sphincter
 Stoma

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