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Faecal Incontinence Causes, Diagnosis, & Contemporary Treatment

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Faecal Incontinence Causes, Diagnosis, & Contemporary Treatment

  1. 1. Faecal Incontinence Causes, Diagnosis, & Contemporary Treatment Mr Darren TONKIN Colorectal Surgeon Adelaide SA
  2. 2. Faecal Incontinence <ul><li>“ Recurrent uncontrolled passage of faecal material in an individual with a developmental age of at least 4 years” </li></ul>Whitehead et al. Functional disorders of the anus and rectum. Gut 1999; 45 (Suppl II): II55–9  
  3. 3. Normal Continence <ul><li>Defaecation is complex </li></ul><ul><li>Interaction of anal function & sensation </li></ul><ul><ul><ul><li>Rectal compliance </li></ul></ul></ul><ul><ul><ul><li>Sphincter function </li></ul></ul></ul><ul><ul><ul><li>Anorectal sensation </li></ul></ul></ul><ul><ul><ul><li>Stool consistency </li></ul></ul></ul><ul><ul><ul><li>Stool volume </li></ul></ul></ul><ul><ul><ul><li>Colonic transit </li></ul></ul></ul><ul><ul><ul><li>Mental alertness </li></ul></ul></ul>
  4. 4. Incontinence - Types <ul><li>Sensory </li></ul><ul><ul><ul><li>Patient not aware of it </li></ul></ul></ul><ul><ul><ul><li>Neuropathic, rectal prolapse </li></ul></ul></ul><ul><li>Motor </li></ul><ul><ul><ul><li>Patient aware, but cannot prevent </li></ul></ul></ul><ul><li>Urgency </li></ul><ul><ul><ul><li>Radiation, IBD </li></ul></ul></ul><ul><ul><ul><li>Poor reservoir </li></ul></ul></ul><ul><li>Soiling </li></ul><ul><ul><ul><li>Anal scarring, IPAA, impaction </li></ul></ul></ul>
  5. 5. Functional <ul><li>Impaired Rectal Reservoir </li></ul><ul><ul><ul><li>Ulcerative colitis / Crohn’s disease </li></ul></ul></ul><ul><ul><ul><li>Radiation </li></ul></ul></ul><ul><li>Reduced Rectal Reservoir </li></ul><ul><ul><ul><li>Low colorectal anastomosis or c oloanal anastomosis </li></ul></ul></ul><ul><li>Diarrhoea </li></ul><ul><li>Overflow </li></ul>
  6. 6. Sphincter Defect <ul><li>Congenital </li></ul><ul><ul><ul><li>Imperforate anus </li></ul></ul></ul><ul><li>Trauma </li></ul><ul><ul><ul><li>Obstetric </li></ul></ul></ul><ul><ul><ul><li>Fistulotomy </li></ul></ul></ul><ul><ul><ul><li>Haemorrhoidectomy </li></ul></ul></ul><ul><ul><ul><li>Sphincterotomy </li></ul></ul></ul><ul><ul><ul><li>Anal stretch </li></ul></ul></ul><ul><li>Disease </li></ul><ul><ul><ul><li>Fistula in ano </li></ul></ul></ul><ul><ul><ul><li>Tumour </li></ul></ul></ul><ul><ul><ul><li>Rectal prolapse </li></ul></ul></ul>
  7. 7. Trauma !
  8. 8. Obstetric Injury <ul><li>Sphincter injury on EUS </li></ul><ul><ul><ul><li>35% primips </li></ul></ul></ul><ul><ul><ul><li>44% multips </li></ul></ul></ul><ul><ul><ul><li>Up to 80% after forceps </li></ul></ul></ul><ul><li>Pudendal neuropathy </li></ul><ul><li>May be asymptomatic </li></ul><ul><li>Worsens with time </li></ul>ANZJS, 1999; 69: 172-7
  9. 9. <ul><li>Neurological </li></ul><ul><ul><li>Pudendal neuropathy </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Degenerative </li></ul></ul><ul><ul><li>Spinal cord injury </li></ul></ul><ul><li>Idiopathic </li></ul>
  10. 10. Assessment - History <ul><li>Details of incontinence </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Nature - Solid, Liquid & Gas </li></ul></ul><ul><ul><li>Distinguish between Passive, Urgency and Post Defaecatory Soiling </li></ul></ul><ul><ul><li>Social impact </li></ul></ul><ul><li>Associated symptoms – blood, mucus etc </li></ul><ul><li>Previous anorectal trauma </li></ul><ul><li>Previous surgery </li></ul><ul><li>Obstetric history (N o VD’s, weight, prolonged 2 nd stage, episiotomy, tear, forceps) </li></ul><ul><li>Comorbidities (eg DM) </li></ul><ul><li>Comprehensive drug history (incl OTC, caffeine) </li></ul><ul><li>Continence Scores </li></ul>
  11. 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. 12. Examination <ul><li>Underwear, pads </li></ul><ul><li>General physical </li></ul><ul><li>Perineal deformity, scars </li></ul><ul><li>Perineal descent </li></ul><ul><li>Prolapse </li></ul><ul><li>Digital rectal exam </li></ul><ul><li>Resting + squeeze pressure </li></ul><ul><li>RV septum </li></ul><ul><li>Perineal sensation </li></ul>
  13. 13. Investigations <ul><li>Colonoscopy </li></ul><ul><li>Manometry </li></ul><ul><li>EUS </li></ul><ul><li>PNTML </li></ul><ul><li>MRI </li></ul>
  14. 14. Endoanal US Normal Anterior defect IAS & EAS
  15. 15. MRI <ul><li>Multi-planar capability </li></ul><ul><li>Higher inherent contrast resolution than EUS </li></ul><ul><li>Not operator dependent </li></ul><ul><li>More expensive </li></ul><ul><li>IAS hyperintense, EAS hypointense </li></ul><ul><li>Good for EAS atrophy </li></ul>
  16. 16. MRI Normal Anterior defect IAS & EAS
  17. 17. Manometry <ul><li>Sphincter </li></ul><ul><ul><ul><li>Resting pressure (>40mmHg) </li></ul></ul></ul><ul><ul><ul><li>Squeeze pressure (>100 mmHg) </li></ul></ul></ul><ul><ul><ul><li>Functional anal canal length (M 4-5cm, F 3-4cm) </li></ul></ul></ul><ul><ul><ul><li>Sphincter asymmetry </li></ul></ul></ul><ul><li>Rectal balloon </li></ul><ul><ul><ul><li>Sensation </li></ul></ul></ul><ul><ul><ul><li>Compliance </li></ul></ul></ul><ul><ul><ul><li>Capacity </li></ul></ul></ul><ul><ul><ul><li>RAIR </li></ul></ul></ul>
  18. 18. Conservative Management <ul><li>Alter stool consistency (bulking agents, loperamide) </li></ul><ul><li>Treatment of cause (IBD, IBS) </li></ul><ul><li>Sphincter exercises </li></ul><ul><li>Biofeedback (70% improvement in symptoms & QoL) </li></ul><ul><li>Enema programme </li></ul><ul><li>Topical phenylephrine </li></ul>
  19. 19. Stop straining Stronger squeeze Longer duration Am J Gastro 2000; 95(8): 1873-80 Biofeedback
  20. 20. Topical Phenylephrine <ul><li>Selective  -1 agonist </li></ul><ul><li>Increase resting sphincter tone </li></ul><ul><li>Apply t o internal & external anal area </li></ul><ul><li>20% gel twice daily </li></ul><ul><li>Improved continence & QoL </li></ul><ul><li>Colorectal Disease 2003; 5(Supp 1): 11 </li></ul>
  21. 21. Surgery Options <ul><li>Sphincter repair </li></ul><ul><li>Injectable agents </li></ul><ul><li>Sacral nerve stimulation </li></ul><ul><li>Dynamic graciloplasty </li></ul><ul><li>Artificial sphincter </li></ul><ul><li>Stoma </li></ul><ul><li>ACE </li></ul>
  22. 22. Anterior Sphincter Repair <ul><li>EAS defect </li></ul><ul><li>Overlapping vs direct apposition </li></ul><ul><li>80% improved </li></ul><ul><li>Function deteriorates with time </li></ul>Hull et al. DCR 2002; 45: 345-8
  23. 23. Injectable Agents <ul><li>IAS pathology </li></ul><ul><li>Silicone biomaterial (eg PTQ) </li></ul><ul><li>Submucosal vs intersphincteric </li></ul><ul><li>Approx 50 to 70% gain >50% improvement </li></ul><ul><li>Better results if US used </li></ul>Tjandra et al. DCR 2004.
  24. 24. Injectable Agents
  25. 25. Sacral Nerve Stimulation <ul><li>Originally described for urological use </li></ul><ul><li>Weak but intact sphincter </li></ul><ul><li>Mechanism poorly understood </li></ul><ul><li>2 stage </li></ul><ul><ul><li>PNE – trial electrode 2/52, diary </li></ul></ul><ul><ul><li>Permanent implant </li></ul></ul><ul><li>Good results – up to 90% report improvement </li></ul>
  26. 26. SNS
  27. 27. Dynamic Graciloplasty <ul><li>First described 1988 </li></ul><ul><li>Severe sphincter injury, congenital malformations </li></ul><ul><li>Convert fast-twitch muscle to slow twitch </li></ul><ul><li>Variable results (35 to 85% continence) </li></ul><ul><li>Congenital malformations do worse </li></ul><ul><li>Complications in 50% (30% infection) </li></ul>
  28. 28. Dynamic Graciloplasty
  29. 29. Artificial Bowel Sphincter <ul><li>Adapted from urological use in 1987 </li></ul><ul><li>Good results with successful implant </li></ul><ul><li>High complications rates </li></ul><ul><ul><li>Infection (up to 50%) </li></ul></ul><ul><ul><li>Erosion </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Obstructed defaecation </li></ul></ul><ul><li>Revision (up to 70%) </li></ul><ul><li>Explantation (30%) </li></ul>
  30. 30. Artificial Bowel Sphincter <ul><li>Not recommended for routine use </li></ul><ul><li>Only in cases of severe sphincter injury, malformation or loss. </li></ul>
  31. 31. Stoma <ul><li>Not without complications </li></ul><ul><ul><li>Parastomal hernia </li></ul></ul><ul><ul><li>Mucus leakage </li></ul></ul><ul><ul><li>Diversion colitis </li></ul></ul>
  32. 32. Faecal Incontinence Non-operative treatment Success Failure Investigate ESD Direct repair Neurogenic ISD Injectable Injectable Sacral nerve Gracilis / Artificial Stoma
  33. 33. Conclusion <ul><li>Faecal incontinence infrequently requires surgery </li></ul><ul><li>Injectable bulking agents and sacral nerve stimulation are likely to be the most applicable treatments in the future. </li></ul><ul><li>Stoma formation is an effective option, but can be avoided in the majority. </li></ul>

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