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Faecal Incontinence: How to investigate and who to refer

Faecal Incontinence: How to investigate and who to refer. Mr Peter Mitchell SpR Colorectal Surgery Mr ES Kiff and Miss KJ Telford, Pelvic Floor Unit University Hospital South Manchester. British Geriatrics Society, NW Branch 7 th Sept 2010. Introduction. FI - ‘involuntary loss of stool’

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Faecal Incontinence: How to investigate and who to refer

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  1. Faecal Incontinence: How to investigate and who to refer Mr Peter Mitchell SpR Colorectal Surgery Mr ES Kiff and Miss KJ Telford, Pelvic Floor Unit University Hospital South Manchester British Geriatrics Society, NW Branch 7th Sept 2010

  2. Introduction • FI - ‘involuntary loss of stool’ • FI - is a sign/symptom not a diagnosis • Stigmatising, adverse effect on Q o L, social restriction, significant cost to NHS • Not talked about, often neglected.

  3. Incidence and prevalence ↑with age • Up to 18% of community dwelling adults1 • 1.4% of all aged >40 2 • 47% of NH residents 3 • 3-4% of all aged >65 4,5 Refs: 1 MacMillan et al DCR 2004 2 Perry et al Gut 2002 3 Nelson et al DCR 1998 4 Peet et al BMJ 1995 5 Campbell et all Age Ageing 1985

  4. Causes of FI - numerous! Your Practice: • Poor mobility • Cognitive impairment • Constipation • Sphincter degeneration Our Practice: • Obstetric trauma • Sphincter defect • Iatrogenic • Fistula • IBS • Inflammatory BD • Congenital • Both: • Prolapse • Haemorrhoids • Drugs • Foods

  5. Questions you must ask: • Do you have to rush? • Stool consistency? • Can you go when you get there? • Does something else come out? • Is it difficult wiping clean? • Do you leak during the day?

  6. Baseline assessment (on the ward) Four key bedside questions: • Have we examined and what did we find ? • Is the patient loaded ? • What is the stool consistency ? • Have we excluded a cancer ? ‘Commence initial treatment and then reassess’

  7. Doing the PR • Two sphincters- • IAS – keeps anus closed • EAS – voluntarily squeezed to ensure closure of anus.

  8. Doing the PR - Inspection • Anus open/closed, ‘gapes to traction’ = Poor IAS function.

  9. Doing the PR - inspection • Can you squeeze ? • An idea of EAS function.

  10. Descent/rectocele

  11. Doing the PR - palpation • Idea of resting tone. • Idea of squeeze tone. • Confirm if loaded or not. • Rectocele ? • Exclude anal/rectal cancer.

  12. Treatment options INITIAL • Bowel habit • Stool consistency • Diet and fluid intake • Fibre • Toilet access/mobility • Skin preps/ pads /plugs • Drugs – cause/treat – oral/rectal SPECIALISED • Pelvic Floor Exercise • Biofeedback • Rectal Irrigation • Electrical Stimulation • Surgery • Stoma

  13. Treatment options Some or most of the initial treatment options may be required. ‘Commence and then reassess’

  14. Initial treatment options Access? • FI due to poor mobility • Urgency

  15. Initial treatment options • Diet/fluid intake – • Anti-diarrhoeal medication – Loperamide • Regular, before meals (syrup or capsules) • prn basis, ‘imodium instants’

  16. Plugs • No good evidence but may help some.

  17. The faecally loaded Plan = 1) initial clearance 2) +/-bowel management programme Some patients restore continence with clearance. Those with chronic loading may benefit from active management. Tobin 1986 – RCT – Constipated FI=lactulose and weekly enemas FI = codeine and enemas twice week Compared with standard care= significant reduction in FI episodes.

  18. Neurological /spinal injury ‘muscles don't work – can’t go, can’t hang on’ Plan = • 1) active bowel management programme premorbid bowel habit patient input/preferences diet/oral laxatives/evacuants – to achieve predictable bowel pattern

  19. The ‘prolapser’ • Don’t strain • Soft formed stool • Suppositories • Plug • Avoid constipation

  20. The patient with descent / rectocele • Digital support • Suppositories • Formed stool • Enemas • Rectal washouts

  21. Who to refer? • Failed initial options and patient keen for further input. • Diet/fluid, Stool consistency, loperamide, suppositories, etc. • Physically and mentally able. • Patients with troublesome prolapse

  22. Specialist Options • Majority still managed with conservative measures. • Biofeedback • Surgery – • Injection bulking agents • Anterior Sphincter repair, prolapse surgery. • SNS • Artificial bowel sphincter • Stoma

  23. Sacral Nerve Stimulation

  24. SNS • Mechanism of action unknown. • Testing phase – allows assessment of response. • Easily performed under LA as daycase. • Mainly Faecal urgency and Urge FI benefit. • May need additional treatments.

  25. Prolapse Surgery • Abdominal Rectopexy Low recurrence rate Post op constipation Operative risks • Perineal (e.g.Delormes) Higher recurrence rate Less operative risk

  26. Summary • FI is common and distressing. • We need to talk about it. • Baseline assessment, commence and reassess • No one recipe for success • Area of future research References : NICE Guidelines June 2007 Website: www.rcsed.ac.uk/fellows/kcattle/fi_home.html

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