Assessment of Fecal Incontinence

1. Assessment of Fecal Incontinence

2. Why should we be interested? • Common problem • Can be iatrogenic • Results of surgery frequently imperfect • Can have an adverse effect on quality of life • Significant cost for the Society

3. Introduction • Common medical problem that is under-reported to physicians • Second leading cause of nursing home placement • 3% of women who give birth by vaginal delivery will develop Some degree ofFI

4. Incidence and prevalence Perry et al, 2002. Prevalence of faecal incontinence in adults aged 40 years or more living in the community

5. Background: definition • Faecal incontinence is defined as involuntary loss of faeces • Commonly classified according to: • character of leakage • symptom • presumed primary underlying cause

7. Diagnosis • HISTORY • EXAMINATION • INVESTIGATION

8. History • LISTEN to what is being said • LISTEN to the problem • LISTEN to the effect on their life

9. Initial evaluation History • Define incontinence: flatus vs. stool (liquid vs. solid) • • Characterize frequency, duration, severity • • Soiling?...fistula, prolapse, hemorrhoids • • Urgency? ..... decreased rectal compliance • • Medications: laxatives, antibiotics, pancreatic enzyme • • Past surgical history: ano-rectal, obstetric

11. Examination of the anus • Skin tags, fissures, fistulas • Descent • Gape • Strain • Length and angle • Muscle bulk • Voluntary contraction

12. The specific questions • Defaecation • Consistency • Urgency • Frequency • Leakage

13. Pathophysiology and Etiology • Partial incontinence – loss of control to flatus and minor soiling • Major incontinence – frequent and regular deficiency in the ability to control stool of normal consistency

14. Normal Continence Internal sphincter: - Visceral innervation - 85% continence External sphincter: - Somatic innervation - 15% continence Secondary Muscles of continence Primary Muscles of continence

15. External Anal Sphincter

18. Fecal Incontinence physiologic factors • stool consistency • rectal and anal sensation • rectal compliance • pelvic floor function • can lead to a defective continence mechanism

19. Fecal Incontinence Altered stool consistency • Inflammatory bowel disease • Infectious diarrhea • Laxative abuse • Radiation enteritis • Short bowel syndrome • Malabsorption syndrome

20. Fecal IncontinenceInadequate rectal compliance • Inflammatory bowel disease • Absent rectal reservoir (ileoanal, low ant. resection) • Rectal neoplasms • Radiation Therapy • Collagen vascular disease (scleroderma, amyloidosis, dermatomyositis)

21. Fecal Incontinence Inadequate rectal sensation • Dementia, CVA, MS, brain or spinal cord injury/neoplasm, sensory neuropathy • Diabetes – multifactorial, impaired rectal sensation is important • Overflow incontinence • Fecal impaction – leading cause of incontinence in institutionalized elderly patients

22. Fecal IncontinenceDescending perinealsyndrome • Constant straining during defecation • Traction neuropathy of the nerves • Denervation of puborectalis and EAS

23. The reflex responsiveness of the anal region

24. Fecal incontinence associated with spinal cord injury

25. Fecal IncontinenceSphincter defect (Internal and/or External) • Traumatic • Obstetric injury • prolonged difficult labor (forceps application) episiotomy complications • Anorectal surgery • anal fistula surgery (most common) hemorrhoidectomy

26. Incidence of Perineal Trauma • 90% of incontinent women with an obstetric history have a sphincter defect (Burnett, S.J. BJS 1991) • Women with 30/40 tear • 74% Symptomatic • 59% Incontinent of Gas • 90% Sphincter Defect(Goffeng, A.R. Act.OGS 1998) • 35% of Primiparous women will have a sphincter defect after delivery (13% symptomatic) (Sultan, A.H. NEJM 1993)

27. Childbirth & Fecal Incontinence • 549 prospective fecal urgency vag7.3% vsCS3.1% Chaliha99 ObstetGyn 259 consecutive women delivered single unit 31 elective CS no FI Primaparousdelivered vaginally 13% FI AbromowitzDis Colon Rectum 2000

28. Howoften do theseproblemsoccur? Incontinence after birth MacLennan and collegues, BJOG 2000

29. The Mechanism OfObstetric Injury

30. Obstetric InjuryMechanisms Rectovaginal septum - rectocoele Ischaemic injury - fistula Sphincter complex - incontinence

31. Investigations Function Ano-rectal Manometry Ano-rectal Electrophysiology Structure Endoanal Ultrasound Magnetic Resonance Imaging Defecography Morphology Endoscopy

32. Anorectalmanometry

33. Anorectalmanometry • Measurement of both resting and voluntarysphincter squeeze pressure • Incontinent patients – low resting and voluntary squeeze pressure • Estimate threshold for rectal sensation/compliance, recto-anal inhibitory reflex

36. Anorectalmanometry in fecal incontinence

37. Anal Endosonography • An ultrasound probe is placed in the anal canal or transvaginally to detect sphincter injuries and to evaluate pelvic floor structures

39. Normal anatomy as viewed by anal endosonography

40. Normal anatomy as viewed by anal endosonography

41. Faecal IncontinenceStructural Defect

42. Electrophysiologic tests • EMG – needle electrodes into the superficial portion of the external sphincter or puborectalis muscle – myoelectricactivit • Pudendal nerve terminal motor latency – measures the delay between the application of an electrical stimulus and external sphincter muscle response. Prolonged – pudendal neuropathy

44. SPHINCTEROPLASTY PNTML & Neuropathy Is PNTML reliable in predicting poor outcome ? • difficult to quantify neuropathy • cut-off value • value of unilateral prolonged latency

45. Defecography • Evacuation is monitored with flouroscopy • Assessment of the anorectal angle at rest and during defecation • Excessive perineal descent, failure of the puborectalis muscle to relax, rectocele and internal intususception

47. Summary • Listen to the story • Ask the questions • Examine the bottom • Do the tests • Fit the jigsaw together • Consider the alternatives for treatment