Download incontinence

Assessment of Fecal Incontinence
Why should we be interested?
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Common problem
Can be iatrogenic
Results of surgery frequently imperfect
Can have an adverse effect on quality of life
Significant cost for the Society
Introduction
Common medical problem that is underreported to physicians
Second leading cause of nursing home
placement
3% of women who give birth by vaginal
delivery will develop Some degree of FI
Incidence and prevalence
Perry et al, 2002. Prevalence of faecal incontinence in adults aged 40 years or more
living in the community
Background: definition
• Faecal incontinence is defined as
involuntary loss of faeces
• Commonly classified according to:
– character of leakage
– symptom
– presumed primary underlying cause
Diagnosis
• HISTORY
• EXAMINATION
• INVESTIGATION
History
• LISTEN to what is being said
• LISTEN to the problem
• LISTEN to the effect on their life
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
Examination of the anus
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Skin tags, fissures, fistulas
Descent
Gape
Strain
Length and angle
Muscle bulk
Voluntary contraction
The specific questions
• Defaecation
• Consistency
• Urgency
• Frequency
• Leakage
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
Normal Continence
Internal sphincter:
- Visceral innervation
- 85% continence
Primary Muscles
of continence
External sphincter:
- Somatic innervation
- 15% continence
Secondary Muscles
of continence
External Anal Sphincter
Fecal Incontinence
physiologic factors
stool consistency
rectal and anal sensation
rectal compliance
pelvic floor function
can lead to a defective continence mechanism
Fecal Incontinence
Altered stool consistency
Inflammatory bowel disease
Infectious diarrhea
Laxative abuse
Radiation enteritis
Short bowel syndrome
Malabsorption syndrome
Fecal Incontinence
Inadequate rectal compliance
Inflammatory bowel disease
Absent rectal reservoir (ileoanal, low ant.
resection)
Rectal neoplasms
Radiation Therapy
Collagen vascular disease (scleroderma,
amyloidosis, dermatomyositis)
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
Fecal Incontinence
Descending perineal syndrome
Constant straining during defecation
Traction neuropathy of the nerves
Denervation of puborectalis and EAS
The reflex responsiveness of the anal
region
Fecal incontinence associated with spinal cord
injury
Fecal Incontinence
Sphincter defect (Internal and/or External)
Traumatic
Obstetric injury
prolonged difficult labor (forceps
application)
episiotomy complications
Anorectal surgery
anal fistula surgery (most common)
hemorrhoidectomy
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,
NEJM 1993)
A.H.
Childbirth & Fecal Incontinence
259 consecutive women delivered single unit
31 elective CS no FI
Primaparous delivered vaginally 13% FI
Abromowitz Dis Colon Rectum
2000
• 549 prospective fecal urgency
vag 7.3% vsCS 3.1%
Chaliha 99 Obstet Gyn
How often do these problems occur?
Incontinence after birth
No
Caesareans
births
ection
Vaginal
delivery
Instrumental
delivery
Stress
11%
33%
41%
44%
Urge
4%
10%
19%
20%
Faecal
2%
4%
5%
11%
MacLennan and collegues, BJOG 2000
The Mechanism Of
Obstetric Injury
Obstetric Injury
Mechanisms
Rectovaginal septum
- rectocoele
Ischaemic injury
- fistula
Sphincter complex
- incontinence
Investigations
Function
Ano-rectal Manometry
Ano-rectal
Electrophysiology
Structure
Endoanal Ultrasound
Magnetic Resonance
Imaging
Defecography
Morphology
Anorectal manometry
Anorectal manometry
Measurement of both resting and
voluntary sphincter squeeze pressure
Incontinent patients – low resting and
voluntary squeeze pressure
Estimate threshold for rectal
sensation/compliance, recto-anal
inhibitory reflex
Anorectal manometry in fecal incontinence
Anal Endosonography
An ultrasound probe is placed in the
anal canal or transvaginally to detect
sphincter injuries and to evaluate
pelvic floor structures
Normal anatomy as viewed by anal endosonography
Normal anatomy as viewed by anal
endosonography
Faecal Incontinence
Structural Defect
Electrophysiologic tests
EMG – needle electrodes into the superficial portion
of the external sphincter or puborectalis muscle –
myoelectric activit
Pudendal nerve terminal motor latency – measures
the delay between the application of an electrical
stimulus and external sphincter muscle response.
Prolonged – pudendal neuropathy
SPHINCTEROPLASTY
PNTML & Neuropathy
Is PNTML reliable in predicting poor outcome ?
• difficult to quantify neuropathy
• cut-off value
• value of unilateral prolonged latency
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
Summary
• Listen to the story
• Ask the questions
• Examine the bottom
• Do the tests
• Fit the jigsaw together
• Consider the alternatives for treatment