Conservative treatment of Conservative treatment of faecal incontinencefaecal incontinence

Jim HillJim Hill

Manchester Royal InfirmaryManchester Royal Infirmary

Why should we be interested?Why should we be interested?

Common problemCommon problem

Requires understanding ARPRequires understanding ARP

Results of surgery frequently imperfectResults of surgery frequently imperfect

Post operative – anterior resection, ileo Post operative – anterior resection, ileo anal pouch anal pouch

Can be iatrogenicCan be iatrogenic

Impacts on Quality of lifeImpacts on Quality of life

OptionsOptions

Drug treatmentDrug treatment

BiofeedbackBiofeedback

Rectal irrigationRectal irrigation

Anal plugsAnal plugs

Internal sphincter bulking agentsInternal sphincter bulking agents

Drug treatmentDrug treatment

Little evidence to guide clinicians in the Little evidence to guide clinicians in the selection of drug therapiesselection of drug therapies

Focus of most of the trials has been on the Focus of most of the trials has been on the treatment of diarrhoeatreatment of diarrhoea

Anti-diarrhoeal drug versus placebo Anti-diarrhoeal drug versus placebo or no active treatment – four or no active treatment – four

randomised trialsrandomised trialsFewer bowel actions (4)Fewer bowel actions (4)More full continence (3)More full continence (3)Lower stool weights (2), incontinence Lower stool weights (2), incontinence scores (1) scores (1) Fewer episodes faecal incontinence (1), Fewer episodes faecal incontinence (1), faecal urgency (1), unformed stools (1), faecal urgency (1), unformed stools (1), pads (1)pads (1)Longer gut transit times (1)Longer gut transit times (1)Increase side effects (2)Increase side effects (2)

LoperamideLoperamide

ReducesReduces– stool weightstool weight– small bowel motilitysmall bowel motility– sensitivity of the rectoanal inhibitory reflexsensitivity of the rectoanal inhibitory reflex

Slight increase in resting anal pressureSlight increase in resting anal pressureInitially small doses (2-4mg) titrated Initially small doses (2-4mg) titrated Combination with codeine phosphateCombination with codeine phosphateCo-phenotrope (diphenoxylate with Co-phenotrope (diphenoxylate with atropine) high incidence of side effectsatropine) high incidence of side effects

Drugs enhancing anal sphincter Drugs enhancing anal sphincter tone versus placebo – four tone versus placebo – four

randomised trialsrandomised trials

Passive incontinence Passive incontinence

Phenylepinephrine improved maximum Phenylepinephrine improved maximum anal resting tone and continence anal resting tone and continence symptomssymptoms

30-40% > 10-20%30-40% > 10-20%

Localised dermatitis, stinging/burningLocalised dermatitis, stinging/burning

Criticisms of drug trialsCriticisms of drug trials

Long term benefits not assessedLong term benefits not assessed

Not analysed on an intention to treat basisNot analysed on an intention to treat basis

Blind outcome assessors to treatmentBlind outcome assessors to treatment

Relevant primary outcome measures (no. cured Relevant primary outcome measures (no. cured or improved)or improved)

If cross over data at end of first arm treatment, If cross over data at end of first arm treatment, within individual comparison of treatment and within individual comparison of treatment and include adequate washout periodinclude adequate washout period

Follow CONSORT guidelinesFollow CONSORT guidelines

Biofeedback - principlesBiofeedback - principles

Improve contraction of Improve contraction of the striated muscles of the striated muscles of the pelvic floor (strength the pelvic floor (strength training)training)

Enhance the ability to Enhance the ability to perceive and respond to perceive and respond to rectal distension (sensory rectal distension (sensory training) training)

To combine sensory and To combine sensory and strength training strength training (coordination training)(coordination training)

Randomised controlled trial of Randomised controlled trial of biofeedback in faecal incontinence – biofeedback in faecal incontinence –

Norton et al Gastroenterology Nov ‘03Norton et al Gastroenterology Nov ‘03

1)1) Advice – diet, fluids, techniques to Advice – diet, fluids, techniques to improve evacuation, bowel training improve evacuation, bowel training programme, anti-diarrhoeal medicationprogramme, anti-diarrhoeal medication

2)2) Anal sphincter exercises taughtAnal sphincter exercises taught

3)3) Computerised biofeedback – sensory Computerised biofeedback – sensory and strength trainingand strength training

4)4) Home biofeedback deviceHome biofeedback device

Outcome measuresOutcome measures

Patients own view of effectivenessPatients own view of effectiveness

Change in bowel symptomsChange in bowel symptoms

Change in continence scoreChange in continence score

QOL assessmentQOL assessment

ARPSARPS

ResultsResults

All groups significant improvement in All groups significant improvement in outcome measures (67% improved outcome measures (67% improved overall)overall)

No significant difference between four No significant difference between four groupsgroups

Only age and BMI predictors of outcomeOnly age and BMI predictors of outcome

Sphincter pressures improved in all groupsSphincter pressures improved in all groups

Continence scores median 15 to 13Continence scores median 15 to 13

Conclusions from Norton paperConclusions from Norton paper

Majority of patients with symptoms of faecal Majority of patients with symptoms of faecal incontinence may be subjectively improved by incontinence may be subjectively improved by nurse-led managementnurse-led management

Anal sphincter exercises, computer assisted Anal sphincter exercises, computer assisted biofeedback and home biofeedback did not biofeedback and home biofeedback did not enhance treatmentenhance treatment

Patients with sphincter disruption not excludedPatients with sphincter disruption not excluded

Patients should be offered the choice of Patients should be offered the choice of conservative managementconservative management

Colonic irrigationColonic irrigation

Colonic irrigation-Kessel et al Colonic irrigation-Kessel et al Dis Colon Rectum 1997Dis Colon Rectum 1997

Faecal soiling and faecal incontinence Faecal soiling and faecal incontinence 500mls – 1 litre normal saline 5-10 mins 500mls – 1 litre normal saline 5-10 mins after first stoolafter first stool10-90 mins for washouts10-90 mins for washouts32 patients, 22 still performing washouts at 32 patients, 22 still performing washouts at 18 months18 monthsResults soiling (79%) > faecal Results soiling (79%) > faecal incontinence (38%)incontinence (38%)

Colonic irrigation physiologyColonic irrigation physiology

Irrigation fluid reaches on average just Irrigation fluid reaches on average just beyond the right colic flexurebeyond the right colic flexure

Antegrade segmental transport induced in Antegrade segmental transport induced in all colonic segmentsall colonic segments

Almost complete emptying of the Almost complete emptying of the rectosigmoid and descending colonrectosigmoid and descending colon

Conveen plugsConveen plugs

Anal continence plug – Mortenson Anal continence plug – Mortenson & Humpreys Lancet 1991& Humpreys Lancet 1991

10 patients – 10 patients – incontinent liquid/solidincontinent liquid/solid

1 withdrew1 withdrew

Worn 12 hoursWorn 12 hours

No incontinence in No incontinence in 82% during time plug 82% during time plug in placein place

11 plugs/week11 plugs/week

Internal sphincter bulking agentsInternal sphincter bulking agents

No randomised No randomised trials/no control trials/no control groupsgroups

Submucosal or Submucosal or intersphincteric planeintersphincteric plane

Symptomatic Symptomatic improvementimprovement

Variable effect on Variable effect on ARPSARPS

Bulking agentsBulking agents

Essential supportEssential support

ConclusionsConclusions

Almost never harmfulAlmost never harmful

Almost all patients appreciate the effort Almost all patients appreciate the effort

Specialist nurse support essentialSpecialist nurse support essential

Worthwhile maximising medical therapy Worthwhile maximising medical therapy prior to any surgeryprior to any surgery

IndicationsIndications

Post surgery Post surgery – Sphincter repairSphincter repair– SphincterotomySphincterotomy– Anterior resection and pouch surgeryAnterior resection and pouch surgery

Idiopathic faecal incontinenceIdiopathic faecal incontinence

Biofeedback trialsBiofeedback trials

Reported success rates 60-90%Reported success rates 60-90%

Absence of well designed randomised Absence of well designed randomised controlled trialscontrolled trials

Do not allow a reliable assessment which Do not allow a reliable assessment which elements of biofeedback therapy have a elements of biofeedback therapy have a therapeutic effecttherapeutic effect

Biofeedback Biofeedback

Norton and Kamm; Gastroenterology 2003Norton and Kamm; Gastroenterology 2003171 patients171 patientsBiofeedback vs standard careBiofeedback vs standard careDiary, symptom questionnaire, continence Diary, symptom questionnaire, continence score, QOL, psychological status, anal score, QOL, psychological status, anal manometrymanometryImproved 53% biofeedback, 54 % Improved 53% biofeedback, 54 % standard carestandard careResults largely maintained at 1 year Results largely maintained at 1 year