faecal incontinencecauses, diagnosis, & contemporary treatment
TRANSCRIPT
Faecal IncontinenceFaecal IncontinenceCauses, Diagnosis, & Causes, Diagnosis, &
Contemporary TreatmentContemporary TreatmentMr Darren TONKINMr Darren TONKIN
Colorectal SurgeonColorectal Surgeon
Adelaide SAAdelaide SA
Faecal IncontinenceFaecal Incontinence
““Recurrent uncontrolled passage of Recurrent uncontrolled passage of
faecal material in an individual with a faecal material in an individual with a
developmental age of at least 4 developmental age of at least 4
years”years”
Whitehead et al. Functional disorders of the anus and rectum.Whitehead et al. Functional disorders of the anus and rectum.
Gut 1999; 45 (Suppl II): II55–9Gut 1999; 45 (Suppl II): II55–9
NormalNormal Continence Continence
Defaecation is complexDefaecation is complex Interaction of anal function & sensationInteraction of anal function & sensation
Rectal complianceRectal compliance Sphincter functionSphincter function Anorectal sensationAnorectal sensation Stool consistencyStool consistency Stool volumeStool volume Colonic transitColonic transit Mental alertnessMental alertness
IncontinenceIncontinence - Types - Types
SensorySensory Patient not aware of itPatient not aware of it Neuropathic, rectal prolapseNeuropathic, rectal prolapse
MotorMotor Patient aware, but cannot preventPatient aware, but cannot prevent
UrgencyUrgency Radiation, IBDRadiation, IBD Poor reservoirPoor reservoir
SoilingSoiling Anal scarring, IPAA, impactionAnal scarring, IPAA, impaction
FunctionalFunctional
Impaired Rectal ReservoirImpaired Rectal Reservoir Ulcerative colitis / Crohn’s diseaseUlcerative colitis / Crohn’s disease RadiationRadiation
Reduced Rectal ReservoirReduced Rectal Reservoir Low colorectal anastomosis Low colorectal anastomosis or cor coloanal oloanal
anastomosisanastomosis DiarrhoeaDiarrhoea OverflowOverflow
SphincterSphincter DefectDefect
Congenital Congenital Imperforate anusImperforate anus
TraumaTrauma ObstetricObstetric FistulotomyFistulotomy HaemorrhoidectomyHaemorrhoidectomy SphincterotomySphincterotomy Anal stretchAnal stretch
DiseaseDisease Fistula in anoFistula in ano TumourTumour Rectal prolapseRectal prolapse
TraumaTrauma!!
ObstetricObstetric InjuryInjury
Sphincter injury on EUSSphincter injury on EUS 35% primips35% primips 44% multips44% multips Up to 80% after forcepsUp to 80% after forceps
Pudendal neuropathyPudendal neuropathy
May be asymptomaticMay be asymptomatic
Worsens with timeWorsens with time
ANZJS, 1999; 69: 172-7ANZJS, 1999; 69: 172-7
NeurologicalNeurological Pudendal neuropathyPudendal neuropathy DiabetesDiabetes DegenerativeDegenerative Spinal cord injurySpinal cord injury
IdiopathicIdiopathic
Assessment - HistoryAssessment - History
Details of incontinenceDetails of incontinence FrequencyFrequency Nature - Solid, Liquid & GasNature - Solid, Liquid & Gas Distinguish between Passive, Urgency and Post Distinguish between Passive, Urgency and Post
Defaecatory SoilingDefaecatory Soiling Social impactSocial impact
Associated symptoms – blood, mucus etcAssociated symptoms – blood, mucus etc Previous anorectal traumaPrevious anorectal trauma Previous surgeryPrevious surgery Obstetric history (NObstetric history (Noo VD’s, weight, prolonged 2 VD’s, weight, prolonged 2ndnd
stage, episiotomy, tear, forceps)stage, episiotomy, tear, forceps) Comorbidities (eg DM)Comorbidities (eg DM) Comprehensive drug history (incl OTC, caffeine)Comprehensive drug history (incl OTC, caffeine) Continence ScoresContinence Scores
Cleveland Clinic Scoring Cleveland Clinic Scoring SystemSystem
NEVERNEVER RARELYRARELY SOMETIMESSOMETIMES USUALLYUSUALLY ALWAYSALWAYS
SOLIDSSOLIDS 00 11 22 33 44
LIQUIDSLIQUIDS 00 11 22 33 44
FLATUSFLATUS 00 11 22 33 44
USE OF PADUSE OF PAD 00 11 22 33 44
LIFESTYLE LIFESTYLE ALTERATIONALTERATION 00 11 22 33 44
ExaminationExamination
Underwear, padsUnderwear, pads General physicalGeneral physical Perineal deformity, scarsPerineal deformity, scars Perineal descentPerineal descent ProlapseProlapse Digital rectal examDigital rectal exam Resting + squeeze pressureResting + squeeze pressure RV septumRV septum
Perineal sensationPerineal sensation
InvestigationsInvestigations
ColonoscopyColonoscopy
ManometryManometry
EUSEUS
PNTMLPNTML
MRIMRI
Endoanal USEndoanal US
NormalNormal Anterior defect IAS & EASAnterior defect IAS & EAS
MRIMRI
• Multi-planarMulti-planar capabilitycapability
• Higher inherent contrast resolutionHigher inherent contrast resolution than EUS than EUS
• Not operator dependentNot operator dependent
• More expensiveMore expensive
• IAS hyperintense, EAS hypointense IAS hyperintense, EAS hypointense
• Good for EAS atrophyGood for EAS atrophy
MRIMRI
NormalNormal Anterior defect IAS & EASAnterior defect IAS & EAS
ManometryManometry
• SphincterSphincter• Resting pressure (>40mmHg)Resting pressure (>40mmHg)• Squeeze pressure (>100 mmHg)Squeeze pressure (>100 mmHg)• Functional anal canal length (M 4-5cm, F 3-4cm)Functional anal canal length (M 4-5cm, F 3-4cm)• Sphincter asymmetrySphincter asymmetry
• Rectal balloonRectal balloon• SensationSensation• ComplianceCompliance• CapacityCapacity• RAIRRAIR
Conservative Conservative ManagementManagement
• Alter stool consistency (bulking agents, loperamide)Alter stool consistency (bulking agents, loperamide)
• Treatment of cause (IBD, IBS)Treatment of cause (IBD, IBS)
• Sphincter exercisesSphincter exercises
• Biofeedback (70% improvement in symptoms & QoL)Biofeedback (70% improvement in symptoms & QoL)
• Enema programmeEnema programme
• Topical phenylephrineTopical phenylephrine
Stop strainingStop straining
Stronger squeezeStronger squeeze
Longer durationLonger duration
Am J Gastro 2000; 95(8): 1873-80Am J Gastro 2000; 95(8): 1873-80
BiofeedbackBiofeedback
Topical PhenylephrineTopical Phenylephrine
• Selective Selective -1 agonist-1 agonist
• Increase resting sphincter toneIncrease resting sphincter tone
• Apply tApply to internal & external anal areao internal & external anal area
• 20% gel twice daily20% gel twice daily
• Improved continence & QoLImproved continence & QoL
Colorectal Disease 2003; 5(Supp 1): 11Colorectal Disease 2003; 5(Supp 1): 11
Surgery OptionsSurgery Options
Sphincter repair Sphincter repair Injectable agentsInjectable agents Sacral nerve stimulationSacral nerve stimulation Dynamic graciloplastyDynamic graciloplasty Artificial sphincterArtificial sphincter StomaStoma ACEACE
Anterior Sphincter Anterior Sphincter RepairRepair
EAS defectEAS defect Overlapping vs direct Overlapping vs direct
appositionapposition 80% improved80% improved Function deteriorates Function deteriorates
with timewith time
Hull et al. DCR 2002; 45: 345-8Hull et al. DCR 2002; 45: 345-8
Injectable AgentsInjectable Agents
IAS pathologyIAS pathology Silicone biomaterial (eg PTQ)Silicone biomaterial (eg PTQ) Submucosal vs intersphinctericSubmucosal vs intersphincteric Approx 50 to 70% gain >50% Approx 50 to 70% gain >50%
improvementimprovement Better results if US usedBetter results if US used
Tjandra et al. DCR 2004.
Injectable AgentsInjectable Agents
Sacral Nerve StimulationSacral Nerve Stimulation
Originally described for urological useOriginally described for urological use Weak but intact sphincterWeak but intact sphincter Mechanism poorly understoodMechanism poorly understood 2 stage 2 stage
PNE – trial electrode 2/52, diaryPNE – trial electrode 2/52, diary Permanent implantPermanent implant
Good results – up to 90% report Good results – up to 90% report improvementimprovement
SNSSNS
Dynamic GraciloplastyDynamic Graciloplasty
First described 1988First described 1988
Severe sphincter injury, congenital Severe sphincter injury, congenital malformationsmalformations
Convert fast-twitch muscle to slow Convert fast-twitch muscle to slow twitchtwitch
Variable results (35 to 85% Variable results (35 to 85% continence)continence)
Congenital malformations do Congenital malformations do worseworse
Complications in 50% (30% Complications in 50% (30% infection)infection)
Dynamic GraciloplastyDynamic Graciloplasty
Artificial Bowel Artificial Bowel SphincterSphincter
Adapted from urological Adapted from urological use in 1987use in 1987
Good results with Good results with successful implantsuccessful implant
High complications ratesHigh complications rates Infection (up to 50%)Infection (up to 50%) ErosionErosion PainPain Obstructed defaecationObstructed defaecation
Revision (up to 70%)Revision (up to 70%) Explantation (30%)Explantation (30%)
Artificial Bowel Artificial Bowel SphincterSphincter
Not recommended for Not recommended for routine useroutine use
Only in cases of Only in cases of severe sphincter severe sphincter injury, malformation or injury, malformation or loss.loss.
StomaStoma
Not without complicationsNot without complications Parastomal herniaParastomal hernia Mucus leakageMucus leakage Diversion colitisDiversion colitis
Faecal IncontinenceFaecal Incontinence
Non-operative treatmentNon-operative treatment
SuccessSuccess FailureFailure
InvestigateInvestigate
ESDESD
Direct repairDirect repair
NeurogenicNeurogenicISDISD
InjectableInjectableInjectableInjectableSacral nerveSacral nerveGracilis / ArtificialGracilis / ArtificialStomaStoma
ConclusionConclusion
Faecal incontinence infrequently Faecal incontinence infrequently requires surgeryrequires surgery
Injectable bulking agents and sacral Injectable bulking agents and sacral nerve stimulation are likely to be the nerve stimulation are likely to be the most applicable treatments in the most applicable treatments in the future.future.
Stoma formation is an effective Stoma formation is an effective option, but can be avoided in the option, but can be avoided in the majority.majority.