IN THE NAME OF GOD

EVALUATION AND TREATMENT OF FECAL INCOTINENCY IN CHIDREN

Ahmad Khaleghnejad Tabari MDPediatric Surgery Research Center, Mofid Chidren’s HospitalShaheed Beheshti University of Medeical Sciences Tehran, Iran

Second annual meeting of Iranian Continence Society, June 2011

EtiologyThree major cause:1-Congenital Anomalies2-Mental Retardation3-Childhood Encopresis

Congenital Anomalies1- Myelomeningocele2- Tethered cord3- Lipomeningocele4- High anorectal atresia

(deficiencies of pelvic musculature and innervation )

5- Three to five sacral missing

Acquired causes1- Encopresis ( chronic

constipation )2- Trauma to the sacrum and

spinal cord3- Anal sphincter destruction by

systemic disease (Crohn’s disease, severe proctitis, extensive anorectal infection)

4- Inappropriate anorectal recostruction ( Imperforate anus, Hirschsprung’s disease, Ulcerative colitis )

5 – Neurologically handicapped children

Evaluation of children with fecal incontinence1- History2- Physical examination3- X-ray4- Ultrasound5- MRI6- Anorectal manometry7- Electrophysiologic study7- Defecography

History1- Normal bowel movement >

intermittent incontinency >pschycologic

2- Congenital anomalies3- Perirectal disease and

operation4- Neurologic impairment5- Trauma

Physical examination1- Abdominal palpation (mass, feces)2- Stroking of the perianal skin-the

external sphincter reflex-anal wink ( periphery sensory and motor nerves, reflex arc )

3- Rectal examination ( fecal mass, strength of the anal sphincter, puborectalis muscle palpation )

4- Lax anus, decrease perianal sensation, absence of the anal wink ( congenital or acquired neural deficiency )

Imaging studies1- Lombo-sacral spine film

( Vertebral anomalies, sacral vertebra missing )

2- Ultrasound (tethered cord, anal sphincters)

3- MRI ( tethered cord, levator and sphincteric complex, position of the anus )

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Hemisacrum with presacral mass.

Currarino’s triad:1. Anorectal anomaly2. Sacral bone

abnormality3. Presacral mass

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Absent lumbosacral vertebrae, a severe vertebral anomaly.

Normal anatomy as viewed by anal endosonography (a)

Lateral internal anal sphincteratomy within the 6 to 10 o’clock position as viewed by anal endosonography (b)

Obstetric traum of the I & E sphincters within the 9 to 1 o’clock position as viewed by anal endosonography (c)

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Tethered cord

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Axial T1-weighted image shows the ectopic anterior location of the anal canal (arrow), ventral of the superficial transverse perineal muscle (arrowheads), and outside the normally developed external anal sphincter (curved arrow)

Normal anatomy

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Unsuccessful repair

PR-sling incomplete

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Axial SE T1-weighted image in a boy, afterreconstructive surgery for a high anorectal malformation. Theneorectum (black arrow) is positioned outside and to the right ofa normally developed external anal sphincter (white arrow)

Functional studies1- Anorectal manometry ( anorectal

sphincter reflexes, sensation and coordination)

2- Three balloon probe3- Rectal sensation in 10 mL4- Rectal compliance5- internal anal sphincter relaxation

(rectoanal inhibitory reflex ) in 20 mLExternal sphincter contraction

(rectoanal contraction )

Fecal incontinence associated with spinal cord injury

The reflex responsiveness of the anal region 1- rectoanal inhibitory reflex 2-rectoanal cotraction

Functional studies1- Electrophysiologic assessment

(pudental nerve terminal motor latency)

2- Defecography ( rectoanal angle, completeness of emptying and descent of the pelvic floor one cm below the pubococcygeal line)

Fecal incontinence associated with pudendal neuropathy (a)

Fecal incontinence associated with pudendal neuropathy (b)

Fecal incontinence associated with pudendal neuropathy (c)

Fecal incontinence associated with pudendal neuropathy (d)

TREATMENTThree approaches to treatment of

incontinence :

1- Control of stool consistency

2- Conditioning or Biofeedback therapy

3- Operation to strengthen the sphincter muscles

TREATMENTBOWEL MANAGEMENT PROGRAMM

Treatment in neurologic deficiency:( myelominingocele, spinal malformations

and variant of high imperforate anus )1- Dietary and pharmacologic manipulation

to thicken the stool2- Regular emptying of the rectum each

morning with glycerin suppositories, saline enema or Bisacodyl suppositories within 30 minutes of a meal

3- Malone appendicocecostomy or sigmoidostomy tube for antegrade enema

TREATMENTBiofeedback

Biofeedback therapy play a role in patients with decreased sphincter function

1- A rectal balloon manometry device is placed into the rectum

2- The rectal and sphincter pressures are shown to the patient

3- The rectal balloon is inflated and the patient is encouraged to contract the external sphincter in response

4- The sensation of rectal distention and external sphincter contraction is learned which may enhance continence

TREATMENTEncopresisIn patients with encopresis associated with chronic

constipation, incontinence is relieved when constipation is alleviated

1- Initial evacuation of stool by aggressive enema program, disimpaction in operating room, rectal water soluble contrast administration under fluoroscopy guidance

2- Administration of stool softeners, mineral oil, polyethylene glycol

3- Biofeedback therapy in pshycogenic incontinence4- Malone appendicocecostomy or sigmoidostomy

tube for antegrade enema5- Resection of megasigmoid

Malone Appendicostomy

Megarectosigmoid in contrast enema

Resection of megarectosigmoid

TREATMENT OF INCONTINENCE AFTER ANORECTAL MAIFORMATION OPERATIONS

Incontinence after repair with normal sacrum and appropriately positioned and functioning sphincter muscle, dietary manipulation and regular evacuation of rectum ( saline enema , Malone )

The rectum positioned inappropiately outside the levator of external sphincter muscles on PE, MRI, endosono and electromyographic localization, remedial operative correction via PSA is indicated

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Axial SE T1-weighted image in a boy, afterreconstructive surgery for a high anorectal malformation. Theneorectum (black arrow) is positioned outside and to the right ofa normally developed external anal sphincter (white arrow)

TREATMENT OF INCONTINENCE AFTER ANORECTAL MAIFORMATION OPERATIONS

Surgical transplantation of one or two gracilis muscles arround the external sphincter, stimulation with special devices

prianal autologous fat injection may enhance continence

Artificial anal sphincter devices Stem cell implantation for muscle

formation

Thank you for your attention