Evaluating the patient with faecal incontinence M62 Course 2004 Mr E S Kiff

Diagnosis HISTORY EXAMINATION INVESTIGATION

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

The specific questions Urgency Consistency Frequency Defaecation Prolapse Wiping Leakage

Urgency Diarrhoea Weak voluntary muscle Quantify – how long have you got - incontinent en route?

Consistency Solid, formed Soft, loose Watery Variable Explosive

Frequency Diarrhoea – think upstream Formed – think irritability, sensory

Can you go? Connective tissue weakness – prolapse Long term strainer End stage neuropathy

Prolapse Grape - mucosal, think eversion of anus Tomato – full thickness rectal Vaginal – rectum,bladder,uterus,small bowel

Difficulty wiping clean Prolapse Low anal tone Slow to regain tone

Leakage during the day Low resting tone Prolapse

Causes of incontinence Brain Body Bowel Bottom

Brain and cord CVA – IAS weakness? Emotion, anxiety Cord injury MS Peripheral neuropathy Think bladder, think legs

Body Mobility Elderly Exposure of minor weakness

Bowel Inflammatory bowel disease Neoplasia Coeliac Drugs OVERFLOW

Bottom Connective tissue Muscle – neuropathy, tear or BOTH Combination Congenital

Examination Abdomen Perineum Anal canal and pelvic floor Sigmoidoscopy

Examination of the anus Position Gape Strain Length and angle Muscle bulk Connective tissue Voluntary contraction

Investigations The colon Anorectal physiology Endoanal ultrasound Defecating proctography MR scan

Anorectal physiology Anal manometry Vector-volume analysis Rectal perception of distension Proctometrogram Recto-anal reflex PNTML EMG Other tests

Endo-anal ultrasound Beware over reporting Tears found later in life = neuropathy Tears are not all or nothing

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

References Investigation of faecal incontinence. Buchanan et al. Hosp.Med.2001;62: AGA position on anorectal testing. Gastroenterology.1999;116: The clinical use of anorectal physiology studies. Ann R Coll Surg Eng. 1983; Suppl 1: 27-29