1. MHS Collie Department of Colorectal Surgery Western General Hospital
FAECAL INCONTINENCE
MHS Collie
Department of Colorectal Surgery
Western General Hospital

3. Features Common Distressing Impact on self esteem
Socially restricting/ isolating
Quality of life impairing

4. Causes Multiple Disruption to Anorectal Anatomy
Disruption to Anorectal Physiology

5. Urge incontinence

7. Prevalence 1 2.2-18.4% Varies according to definition and severity
Underreporting very common
Eg Kumar et al: 30% multiparous women with some degree of faecal incontinence and sphincter damage
Edwards et al; 3% of 3000 people over age 65, with < 50% having reported their symptoms to anyone

8. Prevalence 2: Literature
2.2% overall in Uk (Nelson)
Women over 65 in own homes: 10-20% (Turnberg)
Men over 65 in own homes: 7-10% (Turnberg)
Residential Homes: 25% (Turnberg)
Nursing Homes: 40% (Turnberg)

9. Prevalence increase with:
Increasing age
Female sex
Urinary incontinence
Disability

10. Diagnosis 1: Details about the incontinence
?Passive, unaware
?Urge
Gas/Liquid/ Solids
Frequency
Use of Pads etc
Social restrictions

11. Diagnosis 2: bowel habit
?always incontinent
If not:
?constipated (evacuate how often)
?diarrhoea (what frequency)
?irregular alternating diarrhoea and constipation

12. Diagnosis 3
STOOL DIARY/ CHART

13. Degree: Cleveland Clinic Incontinence Score
Never
< x1/ month
>x1/month<x1/week
>x1/ week < daily
Daily
Gas 1 2 3 4
Liquid
Solids
Requiring Pads
Total

14. Diagnosis 4: Other relevant PM History
Diabetes
Colorectal operations
Pelvic Radiation
Neurological conditions
Spinal Injury
Obstetrics

16. Diagnosis 5: Obstetrics
Kelland’s forceps (70% sphincter damage with incontinence)
Tears
Episiotomies
?Problems immediately after birth

18. Drug History Analgesics, opiates Psychotropics Colpermin/buscopan
PPI/ Zantac
B blockers
Thyroid – hypo or hyper

19. Diagnosis 6: Examination
General examination for systemic/ neurologic disorders
Eg stroke, MS etc

20. Diagnosis 7: Perianal Examination
Look for:
Faecal matter
Prolapsed bowel/ haemorrhoids
Scars
Excoriation
Gaping anus

25. Diagnosis 7: Per Rectal Examination
Check for Anocutaneous Sensation and anocutaneous reflex
Feel inside for masses/ faecal impaction
Check sphincter tone ( at rest and when asked to squeeze)
?Rectocoele (post-defaecatory leak)
Demonstrate prolapse – squatting over a commode/ toilet

26. Investigations Bloods Review Medications Thyroid function aTG1alpha
Potassium
Magnesium
Phosphate
Review Medications

27. Investigations
Rule out proximal obstruction – CT colonoscopy/ flexible sigmoidoscopy or colonoscopy (Unlikely to be able to retain Barium for barium enema)
Endoanal ultrasound
Anorectal Physiology
Proctogram

29. Endoanal Ultrasound Can be done in OP clinic by colorectal surgeons
Shows surgically repairable deficits in sphincters

32. [Help with image viewing] [Email Jumpstart To Image]

35. Anorectal Physiology
Maonmetry – assesses resting tone and squeeze pressures of sphincters
Test reflex squeeze of EAS on coughing
Rectal sensation – thresholds for awareness, discomfort, urgency
Rectal compliance
Pudendal Nerve Terminal Motor Latency

37. Optimise/ treat Underlying conditions
Diabetes
Scleroderma
Central Neurological disorders
Rectal cancer
Inflammatory Bowel diseease
Diarrhoea – esp antibiotic associated

38. Management Education, defaecation management Diet and Exercise Support
Treat Specific Causes – medically/ surgically

40. Manage Bowel Habit Constipation with overflow diarrhoea Diarrhoea
Regular evacuations, with laxatives if necessary (Phosphate enemas/ Lactulose and Senna/ Movicol/ Picolax)
Constipate slightly – solid motion every 1-2 days is ideal
Fybogel if non-overflow diarrhoea
Rectal Irrigation

41. Support Cognitive training, nearby commodes, regular toileting
Diet modifications – less caffeine, beer, chocolate, spicy food, lentils etc.
Perineal hygiene, cleansing after soiling
Barrier creams
Use of Baby wipes, not dry toilet paper
Stool deodorants

42. Specific Therapy: Medical
Anti-diarrhoeals – codeine/ loperamide
NB careful to avoid constipation
May be v useful to allow shopping trips etc
Laxatives (as previous slide)
Amitriptyline for rectal urgency
Cholestyramine for bile salt malabsorption
?HRT

43. Specific Therapy: Biofeedback 1
Behavioural therapy – operant conditioning
Aim to selectively squeeze anal sphincter, not abdo or thigh muscles
Use a manometry probe in the anorectum, or EMG feedback

45. Specific Therapy: Biofeedback 2
All trials show benefit – in up to 70% of patients ???longterm benefit
Unable to predict who will benefit
Mechanism of action unclear
Relationship between patient and therapist very important
Should be offered to patients if surgery is inappropriate or fails

47. Specific Therapy: Surgery
Anal Sphincter repair
Anterior approach (perineally)
Overlapping repair
Appropriate if >90 ° deficit seen on EAUSS, significant loss of squeeze pressures
Usually there is a Hx of obstetric or surgical damage to the sphincter
Success rates about 85% early, deteriorates

49. Surgery 2 Postanal repair For weak but intact sphincter
Poor results over time – rarely performed now
Biofeedback better in these circumstances

50. Surgery 3 Rectocoele repair If rectocoele present and symptomatic
May be demonstrated at PR examination
Perineal repair, usually with levatorplasty
Results similar to anterior anal sphincter repair
Abdominal repair – mesh rectopexy open/ laparoscopic. NB combination treatment of uterine/ vaginal prolapse

53. Surgery 4: Rectal Prolapse
30-80% rectal prolapse patients are incontinent
Treatment for rectal prolapse
Delorme’s operation
Altmeier’s operation
Abdominal rectopexy
Resection rectopexy
Recurrence rates lowest with abdominal approaches
Treat the prolapse, may not help incontinence

55. Surgery 5 Sacral Nerve Stimulation
Pacemaker type insert with implanted wires stimulating S2 or S3 (£6000 every 4-6 yrs)
Works even if the sphincter is not intact
Low complication rate
Can be tried first with temporary external wires

58. Results
Good! Less deterioration: 85% to 70% at 10 year follow up. (Not much in lit)
Selection patients crucial (mobility)
Obstetric aetiology 85%
Spinal injury/ spina bifida/ MS/ dxt – 50%

59. Surgery 7 Sacral Nerve Stimulation
Pacemaker type insert with implanted wires stimulating S2 or S3 (£6000 every 4-6 yrs)
Good results so far, better longterm than other ops (85% obstetric, 50% spinal injury, MS, DXT etc
Works even if the sphincter is not intact
Low complication rate
Can be tried first with temporary external wires

62. Surgery 6 Gracilis Neosphincter
Uses gracilis muscle wrapped around the residual sphincter
Electrically stimulated with pacemaker type box, buried in buttock
Needs a new battery every 4-6 years (£6000)
Infection risk, problems with leg wounds
Success rate averages 70%

66. Surgery 7 Artificial bowel sphincter
Implanted device which can be blown up like a balloon around the sphincter
High infection rate, and other complications
Only used in selected centres (not Edinburgh!)

68. Surgery 8 Stomas Ileostomy or colostomy General anaesthetic
Need to seal off the distal bowel, even if bring out a loop
Will still get mucus PR
Stoma complications – necrosis, stenosis, prolapse, herniae

71. Surgery 9 “Butt plugs” Bulking of Sphincters – inject with silicon
Malone Antegrade enemas, using a wash through via a Caecostomy
Tiersch wires/ anal encirclement
Poor results

74. Summary of Surgical Treatment
Fix any significant anatomical defect
SNS for neurological problems (urgency)
Medical management first – successful in % cases