1. The program will start promptly at 10:00 AM For technical assistance please contact Tech Support at 404-969-0387 or email at support@healthtecdl.org

2. Assessment of Fecal Incontinence and Constipation in the Female Patient Mahmoud Barrie, MD Assistant Professor Department of Gastroenterology/Hepatology Atlanta VAMC/EUH Atlanta, GA December 9, 2008 For technical assistance please contact Tech Support at 404-969-0387 or email at support@healthtecdl.org

3. Outline Anatomy- Anorectum Mechanism of continence Fecal incontinence –Epidemiology, etiology, clinical presentation –Diagnostic studies –Assessment Algorithm Mechanism of defecation Constipation –Epidemiology, etiology, clinical presentation –Diagnostic studies –Assessment Algorithm Summary If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

4. Objectives Anatomy- Anorectum Mechanism of continence Fecal incontinence –Epidemiology, etiology, clinical presentation –Pertinent radiographic and non-radiographic testing Mechanism of defecation Constipation –Epidemiology, etiology, clinical presentation –Pertinent radiographic and non-radiographic testing Summary If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

5. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

6. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

7. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

8. Epithelial nerve endings of the rectum and anus If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

9. Anorectal function Continence Defecation If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

10. Continence mechanisms Anorectal angle Rectal accomodation/compliance Rectal sensation Anal sensory nerves Internal anal sphincter External anal sphincter If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

11. Continence Mechanisms: Anorectal Angle If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

12. Continence Mechanisms: Rectal Accommodation If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

13. Continence Mechanisms: Compliance Ratio of pressure to volume at different volumes of distention Decreased compliance with –Inflammation –Fibrosis –Surgical replacement with sigmoid colon If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

14. Continence Mechanisms: Rectal Compliance If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

17. Continence Mechanisms: IAS & EAS

18. Fecal Incontinence Continuous or recurrent passage of fecal material (>10ml) for at least one month in a person older than 3/4 years of age If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

19. Epidemiology A US study of outpatients found an overall prevalence of 18·4% Incontinence occurred daily in 2·7% of patients, weekly in 4·5%, and monthly or less in 7·1% Symptomatic fecal incontinence occurs in 21% of women presenting with urinary incontinence, pelvic-organ prolapse, or both If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

20. Causes of Fecal Incontinence If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

21. A greater proportion of cases of faecal incontinence are acquired Sphincter disruption resulting from vaginal delivery= most common sphincter injury Sphincter atrophy due to advanced age If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

22. Vaginal delivery injury risks Forceps delivery Primiparous: giving birth to a baby weighing over 4 kg- Traction injury to the pudendal nerve third-degree obstetric lacerations Incidence of both flatus and stool : –6-25% in new postpartum –3-27% in known sphincter tears If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

23. Assessment Essential elements of the history: –Onset –Type of incontinence (flatus, liquid, or solid stool) –Frequency of episodes Pertinent findings in the physical exam include: –A thinned or deformed perianal body and scars from previous surgery or trauma. –Breakdown of the perianal skin is a consequence, not a cause of incontinence –Gaping of the anus suggests rectal prolapse, which can usually be demonstrated with Valsalva’s manoeuvre. –Diminished perianal sensation and the absence of an anal wink suggest a neurogenic cause –Digital exam- weak sphincter squeeze If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

24. Diagnostic Studies Function –Anorectal manometry –EMG: Action potentials of sphincter muscle –PNTL –Defecography: anorectal angle, perineal descent Anatomy –Flexible sigmodoscopy/proctosocpy –Defecography: rectoceles –Anal sonography: Sphincter defect –Barium enema –MRI If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

25. Function: Anorectal manometry in fecal incontinence If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

26. Function: EMG Electromyography — Electromyography of the external anal sphincter and pelvic floor muscles is performed for three purposes: To identify areas of sphincter injury by mapping the sphincter. To determine whether the muscle contracts or relaxes (by the number of motor units firing). To identify denervation-reinnervation potentials indicative of nerve injury. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

27. Function: EAS EMG If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

28. Function: EAS EMG Nerve sprouting Variations of intervals b/w motor unit potentials If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

29. Function: Pudendal n. Latency If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

30. Child Birth Neurologic evidence –PNTL prolongation  42% of postpartum women (Snooks et al )  cesarean delivery performed in late labor (cervical dilation 8 cm or greater) –EMG of the anal sphincter: increased fiber density in multiparous women (Allen RE et al.) If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

31. Anatomy: Defecography Evacuation proctography: process, rate and completeness Assessing ano-rectal angle Structural and functional alterations: rectocele, internal rectal intussusception, external rectal prolapse, enterocele and pelvic floor dysfunction, or dyssynergia. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

32. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

33. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

34. Anatomy: Rectal Ultrasound If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

35. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

36. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

37. Anatomy: Endoanal Coil MRI Sphincter atrophy –89% sensitivity –94% specificity –89% positive predictive value –94% negative predictive value Defect(atrophy) in levator ani m. May not be as good in detecting sphincter tear. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

38. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

39. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

40. Anatomic evidence Endoanal MRI: –20% of primiparous women: defect in the levator ani muscle (Delancey et al ) Endoanal ultrasound for sphincter disruption (Abramowitz L et al) –35% of primiparous – 44% of multiparous If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

41. Summary of diagnostic studies Anorectal manometry: Good EMG/PNTML : –good but limited to specialized centers Defecography : –Not as good Anal endosonography –good Endoanal Coil MRI : –New and promising If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

43. Constipation Straining ≥1/4 of defecation; Lumpy or hard stools ≥1/4 of defecation; Sensation of incomplete defecation ≥1/4 of defecation; Sensation of anorectal obstruction/blockage≥1/4 of defecation; Manual maneuvers to facilitate ≥1/4 of defecation (example: digital evacuation, support of the pelvic floor); Less than three defecations per week. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

44. Defecation

45. Epidemiology Prevalence 2-34% F:M 3 to 5x Increase >65yo If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

46. Types of constipation Normal transit and normal pelvic floor function Slow transit (colonic inertia) Dyssynergic or obstructive defecation or anismus Structural abnormalities: Enteroceles and Rectoceles If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

47. Assessment of Constipation H&P –digital dysimpaction, pelvic and/back pain, bleeding, urinary incontinence, renal insufficiency Colonic scintigraphy Anorectal manometry/Balloon expulsion Surface EMG Evacuation proctography If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

48. Colonic transit If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

49. Balloon Expulsion If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

50. Rectal pressure & EMG in PFD If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

51. Defecography Evacuation proctography involves imaging of the rectum with contrast material and observation of the process, rate, and completeness of rectal evacuation using fluoroscopic techniques. Structural and functional alterations can also be observed and include rectocele, internal rectal intussusception, external rectal prolapse, enterocele and pelvic floor dysfunction, or dyssynergia. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

52. History and exam History –Digital pressure in the vagina Exam –Bulging of the posterior vaginal wall may be an enterocele or a rectocele. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

53. Symptoms/Signs Intractable vaginal mucosal ulcerations Urinary retention (renal failure) A pulling sensation or lower back pain –Worse w/prolong standing –Improves w/laying down If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

54. Rectocele If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

55. Enterocele If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

57. Summary Fecal incontinence –H&P very important –Anal endosonography –Anorectal manometry –EMG –Defecography? (controversal) –Colonic transit (-) –Dynamic MRI w/endoanal coil Constipation –H&P very important –Colonic transit study –Anorectal manometry –Defecography: r/o PFD/enteroceles/rectoceles –EMG(+/-) to r/o PFD Enteroceles/Rectoceles –Beware of surgical treatment except for recurrent vaginal mucosal ulceration or ovarian tension If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

58. Q & A Session

59. Evaluation Please complete the survey that will be provided to you in you in the web browser. Click on the link below: http://www.surveymonkey.com/s.aspx?sm=NwTDvrfbdt4z5T8hw 5FCIA_3d_3d If you are unable to view the survey there will be a separate email sent to all who registered for the event providing the survey.

60. References 1Mellgren A, Jensen LL, Zetterstrom JP, Wong WD, Hofmeister JH, Lowry AC. Long-term cost of fecal incontinence secondary to obstetric injuries. Dis Colon Rectum 1999; 42: 857–65. 2 Johanson JF, Lafferty J. Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 1996; 91: 33–36. 3 Nelson R, Furner S, Jesudason V. Fecal incontinence in Wisconsin nursing homes: prevalence and associations. Dis Colon Rectum 1998; 41: 1226–29. 4 Thomas TM, Egan M, Walgrove A, Meade TW. The prevalence of faecal and double incontinence. Community Med 1984; 6: 216–20. 5 Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA 1995; 274: 559–61. 6 Drossman DA, Li Z, Andruzzi E, et al. US householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci 1993; 38: 1569–80. 7 Faltin DL, Sangalli MR, Curtin F, Morabia A, Weil A. Prevalence of anal incontinence and other anorectal symptoms in women. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 117–20. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

61. 8 Porell F, Caro FG, Silva A, Monane M. A longitudinal analysis of nursing home outcomes. Health Serv Res 1998; 33: 835–65. 9 Chassagne P, Landrin I, Neveu C, et al. Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis. Am J Med 1999; 106: 185–90. 10 Borrie MJ, Davidson HA. Incontinence in institutions: costs and contributing factors. CMAJ 1992; 147: 322–28. 11 Nakanishi N, Tatara K, Shinsho F, et al. Mortality in relation to urinary and faecal incontinence in elderly people living at home. Age Ageing 1999; 28: 301–06. 12 Rizk DE, Hassan MY, Shaheen H, Cherian JV, Micallef R, Dunn E. The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females. Dis Colon Rectum 2001; 44: 1850–56. 13 Jorge JM. Anorectal anatomy and physiology. In: Wexner SD, ed. Fundamentals of anorectal surgery, 2nd edn. Philadelphia: W B Saunders, 1998: 1–24. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org

62. 14. Abramowitz L, Sobhani I, Ganansia R, et al.Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum.2000;43:590–596; discussion 596–598. 15. Allen RE, Hosker GL, Smith AR, et al. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol. 1990;97:770–779. 16. Delancey JOL, Kearney R, Chou Q, et al. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol. 2003;101: 46–53. If you have any technical issues, please contact 404-969-0387 or email support@healthtecdl.orgsupport@healthtecdl.org