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

2. Diagnosis HISTORY EXAMINATION INVESTIGATION

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

4. The specific questions Urgency Consistency Frequency Defaecation Prolapse Wiping Leakage

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

6. Consistency Solid, formed Soft, loose Watery Variable Explosive

7. Frequency Diarrhoea – think upstream Formed – think irritability, sensory

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

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

10. Difficulty wiping clean Prolapse Low anal tone Slow to regain tone

11. Leakage during the day Low resting tone Prolapse

12. Causes of incontinence Brain Body Bowel Bottom

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

14. Body Mobility Elderly Exposure of minor weakness

15. Bowel Inflammatory bowel disease Neoplasia Coeliac Drugs OVERFLOW

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

17. Examination Abdomen Perineum Anal canal and pelvic floor Sigmoidoscopy

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

19. Investigations The colon Anorectal physiology Endoanal ultrasound Defecating proctography MR scan

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

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

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

23. References Investigation of faecal incontinence. Buchanan et al. Hosp.Med.2001;62:533- 537 AGA position on anorectal testing. Gastroenterology.1999;116:732-760 The clinical use of anorectal physiology studies. Ann R Coll Surg Eng. 1983; Suppl 1: 27-29