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

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

Causes Multiple Disruption to Anorectal Anatomy Disruption to Anorectal Physiology

Urge incontinence

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

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)

Prevalence increase with: Increasing age Female sex Urinary incontinence Disability

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

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

Diagnosis 3 STOOL DIARY/ CHART

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

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

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

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

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

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

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

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

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

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

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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

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

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

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

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

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

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

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

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

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

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

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

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

                                             

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%

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

                                             

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%

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!)

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

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

Summary of Surgical Treatment Fix any significant anatomical defect SNS for neurological problems (urgency) Medical management first – successful in 80- 90% cases