Conservative treatment of faecal incontinence Jim Hill Manchester Royal Infirmary

Why should we be interested? Common problem Requires understanding ARP Results of surgery frequently imperfect Post operative – anterior resection, ileo anal pouch Can be iatrogenic Impacts on Quality of life

Options Drug treatment Biofeedback Rectal irrigation Anal plugs Internal sphincter bulking agents

Drug treatment Little evidence to guide clinicians in the selection of drug therapies Focus of most of the trials has been on the treatment of diarrhoea

Anti-diarrhoeal drug versus placebo or no active treatment – four randomised trials Fewer bowel actions (4) More full continence (3) Lower stool weights (2), incontinence scores (1) Fewer episodes faecal incontinence (1), faecal urgency (1), unformed stools (1), pads (1) Longer gut transit times (1) Increase side effects (2)

Loperamide Reduces –stool weight –small bowel motility –sensitivity of the rectoanal inhibitory reflex Slight increase in resting anal pressure Initially small doses (2-4mg) titrated Combination with codeine phosphate Co-phenotrope (diphenoxylate with atropine) high incidence of side effects

Drugs enhancing anal sphincter tone versus placebo – four randomised trials Passive incontinence Phenylepinephrine improved maximum anal resting tone and continence symptoms 30-40% > 10-20% Localised dermatitis, stinging/burning

Criticisms of drug trials Long term benefits not assessed Not analysed on an intention to treat basis Blind outcome assessors to treatment Relevant primary outcome measures (no. cured or improved) If cross over data at end of first arm treatment, within individual comparison of treatment and include adequate washout period Follow CONSORT guidelines

Biofeedback - principles Improve contraction of the striated muscles of the pelvic floor (strength training) Enhance the ability to perceive and respond to rectal distension (sensory training) To combine sensory and strength training (coordination training)

Randomised controlled trial of biofeedback in faecal incontinence – Norton et al Gastroenterology Nov ‘03 1) Advice – diet, fluids, techniques to improve evacuation, bowel training programme, anti-diarrhoeal medication 2) Anal sphincter exercises taught 3) Computerised biofeedback – sensory and strength training 4) Home biofeedback device

Outcome measures Patients own view of effectiveness Change in bowel symptoms Change in continence score QOL assessment ARPS

Results All groups significant improvement in outcome measures (67% improved overall) No significant difference between four groups Only age and BMI predictors of outcome Sphincter pressures improved in all groups Continence scores median 15 to 13

Conclusions from Norton paper Majority of patients with symptoms of faecal incontinence may be subjectively improved by nurse-led management Anal sphincter exercises, computer assisted biofeedback and home biofeedback did not enhance treatment Patients with sphincter disruption not excluded Patients should be offered the choice of conservative management

Colonic irrigation

Colonic irrigation-Kessel et al Dis Colon Rectum 1997 Faecal soiling and faecal incontinence 500mls – 1 litre normal saline 5-10 mins after first stool mins for washouts 32 patients, 22 still performing washouts at 18 months Results soiling (79%) > faecal incontinence (38%)

Colonic irrigation physiology Irrigation fluid reaches on average just beyond the right colic flexure Antegrade segmental transport induced in all colonic segments Almost complete emptying of the rectosigmoid and descending colon

Conveen plugs

Anal continence plug – Mortenson & Humpreys Lancet patients – incontinent liquid/solid 1 withdrew Worn 12 hours No incontinence in 82% during time plug in place 11 plugs/week

Internal sphincter bulking agents No randomised trials/no control groups Submucosal or intersphincteric plane Symptomatic improvement Variable effect on ARPS

Bulking agents

Essential support

Conclusions Almost never harmful Almost all patients appreciate the effort Specialist nurse support essential Worthwhile maximising medical therapy prior to any surgery

Indications Post surgery –Sphincter repair –Sphincterotomy –Anterior resection and pouch surgery Idiopathic faecal incontinence

Biofeedback trials Reported success rates 60-90% Absence of well designed randomised controlled trials Do not allow a reliable assessment which elements of biofeedback therapy have a therapeutic effect

Biofeedback Norton and Kamm; Gastroenterology patients Biofeedback vs standard care Diary, symptom questionnaire, continence score, QOL, psychological status, anal manometry Improved 53% biofeedback, 54 % standard care Results largely maintained at 1 year