Copy of Feacal Incontince 2023 .pptx

By Mr. S.Kader DPKISMH and IALCH - Colorectal Unit  Why is this Important? Significant social and economic impact Significantly impairs quality of life Can contribute to the loss of the ability to live independently  TERMINOLOGY AND CLASSIFICATION Fecal incontinence: involunt...

By Mr. S.Kader DPKISMH and IALCH - Colorectal Unit  Why is this Important? Significant social and economic impact Significantly impairs quality of life Can contribute to the loss of the ability to live independently  TERMINOLOGY AND CLASSIFICATION Fecal incontinence: involuntary loss of solid or liquid feces. Anal incontinence : involuntary loss of solid or liquid feces or flatus. Fecal Incontinence Urge incontinence: desire to defecate, but incontinence occurs despite efforts to retain stool. Passive incontinence: lack of awareness of the need to defecate before the incontinent episode.  EPIDEMIOLOGY Commoner in females Underestimated and under reported due to patient factors Over 70 yrs age, +- 7 % of population  Risk Factors Older age Diarrhoea Faecal urgency Urinary incontinence Diabetes mellitus Hormone therapy  External Internal Sphincter Striated Sphincter Smooth Muscle Muscle Autonomic (Voluntary) Control (Involuntary)  Cerebral Cortex: Superior Frontal & Ant Cingulate Gyri ∑ p Enteri c Nervo ∑ us Syste m Inferior Mesenter ic - L1 – Ganglion + S L3 2 Hypogast S ric + - 3 Nerves S - 4 Pudendal Nerve Anorectal Sampling RectoAnal Inhibitory Reflex p (RAIR) ∑ S 2 S 3 S 4 Anorectal Sampling RectoAnal Inhibitory Reflex p (RAIR) ∑ Every 8-10 minutes + S 2 S ? - 3 ? SoGli Internal S ?d as Sphincter Relaxes allowing contents into upper 4 i qu i anal canal L d  Aetiology and Pathogenesis Dysfunction of the anal sphincters Abnormal rectal compliance Decreased rectal sensation Altered stool consistency. Incontinence is usually multifactorial Urge incontinence patients have weakness of the external anal sphincter as well as decreased rectal capacity and rectal hypersensitivity Passive faecal incontinence often have weakness of the internal anal sphincter  Evaluation History Physical examination Investigations  History Determining whether fecal incontinence is truly present and its severity. True incontinence : frequency and urgency without loss of bowel contents. Onset, duration, frequency, amount, type of leakage Presence of urgency, nocturnal episodes and precipitating events. Lower back/ Perineal pain with motor or sensory symptoms in the lower extremities and urinary incontinence - Neurological cause. Prior anorectal surgery, pelvic irradiation, diabetes, or neurologic disease should be sought. Obstetric history  Physical Examination Inspection of the perianal area and a digital rectal examination. Chemical dermatitis, suggesting chronic incontinence, a fistula, prolapsing haemorrhoids, or rectal prolapse Perianal sensation should be tested by evoking the anocutaneous reflex (anal wink sign) Digital rectal examination should be performed to detect obvious anal pathology Provide a basic assessment of the anal resting tone that is mostly due to tonic contraction of the internal anal sphincter  Investigations Laboratory studies — stool studies Endoscopy — flexible sigmoidoscopy /colonoscopy. Anorectal manometry — functional sphincter weakness and can detect abnormal rectal sensation, which is an important predictor of response to biofeedback training.  Investigations Endorectal ultrasound/magnetic resonance imaging — Structural abnormalities of the anal sphincters, the rectal wall, and the puborectalis muscle Defecography —refractory fecal incontinence- can detect enteroceles, rectoceles and rectal  Aetiology Mechanical Neurogenic Idiopathic Obstetric injury Pudendal nerve stretch No clear etiology Fistula disease Strain Medical illness Trauma Prolonged labor Irradiation Iatrogenic Trauma IBS, multiple sclerosis, Systemic disease Diabetes, scleroderma Diarrheal states Congenital malformations  Principles of Management Patient selection is critical Medically manage those with minimal symptoms or poor surgical candidates (risk or outcome) Rehabilitation- Physiotherapy Surgery reserved for those with repairable, neurologically intact sphincter  Treatment (Conservative) Dietary modification and medications Biofeedback Pelvic floor muscle training & electrostimulation Anal plug  Dietary modification and Medication Dietary Fiber Stool bulking agents e.g. psyllium Avoid dairy products (esp. lactose intolerance) Loperamide Codeine phosphate Cholestyramine Enema programme (Bowel washout)  Biofeedback Mind-body technique that involves using visual or auditory feedback to gain control over involuntary bodily functions Improving the strength of the sphincter (motor skills training) Increasing the ability to perceive weak rectal distention (discrimination training) Combining the previous two mechanisms (training in the coordination of sphincter contractions with rectal sensation) Success more likely if patient motivated, intact cognition and some rectal sensation.  Biofeedback Manometric bio-feedback: recording anal canal pressures Coupled to visual/auditory signals proportional to the pressures themselves. EMG bio-feedback: recording EMG activity from the striated muscles which surround the anal canal The patient is asked to squeeze and relax without rectal distention Sensory discrimination training: catheter- mounted balloon inserted inflated with different air volume Signal when the feeling of distention is perceived, or to contract the pelvic floor  Pelvic Floor Exercises: Kegel exercises Strengthen the pelvic floor muscles which support the bladder and bowel To perform contract the muscles that normally stop the flow of urine. Hold the contraction for three seconds, then relax for three seconds Repeat this pattern 10 times As muscles strengthen, holding the contraction longer gradually working up to three sets of 10 contractions every day. Bridge pose Squats Anal plug  Surgical Options Injection therapy Sphincteroplasty Sacral nerve stimulation Sphincter reconstruction-muscle transposition Artificial sphincters Magnetic anal sphincter Tibial nerve stimulation Stoma  Injection Therapy First described for use in fecal incontinence in 1993 Bulking effect of the injected materials with subsequent collagen deposition helping to enhance continence. This technique is safe and simple Sphincteroplasty Artificial Sphincters  Sacral Nerve Stimulation 2 phases: Screening phase -peripheral nerve evaluation. Therapeutic phase -permanent neurostimulator implantation.  Stomas Antegrade continence enema End stoma  Conclusion Majority of patients have a non surgical cause Conservative management can improve symptoms in many patients Patient selection for surgery is critical Overlapping Sphincteroplasty is the gold standard procedure For patients not amenable: Injection therapy Sacral nerve stimulation Artificial Anal Sphincter Antegrade Continent Enemas  References National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 49. Faecal incontinence: the management of faecal incontinence in adults. http://www.nice.org.uk/nicemedia/pdf/CG49NICEGuidance; June2007[accessed January 2012]. Madoff RD, Parker SC, Varma MG, et al. Faecal incontinence in adults. Lancet 2004;364:621–32. Tjandra JJ, Dykes SL, Kumar RR, et al., and the Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of fecal incontinence. Dis Colon Rectum 2007;50:1497–507. Rao SS. Diagnosis and management of fecal incontinence. Am J Gastroenterol 2004;99:1585–604 Rockwood TH, Church JM, Fleshman JW, et al. Fecal Incontinence Quality of Life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2000;43:9–16. Jones OM, Cunningham C, Lindsey I. Paradigm shifts in the management of faecal incontinence. Aust N Z J Surg 2010;80:205–7. Berger N, Tjandra JJ, Solomon M. Endoanal and endorectal ultrasound: applications in colorectal surgery. Aust N Z J Surg 2004;74:71–5. Norton C, Whitehead WE, Bliss DZ, et al. Management of fecal incontinence in adults. Neurourol Urodyn 2010;29:199–206.  Thank you Lets talk Shit! Contact me if you have any questions: [email protected]