Faecal IncontinenceFaecal IncontinenceCauses, Diagnosis, & Causes, Diagnosis, &

Contemporary TreatmentContemporary TreatmentMr Darren TONKINMr Darren TONKIN

Colorectal SurgeonColorectal Surgeon

Adelaide SAAdelaide SA

Faecal IncontinenceFaecal Incontinence

““Recurrent uncontrolled passage of Recurrent uncontrolled passage of

faecal material in an individual with a faecal material in an individual with a

developmental age of at least 4 developmental age of at least 4

years”years”

Whitehead et al. Functional disorders of the anus and rectum.Whitehead et al. Functional disorders of the anus and rectum.

Gut 1999; 45 (Suppl II): II55–9Gut 1999; 45 (Suppl II): II55–9  

NormalNormal Continence Continence

Defaecation is complexDefaecation is complex Interaction of anal function & sensationInteraction of anal function & sensation

Rectal complianceRectal compliance Sphincter functionSphincter function Anorectal sensationAnorectal sensation Stool consistencyStool consistency Stool volumeStool volume Colonic transitColonic transit Mental alertnessMental alertness

IncontinenceIncontinence - Types - Types

SensorySensory Patient not aware of itPatient not aware of it Neuropathic, rectal prolapseNeuropathic, rectal prolapse

MotorMotor Patient aware, but cannot preventPatient aware, but cannot prevent

UrgencyUrgency Radiation, IBDRadiation, IBD Poor reservoirPoor reservoir

SoilingSoiling Anal scarring, IPAA, impactionAnal scarring, IPAA, impaction

FunctionalFunctional

Impaired Rectal ReservoirImpaired Rectal Reservoir Ulcerative colitis / Crohn’s diseaseUlcerative colitis / Crohn’s disease RadiationRadiation

Reduced Rectal ReservoirReduced Rectal Reservoir Low colorectal anastomosis Low colorectal anastomosis or cor coloanal oloanal

anastomosisanastomosis DiarrhoeaDiarrhoea OverflowOverflow

SphincterSphincter DefectDefect

Congenital Congenital Imperforate anusImperforate anus

TraumaTrauma ObstetricObstetric FistulotomyFistulotomy HaemorrhoidectomyHaemorrhoidectomy SphincterotomySphincterotomy Anal stretchAnal stretch

DiseaseDisease Fistula in anoFistula in ano TumourTumour Rectal prolapseRectal prolapse

TraumaTrauma!!

ObstetricObstetric InjuryInjury

Sphincter injury on EUSSphincter injury on EUS 35% primips35% primips 44% multips44% multips Up to 80% after forcepsUp to 80% after forceps

Pudendal neuropathyPudendal neuropathy

May be asymptomaticMay be asymptomatic

Worsens with timeWorsens with time

ANZJS, 1999; 69: 172-7ANZJS, 1999; 69: 172-7

NeurologicalNeurological Pudendal neuropathyPudendal neuropathy DiabetesDiabetes DegenerativeDegenerative Spinal cord injurySpinal cord injury

IdiopathicIdiopathic

Assessment - HistoryAssessment - History

Details of incontinenceDetails of incontinence FrequencyFrequency Nature - Solid, Liquid & GasNature - Solid, Liquid & Gas Distinguish between Passive, Urgency and Post Distinguish between Passive, Urgency and Post

Defaecatory SoilingDefaecatory Soiling Social impactSocial impact

Associated symptoms – blood, mucus etcAssociated symptoms – blood, mucus etc Previous anorectal traumaPrevious anorectal trauma Previous surgeryPrevious surgery Obstetric history (NObstetric history (Noo VD’s, weight, prolonged 2 VD’s, weight, prolonged 2ndnd

stage, episiotomy, tear, forceps)stage, episiotomy, tear, forceps) Comorbidities (eg DM)Comorbidities (eg DM) Comprehensive drug history (incl OTC, caffeine)Comprehensive drug history (incl OTC, caffeine) Continence ScoresContinence Scores

Cleveland Clinic Scoring Cleveland Clinic Scoring SystemSystem

NEVERNEVER RARELYRARELY SOMETIMESSOMETIMES USUALLYUSUALLY ALWAYSALWAYS

SOLIDSSOLIDS 00 11 22 33 44

LIQUIDSLIQUIDS 00 11 22 33 44

FLATUSFLATUS 00 11 22 33 44

USE OF PADUSE OF PAD 00 11 22 33 44

LIFESTYLE LIFESTYLE ALTERATIONALTERATION 00 11 22 33 44

ExaminationExamination

Underwear, padsUnderwear, pads General physicalGeneral physical Perineal deformity, scarsPerineal deformity, scars Perineal descentPerineal descent ProlapseProlapse Digital rectal examDigital rectal exam Resting + squeeze pressureResting + squeeze pressure RV septumRV septum

Perineal sensationPerineal sensation

InvestigationsInvestigations

ColonoscopyColonoscopy

ManometryManometry

EUSEUS

PNTMLPNTML

MRIMRI

Endoanal USEndoanal US

NormalNormal Anterior defect IAS & EASAnterior defect IAS & EAS

MRIMRI

• Multi-planarMulti-planar capabilitycapability

• Higher inherent contrast resolutionHigher inherent contrast resolution than EUS than EUS

• Not operator dependentNot operator dependent

• More expensiveMore expensive

• IAS hyperintense, EAS hypointense IAS hyperintense, EAS hypointense

• Good for EAS atrophyGood for EAS atrophy

MRIMRI

NormalNormal Anterior defect IAS & EASAnterior defect IAS & EAS

ManometryManometry

• SphincterSphincter• Resting pressure (>40mmHg)Resting pressure (>40mmHg)• Squeeze pressure (>100 mmHg)Squeeze pressure (>100 mmHg)• Functional anal canal length (M 4-5cm, F 3-4cm)Functional anal canal length (M 4-5cm, F 3-4cm)• Sphincter asymmetrySphincter asymmetry

• Rectal balloonRectal balloon• SensationSensation• ComplianceCompliance• CapacityCapacity• RAIRRAIR

Conservative Conservative ManagementManagement

• Alter stool consistency (bulking agents, loperamide)Alter stool consistency (bulking agents, loperamide)

• Treatment of cause (IBD, IBS)Treatment of cause (IBD, IBS)

• Sphincter exercisesSphincter exercises

• Biofeedback (70% improvement in symptoms & QoL)Biofeedback (70% improvement in symptoms & QoL)

• Enema programmeEnema programme

• Topical phenylephrineTopical phenylephrine

Stop strainingStop straining

Stronger squeezeStronger squeeze

Longer durationLonger duration

Am J Gastro 2000; 95(8): 1873-80Am J Gastro 2000; 95(8): 1873-80

BiofeedbackBiofeedback

Topical PhenylephrineTopical Phenylephrine

• Selective Selective -1 agonist-1 agonist

• Increase resting sphincter toneIncrease resting sphincter tone

• Apply tApply to internal & external anal areao internal & external anal area

• 20% gel twice daily20% gel twice daily

• Improved continence & QoLImproved continence & QoL

Colorectal Disease 2003; 5(Supp 1): 11Colorectal Disease 2003; 5(Supp 1): 11

Surgery OptionsSurgery Options

Sphincter repair Sphincter repair Injectable agentsInjectable agents Sacral nerve stimulationSacral nerve stimulation Dynamic graciloplastyDynamic graciloplasty Artificial sphincterArtificial sphincter StomaStoma ACEACE

Anterior Sphincter Anterior Sphincter RepairRepair

EAS defectEAS defect Overlapping vs direct Overlapping vs direct

appositionapposition 80% improved80% improved Function deteriorates Function deteriorates

with timewith time

Hull et al. DCR 2002; 45: 345-8Hull et al. DCR 2002; 45: 345-8

Injectable AgentsInjectable Agents

IAS pathologyIAS pathology Silicone biomaterial (eg PTQ)Silicone biomaterial (eg PTQ) Submucosal vs intersphinctericSubmucosal vs intersphincteric Approx 50 to 70% gain >50% Approx 50 to 70% gain >50%

improvementimprovement Better results if US usedBetter results if US used

Tjandra et al. DCR 2004.

Injectable AgentsInjectable Agents

Sacral Nerve StimulationSacral Nerve Stimulation

Originally described for urological useOriginally described for urological use Weak but intact sphincterWeak but intact sphincter Mechanism poorly understoodMechanism poorly understood 2 stage 2 stage

PNE – trial electrode 2/52, diaryPNE – trial electrode 2/52, diary Permanent implantPermanent implant

Good results – up to 90% report Good results – up to 90% report improvementimprovement

SNSSNS

Dynamic GraciloplastyDynamic Graciloplasty

First described 1988First described 1988

Severe sphincter injury, congenital Severe sphincter injury, congenital malformationsmalformations

Convert fast-twitch muscle to slow Convert fast-twitch muscle to slow twitchtwitch

Variable results (35 to 85% Variable results (35 to 85% continence)continence)

Congenital malformations do Congenital malformations do worseworse

Complications in 50% (30% Complications in 50% (30% infection)infection)

Dynamic GraciloplastyDynamic Graciloplasty

Artificial Bowel Artificial Bowel SphincterSphincter

Adapted from urological Adapted from urological use in 1987use in 1987

Good results with Good results with successful implantsuccessful implant

High complications ratesHigh complications rates Infection (up to 50%)Infection (up to 50%) ErosionErosion PainPain Obstructed defaecationObstructed defaecation

Revision (up to 70%)Revision (up to 70%) Explantation (30%)Explantation (30%)

Artificial Bowel Artificial Bowel SphincterSphincter

Not recommended for Not recommended for routine useroutine use

Only in cases of Only in cases of severe sphincter severe sphincter injury, malformation or injury, malformation or loss.loss.

StomaStoma

Not without complicationsNot without complications Parastomal herniaParastomal hernia Mucus leakageMucus leakage Diversion colitisDiversion colitis

Faecal IncontinenceFaecal Incontinence

Non-operative treatmentNon-operative treatment

SuccessSuccess FailureFailure

InvestigateInvestigate

ESDESD

Direct repairDirect repair

NeurogenicNeurogenicISDISD

InjectableInjectableInjectableInjectableSacral nerveSacral nerveGracilis / ArtificialGracilis / ArtificialStomaStoma

ConclusionConclusion

Faecal incontinence infrequently Faecal incontinence infrequently requires surgeryrequires surgery

Injectable bulking agents and sacral Injectable bulking agents and sacral nerve stimulation are likely to be the nerve stimulation are likely to be the most applicable treatments in the most applicable treatments in the future.future.

Stoma formation is an effective Stoma formation is an effective option, but can be avoided in the option, but can be avoided in the majority.majority.