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For technical assistance please contact Tech Support at 404-969-0387 or email at [email protected]

Assessment of Fecal Incontinence and Constipation in the

Female Patient

Mahmoud Barrie, MDAssistant Professor

Department of Gastroenterology/Hepatology

Atlanta VAMC/EUH

Atlanta, GA

December 9, 2008

For technical assistance please contact Tech Support at 404-969-0387 or email at [email protected]

Outline Anatomy- Anorectum Mechanism of continence Fecal incontinence

– Epidemiology, etiology, clinical presentation– Diagnostic studies– Assessment Algorithm

Mechanism of defecation Constipation

– Epidemiology, etiology, clinical presentation– Diagnostic studies– Assessment Algorithm

Summary

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Objectives Anatomy- Anorectum Mechanism of continence Fecal incontinence

– Epidemiology, etiology, clinical presentation– Pertinent radiographic and non-radiographic testing

Mechanism of defecation Constipation

– Epidemiology, etiology, clinical presentation– Pertinent radiographic and non-radiographic testing

Summary



Epithelial nerve endings of the rectum and anus



Anorectal function

Continence Defecation



Continence mechanisms

Anorectal angle

Rectal accomodation/compliance

Rectal sensation

Anal sensory nerves

Internal anal sphincter

External anal sphincter



Continence Mechanisms: Anorectal Angle



Continence Mechanisms: Rectal Accommodation



Continence Mechanisms: Compliance Ratio of pressure to volume at

different volumes of distention Decreased compliance with

– Inflammation– Fibrosis– Surgical replacement with sigmoid colon



Continence Mechanisms: Rectal Compliance



Continence Mechanisms: IAS & EAS

Fecal Incontinence Continuous or recurrent passage of

fecal material (>10ml) for at least one month in a person older than 3/4 years of age



Epidemiology A US study of outpatients found an overall

prevalence of 18·4% Incontinence occurred daily in 2·7% of

patients, weekly in 4·5%, and monthly or less in 7·1%

Symptomatic fecal incontinence occurs in 21% of women presenting with urinary incontinence, pelvic-organ prolapse, or both



Causes of Fecal Incontinence



A greater proportion of cases of faecal incontinence are acquired

Sphincter disruption resulting from vaginal delivery= most common sphincter injury

Sphincter atrophy due to advanced age



Vaginal delivery injury risks Forceps delivery Primiparous: giving birth to a baby weighing over 4

kg- Traction injury to the pudendal nerve third-degree obstetric lacerations

Incidence of both flatus and stool:– 6-25% in new postpartum– 3-27% in known sphincter tears



Assessment Essential elements of the history:

– Onset – Type of incontinence (flatus, liquid, or solid stool)– Frequency of episodes

Pertinent findings in the physical exam include:– A thinned or deformed perianal body and scars from

previous surgery or trauma. – Breakdown of the perianal skin is a consequence, not a

cause of incontinence– Gaping of the anus suggests rectal prolapse, which can

usually be demonstrated with Valsalva’s manoeuvre.– Diminished perianal sensation and the absence of an anal

wink suggest a neurogenic cause– Digital exam- weak sphincter squeeze



Diagnostic Studies

Function– Anorectal manometry– EMG: Action potentials of sphincter muscle– PNTL– Defecography: anorectal angle, perineal descent

Anatomy– Flexible sigmodoscopy/proctosocpy– Defecography: rectoceles– Anal sonography: Sphincter defect– Barium enema– MRI



Function: Anorectal manometry in fecal incontinence



Function: EMG Electromyography — Electromyography of the external

anal sphincter and pelvic floor muscles is performed for three purposes:

To identify areas of sphincter injury by mapping the sphincter.

To determine whether the muscle contracts or relaxes (by the number of motor units firing).

To identify denervation-reinnervation potentials indicative of nerve injury.



Function: EAS EMG



Function: EAS EMG

Nerve sprouting Variations of

intervals b/w motor unit potentials



Function: Pudendal n. Latency



Child Birth Neurologic evidence

– PNTL prolongation 42% of postpartum women (Snooks et al )

cesarean delivery performed in late labor (cervical dilation 8 cm or greater)

– EMG of the anal sphincter: increased fiber density in

multiparous women (Allen RE et al.)



Anatomy: Defecography

Evacuation proctography: process, rate and completeness

Assessing ano-rectal angle Structural and functional alterations: rectocele,

internal rectal intussusception, external rectal prolapse, enterocele and pelvic floor dysfunction, or dyssynergia.



Anatomy: Rectal Ultrasound



Anatomy: Endoanal Coil MRI Sphincter atrophy

– 89% sensitivity– 94% specificity– 89% positive predictive value– 94% negative predictive value

Defect(atrophy) in levator ani m. May not be as good in detecting sphincter tear.



Anatomic evidence Endoanal MRI:

– 20% of primiparous women: defect in the levator ani muscle (Delancey et al )

Endoanal ultrasound for sphincter disruption (Abramowitz L et al)

– 35% of primiparous– 44% of multiparous



Summary of diagnostic studies Anorectal manometry: Good

EMG/PNTML: – good but limited to specialized centers

Defecography: – Not as good

Anal endosonography– good

Endoanal Coil MRI : – New and promising



Constipation

Straining ≥1/4 of defecation; Lumpy or hard stools ≥1/4 of defecation; Sensation of incomplete defecation ≥1/4 of

defecation; Sensation of anorectal

obstruction/blockage≥1/4 of defecation; Manual maneuvers to facilitate ≥1/4 of

defecation (example: digital evacuation, support of the pelvic floor);

Less than three defecations per week.



Defecation

Epidemiology Prevalence 2-34% F:M 3 to 5x Increase >65yo


Types of constipation Normal transit and normal pelvic floor

function Slow transit (colonic inertia) Dyssynergic or obstructive defecation

or anismus Structural abnormalities: Enteroceles

and Rectoceles


Assessment of Constipation

H&P– digital dysimpaction, pelvic and/back pain,

bleeding, urinary incontinence, renal insufficiency

Colonic scintigraphy Anorectal manometry/Balloon expulsion Surface EMG Evacuation proctography


Colonic transit


Balloon Expulsion


Rectal pressure & EMG in PFD


Defecography

Evacuation proctography involves imaging of the rectum with contrast material and observation of the process, rate, and completeness of rectal evacuation using fluoroscopic techniques.

Structural and functional alterations can also be observed and include rectocele, internal rectal intussusception, external rectal prolapse, enterocele and pelvic floor dysfunction, or dyssynergia.


History and exam History

– Digital pressure in the vagina

Exam– Bulging of the posterior vaginal wall may

be an enterocele or a rectocele.


Symptoms/Signs Intractable vaginal mucosal ulcerations Urinary retention (renal failure) A pulling sensation or lower back pain

– Worse w/prolong standing– Improves w/laying down


Rectocele


Enterocele


Summary Fecal incontinence

– H&P very important– Anal endosonography– Anorectal manometry– EMG – Defecography? (controversal)– Colonic transit (-)– Dynamic MRI w/endoanal coil

Constipation– H&P very important– Colonic transit study– Anorectal manometry– Defecography: r/o PFD/enteroceles/rectoceles– EMG(+/-) to r/o PFD

Enteroceles/Rectoceles– Beware of surgical treatment except for recurrent vaginal mucosal

ulceration or ovarian tension


Q & A Session

Evaluation

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References1Mellgren A, Jensen LL, Zetterstrom JP, Wong WD, Hofmeister JH,Lowry AC. Long-term cost of fecal incontinence secondary toobstetric injuries. Dis Colon Rectum 1999; 42: 857–65.2 Johanson JF, Lafferty J. Epidemiology of fecal incontinence: thesilent affliction. Am J Gastroenterol 1996; 91: 33–36.3 Nelson R, Furner S, Jesudason V. Fecal incontinence in Wisconsinnursing homes: prevalence and associations. Dis Colon Rectum1998; 41: 1226–29.4 Thomas TM, Egan M, Walgrove A, Meade TW. The prevalenceof faecal and double incontinence. Community Med 1984; 6:216–20.5 Nelson R, Norton N, Cautley E, Furner S. Community-basedprevalence of anal incontinence. JAMA 1995; 274: 559–61.6 Drossman DA, Li Z, Andruzzi E, et al. US householder survey offunctional gastrointestinal disorders: prevalence, sociodemography,and health impact. Dig Dis Sci 1993; 38: 1569–80.7 Faltin DL, Sangalli MR, Curtin F, Morabia A, Weil A. Prevalence ofanal incontinence and other anorectal symptoms in women.Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 117–20.


8 Porell F, Caro FG, Silva A, Monane M. A longitudinal analysis ofnursing home outcomes. Health Serv Res 1998; 33: 835–65.9 Chassagne P, Landrin I, Neveu C, et al. Fecal incontinence in theinstitutionalized elderly: incidence, risk factors, and prognosis.Am J Med 1999; 106: 185–90.10 Borrie MJ, Davidson HA. Incontinence in institutions: costs andcontributing factors. CMAJ 1992; 147: 322–28.11 Nakanishi N, Tatara K, Shinsho F, et al. Mortality in relation tourinary and faecal incontinence in elderly people living at home.Age Ageing 1999; 28: 301–06.12 Rizk DE, Hassan MY, Shaheen H, Cherian JV, Micallef R, Dunn E.The prevalence and determinants of health care-seeking behaviorfor fecal incontinence in multiparous United Arab Emiratesfemales. Dis Colon Rectum 2001; 44: 1850–56.13 Jorge JM. Anorectal anatomy and physiology. In: Wexner SD, ed.Fundamentals of anorectal surgery, 2nd edn. Philadelphia:W B Saunders, 1998: 1–24.


14. Abramowitz L, Sobhani I, Ganansia R, et al.Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum.2000;43:590–596; discussion 596–598.

15. Allen RE, Hosker GL, Smith AR, et al. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol. 1990;97:770–779.

16. Delancey JOL, Kearney R, Chou Q, et al. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol. 2003;101: 46–53.


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