continence and the pelvic floor - julie cornish
TRANSCRIPT
Continence and the Pelvic Floor
Julie CornishGeneral Surgical SpR
faecal incontinence
• affects 2-5% of population• increases with age• incidence in >50yrs age – 11% men– 26% women
• significant social stigma
Causes of incontinence
• Structural damage to muscles• Nerve disruption• Marked intestinal hurry
causes• If sphinctor normal– faecal impaction (immobility, medication, parkinsons)– IBD, IBS
• If sphinctor abnormal– Disruption of sphinctor ring due to trauma– Surgical trauma (haemorrhoidectomy)– Complete rectal prolapse– LMN lesion– Muscle atrophy– Congenital abnormality (anorectal atresia)
Obstetric causes
• 10-30% women post VD have signif sphinctor injuries
• Full thickness tears –rare• Prolonged childbirth assoc with damage to
pudendal nerve• Denervation of pelvic floor leads to sphinctor
atrophy in later life
investigation
• Hx– Detailed obstetric hx– Past perianal operations– Defaecation hx– Incontinent to gas/liquid/solids– Urinary incontinence– review medications (e.g. laxatives)
• Examination (don’t forget pr)
investigations
• Anal manometry• Endoscopy• Endoanal USS• Pudendal nerve terminal motor latency
studies• Defacating proctogram• MRI – spine /pelvis
Anorectal manometry• Use– sensory or muscular defects– functional weakness of internal and external
sphinctor• measures pressure of sphinctor muscles,
sensation in the rectum and anal reflexes• can use water or air filled balloons
Anal manometry 2
• Resting and squeeze pressures over anal canal• HPZ – high pressure zone• = length of the anal canal through which the
pressures >50% of the average maximum• Normal values– 40-70ml (threshold)– 60-130 ml (urgency sensation)– Maximum tolerated volume 150-230ml
Pudendal nerve latency studies
• St Marks pudendal electrode• Mounted on volar side of index finger• Four cables emit electrical stimulation• Latency (ms) = from onset of stimulus to first
deflection• Normal values = 2.0 +/- 0.2ms
Non operative management• medication (bulking agents, anti-diarrhoeals)
• specialist dietary assessment• pelvic floor exercises– bowel retraining (education about how the bowel works, and training to
modify bowel function)
– biofeedback (this includes aspects of bowel retraining and also physical treatments to improve bowel and pelvic floor coordination)
• rectal irrigation• anal plugs• repair of a localized sphincter defect
Injection of bulking agents
• Used for weakened or deficient internal sphinctor muscle
• Only limited evidence for use currently• Trials ongoing for PTP and collagen implants
Sacral nerve stimulation
• temporary/permanent• lead threaded down to S3 via spinal needle• GA• Current 0.5 – 3mA at 15 pulse/second• Temporary - 3 weeks• change to permanent if >50% improvement in
incontinence episodes + subjective improvement in symptoms
When do you operate?
When do you operate?
• Correction of some congenital abnormalities• Complete rectal prolapse • Simple disruption of external sphinctor (sphinctor
repair)
• Severe incontinence– implantation of artificial bowel sphinctor– graciloplasty– stoma
When might you consider a stoma?
stoma
• Complex Crohns• Rectovaginal fistula• Extensive injury (e.g cloacal)