Faecal incontinence

Dr. Tariq Akhtar khanFCPS (Surgery)

Consultant surgery.Post fellowship training Colorectal surgery

Definition

• Anal incontinence= Faecal incontinece +flatus incontinence.

• Faecal incontinece: Recurrent uncontrolled passage of faecal material for at least 1 month.

• Partial incontinence: inability to control anal sphincer resulting passage of flatus and faecalsoiling.

Definition (cont..)

• Pseudo incontinence:

– Haemorrhoidal prolapse

– Incomplete evacuation

– Poor hygiene

– Fistula in ano

– Dermatological condition

– Anorectal sexually transmitted diseases

– Anorectal neoplasms

Introduction

• Not a diagnosis but a symptom.

• Socially devastating condition

• Affecting between 1.4 and 18% of the population and up to 50% of all nursing home residents.

• Under reported : social stigma and fear for loss of autonomy.

Continence

• to stool relies on coordinated interplay of several factors– Stool consistency

– Rectal capacity

– Compliance

– Intact neural pathways

– Normal anal sphincter and pelvic floor function

– Normal anorectal sensation

• .

Aetiology

• Deficiency or failures in any component can lead to incontinence.

• In many cases the aetiology of FI is multifactorial and adding complexity to the management.

• More commonly FI is an acquired disorder

Mechanism

• Faecal loading or impaction: overflow incontinence– Major contributor in elderly and frail population

– Easily diagnosed on DRE. When empty the mechanisms are:

• Diarrhoea or loose stool

• Rectal volume/compliance reduction

• Sphincter complex: anatomical or functionaldisruption.

FI

Full rectum

Correction after evacuation

Constipation/

Pelvic floor disorder

no

yes

Empty rectum

diarrhoeaSphincter

insufficiency

trauma Neurological lesions

Rectal conditions (volume/

compliance)

• Active (urge incontinence): Loss of stool despite best effort.

– Intact sensory

– Derangement in external anal sphincter

– Rectal patholoty

• noncompliant rectum

• Inflammatory bowel disease

• Radiation proctitis

• carcinoma

• Passive incontinence

– Loss of stool without patients awareness

– Internal anal sphincter pathology

– Neurological etiology

– Fistula in ano

– Post surgical scarring

Aetiology (cont..)

• Neurological diseases: incontinence is coupled with constipation and evacuation problems

– Central nervous system pathology

• Spinal cord injury/neoplasm

• Multiple sclerosis

• Myelomeningocele (spina bifida)

– Autonomic neuropathy

• DM

Aetiology (cont..)

• Sphincter injury: In adult female most common cause is obstetric trauma: Vaginal delivery:– up to 10% primipara have a clinically recognised

sphincter disruption. – Sonographically 30%– Instrumental – Large birth weight– Prolonged second stage– Episiotomy has not been shown consistently to

protect against sphincter injury. Mediolateralepisiotomy is a risk factor.

Aetiology (cont..)

• Denervation injuries to the pelvic floor are also common sequelae of vaginal delivery.

• 60% of obstetric tear also have evidence of pudendal nerve damage.

• Compression or traction to pudendal nerve

• High birth weight is a risk factor for compression injury.

• End stage of denervation injury is pelvic floor failure and descending perineum syndrome.

Aetiology (cont..)

• Sphincter injury:

– Anorectal surgical procedures

• Haemorrhoidectomy– Minor degree

– Due to loss of normal anal cushion

– & sensory impairment

• Fistulotomy– High or complex

– Repeated procedures for recurrence or persistence

– As high as 35-45%

Aetiology (cont..)

• Sphincter injury:

– Anorectal surgical procedures

• Manual anal dilatation– Up to 20%

• Colo-anal anastomosis– Reduction of rectal reservoir capacity

– Disruption of intramural nerve pathways

– Chemotherapy/ radiotherapy

• Transanal advancement flap

Aetiology (cont..)

• Sphincter injury:

– Direct trauma

– Anal recieptive coitus

Aetiology (cont..)

• Other congenital disease

– Hirschsprung’s disease

• Radiotherapy

– Direct damage to the anal sphincter

– Effect on compliance

Aetiology (cont..)

• Idiopathic FI (Neuropathic; newer term):– Precise aetiology is unclear

– Pudendal neuropathy is considered to be present in majority of these patients• Delayed PNTML

– Low squeeze pressure

– Decreased anal canal sensation

– May result from chronic straining during defecation.

– May have double incontinence.

– Rectal intussusception

Detailed history

• Aetiology

• Frequency and severity

• 3 week stool diary

• Scoring system

– St Mark’s incontinence srore: 0-24

– Cleaveland Clinic Florida Fecal Incontinence Score (CCF-FIS): 0-20

Detailed history

• Consistency using Bristol stool chart

– Seven point from hard to liquid

• Faecal incontinence quality of Life (FIQoL) instrument:

– lifestyle, coping, behaviour, depression, embarassment

• In female: hormonal status

Detailed history (pelvic floor)

• Concomitant urinary incontinence suggest more global pelvic floor deficiency.

• Obstructed defecation

• Rectal prolapse

• Genital prolapse

Examination

• General and abdominal examination

• Perineum examination

– Scar, excoriation, descent, patulous anus, prolapse, perineal body, perianal refles, resting anal tone, squeeze pressure, contraction of puborectalis , rectocele, enterocele, rectal intussusception,

• Neurological examination of the back and lower limbs.

• Anoscopy

• Proctosigmoidoscopy

• Cognitive assessment (if needed)

Investigations

• Endoanal USG• Pelvic USG• Anorectal physiology studies

– Anorectal manometry• Resting pressure• Squeeze pressure• High pressure zone• RAIR• Rectal sensation• Rectal compliance

– PNTML– EMG– Defecography

• colonoscopy

• Coexisting pathology

• Fitness for surgery

Treatment

• Mainly guided by the severity of symptoms, aetiology and structural integrity of the sphincter muscles, patients own view.

• Often multidisciplinary• Conservative measures• Minimally invasive

– Injection therapy – Sacral nerve stimulation– Percucaneous Tibial Nerve Stimulation (PTNS)

• Surgery • Newer

– Secca– Sling implantation– Nerve stimulation techniques– Stem cell injection– Magnetic sphincters

Conservative measures

• Fibre

• Antidiarrhoeal agents

• Luxative, retrograde enemas and suppositories, disimpactions

• Biofeedback

• Anal plug

• Secca procedure: radiofrequency

Surgery

• Reserved for who have failed conservative therapy. Options are:• Sphincteroplasty• Pelvic floor repair• Sphincter reconstruction: muscle transposition

– Gluteoplasty– Graciloplasty

• Adynamic• Dynamic

• Artificial bowel sphincter• Magnetic anal sphincter• Lap ventral rectopexy• Stoma

– Antigrade continence enema• Appendicostomy• Caecal or ileal tube

– End stoma. Sigmoid

Conclusion

• Individualised management approach

• Graduated treatment approach

• Tailored to cause and severity of symptoms

• Anal sphincter assessment is essential

Treatment algorithm

Surgical Treatment algorithm

Sphincteroplasty

• Anal sphincteroplasty is a secondary (delayed) repair

• ‘Anal sphincter repair’ term is used to describe primary (immediate) repair of the anal sphincters following trauma

• Anterior sphincteroplasty following an obsinjury is the most common type of reconstruction performed.

• Anterior sphincteroplasty is the mainstay surgical treatment for severe FI with EAS defect.

• Overlapping sphincteroplasty is the standard of care

• Full mechanical bowel preparation.

• Under G/A

• Prone jack-khife or lithotomy position

• Incision is made transversely between anus and vaginal introitus

• Scar tissue and muscle ends are dissected from the rectum and vagina without separate identification and repair of IAS.

• Adequate mobilisation for tension free wrap

• Care: not to proceed too far posterior due to potential for injury to the nerve entering in this location

• Scare tissue is divided transversely. Preserve scar, it helps holding suture.

• A levatorplasty (anterior, at proximal extent of dissection)can be added, great care not to narrow the vagina excessively (dyspareunia)

• A T closure with interrupted absorbable sutures is often feasible. Don’t confuse with posterior levatorplasty.

• Two ends of EAS overlapped in midline and stitched with 2/0 mattress sutures

• A biological implant to reinforce the anal muscles could be advantageous.

• Preoperative counselling– Postoperrative wound infection– Delayed healing. – These are the most common complications.

• Worse outcome: – Age ≥50 years.– Deep wound infection– Isolated EAS defect

• Short term outcome good to excellent in majority of the patients.

• Continence deteriorates with long term follow up.

• 5-10 years: only 40-45% patients satisfied with functional outcome.

• Adjuvent BFB therapy after surgery

• Previous sphincter repair does not seem to affect the clinical outcome of a subsequent repair.

• Long term benefit of repeat sphincter repair was similar to an initial repair.

Pelvic floor repair

• Postanal, preanal or total• Aim of postanal repair was to

– increase the length of the anal canal– Restore the anorectal angle and – Recreate the flap valve mechanism

• Despite initial improvement, long term results of postanal repair or total pelvic floor repair for neurogenic FI have been disappointing.

• Postanal or total pelvic floor repair now have no place in the treatment of neuropathic FI.

Sphincter reconstruction-muscle transposition.

• Non-stimulated and stimulated• Replace the anal sphincter (Neosphincter).• When local repair is not possible or has failed• Gluteoplasty: transposition of one or both gluteal

muscle.• Graciloplasty:

– Variable success rates have been reported with non-stimulated Graciloplasty.

• These procedures are no longer used due to limited efficacy and significant morbidity

Stimulated or dynamic graciloplasty

• Addition of an implanted electrical stimulator• Permanent contraction of the transposed muscle

and thus a better closure of the anus.• Type II to type I muscle fibre that resemble the

IAS.• Indication:

– Extensive sphincter disruption precluding a direct surgical repair

– Severe neural damage – Congenital disorders e.g. anal atresia– Total anorectal reconstruction after APR

Stimulated or dynamic graciloplasty

• Results variable. Satisfactory continence restoration achieved only in specialised high-volume centres.

• Less experienced surgeons have shown a high morbidity and a poorer functional outcome.

• Some reported mortality, high infection and other morbidities rates and limited success rate it has not gained wide acceptance

• Replaced nowadays by other less aggressive options.

Artificial bowel sphincters

• Currently used silicone made, pressure regulated

• Inflatable cuff placed around the lower rectum or upper anal canal

• A pump placed in the labia majora or scrotum

• Pressurisation fluid is an isotonic solution.

• Walls are semipermeable and radioopaque.

• Three models

• Severe FI.

• To initiate defecation, squeezing the pump empties the cuff by transferring fluid into the ballon, permitting passage of stool

• Cuff then refills automatically from pressure built up in the balloon.• Careful patient selection and sound operative technique for success• Exclusion criteria

– Morbid obesity– IDDM– Crohn’s disease– Pelvic sepsis– Radiation proctitis– Anoreceptive intercourse

• Have to surricient manual dexterity to operate the device independently.

• Risk of constipation. As cuff even when widely open, can still narrow the anal canal enough to prevent complete and easy evatuation.

• Risks of infection, mechanical failure(microperforation)

• Severe morbidity is rare. No mortality reported.

• Primary concern is infection. 20-45%

Magnetic anal sphincter

• Augment the native anal sphincter

• Consists a series of titanium beads with magnetic cores hermetically sealed inside.

• Beads are interlinked with independent titadnium wires to form flexible ring

• Around EAS.

• Begins working immediately once implanted

• Without the need for subsequent manipulation by either the patient or surgeon

• Procedure for implantation is simpler than ABS. (access to perineum alone is required.

• Commercial use in selected centres in Europe.

• Presently the place of MAS in the treatment algorithm of FI remains to be determined.

• Only short term follow up is available.

Injection therapy

• Bulking effect of injected materials with subsequent fibrosis/collagen deposition helps to enhance continence.

• Injected into either submucosa or the intersphincteric plane

• Routine use of ultrasound guidence improve outcome.

• Autologous fat, gluteraldehyde cross linked collagen, pyrolytic carbon beads, silicone biomaterial, PTQ, polyacrylonitrile

• Relative simplicity of the procedure, safe, only minor complications

• Effects of bulking agents appear to be short lived and of limited efficacy

• Recommended for use in only selected cases of mild passive faecal incontinence related to IAS dysfunction and soiling

Stoma

• Antegrade continence enema:– Appendicostomy, by invaginating the tip of the

appendix into the caecum to create a one way valve.– Base of the appendix is tghen brought out to the

abdominal wall – Antegrade enema

• Caecal or ileal tube– Can also be performed percutaneoulsy guided by a

colonoscope and a specially designed catheter.– Minimally invasive, safe and useful for both paediatric

patients and adults.

• Significant reduction in incontinence scores compared to preoperative values.

• Morbidity: wound infection and leakage from the ministoma.

End stoma

• Severe end stage FI, in which

– All other available treatments have failed

– Are inappropriate because of comorbidities, or

– When preferred by the patient.

• Significant psychosocial issues and stoma related complication Vs it resumes normal activities and improves quality of life.

• In FI 83% reported a significant improvement in life style and 84% would choose to have the stoma again.

• End sigmoid colostomy without proctectomy(Hartman’s procedure) is usualy procedure of choice.

• Diversion colitis of the rectal stump and mucus leakage infrequently necessitating a secondary proctectomy.

SNS

• First described in urological disorders

• Function

– Anal sphincters

– Pelvic floor musculature

– Effect on colonic motility

– Local spinal reflex arcs

– Reduce the rectal sensory threshold

– Increase rectal blood flow

• Screening phase of peripheral nerve evaluation (PNE). – Under L/A OR G/A– Prone position– S3 foramen is preferntially cannulated under flouroscopic

guidance with an electrode– Bellows response of the pelvic floor and plantar flexion of

the ipsilateral great toe.– Sometimes repeated on the contralateral side to select the

best response with screeening of S2 and S4 as well.– Electrode is secured in place and connected to a portable

external stimulator.– 3 week trial of stimulation while filling out a bowel habit

diary.

• Second therapeutic phase of permanent neurostimulatior implantation.