Faecal Incontinence: How to investigate and who to refer

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Faecal Incontinence How to investigate and who
to refer

• Mr Peter Mitchell
• SpR Colorectal Surgery
• Mr ES Kiff and Miss KJ Telford, Pelvic Floor Unit
  
• University Hospital South Manchester

British Geriatrics Society, NW Branch 7th Sept
2010
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Introduction

• FI - involuntary loss of stool
• FI - is a sign/symptom not a diagnosis
• Stigmatising, adverse effect on Q o L, social
  restriction, significant cost to NHS
• Not talked about, often neglected.

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Incidence and prevalence ?with age

• Up to 18 of community dwelling adults1
• 1.4 of all aged gt40 2
• 47 of NH residents 3
• 3-4 of all aged gt65 4,5

Refs 1 MacMillan et al DCR 2004 2 Perry et al
Gut 2002 3 Nelson et al DCR 1998 4 Peet et al
BMJ 1995 5 Campbell et all Age Ageing 1985
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Causes of FI - numerous!

• Your Practice
• Poor mobility
• Cognitive impairment
• Constipation
• Sphincter degeneration

• Our Practice
• Obstetric trauma
• Sphincter defect
• Iatrogenic
• Fistula
• IBS
• Inflammatory BD
• Congenital

• Both
• Prolapse
• Haemorrhoids
• Drugs
• Foods

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Questions you must ask

• Do you have to rush?
• Stool consistency?
• Can you go when you get there?
• Does something else come out?
• Is it difficult wiping clean?
• Do you leak during the day?

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Baseline assessment (on the ward)

• Four key bedside questions
• Have we examined and what did we find ?
• Is the patient loaded ?
• What is the stool consistency ?
• Have we excluded a cancer ?
• Commence initial treatment and then reassess

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Doing the PR

• Two sphincters-
• IAS keeps anus closed
• EAS voluntarily squeezed to ensure closure of
  anus.

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Doing the PR - Inspection

• Anus open/closed, gapes to traction
• Poor IAS function.

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Doing the PR - inspection

• Can you squeeze ?
• An idea of EAS function.

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Descent/rectocele
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Doing the PR - palpation

• Idea of resting tone.
• Idea of squeeze tone.
• Confirm if loaded or not.
• Rectocele ?
• Exclude anal/rectal cancer.

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Treatment options

• INITIAL
• Bowel habit
• Stool consistency
• Diet and fluid intake
• Fibre
• Toilet access/mobility
• Skin preps/ pads /plugs
• Drugs cause/treat
• oral/rectal

• SPECIALISED
• Pelvic Floor Exercise
• Biofeedback
• Rectal Irrigation
• Electrical Stimulation
• Surgery
• Stoma

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Treatment options

• Some or most of the initial treatment options may
  be required.
• Commence and then reassess

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Initial treatment options

• Access?
• FI due to poor mobility
• Urgency

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Initial treatment options

• Diet/fluid intake
• Anti-diarrhoeal medication Loperamide
• Regular, before meals (syrup or capsules)
• prn basis, imodium instants

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Plugs

• No good evidence but may help some.

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The faecally loaded

• Plan
• 1) initial clearance
• 2) /-bowel management programme
• Some patients restore continence with clearance.
• Those with chronic loading may benefit from
  active management.
• Tobin 1986 RCT
• Constipated FIlactulose and weekly enemas FI
  codeine and enemas twice week
• Compared with standard care significant
  reduction in FI episodes.

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Neurological /spinal injury

• muscles don't work cant go, cant hang on
• Plan
• 1) active bowel management programme
• premorbid bowel habit
• patient input/preferences
• diet/oral laxatives/evacuants to achieve
  predictable bowel pattern

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The prolapser

• Dont strain
• Soft formed stool
• Suppositories
• Plug
• Avoid constipation

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The patient with descent / rectocele

• Digital support
• Suppositories
• Formed stool
• Enemas
• Rectal washouts

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Who to refer?

• Failed initial options and patient keen for
  further input.
• Diet/fluid, Stool consistency, loperamide,
  suppositories, etc.
• Physically and mentally able.
• Patients with troublesome prolapse

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Specialist Options

• Majority still managed with conservative
  measures.
• Biofeedback
• Surgery
• Injection bulking agents
• Anterior Sphincter repair, prolapse surgery.
• SNS
• Artificial bowel sphincter
• Stoma

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Sacral Nerve Stimulation
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SNS

• Mechanism of action unknown.
• Testing phase allows assessment of response.
• Easily performed under LA as daycase.
• Mainly Faecal urgency and Urge FI benefit.
• May need additional treatments.

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Prolapse Surgery

• Abdominal Rectopexy
• Low recurrence rate
• Post op constipation
• Operative risks

• Perineal (e.g.Delormes)
• Higher recurrence rate
• Less operative risk

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Summary

• FI is common and distressing.
• We need to talk about it.
• Baseline assessment, commence and reassess
• No one recipe for success
• Area of future research

References NICE Guidelines June 2007 Website
www.rcsed.ac.uk/fellows/kcattle/fi_home.html