Fecal Incontinence

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Fecal Incontinence

• Seema Izfar

2/29/12
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Fecal Incontinence

• affects estimated between 2-20 people, 50
  nursing home residents
• at risk parous females, cognitively impaired,
  elderly
• defined as recurrent uncontrolled passage of
  fecal matter for at least one month
• partial incontinence - inability to control
  flatus or fecal soiling

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Etiology

• continence anal sphincters, pelvic floor, stool
  volume/consistency, rectal compliance,
  neurological function
• pseudo-incontinence hemorrhoidal prolapse,
  incomplete evacuation, poor hygiene, STDs,
  neoplasms, IBD
• fecal urgency vs. incontinence
• overflow incontinence

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Obstetrical Trauma

• anal sphincter injury
• occult obstetrical injury in 25- 35 of vaginal
  deliveries (!!!!!!!!!!)
• risk factors forceps, episiotomy, primiparity
• denervation of pelvic floor (compression/traction
  injury to pudendal)

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Iatrogenic

• iatrogenic injury following
• lateral internal sphincterotomy
• fistulotomy (reported as high as 35-45)
• hemorrhoidectomy
• radiation therapy

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Congenital malformations

• spina bifida
• imperforate anus
• myelomeningocele
• related to dysfunction of pelvic floor as well as
  abnormal proprioception of rectum

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Diagnosis

• history (obstetrical/ surgical), changes in bowel
  consistency, passive vs urge incontinence
• quantify degree of incontinence
• Cleveland Clinic Florida Fecal Incontinence Score
  (CCF-FIS)

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CC Fecal Incontinence Scoring

• 0 perfect continence
• 20 complete continence
• never 0,
• rarely lt1x/month,
• sometimes gt1x/month
• usually gt1x/wk,
• always gt1x/day

type of incontinence never rarely sometimes usually always
Solid 0 1 2 3 4
Liquid 0 1 2 3 4
Gas 0 1 2 3 4
Pad Usage 0 1 2 3 4
Lifestyle impact 0 1 2 3 4
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Diagnosis

• physical examination evidence of trauma, skin
  excoriation, fistulae, protruding hemorrhoids
• inspect perineal body
• patulous anus - check for prolapse

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Diagnostic Studies

• endoanal ultrasound - diagnostic cornerstone
• internal sphincter - hypoechoic
• external sphincter - hyperechoic
• scar tissue - mixed echogenicity
• measure perineal body thickness (PBT) - less than
  10mm abnormal

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Diagnostic Studies

• Anorectal manometry - functional status of anal
  sphincters and distal rectum
• station pull through or continuous pull through
• measurements resting pressure (IAS), squeeze
  pressure (2-3x baseline), high-pressure zone
  (length of IAS, in women 2-3cm), RAIR (rectoanal
  inhibitory reflex), rectal sensation and
  compliance
• RAIR - IAS relaxation with EAS contraction with
  small volume rectal distention - enables sampling
  reflex
• absent in Hirschsprungs, Chagas, dermatomyositis,
  scleroderma

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Diagnostic Studies

• pudendal nerve terminal motor latency - electical
  impulses to PN with time response of EAS - nml
  2.0 /- 0.2ms
• pudendal neuropathy implicated in poor outcomes p
  sphincteroplasty
• EMG
• defecography
• colonoscopy

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Nonoperative Management

• medical therapy
• biofeedback
• secca procedure
• injectables

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Medical Therapy

• bulking agents, constipating agents (lomotil,
  codeine, amytriptyline), laxative regimens with
  scheduled disimpaction (for overflow
  incontinence)
• loperamide - synthetic opiod, inhibits small and
  large intesting Mu receptor - also increases IAS
  resting pressure, rectal sensation and increase
  RAIR

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Biofeedback

• pioneered in 1974 (Miller-Abbot balloon used as
  sensor to improve quality of Kegel exercises)
• published studies with improvement of continence
  in adults and children with biofeedback 70 of
  time
• long-term benefit less clear
• randomized controlled trial (Heyman et al.) with
  pelvic floor exercise vs manometric biofeedback
  with 44 vs 21 able to achieve complete
  continence

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Biofeedback
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Secca Procedure

• high-frequency alternating current - modification
  of treatment for GERD
• thermal energy - build collagen, shorten/remodel
  muscle
• RF delivered 90s each quadrant at 5mm increments
  (usually 16-20 increments)
• Takashi et al. 19 pts at 5 yr follow-up, in 16
  pts gt50 improvement

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Secca Procedure
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Injectables

• developed from treatment of urinary incontinence
  with injectable bulking agent
• safe, minimally invasive, outpatient
  administration
• silicone vs carbon-coated microbeads
• maximum improvement 1-6 mos, durability 1-2 yrs

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Injectables
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Operative Treatment

• overlapping sphincteroplasty
• parks posterior anal repair
• sacral nerve stimulation
• artificial bowel sphincter
• muscle transposition
• fecal diversion

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Anterior Overlapping Spincteroplasty

• Anterior Overlapping sphincteroplasty - mainstay
  treatment for incontinence with ext sphincter
  defect
• identification of ends with mobilization
• levator plication at proximal extent of
  dissection
• overlapping repair shown to be superior to
  end-to-end repair, though might be associated
  with evacuation difficulties
• both with diminishing efficacy over time

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Parks Posterior Anal Repair

• treatment of neurogenic fecal incontinence -
  lengthen the canal and correct anorectal angle
• curved incision behind anus, dissection in
  interspincteric plane
• plicate pubococcygeus and puborectalis
• published poor long-term results - 33 at 5 yrs

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Sacral Nerve Stimulation

• developed for urinary incontinence
• staged procedure - percutaneous nerve evaluation
  (2wks), pts with improvement 50 or greater
  offered permanent stimulator
• test stimulate S2, S3,S4 - goal is S3 stimulation
  to contract levator ani, external anal sphincter,
  plantar flexion of first 2 toes
• complications rare - lead migration, infection,
  pain

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Sacral Nerve Stimulation
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Sacral Nerve Stimulation

• largest prospective randomized trial with SNS -
  16 centers, 120 pts with permanent stimulator
  placed
• persistent benefit (50 reduction of symptoms)
  seen in 70 of pts at 36 mos f/u
• interval measurements with 80 success

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Artificial Bowel Sphincter

• first reported in 1987
• transverse perineal incision with subcutaneous
  tunneling around anal canal
• reservoir in space of retzius, pump in labia or
  scrotum, subcutaneous catheter
• pump to evacuate - fluid goes from cuff to
  reservoir - passively refills

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Artificial Bowel Sphincter

• multicenter trial (2002) - 112 pts, 384
  device-related complications in 99 pts
• 25 infection
• 46 revision rate
• 85 pts reports successful outcome

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Gracilis Muscle Transposition

• first reported in 1952 for children with fecal
  incontinence 2/2 neurologic and congenital
  anomalies
• mobilization of gracilis muscle with
  transposition of muscle around anal canal and
  fixation to the contralateral ischial tuberosity
• poorer outcomes with h/o refractory diarrhea or
  constipation, obstetric injury, adv age
• functionally pts can only control solid stool
• skeletal muscle transposition - more easily
  fatigued

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Gracilis Muscle Transposition

• complications evacuatory dysfunction, perineal
  pain, infection
• stimulated gracilopasty with lead placement
  migration/erosion/infection, nerve fibrosis

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Fecal Diversion

• creation of colostomy or ileostomy if all measure
  fail
• uncontrolled perineal stoma --gt controlled
  abdominal stoma
• majority of pts best-served with
  end-sigmoidoscopy
• pts with slow transit or chronic constipation may
  be better served with ileostomy

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Conclusion

• fecal incontinence is a socially devasting
  condition and a symptom describing many
  etiologies
• based on these etiologies, there are many
  non-operative and operative methods of improving
  quality of life

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Management of Fecal Incontience
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