FECAL INCONTINENCE : EVALUATION &...
Transcript of FECAL INCONTINENCE : EVALUATION &...
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FECAL INCONTINENCE : EVALUATION & SURGERY
Dr. Budi Iman Santoso, SpOG(K)
Division of Urogynecology ReconstructiveDepartment of Obstetrics and GynecologyFaculty of Medicine University of Indonesia
Jakarta
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FECAL INCONTINENCE
∆ What is continence ?
∆ The ability to defer and control the call to passage of gas, liquid or solid material to an appropriate time and place
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FECAL INCONTINENCE PREVALENCE
∆ Fecal incontinence∆ 2570 household survey
– 2.2% incidence of incontinence– 30% over age 65– 63% female
Nelson et al, 1995– Only 34% of pts with incontinence have
discussed with physicianJohansen et al 1996
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FECAL INCONTINENCE PREVALENCE
Meta-analysis of over 26.000 people surveyed from the general population
Country Year Patients Prevalence
United Kingdom 2001 2818 3%
Nigeria 2002 3963 6.96%
Australia 2002 660 9%
United Kingdom 2002 10116 1.40%
New Zealand 2001 717 12.70%
United Arab Emirates 2001 450 11.30%
Switzerland 2001 984 4.40%
United States 1995 6959 2.20%
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FECAL INCONTINENCE PREVALENCE
∆ Prevalence of fecal incontinence as high as 17% in pts with urinary incontinence
Jackson et al, Obst Gynec, 1997
∆ 26% of women in urogynecology clinics have fecal incontinence
Khullar et al, BJ Obst Gynaecol, 1999
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BIRTH-RELATED ANAL SPHINCTER TRAUMA
∆ After forceps delivery– 81% defects– 38% symptomatic
∆ After vacuum extractor– 21% defects– 12% symptomatic
∆ Normal delivery– 36% defects– 4% symptomatic
(Sultan et al., IJGO 1993)
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EVALUATION
∆ History & Physical∆ Incontinence Score∆ US∆ Manometry∆ EMG∆ PNTML
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HISTORY∆ Detailed Bowel History
– Passive soiling– Unwanted loss of stool without pts awareness internal
sphincter pathology∆ Urge incontinence
– Unwanted loss of stoot despite attempts to inhibit defacation
– External sphincter pathology∆ Postdefacation soiling
– Unwanted loss of stool immediately after bowel movement with normal continence other times
– Incomplete emptying, perianal disease
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FECAL INCONTINENCE SCORING SYSTEM
Type of incontinence
Never Rarely
< 1/mo
Some times<1/week>1/month
Usually<1/day
>1/week
Always
>1/day
Solid 0 1 2 3 4
Liquid 0 1 2 3 4
Gas 0 1 2 3 4
WearsPad
0 1 2 3 4
Lifestyle Alteration
0 1 2 3 4
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PHYSICAL EXAMINATIONProne Jack-Knife position∆ Inspection
– Excoriation– Skin tags– Scars– Dermatitis– Patulous Anus
Digital examination– Resting tone– Voluntary squeeze pressure
• Exclude accessory muscle contraction– Perineal bulk– Sphincter defect
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PHYSICAL EXAMINATION∆ Examination on straining
– Perineal descent– Rectocele– Cytocele– Perineal hernia
∆ Examination on squatting∆ Vaginal-anal bi-digital exam
– Rectovaginal septum
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ANOSCOPIC EXAMINATION
∆ 360 degree view∆ Hemorrhoidal pathology∆ Anal fissure∆ Anal fistulae
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ANORECTAL PHYSIOLOGIC EVALUATION
∆ Anal manometry∆ Anal ultrasound∆ Pudendal nerve terminal motor latency∆ Anal EMG
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ANAL MANOMETRY
∆ Not standardized: Each facility has its own protocol and normal values
∆ Measurement devices – Fluid / air filled balloon systems– Open tipped perfused catheters– Microtransducers– 4 channel continuously perfused probe
∆ Continuous or stationary pull through techniques∆ Method of measurement
– Static– 24 hour ambulatory
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ANAL MANOMETRY EQUIPMENT
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ANAL MANOMETRY TECHNIQUE
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ANAL MANOMETRY RESTING PRESSURE
∆ 50-70 mmHg∆ Lower in women and elderly∆ Highest pressures 1-2cm cephalad to anal
verge
∆ 55-60% from IAS tone∆ 25% from EAS tone (low sacral reflex)
(EAS, cricopharangeal and paraspinous)∆ 15% from expansion of anal cushions
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ANAL MANOMETRY SQUEEZE PRESSURE
∆ 100-180 mmHg (2-3x resting tone)
∆ Generated by EAS and puborectalis contraction
∆ Rapid fatigue
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ANAL MANOMETRY HIGH PRESSURE ZONE
∆ High pressure zone
Length of the IAS where pressures are greater than ½ of the maximum pressure at rest
Normal 2-3.5 cm
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ANAL MANOMETRY HIGH SENSATION
∆ First rectal sensation 10-20cc air
∆ No receptors in the rectum∆ Proprioceptors in the rectum
Puborectalis and anal sphincters∆ Greather than 25% of pts with fecal
incontinence have abnormal sensation
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ANAL MANOMETRY
∆ Rectal compliance
∆ Compliance = ∆V / ∆P
∆ Impaired in ulcerative colitis, hirschprung’s, radiation therapy
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EAS IAS
ANAL MANOMETRY
∆ Rectoanal inhibitory reflexDescribed by Gowers 1877
Sampling mechanism of the anal canal
Rectal distension causes reflex EAS contraction transient IAS relaxation
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ANAL MANOMETRY NORMAL VALUES
Resting pressure 50-70 mmHg
Squeeze pressure 100-180 mmHg
RAIR Present
Compliance 2-6cc H2O/cm
First sensation 10-30cc
Capacity 100-300cc
HPZ length 2-3cm (female)2.5-3.5cm (male
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ANAL MANOMETRY REPORT
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DRE vs MANOMETRY
∆ How reliable is digital examination for the evaluation of anal sphincter tone?
∆ 64 pts, 1 physician– IAS pathology - DRE 63% sensitivity
57% specificity– EAS pathology - DRE 84% sensitivity
57% specificityEckardt et al., Int J Colorectal Dis. 1993
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ENDOANAL ULTRASOUND∆ Circumferential images using rotating
probe∆ 5,7 or 10Mghz probes available∆ Acoustic coupling via a hard cap filled
with water∆ Limit of images is to the puborectalis
muscle ∆ Evaluates-anal sphincters, anorectal
spaces including fistula tracts
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ENDOANAL ULTRASOUND EQUIPMENT
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ENDOANAL ULTRASOUNDPROCEDURE
∆ Cleansing enema (s)∆ Left lateral decubitus position∆ Digital rectal examination∆ Endoanal ultrasound∆ Image review
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ANAL ULTRASOUND NORMAL ANATOMY-ANAL CANAL LEVELS
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ANAL ULTRASOUND NORMAL ANATOMY-ANAL CANAL LEVELS
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ANAL ULTRASOUND NORMAL ANATOMY-ANAL CANAL LEVELS
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ANAL ULTRASOUND NORMAL ANATOMY-ANAL CANAL LEVELS
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ANAL ULTRASOUND UPPER ANAL CANAL LEVELS
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ENDOANAL ULTRASOUND MID ANAL CANAL LEVELS
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ENDOANAL ULTRASOUND DISTAL ANAL CANAL LEVELS
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ANAL ULTRASOUND
∆ Anal US and correlation with in vitro and in vivo anatomy– 14 fresh specimens (APR and post mortem)– Ultrasound correlated with anatomic dissection– Anatomic dissection confirmed by pathologic
examinationSultana et al, Br J Surg. 1993
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FECAL INCONTINENCE
∆ Abnormal findings on US– External anal sphincter defects– internal anal sphincter defects– Scarring– Thin perineal body
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SPHINCTER DEFECTS
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US vs EMG
∆ Confirmation of US detected EAS defects by simultaneous EMG mapping– 13 US detected traumatic defects– Simultaneous EMG recording of defect and
normal muscle– 11/13 had correlation of US defect and EMG
activity
Bumett et al, Br J Surg 1991
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NEUROPHYSIOLOGIC ASSESSMENT
∆ Anal electomyography (EMG) physiologic assessment of function at the level of the external anal sphincterDetermine if the muscle contracts/ relaxes identify areas of injury-mapping Identify denervation/ reinnervation potentials
∆ Pudendal Nerve terminal motor latency time from stimulation of pudendal nerve at level of ischial spine to muscle response at the anal sphincter
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EMG DATA
∆ Localized quadrant activity– Normal signal– Absent signal (no activity)– Injury and healing (scar)
• Reduced activity• Polyphasic motor unit potentials
∆ Can locate sphincter defect
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US vs EMG
∆ Confirmation of US detected EAS defects by simultaneous EMG mapping– 13 US detected traumatic defects– Simultaneous EMG recording of defect and
normal muscle– 11/13 had correlation of US defect and EMG
activity
Bumett et al, Br J Surg 1991
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PUDENDAL NERVE TERMINAL MOTOR LATENCY(NORMAL 2.0 + 0.2MSEC)
St. Marks Electrode
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PUDENDAL NERVE TERMINAL MOTOR LATENCY
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PUDENDAL NEUROPATHY
∆ PNTML greater than 2.2ms∆ Stretch injury
– Chronic straining– Perineal descent– Vaginal delivery
∆ 31.4% incidence in 395 consecutive studies
∆ More frequent in pts over 70
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PUDENDAL NEUROPATHY TREATMENT OUTCOME
∆ Several authors have proposed a direct correlation between pudendal neuropathy and poor outcome after sphincter repair
∆ Controversy still exists∆ May be helpful in preoperative
counseling
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PUDENDAL INCONTINENCE MANAGEMENT
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FECAL INCONTINENCE SURGICAL MANAGEMENT
∆ Overlapping sphincteroplasty∆ Injectables∆ Radiofrequency ablation∆ Artificial bowel sphincter∆ Sacral nerve stimulation∆ Stoma
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ANTERIOR OVERLAPPING SPHINCTEROPLASTY
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FECAL INCONTINENCE: OBSTETRIC
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OVERLAPPING SPHINCTEROPLASTY
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OVERLAPPING SPHINCTEROPLASTY
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OVERLAPPING SPHINCTEROPLASTY
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OVERLAPPING SPHINCTEROPLASTY
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OVERLAPPING SPHINCTEROPLASTYLONG TERM RESULTS
∆ Cleveland clinic florida experience– 25 pts– 5 year follow-up– Evaluated with fecal incontinence scoring
system• Preop = 17.7• Postop = 4.1 (9 mos)• Long term score = 10.8 (87 mos)
– No patient was completely continent at long term follow-up
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ANTERIOR SPHINCTER REPAIRLONG TERM RESULTS
∆ Cleveland clinic florida experience∆ No correlation between long term
continence and :– Age– # Vaginal delivery– Episiotomies– Previous sphincter repair– Manometric data– PNTML– EAUS findings
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ANTERIOR SPHINCTER REPAIRLONG TERM RESULTS
∆ 46 pts with obstetric related anterior sphincter defects
∆ 5 year follow up∆ 17% required further surgery (failure)∆ 38 pts evaluated for long term functional
outcome– 71% improved– 13% no improvement– 16% deteriorated
• Malouf et al. Lancet, 2000
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ANTERIOR SPHINCTER REPAIRLONG TERM RESULTS
∆ Cleveland clinic foundation experience– 63 patients– 5 year follow up– 57% incontinence to solid or liquid stool– 14% totally continent– 2 pts with colostomy
Halverson, et al, Dis Col Rectum, 2003
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INJECTABLES
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INJECTABLES
∆ Autologous fat∆ Silicone∆ Collagen∆ Carbon beads
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ACYTSTM OR DURASPHERE FITM
∆ Carbon beads
∆ Ice Syringe
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ACYTSTM OR DURASPHERE FITM
∆ Microscopic picture of pyrolitic carbon beads
∆ Each carbon bead is 212-500µm
∆ Suspension of carbon bead in a gel consisting of water and beta-D glucan
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ACYTS
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ACYTS
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ACYTS INJECTION∆ Prospective open label trial∆ Local anesthesia∆ Outpatient setting ∆ Fecal incontinence score = 13 (7-15)∆ 80% of patients improved following ACYTSTM
injections∆ 23% improvement in incontinence scores mean
of 13 preprocedure to 10 at 3 mos∆ 30% improvement in incontinence scores at 6
mos 6 pts, score=9.3Weiss et al American Society of Colon and rectal Surgeons Annual
Meeting Chicago. Illinois, 2000
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DURASPHERE® FI PHASE II IDE STUDY
∆ Prospective , multicenter, sham controlled study for subjects with fecal incontinence
∆ 2:1 randomization∆ Failed atandard options of treatment
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RADIOFREQUENCY SECCA
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RADIOFREQUENCY ABLATION SECCA PROCEDURE
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SECCA PROCEDUREextended Two-Year Follow-up
∆ 10 patients∆ CCF fecal incontinence score
– Pretreatment 13.8– 2 year F/U 7.3
P<0.002
∆ Social and mental component of SF-36 improved at 24 mos
∆ No decease in efficacy from 12-24 mosTakahashi, et al. Dis Colon Rectum 2003
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Results: 2 year follow-upcleveland clinic Florida-Incontinence score
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SECCA PROCEDURE
∆ Multi-center, open label, prospective trial ∆ Five centers enrolled 50 patients∆ At 6 months, the mean CCF-FI score improved
significantly (14.5 to 11.1, p<0.0001)∆ All FIQL parameters improved∆ 60% (n=30) of the patients improved after therapy∆ RF energy delivered for treatment of FI safely improves
CCF-FIS, FIQL, and quality of life
Efron, Song Tecknol Int 2004
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FIQL SCORES
*p<0.0001, ITT analysis
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SECCA
∆ Relatively simple procedure∆ Well tolerated∆ No need for general anesthesia
∆ Consider for patient with mild fecal incontinence or those who can not tolerate more invasive procedures
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ARTIFICIAL BOWEL SPHINCTER
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ARTIFICIAL BOWEL SPHINCTER
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ARTIFICIAL BOWEL SPHINCTER
∆ Originally introduced in late 1970s∆ Reintroduced 1996∆ European series
– 24 pts– 20 month follow-up– 20 pts had active device in place– 4 definitive failures– Clinical success in 18/24 pts
• Lehur et al, Dis Col Rectum 2000
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ARTIFICIAL BOWEL SPHINCTER
∆ Multicenter, prospective, non-randomized∆ 112 patients were implanted∆ Mean age 49 (range 18-81) years∆ 384 device related adverse events in 99 patients∆ 246 required either no or non-invasive intervention∆ 73 revisional operations in 51 (46%) patients∆ Infection requiring surgical revision was 25%∆ 41 (37%) patients had devices completely explanted
– 7 had successful reimplantationsWong et al. DCR. 2002
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ARTIFICIAL BOWEL SPHINCTER
∆ 85% of patients with a functional device had successful outcome
∆ 53% intention to treat success rateWong et al. DCR. 2002
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ARTIFICIAL BOWEL SPHINCTER
∆ Infection is the major challege∆ Once device is implanted successfully
long term success is common∆ Newer series show decreased infection
rates with changes in antibiotic regimen
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ARTIFICIAL BOWEL SPHINCTER
∆ Complex device∆ Patient selection is important
∆ Can avoid a stoma in patients with severe fecal incontinence who are not candidates for or who have failed other therapies
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SACRAL NERVE STIMULATION
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SACRAL NERVE STIMULATION
∆ Initially described for treatment of urinary incontinence
∆ Patients with dual incontinence noted improvement in fecal incontinence
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SACRAL NERVE STIMULATION
∆ Technique– Acute percutaneous nerve evaluation
Establishes integrity of nervesTests relevance of each sacral nerve rootGeneral or local anesthesia
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SACRAL NERVE STIMULATION
∆ Permanent implantation
Remove percutaneous extensionPermanent generatorPulse frequency 210 usecFrequency 15 HzAmplitude adjusted to pts sensation of contraction
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SNS LEAD DEPLOYMENT
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SACRAL NERVE STIMULATIONRESULTS
∆ Multicenter prospective trial∆ 37 patient test stimulation∆ 34 permanent implantation∆ Daily bowel-habit diaries∆ Disease-specific ASCRS scale and in 7/8 SF-36 scales∆ Frequency of incontinent eoisodes per week
– 16.4 vs 3.1 and 2.0 at 12 and 24 monts∆ Mean number of days per week with incontinent episodes
– 5.5 vs 1.4 and 1.2 at 12 and 24 monthsMatzel KE. Et al Lancet. 2004 Apr 17.363(9417):12706
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SACRAL NERVE STIMULATIONRESULTS
∆ UK experience∆ 3 centers∆ 12 month follow-up∆ 59 patient peripheral nerve evaluation ∆ 46 (78%) permanent implantation∆ 44/46 had improved continence at a median of 12 months∆ Median of 7.5 to 1 incontinent episodes/week∆ Ability to defer defecation improved from 1 to 10 min∆ Significant improvement occurred in general health, mental
health, emotional role, social function, and vitality subscales of the SF 36
Jarrett ME, et al. Br J Surg 2004 Jun 91(6) 755-61
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SACRAL NERVE STIMULATIONRESULTS
∆ 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period
∆ 37 permanent implantation∆ Median of six months follow-up∆ CCF incontinence score (0-20) reduced from median 16 to
6Rasmussen OO et al Dis Colon Rectum 2004 Jul 47(7):1158-62
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SACRAL NERVE STIMULATIONRESULTS
∆ 106 potentially relevant reports∆ Six patient series and one crossover study of SNS for fecal
incontinence∆ 19 adverse events among 149 patients∆ SNS results in significant improvement in fecal
incontinence in patient resistant to conservative treatment∆ Early data also suggest benefit in the treatment of
constipation
Jarrett ME, et al. Br J Surg 2004 Dec 91(12) 1559-69
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SACRAL NERVE STIMULATION
∆ 34 patients (31 women)∆ 57 (33-37) years old∆ Double-blind multicenter crossover trial∆ 27/34 “on” or “of”x1 month periods∆ 89% patients felt significant improvement in incontinence
episodes∆ Significant decrease in frequency of FI episodes ∆ Improvement of Cleveland clinic score∆ QOL score improved in all domains∆ With stimulator ON mode-increase in resting and squeeze
pressuresLerol et al, Ann Surg 2005
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SACRAL NERVE STIMULATION
∆ Promising new treatment∆ Still in FDA trials in the US
∆ Consider for patient with severe fecal incontinence and no sphincter defect
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Isolated sphincter defect
Persistentdefect
Intactrepair
Success Failure
Failure
Stoma
FailureSuccess
Sphincteroplasty
Consider
Pudendal neuropathy Alternative procedures
Simple procedures complex procedures
Injectable agentsradiofrequency
Sacral nerve stimulationStimulation graciloplastyArtificial bowel sphincter
Yes Yes No
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SUMMARY
∆ There are many therapeutic options for the patient with fecal incontinence
∆ The decision of which is best for a particular patient depends on:– The etiology of the incontinence– The severity of the symptoms– The patient’s operall health and ability to undergo treatment