Incontinence Alvi

Incontinence alviIncontinence alvi

ObjectivesObjectives

• AnatomyAnatomy

• PhysiologyPhysiology

• AetiologyAetiology

• Patient assessmentPatient assessment

• Anorectal investigationsAnorectal investigations

• Medical and surgical therapyMedical and surgical therapy

Faecal IncontinenceFaecal Incontinence

• “ “ the inability to defer the passage of the inability to defer the passage of faeces or flatus until socially acceptable”faeces or flatus until socially acceptable”

• Affects 0.1% general populationAffects 0.1% general population

• 1% >65 years1% >65 years

• ?60% long stay institutionalised patients?60% long stay institutionalised patients

AnatomyAnatomy

• Anal canal 2-3cm in females, 3-4 in males, Anal canal 2-3cm in females, 3-4 in males, begins at rectum and passes backwards begins at rectum and passes backwards between levator ani musclesbetween levator ani muscles

• Proximally simple columnar epithelium Proximally simple columnar epithelium changing to stratified squamous changing to stratified squamous epithelium via a intermediate transition epithelium via a intermediate transition zone above the dentate linezone above the dentate line

• Subepithelial connective tissue and Subepithelial connective tissue and smooth musclesmooth muscle

AnatomyAnatomy

• Laterally the continuation of rectal circular Laterally the continuation of rectal circular smooth muscle forms the internal anal smooth muscle forms the internal anal sphincter (IAS)sphincter (IAS)

• Longitudinal layer of rectum lies between Longitudinal layer of rectum lies between IAS and external anal sphincter (EAS) with IAS and external anal sphincter (EAS) with striated muscle contributionsstriated muscle contributions

AnatomyAnatomy

• EAS composed of striated muscle around EAS composed of striated muscle around the IASthe IAS

• Exact arrangement contentiousExact arrangement contentious

• Classically tripartite – deep, superficial and Classically tripartite – deep, superficial and subcutaneoussubcutaneous

• Single muscle and two-part theoriesSingle muscle and two-part theories• Anal endosonography , MRI – not resolved Anal endosonography , MRI – not resolved

dilemmadilemma

AnatomyAnatomy

• Anteriorly shorter EAS in femalesAnteriorly shorter EAS in females• EAS innervated via pudendal nerves EAS innervated via pudendal nerves

(S2,3,4)(S2,3,4)• Sympathetic supply 5Sympathetic supply 5thth lumber nerve root lumber nerve root

via superior and inferior hypogastric via superior and inferior hypogastric plexusplexus

• Parasympathetic supply via S2-4 nerve Parasympathetic supply via S2-4 nerve roots via nervi erigentesroots via nervi erigentes

AnatomyAnatomy

• IAS intrinsic nerve supply from myenteric IAS intrinsic nerve supply from myenteric plexus with additional sympathetic and plexus with additional sympathetic and parasympathetic supply (enhance and parasympathetic supply (enhance and reduce IAS activity respectively)reduce IAS activity respectively)

PhysiologyPhysiology

• Resting anal pressure predominantly IAS Resting anal pressure predominantly IAS mediated (60-85%)mediated (60-85%)

• Maximal squeeze pressure EAS mediatedMaximal squeeze pressure EAS mediated

• Passive incontinence IAS dysfunctionPassive incontinence IAS dysfunction

• Defaecatory urge and urge incontinence Defaecatory urge and urge incontinence EAS dysfunctionEAS dysfunction

PhysiologyPhysiology

• Rectal filling and distension leads to reflex Rectal filling and distension leads to reflex relaxation of the IAS (RAIR)relaxation of the IAS (RAIR)

• Rectal content sampling at mucosal Rectal content sampling at mucosal transition zone – discriminating solid, fluid transition zone – discriminating solid, fluid and flatusand flatus

• Synchronous EAS contractionSynchronous EAS contraction

ContinenceContinence

• Complex interaction of multiple processesComplex interaction of multiple processes

• Stool delivered at appropriate rate and Stool delivered at appropriate rate and consistency to a compliant rectumconsistency to a compliant rectum

• Intact sampling and sphincteric mechanismsIntact sampling and sphincteric mechanisms

• Defaecation requires co-ordinated Defaecation requires co-ordinated relaxation of puborectalis and EAS with relaxation of puborectalis and EAS with increased intra-abdominal pressureincreased intra-abdominal pressure

Incontinence - aetiologyIncontinence - aetiology

• CONGENITALCONGENITAL• Anorectal Anorectal

abnormalitiesabnormalities• Hirshsprung diseaseHirshsprung disease• Spina bifidaSpina bifida

• ACQUIREDACQUIRED• Diarrhoeal statesDiarrhoeal states

• Infective colitisInfective colitis• IBDIBD• Short bowel syndromeShort bowel syndrome• Malabsorption Malabsorption

syndromessyndromes• Intestinal fistulaeIntestinal fistulae• Endocrine tumoursEndocrine tumours• Laxative abuseLaxative abuse

Aetiology - acquiredAetiology - acquired

• Faecal impactionFaecal impaction• Rectal prolapseRectal prolapse• Neurological causes -Neurological causes -

Dementia, MS, Dementia, MS, diabetes, Pudendal diabetes, Pudendal neuropathy, Cauda neuropathy, Cauda equina lesionsequina lesions

• Sphincteric trauma -Sphincteric trauma -Obstetric, iatrogenic, Obstetric, iatrogenic, trauma trauma

• Local pathologyLocal pathology• Neoplasia – adenoma, Neoplasia – adenoma,

carcinoma, melanomacarcinoma, melanoma• Inflammatory – Crohns, Inflammatory – Crohns,

lymphogranuloma lymphogranuloma venereumvenereum

• Loss of rectal reservoir Loss of rectal reservoir – radiation proctitis, – radiation proctitis, IBD, previous rectal IBD, previous rectal resectionresection

• Miscellaneous -Miscellaneous -encopresis, behaviouralencopresis, behavioural

Aetiology - acquiredAetiology - acquired

• Commonest surgical presentationsCommonest surgical presentations

• Obstetric injuryObstetric injury

• Pudendal nerve neuropathy- obstetric or Pudendal nerve neuropathy- obstetric or prolapse relatedprolapse related

• Iatrogenic injuries – probably Iatrogenic injuries – probably underestimatedunderestimated

• Fistulae, sphincterotomy, Fistulae, sphincterotomy, haemorrhoidectomyhaemorrhoidectomy

Patient assessmentPatient assessment

• Difficult for patients to discuss Difficult for patients to discuss incontinenceincontinence

• Time, listening and empathy requiredTime, listening and empathy required

Specific questionsSpecific questions

• Do you get warning? – urgency means sphincter is Do you get warning? – urgency means sphincter is overcome from above(diarrhoea) or EAS weaknessovercome from above(diarrhoea) or EAS weakness

• How long can you delay? How long can you delay?

• Can you defaecate easily? Can you defaecate easily?

• Are stools solid, soft or loose? – consistency Are stools solid, soft or loose? – consistency influences urgency, urgency for solid stool most influences urgency, urgency for solid stool most significantsignificant


• Does anything else come down? – mucosal or full Does anything else come down? – mucosal or full thickness prolapsethickness prolapse

• Can you wipe clean? – difficulty implies an open Can you wipe clean? – difficulty implies an open anus secondary to poor tone or prolapseanus secondary to poor tone or prolapse

• Do you leak during the rest of the day? – poor Do you leak during the rest of the day? – poor resting tone or prolapseresting tone or prolapse

• How often do you go? – colorectal disease or IBSHow often do you go? – colorectal disease or IBS


• Full Obstetric and gynaecological historyFull Obstetric and gynaecological history

• Any anal or pelvic surgeryAny anal or pelvic surgery

• DHDH

• Hx of urinary incontinence or frequency or Hx of urinary incontinence or frequency or uterine prolapseuterine prolapse

Incontinence scoresIncontinence scores

• Cleveland/Wexner scoring systemCleveland/Wexner scoring system

NeverNever RarelyRarely

<1 month<1 monthSometimeSometimess

>1 month>1 month

<1 week<1 week

UsuallyUsually

<1 day<1 day

>1 week>1 week

AlwaysAlways

>1 day>1 day

SolidSolid 00 11 22 33 44

LiquidLiquidss

00 11 22 33 44

FlatusFlatus 00 11 22 33 44

PadsPads 00 11 22 33 44

QOLQOL 00 11 22 33 44

Incontinence scoresIncontinence scores

• Score 0 = perfect continenceScore 0 = perfect continence

• Score 20 = complete incontinenceScore 20 = complete incontinence

• Serial measurements to assess treatment Serial measurements to assess treatment responseresponse

• Research toolResearch tool

ExaminationExamination

• Inspect perineum – scars, fistulae or other Inspect perineum – scars, fistulae or other pathology, look at rest and during pathology, look at rest and during straining (perineal descent or prolapse), straining (perineal descent or prolapse), squeezing and coughingsqueezing and coughing

• Gaping anus – poor toneGaping anus – poor tone• DRE – length of anus, anorectal angle, DRE – length of anus, anorectal angle,

muscle bulk, defects, rectocele, estimate muscle bulk, defects, rectocele, estimate resting and squeeze pressureresting and squeeze pressure

• Sigmoidoscopy – mucosal lesions and Sigmoidoscopy – mucosal lesions and prolapseprolapse

InvestigationsInvestigations

• Anorectal manometry – objective functional Anorectal manometry – objective functional datadata

• Measure maximal resting and squeeze Measure maximal resting and squeeze pressurespressures

• Functional lengthFunctional length

• Rectal complianceRectal compliance

• Presence and nature of Rectoanal inhibitory Presence and nature of Rectoanal inhibitory reflex (RAIR)reflex (RAIR)

Anorectal manometryAnorectal manometry

• Pressure decrease > 60 years F>MPressure decrease > 60 years F>M

• Normal resting pressures 50-70 mmHgNormal resting pressures 50-70 mmHg• Increases distally (HPZ)Increases distally (HPZ)• Maximal squeeze 100-180 mmHgMaximal squeeze 100-180 mmHg

• Usually decrease in incontinence (however Usually decrease in incontinence (however 30-45% of symptomatic patients have 30-45% of symptomatic patients have normal pressures and vice versa)normal pressures and vice versa)

Normal manometryNormal manometry


• Vector volume manometryVector volume manometry

• Radially arranged 8-channel catheter Radially arranged 8-channel catheter withdrawn from anal canalwithdrawn from anal canal

• 3-D reconstructions of anal canal – assess 3-D reconstructions of anal canal – assess radial symmetryradial symmetry

• Demonstrates local or global sphincter Demonstrates local or global sphincter defectsdefects

• Research toolResearch tool


• Endo-anal ultrasound – probable better Endo-anal ultrasound – probable better than vector volume manometrythan vector volume manometry

• Allows accurate assessment of the Allows accurate assessment of the completeness if IAS and EAScompleteness if IAS and EAS

• 3-D reconstructions possible3-D reconstructions possible

• Difficult to interpret Difficult to interpret

Normal EAUSNormal EAUS

IAS defectIAS defect

EAS defectEAS defect


• Anal and rectal sensationAnal and rectal sensation

• Can be measuredCan be measured

• Variety of methodsVariety of methods

• Difficult to interpret resultsDifficult to interpret results


• Pudendal nerve terminal motor latencies – suggest Pudendal nerve terminal motor latencies – suggest pudendal neuropathy if prolonged, prognostic pudendal neuropathy if prolonged, prognostic significance in anterior sphincter repairsignificance in anterior sphincter repair

• Electromyography (EMG) – poorly tolerated, EAUS Electromyography (EMG) – poorly tolerated, EAUS better, research toolbetter, research tool

• Defaecating proctography – demonstrates prolapse Defaecating proctography – demonstrates prolapse and CT weakness, should be clinically evidentand CT weakness, should be clinically evident

• MRI, endocoil receiver MRI – excellent anatomical MRI, endocoil receiver MRI – excellent anatomical demonstration ? accessdemonstration ? access

TreatmentTreatment

• Depends on aetiology – determined by Depends on aetiology – determined by assessmentassessment

• Sphincter injury, stool consistency, CNS Sphincter injury, stool consistency, CNS dysfunction or rectal capacitydysfunction or rectal capacity

• ConservativeConservative

• SurgicalSurgical

Conservative treatmentConservative treatment

• Often stool consistency important Often stool consistency important determinant determinant

• Dietary adviceDietary advice

• SuppositoriesSuppositories

• Alteration of colonic motility - loperamide 2-Alteration of colonic motility - loperamide 2-4mg qds +4mg qds +

• FybogelFybogel

• Prevention of impactionPrevention of impaction

• Tricyclic antidepressantsTricyclic antidepressants


• Drugs affecting resting toneDrugs affecting resting tone• Phenylepinephrine gel 30-40%Phenylepinephrine gel 30-40%• Improves continence scores (normal EAS)Improves continence scores (normal EAS)• Side effects local irritationSide effects local irritation

• Evidence for drug Rx – Systemic review (Cheetham Evidence for drug Rx – Systemic review (Cheetham et 2002) 11 trialset 2002) 11 trials

• Conclusions – small numbers of trial, several Conclusions – small numbers of trial, several different drug regimes, heterogenous population of different drug regimes, heterogenous population of patientspatients

• No EBM to support clinical managementNo EBM to support clinical management


• Biofeedback(anorectal reconditioning) – Biofeedback(anorectal reconditioning) – some enthusiam – advocated strongly some enthusiam – advocated strongly ACPGBI 2004ACPGBI 2004

• Evidence lackingEvidence lacking

• Cochrane review 2000 (Norton et al)Cochrane review 2000 (Norton et al)

• Limited trials (5) , methodological Limited trials (5) , methodological weaknesses leading to unreliable weaknesses leading to unreliable assessment assessment


• Anal plugsAnal plugs

• Physical barrierPhysical barrier

• Good results in children (68% continence)Good results in children (68% continence)

• Not assessed in adultsNot assessed in adults

• Painful, difficult to toleratePainful, difficult to tolerate


• Retrograde colonic lavageRetrograde colonic lavage

• 500 – 1000ml warm water500 – 1000ml warm water

• Twice a day/weekTwice a day/week

• Probable better for soilingProbable better for soiling

• Uncomfortable, time consumingUncomfortable, time consuming


• Perianal skin carePerianal skin care• Superabsorbable disposable productsSuperabsorbable disposable products

• SummarySummary• Improvement in symptoms and quality of Improvement in symptoms and quality of

life in 50% patientslife in 50% patients• Important to exhaust medical treatment Important to exhaust medical treatment

before surgery is consideredbefore surgery is considered

Surgical treatmentSurgical treatment

• Principle – correction of underlying Principle – correction of underlying pathologypathology

• Prolapse – Perineal / abdominal proceduresProlapse – Perineal / abdominal procedures• Fistula – fistulotomy, seton, complex Fistula – fistulotomy, seton, complex

proceduresprocedures• Rectocele - repairRectocele - repair

Surgical treatmentSurgical treatment

• CarcinomaCarcinoma

• Radiation stricturesRadiation strictures

• Inflammatory bowel diseaseInflammatory bowel disease

• ResectionResection

Surgical treatment - Sphincter Surgical treatment - Sphincter repairs proceduresrepairs procedures

• Sphincter defects – identified with EAUS or Sphincter defects – identified with EAUS or manometrymanometry

• Realistical anterior sphincter repair (and Realistical anterior sphincter repair (and anterior levatorplasty, plication), SNS, anterior levatorplasty, plication), SNS, stomas only operationsstomas only operations

• Operation of choice for anterior injuriesOperation of choice for anterior injuries

• Video – sphincter repair onlyVideo – sphincter repair only

Plication proceduresPlication procedures

• Plication procedures – when aetiology is Plication procedures – when aetiology is neurogenicneurogenic

• Plication of puborectalisPlication of puborectalis

Plication proceduresPlication procedures

• Total pelvic floor repairTotal pelvic floor repair

• Combines postanal repair, anterior Combines postanal repair, anterior sphincter plication and levatorplastysphincter plication and levatorplasty

Sphincter augmentation Sphincter augmentation proceduresprocedures• Anal augmentation/replacement when repair Anal augmentation/replacement when repair

impossible – insufficient sphincter, major impossible – insufficient sphincter, major neurological defects, previous failed repairsneurological defects, previous failed repairs

• Gracilis muscle augmentation – uni- or bilateralGracilis muscle augmentation – uni- or bilateral• Electrically stimulated gracilis neosphincterElectrically stimulated gracilis neosphincter• Gluteus maximus transpositionGluteus maximus transposition

• Silastic slingsSilastic slings• Artificial sphinctersArtificial sphincters

Alternative proceduresAlternative procedures

• Sacral nerve stimulation for neuropathic Sacral nerve stimulation for neuropathic sphincters– transcutaneous stimulation via sphincters– transcutaneous stimulation via S3 foramen, still not fully evaluatedS3 foramen, still not fully evaluated

• Antegrade colonic enemata – Antegrade colonic enemata – appendicostomy or continent colonic appendicostomy or continent colonic conduitconduit

• Stoma formation - ? Last resort , problems Stoma formation - ? Last resort , problems with rectal stump – mucus incontinence with rectal stump – mucus incontinence

Results of surgeryResults of surgery

• Anterior sphincter repair +/- anterior Anterior sphincter repair +/- anterior levatorplasty (plication)levatorplasty (plication)

• 7 studies7 studies• N= 16-55N= 16-55• Good/excellent results 47-76%Good/excellent results 47-76%

• Poorer outcomes if co-existed pudendal Poorer outcomes if co-existed pudendal nerve neuropathynerve neuropathy


• Postanal repairPostanal repair• 3 studies3 studies

• N= 57-86N= 57-86

• Good/excellent results 57-86% - short term onlyGood/excellent results 57-86% - short term only

• Total pelvic floor repair- encouragingTotal pelvic floor repair- encouraging

• Limited data, 90% improved or fully continentLimited data, 90% improved or fully continent

• Long term follow up of 57 patients only 14% had Long term follow up of 57 patients only 14% had ongoing benefitongoing benefit


• Sphincter augmentation proceduresSphincter augmentation procedures

• Very small numbers of patientsVery small numbers of patients

• Available data difficult to interpretAvailable data difficult to interpret

• High success rates reported but significant High success rates reported but significant morbiditymorbidity

Incontinence Alvi

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