Fecal Incontinence

[xray]
Fecal incontinence
2.2% of population suffers from FI

Men with FI: 51.1% prevalence of urinary incontinence
Women with FI: 59.6% prevalence of urinary incontinence

Higher in institutionalized patients & 7% of those >65
56% prevalence on psychiatric wards
32% prevalence on geriatric wards

Cost $400 Million per year in USA in pads alone!

Definition

Fecal Incontinence (FI) is defined as either the involuntary passage or the inability to control the discharge of stool.

There are 3 subtypes of FI:

Passive incontinence – The involuntary discharge of stool or gas without awareness
Urge incontinence – The discharge of fecal matter in spite of active attempts to retain bowel contents
Fecal seepage – The leakage of stool following otherwise normal evacuation

Another way to describe this is the inability to defer the urge to pass gas or stool to a socially acceptable time and place.

Other names for fecal incontinence:

Bowel accidents
Accidental bowel leakage
Bowel incontinence
Rectal discharge
Loss of bowel control
Anal leaking/leakage
Anal incontinence
Rectal leaking/leakage

Symptoms of Fecal Incontinence

Bowel accidents
Anal leakage
Stained or soiled under garment
Irritation around anus
Accidental loss of gas or bowel contents

Statistics on Fecal Incontinence

The prevalence of FI is increased in the elderly. It is one of the most common reasons for entering a nursing home.

45% of nursing home residents have FI
10% to 15% in the more independent residents
Up to 70% among the most dependent residents

FI affects 16% of non-institutionalized adults aged 70 years and older.

FI affects up to 19 million people in the United States (US)
Studies suggest that only 15%– 45% of FI patients seek treatment.

Consider the following statistics that support the claim that fecal incontinence is a hidden condition:

For 84% of patients with FI, the physician was unaware of the patient’s disorder
54% of patients with FI had not discussed the problem with a professional
65% of patients with severe or major FI which had an impact on the quality of life wanted help with their symptoms

Mechanisms of Fecal Continence

Colonic factors

Stool volume
Stool consistency

Anorectal factors

Capacity/compliance of rectum
Anal seal of vascular cushions

Muscular factors

Sphincteric/pelvic floor function
Intact anal sphincter

Neurological factors

Rectal sensation
Normal mentation
Intact innervation/reflexes

Causes of Fecal Incontinence

Problems with anal leakage are likely due to several causes. Treatment must be directed at multiple causes.

Labs/stool studies

Radiology

Anal ultrasound
Anal MRI
Defecography
Barium enema
Peritoneography

Non-surgical Treatments of Fecal Incontinence

Medicines
Diet / fiber
Stool softeners
Physical therapy

Surgical Options to Treat Fecal Incontinence

There are now successful surgical options. There is no need to suffer any longer. Be open with your doctor about symptoms. Ask about seeing a specialist.

Surgical treatments may include:

Sphincter Repair
Sacral nerve stimulation
Anal bulking agent injection
Antegrade colonic enema
Graciloplasty
SECCA®
Artificial sphincter
Colostomy or diversion

Non-surgical Options to Treat Fecal Incontinence

Enemas
Biofeedback / physical therapy
Medication adjustments
Systemic disease treatment

Gillis Defacatory Disorders Center

Constipation

Constipation Results in 2.5 million doctor visits per year
2 – 28% prevalence in general population

Patients are typically seen by:

Family practitioners (31%)
Internists (20%)
Pediatricians (15%)
Gastroenterologist (4%)

$400 million spent on laxatives annually (1991)

Other Names for Constipation:

Infrequent bowel movements
Rectal outlet obstruction
Excessive straining
Rectal or anal blockage
Rectal or pelvic pressure
Incomplete evacuation

Constipation Counselling Sheet

Mechanisms of Fecal Continence

In order to understand constipation one must understand why people can hold stool. There are multiple factors that affect continence.

Colonic factors
Stool volume
Stool consistency
Anorectal factors
Capacity/compliance of rectum
Anal seal of vascular cushions
Muscular factors
Sphincteric/pelvic floor function
Intact anal sphincter
Neurological factors
Rectal sensation
Normal mentation
Intact innervation/reflexes

Process of Defecation

The process of defecation is very complex. It is as follows:

Entry of stool in the vault
Internal sphincter relaxes
Semi-voluntary Valsalva
Increase intrathoracic/-abdominal pressure
External sphincter relaxes
Pelvic floor descends

If any of these are abnormal or in a different order, defecation can be difficult.

Causes of Constipation

Endocrine diseases
Metabolic disorders
Neurologic disorders
Surgery
Dietary/Activity abnormalities
Collagen vascular disorders
Pharmacologic agents
Obstructive bowel diseases
Functional disorders
Primary or idiopathic
Global motility disorder
Outlet obstruction

Primary Constipation

There are different types or forms of constipation. These different types have certain characteristics.

Colonic Intertia

Infrequent stools
Change in consistency

Normal Transit Constipation

Normal frequency
Normal consistency
“Feel constipated” or “bloated”

Outlet Obstruction

Normal frequency
Normal consistency
Difficulty evacuating

Work-up of Constipation

The work-up of constipation can include many tests. An extensive work-up allows the surgeon to choose the right treatment plan for the individual patient. The work-up can include the following:

History and Physical

Anal Physiology Testing

Anal manometry
Rectal sensation testing
Recto-anal inhibitory reflex testing
Balloon evacuation
Electromyography

Labs/Stool Studies

Radiology

Sitz mark study (colonic transit study)
Defecography

Fluoroscopic
Magnetic resonance

Gastric motility
Upper gastrointestinal series and small bowel follow through
Barium enema
Balloon proctography
Fecoflowmetry
Peritoneography

Colonoscopy

Upper Endoscopy

Pelvic Floor Symptoms

Pelvic/vaginal pressure
Dyspareunia (painful intercourse)
Dragging/drawing vaginal sensation
Urinary incontinence
Difficulty emptying bladder
Repositioning body to empty bladder
Constipation – Infrequency, Straining
Fecal incontinence
Incomplete emptying
Bulging
Pain/pressure
Bleeding
“blockage”

Sitz Mark Test (colonic transit time test)

Good as a screening test
Different techniques are used
Previously stool was X rayed for markers
Segmental transit times can be obtained
Part of workup for all constipation
Cheap
Easy to use & easy to read
Used with UGI&SBFT and/or gastric emptying study
Confirms an outlet obstruction in 75–92% of patients with defecographic non-relaxation

Fluoroscopic Defecography

Evacuation proctography, video defecogram
Cineradiology first used in 1960’s
Primarily assesses anatomical relationships
Abnormal in 50% of asymptomatic patients

Anorectal Manometry

Assesses the physiologic interaction of rectum & anus
Protocols: Static, Continuous pull-through, Station pull-through protocols
Obviates needle EMG

Treatment of Constipation

Dietary changes, fiber, increased fluids
Exercise
Laxatives / enemas
Motility agents
Biofeedback / physical therapy
Medication adjustments
Systemic disease treatment
Surgical correction

Pelvic floor repair
Colectomy
Rectopexy
Rectocele repair
Botox injection