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Incontinence fécale

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Fecal incontinence
DRE SUSANNA SCARSI
04.07.2019
Dre Celine Duvoisin
Epidemiology
- Very common
- Under-reported
- True prevalence difficult to assess
- Reported prevalence 0.4%-18%
- F:M 63%:37%
- 30% older than 65 years
Bharucha et al - Am J Gastroenterol. -2015
Ditah et al - Clin Gastroenterol Hepatol. - 2014
Definition
• Involuntary loss of rectal contents (feces, gas) through the anal canal and the
inability to postpone an evacuation until socially convenient.
• Fecal incontinence classified as:
o passive incontinence (involuntary discharge without any awareness)
o urge incontinence (discharge despite active attempts to retain contents)
o fecal seepage (leakage of stool with grossly normal continence and evacuation)
Ruiz and Kaiser - World J Gastroenterol -2017
Etiology
Rao et al - Am J Gastroenterol. - 2004
Risk factors
•Older age
•Diarrhea
•Fecal urgency
•Urinary incontinence
•Diabetes mellitus
•Hormone therapy
Bharucha et al - Am J Gastroenterol. -2015
Physiopathology
•diarrhea
•anal and pelvic floor weakness
•reduced rectal compliance
•reduced or increased rectal sensation
•multi-faceted anorectal dysfunctions
Physiopathology
Anal Sphincter injury
Alterated rectal sensation
Impaired rectal capacity
Stool consistency
Clinical presentation
• Primary symptoms: worsening lack of control for different rectal components
• Secondary symptoms of fecal incontinence result of leaking stool and include:
- pruritus ani
- perianal skin irritation
- urinary tract infections
- urinary incontinence
- vaginal bulging (rectocele, cystocele)
- prolapse (hemorrhoidal, mucosal, full-thickness rectal)
- rectovaginal fistula
- altered bowel habits
Clinical presentation
•Significant impact on the quality of life
- self-esteem
- embarrassment
- shame
- depression
- need to organize life around easy access to bathroom
Diagnosis
• History
• Incontinence score
• Physical examination
• Anophysiology testing
Saldana Ruiz N et al. - World J Gastroenterol - 2017
Diagnosis
Diagnosis
Clinical Exam
- visual inspection
- rectal exam (sphincter integrity, sphincter tone, compensatory auxiliary muscle contraction,
length of anal canal, rectocele, palpable mass), as well as at least a limited
- visualization of the anorectum
Diagnosis
Anorectal ultrasound most sensitive tool to assess the sphincter
complex for the presence/absence of defect/structural alteration
EAUS - identifies injuries to both the internal and external sphincters
- informs on the quality of the internal sphincter, in particular
identifying atrophy.
- central role in the algorithm for deciding suitability for
surgery
Diagnosis
Diagnosis
Anal manometry :
- anorectal sensation
- volume tolerance
- determination of the rectal compliance
- objectively assessing the muscle strength and the reservoir function
PTNML :
- can identify pudendal neuropathy
Electromyography (EMG) :
- aims at analyzing the neuromuscular motor-units
- role in confirming paradoxical puborectalis contraction in patients with obstructed defecation
- limited value for workup of fecal incontinence.
Diagnosis
Endoanal MRI:
- sensitive for imaging the external anal sphincter Its usefulness lies in visualizing external anal
sphincter injuries
- puborectalis atrophy causative in some patients with ‘idiopathic’ faecal incontinence
- Endoanal imaging suitability for surgery or reoperation
Barium proctography, to highlight pelvic floor problems:
- descente
- relaxation
of the pelvic floor
- contraction
- presence of a rectocele
Treatment
- Demanding and needs to be tailored to the individual circumstances
- Starts with non-operative measures
- most pressing goals are: to optimize the stool consistency
to slow down bowel motility
to minimize the average stool load in the rectum
- Correct inflammatory conditions to control related diarrhea
- Dietary changes
- Bowel habit and behavioral training is important to develop regularity
Treatment
Medications:
- to slow down the bowels movements (anti-diarrheal medications)
- bind bile acids (cholestyramine)
- to reduce the reflectory sphincter relaxation (antidepressants as
amitriptyline)
- role of hormone replacement therapy in postmenopausal women?
Treatment
Medications:
- Anti-diarrheal
- Cholestyramine
- Antidepressant
- Hormone replacement therapy in postmenopausal women?
Treatment
Physical therapy and biofeedback training:
- strengthening
- coordinating
the pelvic floor and sphincter function
- subjective benefit in 64%-89% Mettre la référence
- patients are asked to take an active role in overcoming their incontinence
Treatment
Surgical options
- if significant fecal incontinence refractory to conservative
management
- Correctable structural deformities
Treatment
Sphincter repair (sphincteroplasty)
- if a segmental sphincter defect is identified
- reconstitute the circular configuration of the muscle around the anal canal and with that the
high pressure zone.
- short-term results are 75%-86% improvement of incontinence episodes
- long-term function has been noted to deteriorate with some series reporting only 0%-50% of
patients still being fully continent after 5-10 years
Glasgow et al. - Dis Colon Rectum - 2012
Treatment
Treatment
16 studies, 900 sphincter repair, 5y FU
Glasgow, Dis Colon Rectum, 2012
Treatment
SNS:
- transformed the management of fecal incontinence in the most dramatic way.
- does not focus on the anal canal
- remarkable short- and long-term improvements regardless of whether a sphincter defect was
present or not[
- widely utilized for patients with urinary incontinence
- technique: two short outpatient procedures under superficial anesthesia
- the exact mechanism of this technique is yet to be completely understood
Treatment
SNS:
- two thirds of the patients have > 50% improvement such that they have the a definitive
stimulator implanted
- after definitive implantation, 86%-87% of patients reported a greater than 50% improvement
- about 40% perfect control
- a success than persisted over 3-5 years and beyond
- complication infection 3% and dislocation of the electrode 12%
- 19%-36% of patients require subsequent interventions for revision or device replacement
(battery life)
Treatment
Tibial nerve stimulation:
- Similar to the introduction of SNS
- initially used for the treatment of urinary incontinence
- transcutaneous or percutaneous electrodes
- posterior tibial nerve is stimulated in sessions
of approximately 30 min duration over a minimum of 3 months
- mechanism of action : activation of the central nervous system and supra-sacral neural centers
via the afferent fibers of the peripheral nervous system.
Treatment
Radiofrequency energy administration (“SECCA procedure”):
- delivery of a thermo-controlled multipoint radio-frequency energy to the depth of the anal
canal without burning the mucosal surface.
- purpose to induce an increase of the outlet resistance by means of a controlled scarring;
to remodel the sphincter muscle fibers
- moderate clinical benefit with 0%-38% of patients achieving more than 50% improvement, but
never perfect control
Treatment
Injection/implantation of bulking agents:
- to bulk up the anal canal or perianal tissues and increase the passive outlet resistance
- a number of different techniques have been used to inject or implant a variety of materials
- patient selection:
mild passive incontinence secondary to internal anal sphincter weakness
patients with postsurgical deformities
uneven shape of the anal canal.
- 15%-50% improvement
- Complications and side effects occurred in up to 10% and 12%, respectively
- What’s new? elf-expandable hyexpan (polyacrylonitrile) prosthesis or of stem cells
Luo et al, - Colorectal Dis - 2010
Treatment
Dynamic sphincter replacement
- Implantation of artificial bowel sphincter: not on the market anymore
- Dynamic graciloplasty:
the ability to consciously use this muscle and learn voluntary contractions is very
limited.
implantation of a pulse generator devic
The technique has a reasonable efficacy
associated high morbidity
Treatment
Nondynamic sphincter and pelvic floor support:
Thiersch and related procedures: placement of an anal encirclement with the aim of narrowing
the anal canal and subsequently increase the passive outlet resistance, even when lacking a
dynamic component.
Both non-elastic and elastic silicone-based implants have been used.
The approach is uncommon
Non-dynamic graciloplasty or gluteoplasty: The non-stimulated transposition and wrapping of
gracilis or gluteus muscle around the anal canal (“bioThiersch”) has limited indications because
of the high risk of complications and a lack of true functionality
Treatment
Pelvic floor repairs/sling:
- was hence abandoned
- recently regained some momentum when an investigational trans-obturator posterior anal
sling system was introduced and a multi-center trial was launched
- a self-fixating poly-propylene mesh is inserted and placed behind the anorectum via two small
incisions by means of two curved introducer needles
Mellgren et ali, - Am J Obstet Gynecol - 2016
Treatment
STOMA
- When other therapies have failed
- When they are preemptively believed to eventually inevitably fail
- If co-morbidities preclude a more aggressive or time-consuming strategy
- More satisfying than acknowledged alternative
- Even if it does not restore continence in a strict sense and has an impact on the body image
- It provides the patient with the luxury of a controlled waste management and hence permits
resumption of a normal personal and social life style
Norton, 2005, DCR
Colquhoun, 2006, WJS
Treatment
Norton, 2005, DCR
Colquhoun, 2006, WJS
Take home message
- Condition underestimated
- High impact on the quality of life
- Tailored traitement
Solutions exist
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