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