Evaluating the patient with faecal incontinence

M62 Course 2004

Mr E S Kiff

Diagnosis

• HISTORY

• EXAMINATION

• INVESTIGATION

History

• LISTEN to what is being said

• LISTEN to the problem

• LISTEN to the effect on their life

The specific questions

• Urgency

• Consistency

• Frequency

• Defaecation

• Prolapse

• Wiping

• Leakage

Urgency

• Diarrhoea

• Weak voluntary muscle

• Quantify – how long have you got

• - incontinent en route?

Consistency

• Solid, formed

• Soft, loose

• Watery

• Variable

• Explosive

Frequency

• Diarrhoea – think upstream

• Formed – think irritability, sensory

Can you go?

• Connective tissue weakness – prolapse

• Long term strainer

• End stage neuropathy

Prolapse

Grape - mucosal, think eversion of anus

Tomato – full thickness rectal

Vaginal – rectum,bladder,uterus,small bowel

Difficulty wiping clean

• Prolapse

• Low anal tone

• Slow to regain tone

Leakage during the day

• Low resting tone

• Prolapse

Causes of incontinence

• Brain

• Body

• Bowel

• Bottom

Brain and cord

• CVA – IAS weakness?

• Emotion, anxiety

• Cord injury

• MS

• Peripheral neuropathy

• Think bladder, think legs

Body

• Mobility

• Elderly

• Exposure of minor weakness

Bowel

• Inflammatory bowel disease

• Neoplasia

• Coeliac

• Drugs

• OVERFLOW

Bottom

• Connective tissue

• Muscle – neuropathy, tear or BOTH

• Combination

• Congenital

Examination

• Abdomen

• Perineum

• Anal canal and pelvic floor

• Sigmoidoscopy

Examination of the anus

• Position

• Gape

• Strain

• Length and angle

• Muscle bulk

• Connective tissue

• Voluntary contraction

Investigations

• The colon

• Anorectal physiology

• Endoanal ultrasound

• Defecating proctography

• MR scan

Anorectal physiology

• Anal manometry• Vector-volume analysis• Rectal perception of distension• Proctometrogram• Recto-anal reflex• PNTML• EMG• Other tests

Endo-anal ultrasound

• Beware over reporting

• Tears found later in life = neuropathy

• Tears are not all or nothing

Summary

• Listen to the story

• Ask the questions

• Examine the bottom

• Do the tests

• Fit the jigsaw together

• Consider the alternatives for treatment

References

• Investigation of faecal incontinence. Buchanan et al. Hosp.Med.2001;62:533-537

• AGA position on anorectal testing. Gastroenterology.1999;116:732-760

• The clinical use of anorectal physiology studies. Ann R Coll Surg Eng. 1983; Suppl 1: 27-29