analfunction in geriatricpatients faecal incontinence · r=003, n=57, p=083) but there was a...

Gut, 1989, 30, 1244-1251

Anal function in geriatric patients withfaecal incontinenceJ A BARRETT, J C BROCKLEHURST, E S KIFF, G FERGUSON,AND E B FARAGHER

From the Departments of Geriatric Medicine, Surgery and Medical Statistics, University Hospital ofSouthManchester, Manchester

SUMMARY The association of faecal incontinence with constipation and confusion in the elderly iswell recognised but the anal function of faecally incontinent geriatric patients is poorly understood.Anal studies were therefore performed on 99 geriatric patients (49 with faecal incontinence, 19continent patients with faecal impaction and 31 geriatric control patients with normal bowel habit)and 57 younger healthy control patients. An age related reduction in anal squeeze pressure but notresting pressure was identified. A reduction in anal resting pressure was detected in the faecallyincontinent geriatric patients but squeeze pressure did not differ significantly from that found in theother geriatric patients. Anal sensation was impaired in the faecally incontinent patients. Nodifference was found between the groups as measured by pudenal nerve terminal motor latency.Gross neuropathy of the distal part of the pudendal nerve does not account for the observed externalanal sphincter weakness in geriatric patients or for their faecal incontinence. Internal anal sphincterdysfunction is an important factor in faecal incontinence in the elderly.

Faecal incontinence is an unpleasant problem whichaffects up to 1% of over 65's in the population.' It ismost prevalent among the institutionalised elderly.Approximately 10% of those in residential homes'4and 30% of patients in geriatric continuing carewards are incontinent of faeces at least once perweek.4`Many younger patients, mainly women,6 also

suffer with faecal incontinence. There are now manyreports of external anal sphincter and pelvic floormuscle weakness in these patients with idiopathicfaecal incontinence.7-'4

Denervation of the external sphincter andpuborectalis muscles has been shown in theseyounger patients by concentric needle" 'h and singlefibre electromyographic (EMG) studies." '4 It hasbeen proposed that idiopathic faecal incontinence isthe result of damage to the nerve supply of thesemuscles'7 as there is pudendal neuropathy in theseAddress for corresponidence: Dr J A Barrett, Department of GeriatricMedicine, Hope Hospital, Eccles Old Road, Manchester M6 8HD.

Accepted for publication 17 January 1989.

patients" '` lX which is associated with either difficultchildbirth, especially forceps delivery,6 "2" or chronicstraining at stool.2' 22 Impaired anal sensation is alsorecognised in these patients.2-2'Read and Abouzekry26 have proposed that age

related anal sphincter weakness and some degree ofpudendal neuropathy may account for the highincidence of faecal incontinence in the elderly. Insupport of this they quoted a study by Percy et al7where external anal sphincter single fibre EMG wascarried out on six faecally incontinent geriatricpatients and four continent geriatric patients.External sphincter fibre density is known to increasewith age.26 Percy et al thought that the fibre densitywas higher in their incontinent geriatric patients butthe small number of patients studied did not allowany valid comparison to be made between the twogroups.The pathophysiology of idiopathic faecal incontin-

ence is now better understood but as previous studieshave not included geriatric patients conclusionsdrawn do not necessarily apply to them. The follow-

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Analfunction in geriatric patients with faecal incontinence

ing study was undertaken to assess the anal functionof faecally incontinent geriatric patients.

Methods

PATIENTSAnal studies were carried out on 99 patients recruitedfrom the Geriatric Unit, University Hospital of SouthManchester. They were either inpatients or attendedthe Day Hospital for outpatient treatment. Fortynine of these patients were classified as faecallyincontinent defined as the involuntary expulsion offaeces occurring at least once per week in theprevious month. The frequency of these incontinentepisodes ranged from one per week to six per day(median 6*8 per week). Nineteen patients with faecalimpaction without faecal incontinence were alsostudied. Digital rectal examination was used todetect the presence of faecal impaction which wasdefined as rectal loading with a large amount offaeces of any consistency. Thirty one geriatricpatients with normal bowel habit and 57 patientsfrom the Surgical Unit, University Hospital of SouthManchester were studied as controls.The surgical control patients were all in good

general health and were able to walk unaided. Thegeriatric patients all had multiple medical problemsand most had impaired mobility.

ETHICAI1 APPROVALThis study was approved by the Ethical Committee ofthe South Manchester Health Authority in April1986, and informed written consent was obtained forall patients studied. Consent for studies on confusedpatients was provided by the patients next of kin.

CLINICAL DETAILSClinical details and physical examination findingswere recorded for each patient. Mobility wasassessed and classified into one of four groups. Theabbreviated mental status questionnaire validated byQuereshi and Hodkinson" was used to screen fordementia. In the absence of dysphasia a score of 7/10or less on two or more occasions was considered toindicate dementia.Each patient was studied lying in the left lateral

position. No bowel preparation was given thougheach patient was given the opportunity to use thetoilet before the examination.

ANAL MANOMETRYAnal pressures were measured at 1 cm stations usinga water filled microballoon catheter system (externaldiameter 4 mm) connected via a transducer to aDevices chart recorder. At each station one to twominutes were allowed to elapse to allow anal pressure

to reach a steady state. This steady state pressure wasrecorded as the resting pressure for that station.Patients were then asked to squeeze the anal canaltightly shut for five to 10 seconds. They wereobserved during this procedure to ensure compli-ance. The maximum anal resting pressure and analsqueeze pressure above resting pressure wererecorded for subsequent analysis.

RECTOANAL REFILEXThis reflex was examined by distending the rectumwhilst recording anal resting pressure at the site atwhich resting pressure was highest. A party balloon(from W H Smiths) tied to the end of a length of stiffpolyvinyl tubing and connected to a 50 ml syringethrough a three way tap was used to distend therectum. Fifty millilitre boluses of air were injectedinto the rectal balloon over a period of six to eightseconds. The anal sphincter pressure trace was simul-taneously monitored for the presence or absence ofthe two components of the rectoanal reflex: inflationreflex - an early rise in pressure caused by externalsphincter contraction;3" ' inhibitory reflex caused byinternal and external anal sphincter relaxation.The reflexes were considered to be present if a

pressure change of more than 15 cm H20 wasrecorded. No attempt was made to elicit the inhibi-tory reflex in patients with very low resting pressure -that is, <30 cm H20 as further inhibition of restingpressure was considered unlikely.

PUDENDAI. NERVE TERMINAL MOTOR LATENCYPudendal nerve terminal motor latency (PNTML)was measured using the method previously describedby Kiff and Swash.'3 The nerve stimulator of aMedelec MS91 EMG machine was used with atransrectal stimulating/recording device to stimulatethe pudendal nerve. Single square wave stimuli of 0 1ms duration once per second not exceeding 50 V inintensity were used. The evoked external sphincterresponse was displayed and recorded on the MS91.The latency (PNTML) was defined as the time fromthe onset of the stimulus to the onset of the response.Measurements were made from the right and leftpudendal nerves.

ANAI SENSATIONAnal sensation was assessed by asking patients todiscriminate between water (37°C) and air infusedinto the anal canal through the side opening of apolyvinyl catheter inserted into the anal canal usingthe method described by Read and Read.

STATISTICAI ANAI YSISCategorical variables were compared for the fourpatient groups using Yates's corrected contingency

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Barrett, Brocklehurst, Kiff, Ferguson, and Faragher

table (X') analyses or Fisher exact tests as appro-priate.

Continuous variables were examined using a one-way analysis of variance or Student's t test asrequired. Each variable was tested for statisticalnormality. Where this could reasonably be assumed,the data were analysed untransformed. Otherwise anormalising transformation - for example, logarith-mic or square root, was sought. If all else failed anappropriate non-parametric test (Kruskal-Wallis orMann-Whitney) was used. Where necessary, signifi-cant effects revealed by the analyses of variance wereinvestigated using a multiple comparison test basedon the technique of Tukey. Correlations betweencontinuous variables were measured using thePearson coefficient if both variables were normallydistributed and by the Spearman coefficient other-wise.

Statistical significance was set at the conventional5% level. The calculations were performed using theStatistical Package for the Social Sciences as imple-mented at the University of Manchester RegionalComputer Centre."

Results

PATI E NTS

The three groups of geriatric patients were wellmatched for age and sex with a 2:1 female:male ratio(Table 1). There was a slight male bias among thesurgical patients who were also significantly youngerthan the geriatric patients (Tukey multiple compari-son test, p<005) (Table 1).The mental status scores of the faecally incontinent

patients were significantly lower than those of theother patients studied (Kruskal Wallis one wayanalysis of variance, p<0()01). The incidence ofdementia was significantly higher among the faecallyincontinent patients (59%). Thirty four (69%) of thefaecally incontinent patients were impacted. Theincontinent patients were significantly less mobilethan the other groups of patients (corrected X'=141-6, df=9, p<0.001) (Table 1).

ANORECTAL MANOMETRYThe effect of age on the anal pressures was deter-mined in the control patients after excluding patientswith neurological disease, dementia and/or diabetesmellitus. No correlation was found between age andresting pressure (Pearsons correlation coefficientr=0 03, n=57, p=083) but there was a significantreduction in anal squeeze pressure with age(Pearsons correlation coefficient r=-0 46, n=56,p=O-OOl).

Resting pressure was significantly lower in theincontinent patients than in the other groups of

Table I Comparison of thle characteristics of the geriatricand surgical patients studied

Geriatric pattiwts

Facecal Faccal Suirgigcalin(cottiiet(ce inJnpactiloti Conztrols controls

n 49 19 31 57Female 31 (63%) 12(63%) 22(71% ) 23(40%),Mean age (yr) 80 76 77 4895% Cl 78-83 72-80 74-79 43-52

Faecal impaction 34 (690,,) 19 (I(0)%,) ( ()Urinary incontinence 41 (84%0) 9 (47%0) 5 (160,,) 0Dementia 26 (59%,) 6 (33%0) 5 (16',) ()Mental status score

(median) 45 9'7 9'8 1Other neurological

disease - forexample. stroke 21 (430%O) 10 (53%0) 11 (360,,) ()

Diabetics 2 (40,,) 3 (16%)) 6(19%",) (0

MobilityWalks without

walking aid orassistance 9 (180,) 3 (16%) 6 (190,) 57 (1(X)%)

Walks with walkingstick 4 (8,) 5 (260,,) 14 (45",) (0

Walks with walkingframe 5 (1()00) 6 (32o) 7 (23"Y,) 0

Immobile 31 (64",,) 5 (26%'o) 4(130,,) 0)

Table 2 Anal manometry andipudendal nercte terminalmotor latency results

Ge'riatric patietttx

Faecal Faecal Suir,gic(aliiwtonltinenetltX inpaction C'ontrols ci,ntrols

Anal manometry (n) 43 I1 27 42Resting pressureMean (cmH0) 55 84 74 7195%) Cl 47-64 69-99 63-86 63-79

Squeeze pressureMean (cm H20) 37 44 51 167950,, Cl 25-49 29-58 36-65 138 195

PNTML (ms) (n) 34 17 21 43Right 21) 22 20) 2 1Left 20( 2.1 1 20(Mean 20 2 22 2I 0

950.°,S, CI 1 9-92 '2 1 23 1 22 1.9 21

patients studied (Tukey multiple comparison test,p<0 (5) (Table 2). No difference was found inresting pressure between the impacted geriatricpatients (continent or incontinent) (n=48, mean 67cm H20) and the geriatric patients without faecalimpaction (n=40, 67 cm H20) (Student's t test,t=0*06, df=86, p=0.95).Anal squeeze pressure was significantly lower in

the geriatric patients than in the surgical patients

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Analfunction in geriatric patients with faecal incontinence

Table 3 Mobility and anal splhincter pressures

Walks Walks witli Walks withMobilts' nitaitided stick frampie lInmmlobile

(n) I1 22 16 37Anal resting pressureMean 76 78 68 5995% CI 59-92 64-92 54-82 49-69

Anal squeeze pressureMean 89 56 56 32950) Cl 40-138 38-75 34-78 22-42

Table 4 Rectoanal reflex and anal sensation results ingeriatric patients

Geriatric patients

Faeccal Faecalinicontitienice itnpactioil C'ontrol.

Rectoanal reflexInflation reflex (n) 36 18 27Reflexpresent 22(61%) 9(50o%) 11(41%)Inhibitory reflex (n) 32 18 27Reflex present 17 (53%Y, ) 16 (89%) 22 (82 )

Anal sensationAir and water sensed 12 (26%) 2 (14% ) 9 (33'%o)Only water sensed 9 (2'(0 ) 9 (64%) 13 (48%)Neither water or air sensed 15 (33%) 3 (21.) 4 (15%)Communication difficulty 1( (22%o) () 1 (4%))

(Tukey multiple comparison test, p<000(1) but no

significant difference was detected between thegroups of geriatric patients. A relationship was

detected between mobility and anal squeeze pressure(analysis of variance, p<001). The lowest pressureswere recorded in the least mobiie patients (Table 3).

PUDENDAI NERVF TERMINAL MOTOR LATENCY

This was not found to be significantly correlated withage (Pearsons correlation coefficient r=-0()17,n=55, p=0.2). Pudendal nerve terminal motorlatency was similar in all four groups of patients(analysis of variance, p=0.35) (Table 3).

RECTOANAL RE FLEX

This test was only done on the geriatric patients.There was no significant difference between thegroups in the presence of the inflation reflex(corrected x'=2 6, df=2, p=0.27) (Table 4).The inhibitory reflex was detected in 53% of theincontinent patients which was significantly less thanin the geriatric control (82%) and impacted (89%)patients (corrected X5=9 3, df=2, p=0.01).

ANAL SENSAT IONThis test was only done on the geriatric patients

(Table 4). Eighty one per cent of the geriatric controlpatients were able to identify the presence of water inthe anal canal but only 33% of these patients wereable to correctly differentiate between water and airinstilled into the anal canal. Nineteen per cent of thecontrol patients and 21% of the continent impactedpatients were unable even to identify water in theanal canal. This was found more frequently in theincontinent patients (55%). Forty per cent of thesepatients had communication difficulty. The exclusionof these patients from the analysis, however, didnot alter the conclusion that there is significantimpairment of anal sensation in faecally incontinentgeriatric patients (X'= 10, df=4, p<O0(5).

Discussion

This study has confirmed that faecal impaction,dementia, and immobility are important factorscontributing towards the development of faecalincontinence in geriatric patients. The main purposeof the study, however, was to investigate analfunction in these patients.Anal squeeze pressure, which is produced by

contraction of the external anal sphincter muscle,was found to decrease with age thus confirmingprevious reports.' 11 4 Muscle strength""' and musclemass-37 41L generally decline in old age and thereis histological 7 44 4S and clectrophysiologicalevidence 31174=1to suggest that this muscle atrophyis the result of denervation. Denervation andreinnervation also appears to affect the external analsphincter muscle in old age as the mean duration ofmotor unit potentials'` and fibre density27 ' bothincrease in the external sphincter with age.Many studies have shown an age related reduction

in nerve conduction velocity.41-'5 Pudendal nerveterminal motor latency, however, was not found tochange with age which suggests that the observedexternal sphincter weakness in the elderly is notcaused by neuropathy of the distal segment of thepudendal nerve. Age related loss of anterior horncells or motor nerve fibres from the proximal innerva-tion of the external sphincter, however, cannot beexcluded and there is evidence to suggest that thismay occur in old age. 1 14An association was found between squeeze

pressure and mobility. The lowest pressures wererecorded in the least mobile patients which suggeststhat atrophy of skeletal muscle and the externalsphincter may occur together because of a commonunderlying neurological abnormality.The mean squeeze pressure recorded in the

geriatric control patients in this study was similarto that recorded in younger faecally incontinentpatients - that is, approximately 45 cm H210."

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External sphincter weakness may therefore renderelderly patients liable to faecal incontinence assuggested by Read and Abouzekry`" but the presenceof faecal incontinence does not appear to be relatedto the degree of external sphincter weakness assqueeze pressure was not significantly lower in theincontinent patients than in the other geriatricpatients.The absence of any abnormality in pudendal nerve

terminal motor latency suggests that pudendal neuro-pathy is not a major factor in the development offaecal incontinence in geriatric patients unlike theresults of studies performed on younger faccallyincontinent patients.'3 14

External anal sphincter contraction in response torectal distension (inflation reflex) was frequentlyabsent in the geriatric patients though there was nosignificant difference in the presence of the reflexbetween the faecally incontinent (61%), faecallyimpacted (50%), and geriatric control patients(41%). The incidence among the control patients waslower than expected. Read and Abouzekrfy2 haddemonstrated this reflex in 80% of their elderlycontrol group. The high incidence of neurologicaldisease in the patients in the current study mayaccount for the difference between the studies.Absence of the reflex has previously been noted inparaplegic patients with lesions above the level ofLi 75`Anal resting pressure, which is almost entirely

generated by the internal anal sphincter,' has pre-viously been reported to decrease with age.s431'-83 Thelack of any change in resting pressure with age in thisstudy or in a small study performed by LoeningBaucke and Anuras`" and the demonstration of lowanal resting pressure only in the very elderly byMatheson and Keighley' implies that this agingeffect is not yet proven. Resting pressure was,however, significantly lower in the faecally inconti-nent geriatric patients studied which implies thatthere is dysfunction of the internal anal sphincter inthese patients.

Internal sphincter weakness has been reported inyounger patients with faecal incontinence` '4 in con-junction with external sphincter weakness but hasaroused comparatively little interest. Swash'` at onestage even dismissed it as a factor contributing to thedevelopment of faecal incontinence.There is now, however, evidence that internal

sphincter dysfunction is an important factor in thedevelopment of faecal incontinence, particularly inpatients with faecal incontinence and perinealdescent`'6 in whom there is low anal resting pressurein addition to pudendal neuropathy and externalsphincter weakness. Similar internal sphincter weak-ness has also been shown in patients with faecal

incontinence and rectal prolapse," and in faecallyincontinent diabetic patients.' Internal sphincterabnormalities have also recently been confirmed inpatients undergoing postanal repair for severeanorectal incontinence.65

It has been suggested that faecally impactedgeriatric patients become incontinent because ofeither stretch or reflex inhibition of the anal sphinctermuscles."" Anal resting pressure was not found to beaffected by faecal impaction in this study or by Readand Abouzekry2' and the rectoanal inhibitory reflexremains intact.

Schiller et al' reported that the onset of faecalincontinence in diabetic patients usually coincideswith the onset of chronic diarrhoea. They suggestthat the internal sphincter dysfunction in thesepatients is the result of a defect in either theautonomic innervation or the smooth muscle.Diabetic autonomic neuropathy, however, does notinvariably cause internal sphincter dysfunction ascontinent diabetic patients have normal restingpressure even though 79% have symptoms suggestiveof autonomic neuropathy.

It is unclear at present whether autonomic neuro-pathy contributes towards the development of faecalincontinence. Studies of patients with progressiveautonomic failure with multiple system atrophy haveled to the discovery of many interesting features ofautonomic dysfunction." Bladder dysfunctioncausing frequency, urgency, and urge incontinence iscommon in these patients"" and low anal sphinctertone" and faecal incontinence` are also recognisedfeatures.A myenteric plexus abnormality also appears to

be present in many incontinent geriatric patientsas the rectoanal inhibitory reflex was frequentlyabsent in the incontinent patients studied (Table 4).Hirschsprung's disease had not previously beensuspected in these patients. Myenteric plexusdegeneration or damage can, however, probably bediscounted as the cause of the internal sphincterdysfunction identified in this study as normal internalsphincter pressures have been recorded in infantswith Hirschsprung's disease.

Anal sensation appeared to be impaired in themajority of geriatric patients. Only 33% of thecontrol patients were able to discriminate betweenwater and air in the anal canal (Table 4). Althoughthis may be because of pudendal sensory neuropathy;anal sensation and pudendal nerve terminal motorlatency were not found to be correlated.Anal sensation appears to be more severely

impaired in incontinent geriatric patients as theywere less aware of the presence of water or air in theanal canal than the control patients. Twenty five(57%) of the 46 incontinent geriatric patients

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Analfunction in geriatric patients with faecal incontinence 1249

assessed failed to identify either water or air instilledinto the anal canal compared with just five (19%) ofthe 27 control patients assessed. Although cognitiveimpairment secondary to cerebral pathology - forexample, Alzheimers disease may have contributedto this loss of awareness in incontinent patients theredoes appear to be an abnormality in anal sensationsimilar to that reported in younger incontinentpatients.2'4'

Loss of anal sensation as a single isolated factor,however, does not necessarily result in faecal incon-tinence, as Read and Read32 demonstrated thatcontinence can be maintained when the anal canal isanaesthetised with lignocaine gel. This suggests thatcontinence is only lost when a number of coexistentabnormalities are present.

Geriatric patients therefore have abnormalities inanal sensation, external sphincter strength and reflexactivity which increases their risk of developingfaecal incontinence. The main factor that appears todetermine whether their continence is maintained isinternal sphincter function.

We thank Sr M Blakeborough, Mr J Coolie, andMrs J Redfearn for their assistance during this study.Dr Barrett was supported by Ciba-Geigy.

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