bowel symptoms faecal incontinence: ‘tear’ assessment and ... · urinary incontinence/prolapse...

24-May-16

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Sydney Colorectal + Pelvic Floor Centre

Faecal Incontinence: Assessment and Management

Professor Marc A Gladman MBBS DFFP PhD MRCOG FRCS (UK) FRACS

Professor of Colorectal Surgery


Mrs PK; 56 yrs; Married; 2 children

• Bowel symptoms – IBS with loose stools

• Para 2 x VD - #1 forceps with ‘tear’

• Back injury 15 years ago – microdiscectomy

• Working for the Federal Government in Canberra

• Dramatic impact on work/social/psychological well-being

• >10 years of incontinence to faeces / flatus

• Initially monthly episodes – now weekly

• Associated faecal urgency – 5 mins max

• Embarrassment – didn’t seek help for 5 years


What is incontinence?

‘Any accidental or involuntary loss from the bladder or bowels’


Urinary Incontinence


Faecal incontinence (FI): bowel leakage

‘Involuntary or uncontrolled passage of bowel motion, faeces or wind from the bowel’.


How common is bowel leakage?

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Australian Health Survey 2011-13

Diabetes Mellitus

Osteoporosis

Cancer

_____________________________________________

Diabetes Mellitus 4.0%

Osteoporosis 3.4%

Cancer 1.6%

_____________________________________________

9%


FI: extent of the problem

12% reported FI - half moderate/severe


FI: extent of the problem


FI

FI afflicts more adults than DM (4.0%),

osteoporosis (3.4%) and cancer (1.6%)


Stigmatisation of FI


Take Home Message 1

‘Bowel leakage affects 1 in 8 of your patients’

‘Two-thirds will NOT volunteer it’.

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Overview

The role of the GP: GPMP

Identification, assessment & treatment of sufferers

When symptoms persist – what next?

The multidisciplinary team - when & where to refer

Latest Treatments – Sacral Neuromodulation

What every GP needs to know


Overview








The role of the GP

Identification in primary care

Screening questions A.I.M. & ‘hi-risk’ patients - C.O.N.T.R.O.L

Assessment priorities

Red flags & Reversible factors

Treatment options in primary care

L.E.A.K.A.G.E

Chronic disease management plans

GPMPs & TCAs


Screening questions: general approach

“I’ve noticed that many people in your situation suffer with a problem that they feel embarrassed talking about”

“Do you mind if I ask you some personal questions that will help me determine if you also have the same trouble as lots of others?”

“Please don’t be embarrassed to tell me all about the problem….once I know all the details, we can start to improve the problem”


Screening: 3 simple questions: A.I.M

Anxious: “Are you ever anxious because you think you might lose control of bowel?”

In time: “Do your bowels sometimes start to empty before you get to the toilet?”

Mess: “Do you ever notice staining in your underwear from bowel leakage?”


Take Home Message 2

A.I.M to screen patients for leakage:

AnxiousIn-timeMess

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Hi-risk groups: C.O.N.T.R.O.L

Cognitive impairment

Older people

Neurological / spinal problems

Trauma – colorectal / anal surgery*

Runny stools – diarrhoea from any cause

Obstetric trauma*

Light bladder leakage / pelvic floor prolapse*



1st Degree 2nd Degree

3rd Degree 4th Degree

OASIS: Obstetric Anal Sphincter InjurieS


OASIS: Obstetric Anal Sphincter InjurieS

35% occult anal sphincter injury

Sydney Colorectal + Pelvic Floor Centre Sydney Colorectal + Pelvic Floor Centre

HaemorrhoidectomyAnal Fistula

Anal surgery and bowel leakage (FI)

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Colorectal surgery and FI


Urinary incontinence/prolapse and FI

21% of patients with urinary incontinence, prolapse or both had faecal incontinence


The role of the GP


Screening questions & ‘hi-risk’ patients - C.O.N.T.R.O.L




L.E.A.K.A.G.E


GPMPs & TCAs



Exclusion of organic pathologyRed Flag symptoms

Identify / treat reversible factorsGastrointestinal / extra-gastrointestinal

Symptom assessment / impact on QoLTypes of incontinence / impact on daily activities,

function, interaction


Red flags ABCD

A – age

>60yrs: ‘B’ OR ‘C’; >40yrs: ‘B’ AND ‘C’

B – bleeding PR

Typically >6/52 WITHOUT anal symptoms

C – change in bowel habit

Typically to loose, frequent stools

D – deficiency

Unexplained Fe deficiency anaemia


Reversible factors

GI

constipation / faecal loading – FIBRE / FLUID

diarrhoea (e.g. infective, IBD, IBS) - Loperamide

rectal prolapse or third-degree haemorrhoids

ExtraGI

acute disc prolapse/cauda equina syndrome

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Assessment priorities: summary

‘Faecal incontinence is a symptom nota diagnosis

It is important to exclude / Rx other serious / benign GI / non-GI conditions’


The role of the GP






L.E.A.K.A.G.E


GPMPs & TCAs


Treatment Options: L.E.A.K.A.G.E

Loperamide (Gastro-Stop 2mg PRN max 16mg daily)*

Exercise

Assessment of bowel habit / stool consistency* - FIBRE

Kegal exercises*

Assessment of diet*

Garment protection*

Encourage weight loss


Loperamide


Assessment of stool consistency:fibre demystified


Assessment of stool consistency:fibre demystified

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Fibre: insoluble and soluble


Kegel Exercises

8 second lift / squeeze

8x repetitions

8 weeks


Assessment of diet: food allergens


Garment protection: anal plugs

Peristeen plugs: coloplast.com.au


Take Home Message 3

‘Significant improvements can be made to patients’ symptoms with simple interventions’

‘L.E.A.K.A.G.E’


The role of the GP






L.E.A.K.A.G.E


GPMPs & TCAs

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Chronic disease management plan

Preparation of a GPMP – 721Initial assessment, goal setting, treatment

Review of a GPMP – 732

At 3 months undertake review

Coordination preparation/review of TCAs: 723/732GP, physiotherapist, dietician, psychologist


Chronic disease management plan

‘Faecal incontinence is a chronic disease. Patients have MDT needs’

‘GPMP’


Overview








Specialist referral

Troublesome symptoms

Impact on QoL

Failed simple measures

Long-term compliance is problematic

High risk

Post partum (traumatic); perianal pathology / surgery


The multidisciplinary team

Complex patient needs

Dietary; psychological; physiotherapist; medical; surgical

Evolving technology for physiological assessment

Hi-resolution anorectal manometry; 3D endoanal US

Rapidly expanding spectrum of interventions

Biofeedback; PTNS; SNS; ESGN


Anorectal physiology

“Bowel urodynamics”

Provides objective physiological measures of function

Anorectal manometry

Canal pressures; rectal sensation; rectoanal reflexes &coordination

Endoanal ultrasound

Morphological information about the internal / externalsphincters

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Conventional anorectal manometry


Conventional anorectal manometry


Hi-Resolution Manometry Hi-Resolution Manometry


3D endoanal US


ineffective anal squeeze pressures

normalrestingtone

minimal squeeze increment generated

Urge faecal incontience / external sphincter weakness

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2 sessions of biofeedback – now impressive squeeze pressures

normalrestingtone

strong, well-sustained (30 sec) squeeze

increment generated

Following physiotherapy


Overview








Sacral Neuromodulation

Terminology

Sacral Nerve Stimulation Sacral Neuromodulation

Aim

Recruitment of residual function of a functionallydeficient anorectum by modulation of its nerve supply

Principle

Impacts upon neural interfaces to produce benefit


More than 100,000 patients worldwide have received SNS

SNM for Bowel Control

‘Like a cardiac pacemaker for the nerves of the bowel’


SNM: surgical phenomenon

Neuromodulation-fast growing area of medicine

20 years experience

Procedure: bridging the divideConservative & potentially hazardous surgery .

Evidence-based Medicine

RCT; unprecedented attentive / prolonged FU


SNM: patient info

The procedure: try before you buy

day-case; minor procedure; 2 stage (test / permanent implant)

Safety

“Zero” mortality Low morbidity; day-case; minor procedure

Effective

80% success rates – preserved in long-term

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Test Implant

SNM: try before you buy


S 1

S 2

S 3

S 4

The procedure: S2-4


SNM – XR position


SNM: patient info

The procedure: try before you buy

day-case; minor procedure; 2 stage (test / permanent implant)

Safety

“Zero” mortality Low morbidity; day-case; minor procedure

Effective

80% success rates – preserved in long-term


SNM: outcomes

50% reduction

100% continent

Short-term (12/12) 79 (69-83) 42 (21-66)

Medium-term (24/12) 80 (65-88) 40 (5-74)

Long-term (56/12) 84 (75-100) 35 (4-52)


Take Home Message 4

‘Persistent leakage-refer to an expert

SNS – minor, safe, success in 8/10’

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Summary: take home messages

Incontinence is a COMMON, debilitating condition

FI: 1 in 8 YOUR pts; 2 of 3 WON’T admit; coexist with UI

ACTIVELY screen patients for leakage / target ‘hi-risk’ groups

A.I.M & C.O.N.T.R.O.L

SIMPLE interventions lead to SIGNIFICANT improvements

L.E.A.K.A.G.E

Patients DON’T have to live with incontinence

Specialist MDT is crucial; safe treatments with high success rates


Further information

web: www.bowelproblems.solutions

email: [email protected]

bowel symptoms faecal incontinence: ‘tear’ assessment and ... · urinary incontinence/prolapse...

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