w28: ics institute - school of anorectal dysfunction: anal ...anorectal physiology and endoanal...

W28: ICS Institute - School of Anorectal Dysfunction: Anal

Incontinence? What should I do next? Workshop Chair: Alexis Schizas, United Kingdom

05 September 2019 09:30 - 11:00

Start End Topic Speakers

09:30 09:45 Introduction, pathophysiology and epidemiology of anal

incontinence

Alexis Schizas

09:45 10:00 Clinical assessment Massarat Zutshi

10:00 10:15 Assessment with anal imaging and physiological investigation Alison Hainsworth

10:15 10:40 Conservative management Paula Igualada-Martinez

10:40 10:55 Neuromodulation and surgical management Samantha Morris

Massarat Zutshi

10:55 11:00 Discussion Alexis Schizas

Alison Hainsworth

Paula Igualada-Martinez

Samantha Morris

Aims of Workshop

The aim is to provide an update on the current evidence for best practice in the assessment and treatment of patients with anal

incontinence.

Anal incontinence is a common problem which often presents alongside other pelvic floor dysfunction. This workshop will cover

the possible reasons behind anal incontinence, current methods for patient assessment and up to date treatment options. This

workshop will enable you to understand why a patient may suffer anal incontinence and provide you with the expertise to

assess and treat a patient as well as understand when the patient needs to be referred for further intervention.

Learning Objectives

Understand the epidemiology of anal incontinence including its’ prevelance, inconsistencies in reported prevelance and the

anticipated increase in future prevelance.

Understand the causes and risk factors for anal incontinence. Appreciate that the aetiology for anal incontinence is often

multifactorial and that causes other than obstetric anal sphincter injury must also be considered.

Learn how to perform a clinical assessment of a patient with anal incontinence (history, questionnaires, bowel diaries and

examination).

Know that investigations such as anorectal physiology and endoanal ultrasound are also useful for assessment. Recognise the

relevance of the key findings using these investigations.

Be able to implement an initial conservative treatment plan.

Know when further treatment with neuromodulation or surgery may be beneficial.

Target Audience

Bowel Dysfunction, Conservative Management

Advanced/Basic

Basic

Workshop Outline

Introduction, pathophysiology and epidemiology of anal incontinence

Alexis Schizas – UK

The workshop will open with a short overview of the causes of anal incontinence, who suffers with anal incontinence, its’

prevelance and the reasons for increased future prevelance.

Anal incontinence is defined as the recurrent uncontrolled passage of faecal material or flatus.

Pathophysiology: Continence is maintained by the integrity and function of the anorectum. Factors which affect continence are

the delivery of stool to the rectum, the ability of the rectum to store faeces, the anal sphincter mechanism, nerve supply and

physical mobility. Interruption to any of these mechanisms causes incontinence.

The aetiology of anal incontinence is usually multifactorial. Risk factors include age, nursing home residence, childbirth,

diarrhoea, faecal impaction, diabetes, urinary incontinence, neurological and psychiatric disorders, nutritional factors, poor

mobility, prolapse, some surgeries and smoking.

Passive anal incontinence - Passive anal incontinence with faecal seepage occurs when the anal canal does not close properly.

This may occur due to either damage or weakness of the internal anal sphincter or anal vascular cushions. Damage to the

internal anal sphincter most commonly occurs due to obstetric anal sphincter injury (OASIs). Rectal prolapse may also prevent

full closure of the anal canal.

Urge anal incontinence - Urge anal incontinence is the result of the continence mechanisms being overwhelmed; either the

rectum cannot distend to act as a reservoir to hold the faecal material or the anal sphincter mechanism cannot contain the

stool. For example, radiation may affect rectal compliance (i.e. ability to store faeces) or uncontrolled delivery of stool to the

rectum with irritable bowel syndrome may overwhelm continence mechanisms.

Additionally, incomplete evacuation of stool (for example, due to a rectocoele) may lead to subsequent post defaecatory

seepage.

Epidemiology: Anal incontinence is common, chronic and debilitating and adversely affects quality of life. Despite this its’

prevalence is inconsistently reported and its’ incidence is seldom referred to.

Prevalence - Prevelance may vary from 1.4 to 19.5%. There is a paucity of high-quality population studies and symptoms are

underreported so anal incontinence may be underestimated. Future estimates may increase as the definition of anal

incontinence is standardised and barriers to reporting symptoms are broken down.

Incidence - There are some clinical trials which report incidence of anal incontinence following treatment but none which report

incidence prior to treatment. Two Cochrane reviews examining the treatment for anal fissure found rates of anal incontinence to

flatus varied from 0 to 30% following treatment.

Male/ Female - Previously, it has been assumed that anal incontinence is more common in women and is primarily due to

obstetric injury, with either injury to the anal sphincter or pudendal nerve. (Other common contributors include irritable bowel

syndrome (more often seen in women) and neurological diseases such as diabetes). However, population studies show that

prevalence of anal incontinence is also high in men and so other causes in addition to obstertic injury must also be appreciated.

Future: In the era of increased patient expectation and as barriers to reporting anal incontinence are broken down, it is expected

that its’ prevalence and demand to treatment will increase. Successful treatment will depend upon a comprehensive

understanding of the causes of anal incontinence.

Assessment

A guide to the assessment of the patient presenting with anal incontinence (either as their main presenting complaint or

alongside other pelvic floor dysfunction).

This includes clinical assessment (history, examination, questionnaires, bowel diaries) and assessment with tools such as

anorectal physiology and endoanal ultrasound. Anal incontinence can be assessed by subjective means (symptom assessment)

and objective means (assessment of the anorectal structure and function).

Assessment can be performed at the time of diagnosis, before and after treatment to assess the efficacy of treatment, during

treatment to assess an ongoing improvement or to investigate the cause of no improvement or a recurrence of symptoms.

Organic pathology such as malignancy or inflammatory bowel disease must first be excluded.

Clinical Assessment

Massarat Zutshi – USA

The underlying pathophysiology of anal incontinence is multifactorial and so symptoms alone cannot be used to determine

treatment1. However, the assessment of symptoms and how they have changed following treatment is an important indicator of

how ‘successful’ any interventions are.

Symptom assessment can be with patient questionnaires, stool diaries and patient interviews. Symptom assessment includes;

severity (frequency and type of incontinence, urgency, avoidance behaviours and adjuncts such as pads, plugs and

antidiarrheal medications),

amount of bother inflicted,

and impact upon quality of life.

Patient questionnaires examine severity, bother and quality of life. Stool diaries examine severity. Patient interviews can allow

qualitative assessment of a patients’ perception and acceptability of treatments.

There may be difficulty in comparing the results from questionnaires between different populations as concepts of anal

incontinence are affected by cultural and psychosocial factors. Patients use avoidance behaviour which leads to underestimation

of severity. Some questionnaires assess symptom severity and others quality of life, but few assess both. Often a combination of

questionnaires is required for complete evaluation.

Symptom Severity Questionnaires: Examples include the Jorge Wexner score (grades severity and impact upon lifestyle), the St

Marks’ incontinence score (developed to account for avoidance behaviour adopted to control symptoms), the Revised Faecal

Incontinence Scale (a short, psychometrically sound tool) and the Faecal Incontinence Severity Index (a diagnostic tool).

Symptom Severity Questionnaires Designed to Assess Outcomes for Rectal Cancer Treatment: The LARS score and MSKCC

bowel function instrument are suitable for in-depth assessment.

Diary Monitoring: Symptom questionnaires may be misleading, only provide a snapshot of bowel habits and fail to reflect day to

day variations or the relationship between bowel symptoms and stool form2. Bowel diaries are recordings of bowel habits which

are widely used in diagnostic and interventional studies3.

Quality of Life Questionnaires: There may be poor correlation between symptom severity and quality of life4,5. Symptom scores

alone do not allow satisfactory evaluation of the impact of anal incontinence on quality of life and therefore both aspects of anal

incontinence should be assessed6. Quality of life can be assessed using generic scales such as the SF36 questionnaire or specific

scales such as the Rockwood scale.

The Combined Assessment of Symptom Severity and Quality of Life: The Rapid Assessment Faecal Incontinence Score was

developed to quickly assess both severity and impact upon quality of life. The modular international consultation on

incontinence questionnaire for bowel symptoms (ICIQ-BS) is a comprehensive, robust, condition-specific self-completion

questionnaire to assess bowel symptoms, the bother they cause and their impact on quality of life7,8. It is the top-rated

questionnaire for evaluation of symptoms severity and impact on health-related quality of life.

Visual Analogue Scores: Developed to assess the severity of anal incontinence and its’ impact upon on quality of life but have

not been shown to be a suitable substitute for other scoring systems.

Interview Assessment: Interviews can be used for qualitative assessment and to assess patient acceptability of treatments and

patient perception of their symptoms.

Examination: Inspection of the perineum and anus can reveal excoriated skin due to anal leakage, scarring from OASIs, previous

surgery or trauma, prolapse, haemorrhoids and an open anus at rest. Digital rectal examination can be used to assess resting

and squeeze pressures and muscle co-ordination. Proctoscopy and sigmoidoscopy may be performed to assess haemorrhoids

and occult disease, for example malignancy. Rectocoele, intussusception and rectal prolapse may be assessed. Vaginal

examination may detect concurrent prolapse.

References

1. Scott, S. M. & Gladman, M. A. Manometric, sensorimotor, and neurophysiologic evaluation of anorectal function.

Gastroenterol. Clin. North Am. 37, 511–538 (2008).

2. Bharucha AE1, Seide BM, Zinsmeister AR, Melton LJ 3rd.

Insights into normal and disordered bowel habits from bowel diaries. Am J Gastroenterol. 2008 Mar;103(3):692-8.

Epub 2007 Nov 16.

3. Sultan AH, Monga A, Lee J, Emmanuel A, Norton C, Santoro G, et al. An International Urogynecological Association

(IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction.

Neurourol Urodyn. 2017;36(1):10–34.

4. Damon H1, Dumas P, Mion F. Impact of anal incontinence and chronic constipation on quality of life. Gastroenterol

Clin Biol. 2004 Jan;28(1):16-20.

5. Bordeianou L, Rockwood T, Baxter N, Lowry A, Mellgren A, Parker S. Does incontinence severity correlate with

quality of life? Prospective analysis of 502 consecutive patients. Colorectal Dis. 2008 Mar;10(3):273-9. Epub 2007

Jun 30.

6. Damon H, Dumas P, Mion F. Impact of anal incontinence and chronic constipation on quality of life. Gastroenterol

Clin Biol. 2004 Jan;28(1):16-20.

7. Cotterill N, Norton C, Avery KN, Abrams P, Donovan JL. Psychometric evaluation of a new patient-completed

questionnaire for evaluating anal incontinence symptoms and impact on quality of life: the ICIQ-B. Dis Colon

Rectum. 2011 Oct;54(10):1235-50. doi: 10.1097/DCR.0b013e3182272128.

8. Coyne K, Kelleher C. Patient reported outcomes: the ICIQ and the state of the art. Neurourol Urodyn. 2010

Apr;29(4):645-51. doi: 10.1002/nau.20911.

Assessment with anal imaging and physiological investigation

Alison Hainsworth – UK

Patients’ symptoms, the amount of bother experienced and their impact upon quality of life may be considered the most

important and relevant assessment tools for anal incontinence. However, anorectal structure and function are also useful

measures, particularly in the context of therapeutic trials for anal incontinence. This is because;

1) symptom severity may be underestimated by day to day variation in symptoms and patient avoidance of certain

activities to reduce incontinent episodes,

2) the pathophysiology of anal incontinence is multifactorial and there may be several contributing factors toward

symptoms which may not all be solved with a single intervention

3) objective parameters may be useful to determine outcomes in uncontrolled studies

4) if anal incontinence initially responds to treatment and then symptoms deteriorate there may be failure of treatment or

another contributing factor (for example, recurrent incontinence after sacral nerve stimulation due to device

malfunction).

Tests of anorectal structure and function include; anal manometry, rectal compliance and sensation with either balloon studies

or Barostat, saline continence tests, porridge enema, pudendal nerve terminal motor latency, needle EMG of the external

sphincter, endoanal ultrasound and endoanal MRI.

Anorectal Physiology: Includes anorectal manometry, sensory measurements and neurophysiology.

Anorectal Manometry - Anorectal manometry includes conventional anal manometry, high resolution manometry, vector

volume manometry and ambulatory manometry. Anorectal manometry measurements include functional anal canal length,

squeeze and resting pressures.

Manometry may be useful to evaluate symptoms. For example, in patients with low anterior resection syndrome there is

reduced anal pressure which can be treated with biofeedback. The level of incontinence correlates with reduced resting

pressure levels1.

Sensory Measurements - Sensory measurements are made with rectal balloon distention, Barostat and rectal impedance

studies. Measurements include rectal sensation (first and urge sensation and maximal tolerated volume) and compliance.

Progress after treatment with pelvic floor rehabilitation or rectal sensitivity training with balloon distension can be documented

according to the volumes tolerated. However, an improvement in rectal capacity may not be reflected by patients’ symptoms.

Neurophysiology - Neurophysiology includes EMG (electromyography) and pudendal nerve terminal motor latency.

Measurements include assessment of activity in the external sphincter and puborectalis.

Saline Continence Tests or Porridge Enema: Saline or another liquid (for example porridge) is inserted into the rectum via a

catheter and the patient asked to walk around with a pad in for 20 minutes to assess continence.

Imaging:

Endoanal Ultrasound - Used to assess the integrity of the anal sphincter complex. Obstetric anal sphincter injuries can be

identified and graded. Endoanal ultrasound may be used pre and post-surgical sphincter repair to assess the effect of the

operation on the sphincter defect and to investigate unsatisfactory results after surgery2,3. Other pathology such as iatrogenic

anal sphincter injury following a lateral sphincterotomy, perianal sepsis and fistula can also be evaluated.

Endoanal ultrasound can also be used to assess the safety of new treatments, for example, to ensure that there is no migration

of an artificial bowel sphincter.

MRI - MRI is equivalent to endoanal ultrasound for the assessment of external sphincter defects but not internal sphincter

defects.

References

1. van Duijvendijk P: Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with

or without preoperative radiotherapy. Am J Gastroenterol 2002;97:2282–2289.

2. Nielsen MB1, Dammegaard L, Pedersen JF. Endosonographic assessment of the anal sphincter after surgical

reconstruction. Dis Colon Rectum. 1994 May;37(5):434-8.

3. Wong WD1, Congliosi SM, Spencer MP, Corman ML, Tan P, Opelka FG, Burnstein M, Nogueras JJ, Bailey HR, Devesa

JM, Fry RD, Cagir B, Birnbaum E, Fleshman JW, Lawrence MA, Buie WD, Heine J, Edelstein PS, Gregorcyk S, Lehur

PA, Michot F, Phang PT, Schoetz DJ, Potenti F, Tsai JY. The safety and efficacy of the artificial bowel sphincter for fecal

incontinence: results from a multicenter cohort study. Dis Colon Rectum. 2002 Sep;45(9):1139-53.

4. Malouf AJ1, Williams AB, Halligan S, Bartram CI, Dhillon S, Kamm MA.Prospective assessment of accuracy of endoanal

MR imaging and endosonography in patients with fecal incontinence. AJR Am J Roentgenol. 2000 Sep;175(3):741-5.

Conservative Management

Paula Igualada-Martinez – UK

A lecture on the initial treatment of anal incontinence with conservative measures (for example, lifestyle and dietary

modifications, medications, anal plugs, rectal irrigation).

The first line management of anal incontinence is conservative management. Conservative management strategies range from

educating patients about normal defecation and possible alterations in anal incontinence, setting goals for therapy, making

lifestyle modifications such as diet and weight loss, using medications, emptying the rectum with Transanal irrigation, and

selecting/using containment (e.g., absorbent products, anal plug or insert)1. Conservative management also includes

electromyographic (EMG) biofeedback, neuromuscular electrical stimulation (NMES) and in particular, pelvic floor muscle training

(PFMT). PFMT aims to increase strength/power (the maximum force produced by a muscle in a single contraction), endurance

(ability to contract repetitively and to maintain the muscle contraction over a period of time) and synchronize muscle activity (such

as the pre-contraction of pelvic floor muscles including the external anal sphincter previous to a rise in intraabdominal pressure,

or to repress urge). 2

Success of conservative management of anal incontinence depends in part on self-management by the patient, a plan

recommended by an informed healthcare provider, and consideration of the patient’s goals for treatment.3

This part of the workshop will review the most up-to-date literature regarding the conservative management of AI. This workshop

also aims to familiarise delegates with the interventions used in this group of patients and provide guidance for evidence-based

decision-making regarding conservative management of AI.

References

1. Bliss D, Mimura T, Berghmans B, et al., eds. Assessment and conservative management of faecal incontinence and

quality of life in adults. In Abrams P, Cardozo L, Wagg A, & Wein A, Eds. Incontinence, 6th ed. Bristol, UK: International

Continence Society; 2017.

2. Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane

Database of Systematic Reviews 2012, Issue 7. Art. No.: CD002111. DOI: 10.1002/14651858.CD002111.pub3.

3. Wilde MH, Bliss DZ, Booth J, Cheater FM, Tannenbaum C. Self-Management of Urinary and Fecal Incontinence.

American Journal of Nursing. 2014;114(1):38-47.

Neuromodulation

Samantha Morris – UK

An explanation of the indications for neuromodulation, the evidence for its’ use for anal incontinence and the steps needed

to implement treatment.

Neuromodulation is a recommended treatment for urge anal incontinence following the failure of conservative treatment

methods. There are a variety of neuromodulation systems on the market, ranging from the minimally invasive that can be

performed in the outpatient clinic (e.g. Percutaneous Tibial Nerve Stimulation (PTNS)) to surgical treatment (e.g. Sacral

Neuromodulation (SNM)). They are ineffective for other forms of anal incontinence, e.g. passive leakage, and thus patient

selection is key.

PTNS is a simple and non-invasive treatment form of neuromodulation which can be performed in the outpatient setting. PTNS

stimulates the tibial nerve, which contains L4-S3 fibres. It involves the insertion of a fine gauge needle electrode next to the

posterior tibial nerve. This is connected to a surface electrode placed on the under-surface of the foot and to a stimulator.

Simulation is gradually applied, and the needle position altered, until the patient experiences a sensory and/or motor response.

At this point, the stimulator is set to provide stimulation to the patient for a 30 minute period. The patient undergoes many of

these 30-minute stimulations, and the number and time between each varies between centres, making studies hard to compare.

“Top-Up” stimulations can also be administered after initial treatment to help maintain symptom improvement, but again the

protocol of administration of these “Top Ups” varies widely. Effectiveness of PTNS for treatment of anal incontinence is debated.

Numerous single-centre reviews suggest a significant improvement in reduction in anal incontinence episodes. The CONFIDeNT

trial – a double-blinded randomised control trial comparing PTNS with sham stimulation (Knowles et al 2015) showed no significant

benefit of PTNS over sham, with further analysis suggesting that additional obstructive defaecation symptoms negatively affected

the outcome (Knowles et al 2017). Conversely, a second randomised trial (Baeten et al 2017) did show an improvement in anal

incontinence symptoms above sham stimulation. Despite the conflicting data, PTNS may be a suitable treatment option for a

particular subset of patients who have failed conservative treatment and are not suitable for surgical options.

SNM is recommended by the ICS as a treatment option for those with anal incontinence following the failure of conservative

treatment options, and is the preferred treatment option if the patient has combined urinary symptoms (Siegel et al 2018). It

involves the same two-stage surgical procedure used to treat urinary urge incontinence and voiding dysfunction, with either a pne

or tined lead first stage, followed by second stage permanent implantation if significant symptom relief is seen. The lead is placed

intraoperatively in the S3 foramen, and connected to an external (first stage) or internal (second stage) stimulator. Stimulation is

set to a sub-threshold level. Numerous groups, including a double-blind crossover study (Leroi et al 2005) and a Cochrane Review

(Thaha M.A. 2015) , have shown SNM to be successful and above placebo in reducing anal incontinence in a subset of patients

Success is deemed as a 50% reduction in urge anal incontinence episodes. There are now numerous systems available on the

market, with options including implant rechargability and MRI compatibility.

References

1. Horrocks E. J., Bremner S. A., Stevens N., Norton C., Gilbert D., O’Connell P. R., Eldridge s., Knowles C. H. 2015 “Double-

blind randomised controlled trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in the

treatment of faecal incontinence: CONtrol of Faecal Incontinence using Distal NeuromodulaTion (the CONFIDeNT trial)”

Health Technology Assessment 19(77): 1-164

2. Horrocks E. J., Chadi S. A., Stevens N. J., Wexner S. D., Knowles C. H. 2017 “Factors associated with efficacy of percutaneous

tibial nerve stimulation for fecal incontinence, based on post-hoc analysis of data from a randomised trial” Clinical

Gastroenterology and Hepatology 15(12): 1915-1921

3. Van der Wilt A. A., Giuliani G., Kubis C., van Wunnik B. P. W., Ferreira I., Breuknik S. O., Lehur P. A., La Torre F., Baeten C.

G. M. I 2017 “Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in

patients with faecal incontinence” The British Journal of Surgery 104(9): 1167-1176

4. Goldman H. B., Lloyd J. C., Noblett K. L., Carey M. P., Casta No-Botero J. C., Gajewski J. B., Lehur P. A., Hassouna M. M.,

Matzel K. E., Paquette I. M., Wachter S. G., Ehlert M. J., Chartier-Kastler E., Siegel S. W 2018 “International continence

society best practice statement for use of sacral neuromodulation” Neurourology and Urodynamics 37(5): 1821-22

5. Leroi, Parc, Lehur, Mion, Barth, Rullier, Bresler, Portier and Michot “Efficacy of sacral nerve stimulation for fecal

incontinence: results of a multicentre double-blind crossover study” Annals of Surgery 2005 242(5): 662-9.

6. Thaha MA, Abukar AA, Thin NN, Ramsanahie A, Knowles CH. Sacral nerve stimulation for faecal incontinence and

constipation in adults. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD004464. DOI:

10.1002/14651858.CD004464.pub3.

Surgical Management

Massarat Zutshi – UK

An outline of the main surgical options for anal incontinence and the evidence and indications for each (for example, artificial

sphincter, sphincter repair).

Surgery is used selectively, particularly in those with defects of the anal sphincter which can be corrected mechanically. There is

no one perfect surgical option and there have been different techniques which have been available over the years, only some

have proven useful and many have been hampered by complications and adverse outcomes.

Sphincter repair: This is the mainstay surgical treatment for anal incontinence. Obstetric anal sphincter injuries may be repaired

primarily (at the time of injury) or secondarily (after the event). For a secondary repair the free ends of the sphincter are

mobilised and an overlapping repair is performed. Complications include wound infection and fistula.

Neoanal sphincters: May be biological or non-biological.

Artificial sphincter - An inflatable cuff is implanted around the anal canal and a pressure regulating balloon and pump which is

placed in the scrotum or labia majora. Continence is controlled by inflating and deflating the cuff. Other devices which have

been used include the Fenix device (not currently available) which is a ring of magnetic beads placed around the sphincter

complex to reinforce the sphincter. Complications of an artificial sphincter include infection, mechanical failure and migration.

Muscle transfers - The gluteus maximus muscle or gracilis muscle may be used to create a neoanal sphincter. Although these

muscle transfers are both still used the results are disappointing as patients are unable to sustain voluntary contraction of the

skeletal muscle. The development of an electrically stimulated anal neosphincter involves the use of a pulse generator and

stimulating electrodes to convert fast twitch fatigable muscle to slow twitch fatigue resistant muscle, which is continuously

stimulated.

Sphincter bulking: Bulking agents are injected into the anal sphincter to provide extra strength. Complications include sepsis and

migration.

Other surgical options include the surgical treatment of underlying rectal prolapse, a rectocoele or haemorrhoids or the

formation of a stoma.

Stoma:

MACE (Malone antegrade continence stoma for enema administration) – the formation of a non-refluxing, catherterisable

appendico-caecostomy to irrigate the distal colon keeps the colon free of stool.

Colostomy - A last resort when other procedures have failed or not likely to be successful.

Take Home Messages

Anal incontinence is a common, debilitating condition which may present alongside other pelvic floor dysfunction.

Assessment comprises of clinical assessment, anorectal physiology and endoanal ultrasound. Assessment of the salient features

can help to direct treatment and assess treatment outcomes.

The mainstay of treatment is conservative.

Suggested Learning before Workshop Attendance

Faecal Incontinence: Introduction. Falco Giuseppe

Pelvic floor disorders: Imaging and Multidisciplinary Approach to Management.

Editors: Santoro Giulio, Andrzej P Wieczorek, Clive Bartram

ICI Incontinence 6th edition book chapters 1, 16 and 17

Chapter 1 (Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse

(POP) and anal incontinence (AI).

Chapter 16 (Assessment and conservative management of faecal incontinence and quality of life in adults)

Chapter 17 (Surgery for faecal incontinence)

Abrams,P, Cardozo, L, Wagg, A, Wein, A. (Eds) Incontinence 6th Edition (2017). ICI-ICS. International Continence Society, Bristol

UK, ISBN: 978-0956960733.

https://www.acpgbi.org.uk/patients/conditions/bowel-incontinence/

https://masic.org.uk/

https://www.nice.org.uk/Guidance/qs54

02/10/2019

1

ICS Institute – School of Anorectal Dysfunction

Anal Incontinence? What Should I Do Next?

Alison Hainsworth


Samantha Morris

Alexis Schizas

Massarat Zutshi

Affiliations to disclose†:

Funding for speaker to attend:

Self-funded

Institution (non-industry) funded

Sponsored by:

Alexis Schizas

Nil

x

Speakers

Alexis Schizas Paula Igualda-Martinez

Samantha Morris

Alison Hainsworth

MassaratZutshi

Start End Topic Speakers09:30 09:45 Introduction pathophysiology and

epidemiology of anal incontinenceAlexis Schizas

09:45 10:00 Clinical Assessment Massarat Zutshi10:00 10:15 Assessment with anal imaging and

physiological investigationAlison Hainsworth

10:15 10:40 Conservative management Paula Igualada-Martinez10:40 10:55 Neuromodulation and surgical

managementSamantha MorrisMassarat Zutshi

10:55 11:00 Discussion Alexis SchizasAlison HainsworthPaula Igualada-MartinezSamantha Morris

IntroductionAlexis Schizas

Pathophysiology and Epidemiology of Anal Incontinence

Alexis Schizas

Consultant Colorectal Surgeon

1 2

3 4

5 6

02/10/2019

2

Anal incontinence

The complaint of involuntary loss of flatus or faeces

Maintained by the integrity and function of the anorectum

Factors which affect continence

delivery of stool to the rectum

ability of the rectum to store faeces

anal sphincter mechanism

nerve supply and physical mobility

Interruption to any of these mechanisms causes incontinence

Incidence

In the community varied from 1.4 to 19.5%

8.3 – 8.4% for face to face interviews

11.2 – 12.4% for postal surveys

Anal incontinence equally

men (median 8.9%; range 2.3% – 16.1%)

women (median 8.8%; range 2.0 – 20.7%)

increased with age (15 – 34 years, 5.7%; >90 years, 15.9%)

Epidemiology of anal incontinence after childbirth

3 – 6 months post-partum found that 29% reported anal incontinence

46% of these women experienced incontinence to stool and 38% to flatus

3.1% complained of faecal incontinence and 25.5% of flatus incontinence in the three months following birth

Obstetric anal sphincter injury

anal incontinence in up to 50% of patients

10 years after delivery 57% of women with a sphincter tear

28% of all women had anal incontinence

Factors associated with anal incontinence following childbirth

higher BMI

longer second stageforceps assisted delivery

sphincter tears

Anorectal physiology made simple

Delivery -RateType

Bipass

Warehouse -Capacity

Expansion CapabilityStretchabilityStolen GoodsSublet Space

Poor Stock Control

Warehouse Doors –“Ram raided”

Poor electric supplyToo thin / Rotten

Cause Mechanism for anal

incontinence

Risk Factors

Delivery to

the rectum

Rapid transit Inflammation (Inflammatory bowel disease

ischaemic colitis

microscopic colitis)

Infection, Irritable bowel syndrome

Malignancy

Post cholecystectomy diarrhoea

Polypharmacy

Tube feeds

Sports such as running

Constipation with faecal

impaction

Nursing home residents

Behavioural

lifestyle factors

Medication


incontinence

Risk Factors

Rectal

Storage

Rectal compliance

and capacity

Ulcerative colitis

Crohns’ disease

Radiation proctitis

Rectal tumour

Spinal cord injury

Rectal surgery

7 8

9 10

11 12

02/10/2019

3

Cause Mechanism for anal incontinence Risk Factors

Anal

Sphincter

Mechanism

Sphincter muscle injury Obstetric Trauma, Surgical Trauma (lateral sphincterotomy or anal stretch,

anorectal surgery for haemorrhoids or anal fistula), Accidental Trauma

Puborectalis dysfunction Obstetric trauma causing denervation so that anorectal angle is not maintained

Pelvic floor dyssynergia leading to incomplete evacuation and subsequent

soiling

Injury to anal mucosal folds which

maintain tight seal

Obstetric Trauma , Surgical Trauma

Prevention of closure of the anal

canal

Mucosal or full thickness rectal prolapse

Nerve

Supply

Pudendal nerve injury Obstetric trauma, Idiopathic, Peripheral neuropathy

Loss of sensation to the

anorectum

Obstetric trauma , Idiopathic, Peripheral neuropathy, Central nervous system

injury (spina bifda, spinal cord injury, stroke)

Nerve supply to external anal

sphincter and puborectalis

Obstetric trauma

Internal Anal Sphincter

• Extension of the circular muscle layer of the rectum

• Constant maximal contraction

• 50-85% of resting anal tone

• Autonomic innervation• Parasympathetic…..S2-4

• Sympathetic……..thoracolumbar ganglia (L5)

External Anal Sphincter

• Multiple layers of striated muscle

• Voluntary contractions to prevent fecal leak

• 25-30% of resting anal tone

• Somatic innervation from the inferior rectal branch of the pudendal nerve (S2-3) and the perineal branch of S4


incontinence

Risk Factors

Physical

Mobility

Inability to reach toilet

in time

Immobility

Dependence on others for activities of daily

living

Nursing home residents

Summary

Anal incontinence is a common condition

Prevalence and burden is expected to increase in the future

Anal incontinence is multifactorial

As important in men as in women

Better understanding of its’ aetiology

risk factors can be modified

aim for prevention

treat cause

Clinical AssessmentMassarat Zutshi

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Self-funded


Sponsored by:

Alison Hainsworth

Nil

x

† All financial ties (over the last year) that you may have with any business organisation with respect to the subjects mentioned during your presentation

Assessment with anal imaging and physiological investigation

Alison Hainsworth

Colorectal Surgical Registrar

Why investigate?

BECAUSE SOMETHING CAN BE DONE ……

Patient symptoms are a poor indicator of underlying pathophysiology

Townsend DC, Carrington EV, Grossi U, Burgell RE, Wong JY, Knowles CH, Scott SM. NeurogastroenterolMotil. 2016 Oct;28(10):1580-8. doi: 10.1111/nmo.12858. Epub 2016 May 20. Pathophysiology of fecalincontinence differs between men and women: a case-matched study in 200 patients.

But first…

Must exclude organic pathology with colonoscopy or flexible sigmoidoscopy

Anorectal Physiology

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Anorectal Physiology

Anal Manometry

(ARM)

Sensory

Rectal Balloon Testing (RBT)

Neurophysiology

Anorectal Manometry

(a) To define functional weakness of anal sphincter muscles

(b) To support findings of other tests

(c) To monitor outcome and predict response to conservative training

(d) To build a three-dimensional anatomical view of sphincter muscles

*Schizas AMP, Emmanuel AV, Williams AB. Anal canal vector volume manometry. Dis Colon Rectum. 2011 Jun;54(6):759–68.

Anorectal Manometry

Catheter

Measure pressure in different parts of anal canal

Assesses

• Internal anal sphincter

• External anal sphincter

Anorectal Manometry

EAS

IAS

Puborectalis

Catheter

Anal Manometry Anal manometry – water perfused system

Deepa Solanki, Fiona Hibberts, Andrew B Williams Pelvic floor investigations for bowel dysfunction (part 2): anorectal physiology (manometry) Gastrointestinal Nursing, Vol 17, No 5

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Anal Manometry

Conventional

• Standard catheter

• Station / continuous pull through

High definition

• High definition catheter

High resolution

• Conventional catheter with high definition software

Anorectal Manometry – Advanced techniques

Vector volume manometry Ambulatory monitoring

Anal Manometry

Measurements include

• Functional anal canal length

• Maximum resting pressure

• Maximum squeeze pressure

• The length from the anal verge to the peak pressure

• The high-pressure zone length (HPZ)

• Involuntary maximum squeeze pressure

• Endurance squeeze pressure

• The average anal canal pressure

• Rectoanal inhibitory reflex (RAIR)

• Balloon expulsion pressure

Measurements include

• Functional anal canal length

• Maximum resting pressure

• Maximum squeeze pressure

• The length from the anal verge to the peak pressure

• The high-pressure zone length (HPZ)

• Involuntary maximum squeeze pressure

• Endurance squeeze pressure

• The average anal canal pressure

• Rectoanal inhibitory reflex (RAIR)

• Balloon expulsion pressure

Anal Manometry and Symptoms

Association between symptoms and manometry No association between symptoms and manometry

Patients with low anterior resection syndrome -Incontinence correlates with reduced resting pressure van Duijvendijk P: Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy. Am J Gastroenterol 2002;97:2282–2289

No correlation between anal pressures and severity of symptoms after primary obstetric injury repairSoerensen MM, Pedersen BG, Santoro GA, Buntzen S, Bek K, Laurberg S.Long-term function and morphology of the anal sphincters and the pelvic floor after primary repair of obstetric anal sphincter injury. Colorectal Dis. 2014 Oct;16(10):O347-55. doi: 10.1111/codi.12579.

Improvements in faecal incontinence and quality of life are also associated with a significant increase in maximal anal resting pressure following artificial sphincter reimplantation for faecal incontinenceLehur PA, Zerbib F, Neunlist M, Glemain P, Bruley des Varannes S Comparison of quality of life and anorectal function after artificial sphincterimplantation. Dis Colon Rectum. 2002 Apr;45(4):508-13.

85 patients following anal sphincter repair Significant improvements in quality of life, there were no changes in anal manometryBenjamin R Grey, Rowena R Sheldon, Karen J Telford and Edward S Kiff BMC Surgery20077:1Anterior anal sphincter repair can be of long term benefit: a 12-year case cohort from a single surgeon

Reduced anal pressures in patients with persistent incontinence despite surgical repair obstertic anal sphincter injuryDickinson KJ, Pickersgill P, Anwar S. Functional and physiological outcomes following repair of obstetrics anal sphincter injury. A case. Int J Surg.2013;11(10):1137-40. doi: 10.1016/j.ijsu.2013.08.017. Epub 2013 Sep 27.

Systematic review Long term outcomes after anal sphincter repair for FI16 studies (nearly 900 repairs) Poor correlation between symptoms and quality of life and the authors concluded that despite worsening results over time, most patients remain satisfiedGlasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review Dis Colon Rectum. 2012 Apr;55(4):482-90. doi: 10.1097/DCR.0b013e3182468c22.

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Sensory Measurements

Distension sensitivity testing is useful in:

(a) Conservative treatment for anal incontinence to help with normalisationof threshold sensations

(b) Identifying

visceral hypersensitivity

poor rectal compliance

rectal irritability

Not proven valuable in identifying candidates for specific therapies


First (threshold) sensation

Urge sensation

Maximum tolerated volume

Rectal hypersensitivity

Rectal hyposensitivity

Rectal Compliance

Catheter

Balloon


• Rectal Sensitivity Test (RST)

• Rectal sensitivity training with balloon distension

• Progress documented according to volumes tolerated

• BUT improvement in rectal capacity may not be reflected by patients’ symptoms …

moderate improvement maximal tolerated volume BUT

only a few showed substantial improvement St Mark’s incontinence score

Additional: Sensory Measurements - Barostat

Barostat?more reproducible than balloon distention (published ranges still vary widely).

Distension thresholds 1.5 to 3 times higher than for manual balloon inflation.

May take up to an hour to perform.

Not widely available.

‘Rapid’ barostat ?routine use.

Additional: Neurophysiology

• Pudendal nerve terminal motor latency

• Assessment of activity in external sphincter and puborectalis

• Strength training during biofeedback

• User dependent

• Not routinely used.

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Anal Imaging

Imaging

Endoanal Ultrasound

MRI Defaecatory Imaging

Endoanal Ultrasound

• Dynamic assessment

• Thickness and structural integrity

• External anal sphincter

• Internal anal sphincter

Endoanal Ultrasound

Endoanal Ultrasound Endoanal Ultrasound

Obstetric anal sphincter injury Lateral sphincterotomy

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Endoanal Ultrasound – Sphincter Repair

Pre and post surgical sphincter repair

Assess effect of the operation

Investigate unsatisfactory results

Endoanal Ultrasound

• And approaches 100% sensitivity and specificity for identifying sphincter defects.

• BUT….Sphincter defect does not necessarily correlate with incontinence.

Karoui S., Savoye-Collet C., Koning E., et al.: Prevalence of anal sphincter defects revealed by sonography in 335 incontinent patients and 115 continent patients. AJR Am J Roentgenol. 173 (2):389-392 1999 10430142

Number of subjects % with sphincter defect on endoanal ultrasound

335 patients with incontinence 65%

115 continent patients 43%

18 asymptomatic female volunteers

22%

MRI

• Equivalent to ultrasound for external sphincter defects

• External anal sphincter atrophy following sphincteroplasty (for obstetric injury causing incontinence) can only be visualised on endoanal MRI but not ultrasound

• Atrophy affects continence post operatively

Briel JW, Stoker J, Rociu E, Laméris JS, Hop WC, Schouten WR.

External anal sphincter atrophy on endoanal magnetic resonance imaging adversely affects continence after sphincteroplasty. Br J Surg. 1999 Oct;86(10):1322-7.

Other – Defaecation Proctogram

Summary – key investigations and results

Faecal Incontinence

Rectal Balloon Distention

Rectal hypersensitivity

Future – rapid Barostat

Anorectal Manometry

Low resting pressures

Low squeeze pressures

Endoanal Ultrasound

Sphincter defect

Concomitant Incomplete Evacuation

Defaecatory Imaging

Rectocoele

Intussusception

Conservative ManagementPaula Igualada - Martinez

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Self-funded


Sponsored by:


Coloplast Ltd

(Continence Advisory Board-Product Development)

x

x


Conservative Management of

Anal IncontinenceBy


Clinical Specialist Physiotherapist

Physiotherapy Department- Pelvic Floor Unit

Guy’s and St Thomas NHS Foundation Trust

London, UK

What is conservative management?

Defecation techniques

Dietary Advice

Emotional support & Therapeutic Alliance

EMG Biofeedback

Bowel Training

Pelvic floor rehabilitation

Rectal balloon training

Conservative management

A combination of all of these therapies will help the patient to manage AI symptoms and

should be first line management

Containments products

Trans anal irrigation

Aims of conservative management

• To change stool consistency

• To promote and complete effective defecation

• To improve the strength, tone, endurance and coordination of thePelvic Floor Muscles including EAS

• To normalise the sensibility of rectum

Bø et al (2007) Evidence-Based Physical Therapy for the Pelvic Floor

Bols et al (2013) KNFG Evidence Statement Anal incontinence

Initial clinical assessment:

History taking

Observation and Physical examination

Outcome measures

Reverse

Primary interventions

Secondary Interventions

Bliss et al (2017) 6th International Consultation on Incontinence

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Primary Interventions

Education of the patient bowel pathology and

treatments available

Review the medication if

AI is a side effect

Diet and eating pattern modification

Practical advice for coping:

Locating toilets

Radar Key Card

Just Can’t Wait Card

Support networks, the B&B Foundation Ward J. (2011) Gastroenterol Clin N Am;36:687–711

Foxx- Orenstein et al (2014) Gastroenterol Hepatol (NY);10(5):294–301.

Bliss et al (2017) Committee 16 Incontinence 6th edition ICI: 1996-2086

Address

reversible

Factors:

Toilet Access and Mobility


• Bowel habit training

Good rectal evacuation is pivotal to decrease

episodes of AI!


2. Glycerine Suppositories

1. Good defecation dynamics


What about

stool consistency?

Ask your patients which one is easier to hold on the hand!

- Bowel diary

- Avoidance of known triggers

- Two RCT’s to show that psyllium iseffective in reducing AI comparedwith Loperamide and has less sideeffects

- Liquid Loperamide a better option asreduces the risk of constipation

Bliss et al (2017) Committee 16 Incontinence 6th edition ICI: 1996-2086Bliss et al (2017) 6th International Consultation on Incontinence


Pelvic floor muscle training

• PFMT: training consists of repetitive and maximal voluntary contractions andrelaxations of the PFM’s and external anal sphincter

• Exercise programs should follow the principles of:- Specificity, Overload, Progression and Maintenance- Endurance of squeeze

• For a minimum of 5 months

• Include strategies to adhere to the exercise regime• PFMT apps?

Bø K (1995) Int Urogynecol J; 6: 282–91.


American College of Sports Medicine (ACSM) (1998) Med Sci Sports Exer 30: 975-991


EMG Biofeedback

Neuromuscular electrical

stimulation

Rectal Balloon Training



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Deutekom and Dobben (2012) Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD005086.

Omar and Alexander (2013) Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD002116

Bliss et al (2011). J Wound Ostomy Continence Nurs. 2011 May-Jun; 38(3): 289–297

Anal Plugs and Pads


Christensen et al (2003) Diseases of the Colon and Rectum 46:68-76

Trans-anal Irrigation

Coping strategies

• Inquire about the patent’s current level of coping andstrategies used – Reinforce good self-managementstrategies!

• Share practical strategies for coping with faecalincontinence used by other patients to increase a sense ofcontrol

• Suggest participation in a support group if available

• Locating toilets, carrying cleansing kits

Conclusions

• Conservative management has NO ADVERSE EFFECTS:• It should be first line management of anal incontinence!

• Have clear goals and expectations and promote self-management

• Ensure good communication with the Colorectal Team!

• We should aim for a standardization of protocols and equipment• “There is marked variation in practice, training and supervision of therapists in the

UK”Etherson et al. (2016) Frontline Gastroenterology. 0:1-6.

TAK!Neuromodulation

Samantha Morris

Clinical Scientist

Guys and St Thomas’ NHS Foundation Trust, UK

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Self-funded


Sponsored by:

Samantha Morris

Nothing to disclose

X


Aims

• What is neuromodulation?

• Indications for neuromodulation

• Forms of neuromodulation

• Evidence for its use

• Future

Neuromodulation

• Recommended treatment for Faecal Incontinence following failure of conservative treatment methods

• Range of modalities• Sacral Neuromodulation (SNM)

• Percutaneous Tibial Nerve Stimulation (PTNS)

• Transcutaneous Tibial Nerve Stimulation (TTNS)

• Implantable Tibial Nerve Stimulation

• All initially developed to treat overactive bladder

What is Neuromodulation?

• “The alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body” - International Neuromodulation Society

• Anorectal Pudendal and Parasympathetic nerve fibres originate in the sacral foramen

• Involved in defaecation and continence

• SNM aims to stimulate these directly

• Tibial stimulation (PTNS, TTNS) stimulate the tibial nerve, which contains L4-S3 fibres

Sacral Neuromodulation (SNM)

• FDA and NICE approval for treatment of faecal incontinence

• ICS recommended treatment

• Two stage surgical procedure • Either tined lead or pne test phase followed by permanent implantation

• Exactly the same as for urinary patients

• Lead placed into S3 foramen , with placement confirmed with intra-operative x-ray and on-table stimulation to asses motor response

• Numerous systems on the market

SNM - ICS

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Percutaneous Tibial Nerve Stimulation (PTNS)

• Simple and non-invasive, outpatient setting

• Fine gauge needle electrode inserted next to posterior tibial nerve. Connected to surface electrode and stimulation

• 30 minute stimulation

• Frequency and number of stimulations vary

PTNS - Evidence

• Efficacy is debated

• Many single centre reviews indicate significant improvement in faecal incontinence

• Randomised trials PTNS v sham – opposing results

• Suitable option for patients with bothersome faecal incontinence refractory to conservative treatment, but not suitable for surgical management

Transcutaneous Tibial Nerve Stimulation

• Surface electrodes with TENS stimulators

• Cheaper

• “A systematic review and network meta-analysis comparing treatments for faecal incontinence” Simillis et. al. 2019 –improvement in faecal incontinence QoL embarrassment score compared to placebo

• “Randomized controlled trial of percutaneous versus transcutaneous posterior tibial nerve stimulation in faecal incontinence” George et. al. 2013 – inferior to PTNS

• NICE – “Do Not Do Recommendation” for OAB

Implantable Tibial Nerve Stimulators

• BlueWind RENOVATM

• eCOINTM (Valencia Technologies Corp.)

• Both approved for investigational use only

• Limited evidence for OAB

• No data for faecal incontinence

• Potential option for future

Surgical ManagementMassarat Zutshi

Discussion

Questions?

Thank you

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Assessment of a patient with anal incontinence

Massarat Zutshi

Associate Professor of Surgery

Staff Surgeon

Department of Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic Foundation



Self-funded


Sponsored by:

x


Fecal Incontinence

• Gas/ soft or liquid stool /solid stool

• Passive or with awareness

• Mild (soiling); moderate ; severe

• Etiology : Anatomical/Neurological/both

Clinical assessment: History

Symptoms of FI

• Onset

• Frequency of episodes of incontinence

• Type of incontinence : to solid, liquid or mushy

stool

• Passive or incontinence with awareness

• Urgency

• Incontinence free days in a week

• Use of pads, number of pads used

• Affect on quality of life

• Incontinence to gas

• Incontinence to urine

Assessment

• Stool description including frequency

• Evaluate if constipation with overflow

• Evaluate if other pathology of the colon may coexist like IBD

• Food allergies/sensitivities

• History of surgery to the anal canal/colon

• History of radiation

• Date of last colonoscopy

Clinical assessmentCoexisting problems: like diabetes, back issues,

spina bifida, multiple sclerosis

Obstetric history: weight of last baby; tears or episiotomies

Medication: if symptoms of loose a stool look for

medications like metformin

Evaluation of local and general health

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Physical examDigital rectal exam :

Inspect

Evaluate the perineal area for skin condition, presence of scars, fistula

Ask the patient to squeeze and bear down and watch for the movement of the perianal

/anal area

Anocutaneous reflex

Palpate

Look for any pathology in the anal canal like a fissure, polyp, tumor and obvious scar

tissue anteriorly.

Ask the patient to squeeze and strain and evaluate the anal sphincter tone both resting

and squeezing.

Evaluate any pathology like a rectal prolapse, prolapsing hemorrhoids enterocele or a

sigmoidocele when asked to bear down. Examine on a commode/squatting if in doubt.

Anoscopy

To collaborate findings of a digital exam. Rule out any prolapsing hemorrhoids that

may be the cause of fecal leakage

Validated Scoring System

Bristol Stool Form Scale

Severity scales : Wexner (0-61)

ASCRS FISI (0-20)

FIQL (0-16)

Vaizey

Bowel Diary

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02/10/2019

1



Self-funded


Sponsored by:


Coloplast Ltd

(Continence Advisory Board-Product Development)

x

x


Conservative Management of

Anal IncontinenceBy


Clinical Specialist Physiotherapist

Physiotherapy Department- Pelvic Floor Unit

Guy’s and St Thomas NHS Foundation Trust

London, UK

What is conservative management?

Defecation techniques

Dietary Advice

Emotional support & Therapeutic Alliance

EMG Biofeedback

Bowel Training

Pelvic floor rehabilitation

Rectal balloon training

Conservative management

A combination of all of these therapies will help the patient to manage AI symptoms and

should be first line management

Containments products

Trans anal irrigation

Aims of conservative management

• To change stool consistency

• To promote and complete effective defecation

• To improve the strength, tone, endurance and coordination of thePelvic Floor Muscles including EAS

• To normalise the sensibility of rectum


Bols et al (2013) KNFG Evidence Statement Anal incontinence

Initial clinical assessment:

History taking

Observation and Physical examination

Outcome measures

Reverse

Primary interventions



1 2

3 4

5 6

02/10/2019

2


Education of the patient bowel pathology and

treatments available

Review the medication if

AI is a side effect

Diet and eating pattern modification

Practical advice for coping:

Locating toilets

Radar Key Card

Just Can’t Wait Card

Support networks, the B&B Foundation Ward J. (2011) Gastroenterol Clin N Am;36:687–711

Foxx- Orenstein et al (2014) Gastroenterol Hepatol (NY);10(5):294–301.

Bliss et al (2017) Committee 16 Incontinence 6th edition ICI: 1996-2086

Address

reversible

Factors:

Toilet Access and Mobility


• Bowel habit training

Good rectal evacuation is pivotal to decrease

episodes of AI!


2. Glycerine Suppositories

1. Good defecation dynamics


What about

stool consistency?

Ask your patients which one is easier to hold on the hand!

- Bowel diary

- Avoidance of known triggers

- Two RCT’s to show that psyllium iseffective in reducing AI comparedwith Loperamide and has less sideeffects

- Liquid Loperamide a better option asreduces the risk of constipation

Bliss et al (2017) Committee 16 Incontinence 6th edition ICI: 1996-2086Bliss et al (2017) 6th International Consultation on Incontinence


Pelvic floor muscle training – Sphincter exercises

• PFMT: training consists of repetitive and maximal voluntary contractions andrelaxations of the PFM’s and external anal sphincter

• Exercise programs should follow the principles of:- Specificity, Overload, Progression and Maintenance- Endurance of squeeze

• For a minimum of 5 months

• Include strategies to adhere to the exercise regime• PFMT apps?

Bø K (1995) Int Urogynecol J; 6: 282–91.


American College of Sports Medicine (ACSM) (1998) Med Sci Sports Exer 30: 975-991


EMG Biofeedback

Neuromuscular electrical

stimulation

Rectal Balloon Training



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3


Deutekom and Dobben (2012) Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD005086.

Omar and Alexander (2013) Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD002116

Bliss et al (2011). J Wound Ostomy Continence Nurs. 2011 May-Jun; 38(3): 289–297

Anal Plugs and Pads


Christensen et al (2003) Diseases of the Colon and Rectum 46:68-76

Trans-anal Irrigation

Coping strategies

• Inquire about the patent’s current level of coping andstrategies used – Reinforce good self-managementstrategies!

• Share practical strategies for coping with faecalincontinence used by other patients to increase a sense ofcontrol

• Suggest participation in a support group if available

• Locating toilets, carrying cleansing kits

Conclusions

• Conservative management has NO ADVERSE EFFECTS:• It should be first line management of anal incontinence!

• Have clear goals and expectations and promote self-management

• Ensure good communication with the Colorectal Team!

• We should aim for a standardization of protocols and equipment• “There is marked variation in practice, training and supervision of therapists in the

UK”Etherson et al. (2016) Frontline Gastroenterology. 0:1-6.

TAK!

13 14

15 16

17

http://deedtheinky.com/inkydeeds/career-advice/

02/10/2019

1

Surgical management of anal incontinence

Massarat Zutshi

Associate Professor of Surgery

Staff Surgeon

Department of Colorectal Surgery

Digestive Disease and Surgery Institute

Cleveland Clinic Foundation



Self-funded


Sponsored by:

Massarat Zutshi

Funded by Armed Forces Institute of Regenerative Medicine

X


Non/Minimally invasive treatments

• Anal Plugs (Renew insert; Peristeen)

• Peristeen Anal Irrigation System

• Injectables ( Solesta)

• Electrical stimulation

Local or peripheral

• Surface sacral stimulation

• Secca

Renew/Peristeen Inserts/Plugs : Good for small, few accidents

Evaluation of an Anal Insert

Device for the Conservative

Management of Fecal

Incontinence.Lukacz ES, Segall MM, Wexner SD.Dis Colon Rectum. 2015 Sep;58(9):892-8.

Median fecal incontinence

frequency reduced by 82%

.Mean fecal incontinence

severity scores improved by

32.4% (16.2, ±2.1 vs 10.9, ±4.4

of 20, p < 0.001) . 78% of

completers were very or

extremely satisfied with the

device with no serious adverse

events related to device use.

Anal Irrigation System

For patients with a

neurogenic disorder

Secca Procedure

• At 12 months: Wexner score improved 13.5-5.0 (p<0.001)

• All parameters in fecal incontinence quality of life index significantly improved

• SF-36 improved (NS) Takahashi et al DCR 2002

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The Ideal Secca Patient

• Has mild to moderate symptoms - Wexner score of 9-17

•Does not have a large sphincter defect*

•Does not have a patulous anus

• Has failed conservative therapies

•Does not have diarrhea/constipation

*Secca candidates should have relatively normal anorectal anatomy,

without significant scar or tissue loss not greater than a 30% external

anal sphincter disruption as seen on exam or ultrasound.

Eclipse Device

A vaginal bowel-control system

for the treatment of fecal

incontinence.

Richter HE, Matthews CA, Muir T,

Takase-Sanchez MM, Hale DS,

Van Drie D, Varma MG.

Obstet Gynecol. 2015

Mar;125(3):540-7

60/110 patients fitted 78% were

happy

No SAE’s

Main AE pelvic cramping

Solesta Injections

• Anoscopy to the

proximal anal canal

• Submucosal

injection

• Four separate 1mL

blebs

• No anesthesia

• Outpatient setting

Surgery

Patients with moderate incontinence with no sphincter defect

• Post anal repair

• Sacral nerve stimulation

Post anal repair

• Devised by Parks to

increase the length of

the anal canal and

restore the anorectal

angle

• Promoted in past for

those with intact

sphincter, but could

have nerve damage

• Long term results

reported only in 30-40%,

• 30% not improved at all.

Surgery

Patients with moderate incontinence with a sphincter defect

• Sphincter repair

• Sacral nerve stimulation

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Sphincter repair

Factors predicting failure

Poor tissue

Extensive dissection

No movement on squeeze pre op

PTNML- delayed

Absent IAS

Unrecognized pelvic floor issues

Results

Direct = Overlapping

Good short term results

Some individual series –good long

term results

Outcomes –sphincter repair

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St Marks

2000 n=38

F/U 77 m

France 2000

n=74

F/U 40 m

CCF 2002

n=49

F/U 69 m

U of Minn

2004 n=104

F/U 120 m

CCF 2007

n=41

F/U 126 m

continent

gas incon

total incon

Anal Encirclement• Thiersch 1891

High complication

• Anal Encircling Sphincter Repair (AESR)

Surgery

Patients with severe incontinence with a sphincter defect / failed repair / failed sacral nerve stimulation

• Re-repair

• Dynamic graciloplasty

• Artificial anal sphincter (AMI Anal Band)

• Stoma

Re-repair of anal sphincter

• Three studies total 80 patients

• Wexner score 19 to 12 (St Marks)

18 to 5 first repair (CCF Fla)

17 to 7 repeat (CCF Fla)

• All three concluded repeat repair yields significant improvement in

incontinence score and ability to defer defecation

• Vaizey study : 1 fully continent,12>50% improved, 4 unimproved

Giordano DCR May 2002 , Pinedo Br J Surg Jan 1999, Vaizey DCR 2004

Dynamic GraciloplastyIndications

• Extensive sphincter disruption

• Severe neural damage

• Congenital disorders

Problems

• Loosening of the wrap

• Pain at stimulator site

• Displacement of leads

• Steep learning curve

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Artificial Anal Sphincter

Absolute

contraindications

• Active perianal sepsis

• Crohn’s Disease

• Radiation proctitis

• Scarred perineum

• Anoreceptive intercourse

AMI BandAMS artificial anal sphincter

Artificial anal sphincterComplications• Range from 23-67%

• Infection/perineal wound problems

• Mechanical failure

• Difficult evacuation

• Still about 30% after learning curve

Wong 1996, Lehur 1997, Vaizey 1998, Savoye 2000, Lehur 2002, O’Brien 2004

Stoma

• For patients who have failed or are not candidates for other surgical repairs

• Patients with spinal injuries

• Patients deserve to be evaluated at a center which specializes in all options of evaluating and treating fecal incontinence before a stoma

• Allows opportunity to leave home, attend work, and social functions

Future: treating the chronic defect with a cytokine

Control : saline treated SDF-1 1 injection SDF-1 2 injectionsAnterior

25 pigs injected with a cytokine ( plasmid encoding SDF-1) 6 weeks after injury and evaluated 8 weeks

after surgery

Anterior

EAS EASIAS IAS

Regeneration of both smooth and skeletal muscle with increased pressures

Next step : Dose escalation study

Clinical trial

Thank you.

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