Fecal incontinencePathophysiology and etiologyPartial incontinence â€" loss of control to flatus and minor soiling Major incontinence â€" frequent and regular deficiency in the ability to control stool of normal consistencyFour basic physiologic factors:1.stool consistency, 2.rectal compliance,3.rectal and anal sensation4.pelvic floor function can lead to a defective continencemechanismIncontinence with normal pelvic floorfunction:-
1-Altered stool consistencyâ€¢Inflammatory bowel diseaseâ€¢Infectious diarrheaâ€¢Laxative abuseâ€¢Radiation enteritisâ€¢Short bowel syndromeâ€¢Malabsorption syndrome2-Inadequate rectal compliance â€¢Inflammatory boweldiseaseâ€¢Absent rectal reservoir (ileoanal, low ant. resection)â€¢Rectal ischemiaâ€¢Collagen vascular disease (scleroderma, amyloidosis, dermatomyositis)â€¢Rectal neoplasms3-Inadequate rectal sensationâ€¢Dementia, CVA, MS, brain or spinal cord injury/neoplasm, sensoryneuropathy, tabes dorsalis â€¢Overflow incontinence:-Fecal
impaction â€" leading cause of incontinence in institutionalizedelderly patientsâ€¢Diabetes â€" multifactorial, impaired rectal sensation is importantIncontinence with abnormal pelvic floorfunction
Anatomic sphincter defect â€" internal or externalTraumatic
Obstetric injury â€" prolonged difficult labor with forceps application,episiotomy complications, third or fourth-degree lacerationsAnorectal surgery â€" anal fistula surgery - most common operativeprocedure that results in fecal incontinence; hemorrhoidectomyPelvic floor denervation â€" degenerative neurogenicfactors are a common cause of non-surgically relatedincontinence1-Primary (idiopathic neurogenic incontinence)
a-Pudendal neuropathy â€" 80%. Denervation of the puborectalis muscle andexternal anal sphincter muscles â€" results in an impaired ability tomaintain the anorectal angle and prevent gross incontinenceb-â€œDescending perineal syndromeâ€â€" results from constant strainingduring defecation that causes a traction neuropathy of the nervesrunning along the pelvic floor muscles. Both the puborectalis andexternal anal sphincter muscles become denervatedc-Vaginal deliveries2-Secondary:-
1.Injuries to spinal cord, cauda equina2.Diabetic neuropathyCongenital abnornmalities:-
TreatmentImproving stool consistency:-
- Rectal prolapse â€" 60-70% incontinence.
- Aging â€" anal canalpressure and rectal compliance are decreased
- Diagnostic evaluation
Increase intake of bulking agents â€" bran, psylliumAntidiarrheal agents â€" loperamide, lomotil, cholestyramineBowel management:-
â€¢Fecal disimpactionâ€¢Scheduled toiletingâ€¢Glycerin suppositories daily, 30 min postprandialâ€¢Attempt to defecate at the same time dailyâ€¢Daily tap water enemaBiofeedback therapy
Patients looks at a polygraph tracing while attempting to contract theexternal anal sphincterThrough visual â€œfeedbackâ€ of looking at anal canal pressures duringcontraction and verbal guidance, patients can learn to appropriatelycontract the external sphincter in response to the sensation of rectaldistension70% restoring continence 90% reduction in incontinent episodesSurgery....................