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 consistency•Inflammatory bowel disease•Infectious diarrhea•Laxative abuse•Radiation enteritis•Short bowel syndrome•Malabsorption syndrome2-Inadequate rectal compliance •Inflammatory boweldisease•Absent rectal reservoir (ileoanal, low ant. resection)•Rectal ischemia•Collagen vascular disease (scleroderma, amyloidosis, dermatomyositis)•Rectal neoplasms3-Inadequate rectal sensation•Dementia, CVA, MS, brain or spinal cord injury/neoplasm, sensoryneuropathy, tabes dorsalis •Overflow
incontinence:-Fecal impaction â€" leading cause of incontinence in institutionalizedelderly patients•Diabetes â€" multifactorial, impaired rectal sensation is important
Incontinence with abnormal pelvic floorfunctionAnatomic sphincter defect â€" internal or external
TraumaticObstetric 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; hemorrhoidectomy
Pelvic 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-“Descending 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 deliveries
2-Secondary:-1.Injuries to spinal cord, cauda equina2.Diabetic neuropathy
Congenital abnornmalities:-•Spina bifida•Myelomeningocele
Miscellaneous
- Rectal prolapse â€" 60-70% incontinence.
- Aging â€" anal canalpressure and rectal compliance are decreased
- Diagnostic evaluation
TreatmentImproving stool consistency:-Increase intake of bulking agents â€" bran, psylliumAntidiarrheal agents â€" loperamide, lomotil, cholestyramine
Bowel management:-•Fecal disimpaction•Scheduled toileting•Glycerin suppositories daily, 30 min postprandial•Attempt to defecate at the same time daily•Daily tap water enema
Biofeedback therapyPatients looks at a polygraph tracing while attempting to contract theexternal anal sphincterThrough visual “feedback†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 episodes
Surgery....................