210 - Fecal Incontinence Flashcards
Fecal Incontinence definition
involuntary loss of solid or liquid stool or mucus from the rectum
What is dyssenergia (WRT fecal incontinence)
when the anal sphincter, pelvic floor muscles, or both, do not relax appropriately with attempts at defecation, and the resultant incomplete emptying and evacuation difficulties lead to overflow incontinence
Prevalence of fecal incontinence in community-dwelling women? Age 20-29? Age 70+? Prevalence of fecal incontinence in nursing home women?
Community: 8.3%! (liquid stool > mucus > solid stool) 20-29: 2.6% 70+: 15.3% Nursing home 40-70%
Common non-neurologic causes of fecal incontinence?
Risk factors for fecal incontinence
lose/watery stools, frequent stools (>21/w), 2+ chronic illnesses, urinary incontinence, obesity, smoking, increasing age, decreased physical activity, anal intercourse, history of OASIS, history of pelvic irradiation, and other medical comorbidities, such as diabetes mellitus and inflammatory bowel disease
Medications associated with fecal incontinence
Treatment options for fecal incontinence
Who should be screened for fecal incontinence?
age 50 years and older; residence in a long-term care facility; prior OASIS; history of pelvic irradiation; engagement in anal intercourse; or the presence of urinary incontinence, chronic diarrhea, diabetes, obesity, or rectal urgency
What is the initial workup of fecal incontinence?
History: RFs (especiall ymodifiable), symptoma assessment including impat on life and Bristol scale
Physical: visual exam, DRE, look for Dovetail sign (loss of anteiror puckering indicating anal sphincter injury)
Labs: not needed unless infection suspected
Tests: if exam is abnormal, “referral for ancilary testing considered”
What are the different Bristol stool descriptions?
Who requires evaluation for colon cancer among women with fecal incontinence?
Changes in bowel habits, especially when accompanied by any “red flag” symptoms, including unexplained weight loss, abdominal pain, rectal bleeding, melena, or anemia
In what % of fecally incontinent women did 16g daily fibre help, and how to dose it per age group?
50% (compared to 10% placebo) to decrease
19-30: 28g/d
30-50: 24g/d
50+: 22g/d
increase 5g/d every 1-2w to prevent bloating/gas
Loperamide for fecal incontinence? Dosing?
Yes
start 1/2 tab/d, use prn to max 16mg/d
titrate prn
Medical rx of overflow fecal incontinence associated with constipation/impaction?
Osmotic laxatives;
- PEG (polyethylene glycol aka miralax)
- Lactulose
Has pelvic floor PT been shown to be helpful in fecal incontinence? What about biofeedback? What about electrical stimulation?
Yes
With biofeedback is better
One study said stim + bio > bio > PT alone, but AHRQ 2016 review concluded that biofeedback with electrical stimulation was no more effective than pelvic floor biofeedback alone and that up to 9% of participants may experience discomfort
Devices for anal incontinence? how efficacious are they?
- Anal plug
- Vaginal bowel control devie (baloon pushed on rectum from inside vagina, deflate to have BM)
Both have about 78% success in decreasing incontinence episodes by 50%
How effective are anal sphincter bulking agents for the treatment of fecal incontinence?
50% had >50% reduction in incontience episodes (but placebo had 30%), but doesnt last and may get worse
Whos is a surgical candidate for fecal incontinence
First line for fistula and rectal prolapse
For other conditions not first line and associated with many complications and failure
Neuromodulation for fecal incontinence? What are the long term success rates?
1st line for conservative-refractor patients, with or without anal sphincter injuries.
50% decrease in incontinence episodes in:
- 63% in the short term (6–12 months)
- 58% in the medium term (17–36 months)
- 54% in the long term (44–118 months)
- At 56 months, 20% of patients reported complete continence, with a 10% decrease in efficacy within 5 years
What is the success rate of anal spincter repair for anal incontinence? Which method is best? What is the most common complication?
85% have improvement in symptoms. 50% have continence after 5-10 years but 75% are still satisfied with results.
End-to-end or overlapping is the same outcome
MC complication is wound infection: 6-35%
Radiofrequency Anal Sphincter Remodeling?
Works by scarring and fibrosing the mucosa.
Not recommended because no high quality studies. 20% risk of bleeding.
Other surgical techniques for feval incontinence?
gracilis muscle transposition, artificial anal sphincter placement, and diverting colostomy
