Anal Incontinence

Question 1

subtypes of anal or fecal incontinence

Answer 1

3 Subtypes:
• Passive incontinence (without awareness)
• Urge incontinence (in spite of active attempts to retain)
• Fecal seepage (leakage following normal evacuation)

Question 2

Fecal Continence depends on

Answer 2

– A competent, closed anal sphincter
– Normal anorectal sensation and reflexes
– Normal rectal compliance
– Normal stool volume and consistency
– Conscious control

1. Internal anal sphincter (IAS)
• Circular, smooth muscle
• Autonomic control
• ~ 80% of resting tone
2. External anal sphincter (EAS)
• Striated muscle
• Pudendal nerve (S2-4)
3. Puborectalis
• Striated muscle; S3 & S4
• Sling around anorectum

Question 3

imaging for anal incont

Answer 3

Anal manometry
- Study of rectal function and sensation.
- Info on rectal sensation, rectal compliance,
strength of the IAS and EAS, dyssynergia, balloon
expulsion test

Endoanal US - Ultrasound to assess anal sphincter defects

Defecography
- Dynamic imaging to assess function & anatomy.
- Info on emptying using barium paste in rectum;
anatomy
(enterocele, rectal prolapse, intussusception,
rectocele)

Electromyography - EMG to assess neuropathy and denervation

Endoscopy - Colonoscopy, sigmoidoscopy, anoscopy

Question 4

Anal Incontinence Treatment - supportive

Answer 4

Ritualize bowel habits
 Improve skin hygiene
 Stool deodorants (Periwash ®)
 Avoid increases in colonic motility
– Caffeine
– Brisk physical activity after meals
– Insoluble (unabsorbable) fiber

There are plugs and pessaries

Question 5

Medical Treatment for Anal Incontience

Answer 5

Treat underlying disorder: IBS, IBD, food allergy, fissure

2. Medication:
   – Bulking agents: soluble fiber supplementation

– Antidiarrheal agents: ↓ transit ↑ AS resting pressure
• Loperamide (Imodium) – preferred; opiate w/ ↓CNS effects

Question 6

Biofeedback for Anal Incontinence

Answer 6

Biofeedback
– Improve EAS strength
– Improve sensitivity to less rectal distension
– Enhance voluntary contraction
 Improvement noted in 60-90% but few long-term studies
 Alternative or adjunct to surgical repair
– Best alternative for patients with pudendal nerve
injury

Question 7

Sphincteroplasty success rate at 5 years

Answer 7

as
low as 11-14% at 5 years. Another study of 86 patients
reported a success rate of 50% at 5 years.

Question 8

Neuromodulators

Answer 8

Sacral neurostimulation
– 2 stage procedure
• Stage I sacral tine placement
• Bowel diary for 2 weeks for 50% improvement
• Stage II implantable generator placement

– >80% had a 50% reduction in #FI episodes / week for
1, 2, and 3 years