Lesson 15: Fecal Incontinence Flashcards
Factors Affection Bowel Function - Colonic Transit Time
Goal = delivery of softened formed stool to rectum at intervals
Peristaltic Stimulants
- Activity
- Colonic distension
- Cholinergics
- Caffeine
- Eating
Peristaltic inhibitors
- Inactivity
- Low fiber diet
- Meds
- Age >65
Innervation
- Enteric nervous system
- Autonomic nervous system modulates
- Parasympathetic stimulates
- Sympathetic inhibits
Factors Affection Bowel Function - Sensory Awareness
Rectal distension + delivery of stool
- Stretch receptors in rectal walls + perirectal muscles
- Activated by low levels of distension
Anoderm
- Receptors in anal canal distal to the dentate line
- Ability to differentiate between solid, liquid, and gas
Factors Affection Bowel Function - Sphincter Function
Internal anal sphincter (IAS)
- Surrounds proximal anal canal and anorectal junction
- Normally closed; relaxes in response to rectal distension
- 5 - 20 mLs causes transient relaxation
- 60 mLs causes persistent relaxation
External Anal Sphincter (EAS)
- Surrounds IAS and anal canal
- Partially contracted at rest
- Rectal distension causes increased reflex tone
- Must voluntarily relax sphincter for defecation
- Continuous with puborectalis muscle
Factors Affection Bowel Function - Rectal Capacity + Compliance
Ability to relax around bolus of stool + store stool at low pressures
Continence is dependent on
- Interruption of mass movements
- Relaxation of rectal walls
Normal function (in sequence)
- Contraction of EAS increases anal pressures
- Blocks rectal emptying + interrupts mass movements
- Rectum relaxes to provide temporary storage
- Voluntary defecation involves relaxation of EAS + abdo muscle contraction
- Ultimately facilitates evacuation
Factors Affection Bowel Function - Environmental/Psychosocial Factors
- Availability + accessibility to toileting facilities
- Impact of social taboos + restrains
— Causes subconscious withholding of stool - Involuntary defecation
— When rectal pressures exceed anal canal pressures
— Impaction causes constant relaxation of IAS
— Permits leakage
Risk Factors
- Diarrhea
- Impaction with overflow incontinence
- Neurologic disorders
- Dementia
- Anorectal trauma or surgery
- Traumatic vaginal delivery
- Restricted mobility
- Inadequate toileting facilities
- Conditions affecting rectal capacity/compliance
Etiologic Factors
alterations in peristaltic activity
- High volume diarrhea = rapid rectal distension
- Overrides sphincter function
Reduced sensory awareness of rectal filling
- No warning or response time
Impaired sphincter function
- No ability to delay
Reduced rectal capacity
Patient Assessment - History
- Onset + severity of fecal incontinence
- Impact on lifestyle + quality of life
- Exacerbating + relieving symptoms
Systems review
- GI: IBD, IBS, anorectal trauma
- Neuro: spinal cord injury, lower back injury, MS, TBI
- Gyne: GTPAL
Medication review
- Both rx and OTC
- Laxatives, softeners, opioids, antidiarrheals
- Not obvious offenders
— Antacids
— Anticholinergics
— Cardiovascular meds
— Oral hypoglycemics
— Alzheimer’s meds
Patient Assessment - Diet
- Fiber and fluid intake
- consumption of sorbitol
Patient Assessment - Specific Questions
Peristaltic function
- # of stools, volume, consistency, peristaltic inhibitors/stimulants
Sensory awareness
- Do you know when you have to go?
- Can you differentiate between solid, liquid, and gas?
Sphincter function
- Ability to delay elimination?
- How long can you delay?
Rectal capacity/compliance
- Ability to delay for more than 1-2 minutes
- Any frequency or urgency associated with bowel movements?
Patient Assessment - Physical
Abdo inspection with percussion + palpation
- R/o colonic distension
Sphincter function
- Anal tone at rest
- Sensory awareness on digital exam
- Ability to voluntarily contract sphincter
- Sphincter strength + endurance
- Ability to perform Valsalva
- Retained stool in rectum?
Patient Assessment - Bowel Chart
- Frequency
- Volume
- Consistency
- Voluntary vs incontinent stools
- Food + fluid intake
Diagnostics
Endoanal ultrasound/MRI
- Detects problems with structural damage
Anorectal manometry
- Assess sensory awareness + sphincter function
- Catheter with 3 pressure-sensitive balloons inserted into anal canal
— Intrarectal pressure
— IAS pressure
— EAS pressure
Sphincter EMG
- Assesses innervation + contractility
Defecography
Transient Fecal Incontinence
- Caused by large volume liquid stool overwhelming continence mechanism OR
- Altered mental status affecting patient’s ability to recognize/respond to rectal distention
Management
- Correction of etiologic factors
- Correction of factors causing altered mental status
- Containment + skin care
Episodic Fecal Incontinence
- Some degree of sphincter damage is present
- Damages sphincter is competent for formed stool but not liquid
Management
- Manage underlying conditions
- Sphincter strengthening exercises
- Containment products PRN
Chronic Incontinence d/t Altered Mental Status
- Reduced ability to recognize/respond to rectal distention
- Incontinence in response to mass movements
- May have superimposed constipation d/t meds or diet
Management
- Stimulate defecation on routine basis
- Containment products PRN
Chronic Incontinence d/t Loss of Sensorimotor Innvervation
Neurologic process that results in
- Diminished sensory awareness of rectal distension
- Diminished ability to contract EAS
- Profound constipation d/t reduced activity
Management
- Normalize stool consistency
- Stimulation defecation on routine basis to provide control of fecal elimination
Passive Incontinence
- Unrecognized leakage of stool
- Leakage occurs but patient is aware
- D/t loss of sensory function or dementia
Urge Incontinence
- Leakage of stool associated with intense fecal urgency
- Patient aware of rectal distention but unable to effectively delay defecation
— Damaged or weak EAS
— Motility disorder
— Loss of rectal compliance
Seepage and Soiling
- Leakage of small amounts of stool without conscious awareness
- Occurs in between normal bowel movements
- D/t IAS weaknesses or diminished sensory awareness
Flatus Incontinence
- Loss of control of flatus
- Stool continence maintained
Management - Correct Stool Consistency
Colonic distension/constipation
- Clean out with laxatives and/or enemas/suppositories
- Fiber + fluid to normalize stool consistency
Diarrhea
- Correct etiologic factors
- Dietary modifications
- Medications PRN
- Improve sensory awareness
Management - Improve Sensory Awareness
Biofeedback programs
- Balloon-tipped catheter inserted into rectum and inflated until patient senses balloon
- Repeated inflated + deflated
Abnormal rectal sensitivity
- Inflate balloon until patient perceives urgency
- Leave in place and have patient practice deep breathing until urgency subsides
Management - Strengthening Muscles
If pelvic trauma
- Surgical consult if repair is indicated
Weak pelvic muscles but ability to contract muscles + cognitively intact
- Sphincter exercises
Management - Improve ability to delay + control urgency
Freeze-Squeeze-Breathe until urgency subsides
Supportive counseling to reduce anxiety
Management - Initiate Stimulated Defecation Program
For patients with total loss of sensory awareness + sphincter control
Goal to stimulate defecation on routine basis before rectum fills + causes involuntary defecation
- Patient cannot sense rectal distention or control sphincter to delay
- Must stimulate peristalsis to deliver stool to rectum
- Reduce risk of incontinence overtime
Steps
- Disimpact PRN
- Colonic clean out to eliminate retained stool
- Measures to establish soft, formed stool
- Establish schedule for stimulated defecation
- Select peristaltic stimulus
Stimulus Options - Digital Stimulation
Gloved finger inserted to stimulate nerves in anal canal + anorectal junction
Causes reflex relaxation of IAD + peristalsis in left colon
Stimulus Options - Suppositories
Placed against wall of rectum and retained long enough to melt
- Used with digital stimulation
Stimulus Options - Mini-Enemas
4 mL ampules with twist-tops
- Contain docusate + soft soap
- Instilled slowly and retained for 10 mins
Stimulus Options - Tap Water Enemas
- Given via balloon-tipped catheter
- Lukewarm water administered via catheter to distend the bowel
- Pt transferred to toilet and balloon deflated to permit returns
Stimulus Options - Transanal Irrigation
- System composed of rectal balloon, water reservoir, and handheld unit
- Allows patient to inflate balloon and control water instillation
- Pump propels water proximally to promote effective evacuation
Management - Improve Rectal Compliance and Capacity
Environmental
- Bedside commode
- Improve mobility
- Clothing modifications
Absorbent products
- Adult briefs are best option
- Provide appropriate skin care
Surgical Intervention - Repair of EAS
For obstetric trauma
Ends of sphincter overlapped and sewn together
Successful if IAS remains innervated + intact
Surgical Intervention - Sphincter Plication
Best approach to manage incontinence associated with IAS
Continence deteriorates overtime
Surgical Intervention - Malone Antegrade Continence Enema
Continent stoma created into proximal colon
Self-administration of high volume irrigations at regular intervals
Surgical Intervention - Artificial Anal Sphincter
Anorectal cuff connected to reservoir + controlled by pump
Surgical Intervention - Injectable Bulking Agents
Collagen, silicone, or carbon-coated beads
Surgical Intervention - Sacral Nerve Stimulation
Surgically implanted wires and stimulator
Wires places adjacent to sacral serves
Only if patient has failed behavioral or pharmacologic therapy
Surgical Intervention - Fecal Diversion
Colostomy
Best option for uncorrectable fecal incontinence
- Neurologic process causing loss of sensory awareness + sphincter function
- Poor results from stimulated defecation program
Encopresis
fecal soiling usually associated with functional constipation
Primary encopresis
child who never gained fecal continence
Secondary encopresis:
child who was continent x1 year and then became incontinent
Retentive encopresis
soiling associated with stool retention
Non-retentive encopresis
soiling not associated with stool retention
Pathology non-retentive encopresis
caused by organic disorder or emotional stressors
Pathology retentive encopresis
Caused by psychological issues
- Coercive/permissive toilet training
- Toileting fears
- Painful/difficult defecation
- Social taboos
- Lack of privacy
Encopresis Presentation
- Stool accidents
- Abdominal pain
- Lack of awareness of incontinence episodes
- No awareness of fecal odor
Encopresis - Assessment
History
- Med-surg and developmental history
- Onset + duration of encopresis
- Impact on child + family relationship
Physical
- Neurological lesions
— Observe gait
— Check base of spine
- Abdo exam re: retained stool
- Inspect perineum for skin breakdown
Encopresis - Diagnostics
- Abdo imaging for severity of retained stool
- Transit study
- Defecography and anorectal manometry
Encopresis - Management
Education + counseling
- To eliminate blame + guilt
Bowel cleansing
- To eliminate all stained stool
Bowel program
- To establish regular elimination of soft formed stool
- Softeners + laxatives
- Fiber + fluids
- Age (in years) + 5 OR 0.5 g/kg/day
Routine toileting
- Child sits on toilet 10-15 mins BID after meals
- Taught to respond promptly to “urge to go”
