fecal incontinence

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سورة البقرة(32 آية )

ACKNOWLEDGMENTACKNOWLEDGMENT

First and foremost I would like to thank First and foremost I would like to thank ALLAHALLAH, the Most Merciful and Gracious, for , the Most Merciful and Gracious, for lightening my path and guiding me.lightening my path and guiding me.

I would like to express my gratitude to I would like to express my gratitude to Prof. Dr. Osama Abd-Elrahman KhalilProf. Dr. Osama Abd-Elrahman Khalil, , professor of general surgery faculty of professor of general surgery faculty of medicine Zagazig University, for giving me medicine Zagazig University, for giving me the honor to perform this essay, and for his the honor to perform this essay, and for his kind supervision during all stages of this kind supervision during all stages of this work.work.


In addition, my thanks go to In addition, my thanks go to Prof. Dr. Prof. Dr. Mohammad Selim AbbodMohammad Selim Abbod, professor of general , professor of general surgery faculty of medicine Zagazig University, surgery faculty of medicine Zagazig University, for his constant advice and guidance throughout for his constant advice and guidance throughout this workthis work..

Also I would like to thank Also I would like to thank Dr. Abd-Elhafez Dr. Abd-Elhafez Mohammad El-ShewelMohammad El-Shewel, lecturer of general , lecturer of general surgery faculty of medicine Zagazig University, surgery faculty of medicine Zagazig University, who provided me a great support and help all who provided me a great support and help all through the time I spend to collect the material through the time I spend to collect the material for this essayfor this essay..


Last I am extremely indebted to Last I am extremely indebted to my my familyfamily, to whom I dedicate my successes, , to whom I dedicate my successes, which are only a pure product of their which are only a pure product of their answered prayers.answered prayers.

Fecal Fecal IncontinenceIncontinence

INTRODUCTIONINTRODUCTION

INTRODUCTIONINTRODUCTIONFecal incontinence )FI( is the involuntary Fecal incontinence )FI( is the involuntary

passage of bowel contents through the anus passage of bowel contents through the anus or through an external stoma. It ranges from or through an external stoma. It ranges from the unintentional elimination of flatus to the the unintentional elimination of flatus to the seepage of liquid fecal matter or sometimes seepage of liquid fecal matter or sometimes the complete evacuation of bowel contents. the complete evacuation of bowel contents.

It occurs in about 1% to 7.4% in general It occurs in about 1% to 7.4% in general populations, and up to 25% in elderly populations, and up to 25% in elderly populations. This condition causes populations. This condition causes considerable embarrassment that in turn considerable embarrassment that in turn causes loss of self-esteem, social isolation causes loss of self-esteem, social isolation and diminished quality of life.and diminished quality of life.

INTRODUCTIONINTRODUCTIONThe anus is the outlet of the gastrointestinal The anus is the outlet of the gastrointestinal

tract and evacuation of bowel contents tract and evacuation of bowel contents depends on action by the muscles of the depends on action by the muscles of the involuntary internal anal sphincter )IAS(, the involuntary internal anal sphincter )IAS(, the voluntary external anal sphincter )EAS( and voluntary external anal sphincter )EAS( and pelvic floor muscles.pelvic floor muscles.

The anorectal region is composed of:The anorectal region is composed of:

11 ) )Anus and anal vergeAnus and anal verge

22 ) )Anal canalAnal canal

33 ) )Anorectal ringAnorectal ring

INTRODUCTIONINTRODUCTIONThe factors considered responsible for maintaining The factors considered responsible for maintaining

anal continence and facilitating defecation are:anal continence and facilitating defecation are:11 . .The anal canal high-pressure zoneThe anal canal high-pressure zone

22 . .Anorectal angleAnorectal angle33 . .Flutter valveFlutter valve

44 . .Anorectal sensitivity and reflex mechanismAnorectal sensitivity and reflex mechanism55 . .Rectal compliance and capacityRectal compliance and capacity

66 . .Rectal motilityRectal motility77 . .Anal canal motilityAnal canal motility88 . .Colonic transit timeColonic transit time

99 . .Stool volume and consistencyStool volume and consistency1010 . .Rectosigmoidal junction sphincterRectosigmoidal junction sphincter

1111 . .Corpus cavernosum of the anusCorpus cavernosum of the anus

AIM OF THE AIM OF THE ESSAYESSAY

AIM OF THE ESSAYAIM OF THE ESSAY

The aim of this essay is to discuss the The aim of this essay is to discuss the different dimensions of FI and to declare different dimensions of FI and to declare the different tools of making clear the different tools of making clear diagnosis and the different options of diagnosis and the different options of management of this condition and its management of this condition and its complications.complications.

ETIOLOGY OF ETIOLOGY OF FIFI

ETIOLOGY OF FIETIOLOGY OF FI There are many causes as:There are many causes as:

1. Congenital causes: Anorectal anomalies, 1. Congenital causes: Anorectal anomalies, Spinal cord abnormalities, Isolated sacral Spinal cord abnormalities, Isolated sacral agenesis agenesis

2. CNS: Cerebrovascular accidents, Multiple 2. CNS: Cerebrovascular accidents, Multiple sclerosis, Spinal cord injury sclerosis, Spinal cord injury

3. Diabetes Mellitus 3. Diabetes Mellitus

4. Aging4. Aging

5. Intestinal Disorders: Inflammatory Bowel 5. Intestinal Disorders: Inflammatory Bowel Disease, Irritable Bowel Syndrome Disease, Irritable Bowel Syndrome

ETIOLOGY OF FIETIOLOGY OF FI6. Pelvic Radiotherapy6. Pelvic Radiotherapy

7. Fecal impaction7. Fecal impaction

8. Rectal Prolapse8. Rectal Prolapse

9. Obstetric trauma 9. Obstetric trauma

10. Anal Surgery: Sphincterotomy, Anal 10. Anal Surgery: Sphincterotomy, Anal Dilatation, Fistula Surgery, Dilatation, Fistula Surgery, HemorrhoidectomyHemorrhoidectomy

11. Rectal Resection11. Rectal Resection

12. Hysterectomy12. Hysterectomy

EVALUATION EVALUATION OF FIOF FI

EVALUATION OF FIEVALUATION OF FIEvaluation of FI can be done by:Evaluation of FI can be done by: Clinical history and assessment of severityClinical history and assessment of severity General examination General examination Anorectal examination: Inspection, Anorectal examination: Inspection,

Palpation and Digital examinationPalpation and Digital examination Investigations: Endoscopy, Anorectal Investigations: Endoscopy, Anorectal

manometry, Balloon expulsion test, manometry, Balloon expulsion test, Pudendal nerve terminal motor latency, Pudendal nerve terminal motor latency, Saline infusion test, Electromyography, Saline infusion test, Electromyography, Endoanal ultrasound )EAUS(, Magnetic Endoanal ultrasound )EAUS(, Magnetic resonance imaging )MRI(, Defecography resonance imaging )MRI(, Defecography

Psychological and Quality of Life Psychological and Quality of Life evaluation.evaluation.

EVALUATION OF FIEVALUATION OF FI

EAUS showing EAUS showing EAS defect EAS defect after obstetric after obstetric injury.injury.

EVALUATION OF FIEVALUATION OF FI

MRI showing MRI showing severe severe thinning of IAS thinning of IAS and a and a disruption of disruption of EASEAS

TREATMENT TREATMENT OFOF FIFI

TREATMENT OFTREATMENT OF FIFIIndeed, a wide range of therapeutic options is Indeed, a wide range of therapeutic options is

available, including non-surgical and surgical available, including non-surgical and surgical procedures. procedures.

Non-surgical treatment:Non-surgical treatment: Medical treatment Medical treatment Rehabilitation Rehabilitation Radiofrequency Radiofrequency Hyperbaric oxygen Hyperbaric oxygen Anal plugs and devices Anal plugs and devices Psychological Management Psychological Management

TREATMENT OFTREATMENT OF FIFI Medical treatment:Medical treatment:

Diet and Patient EducationDiet and Patient Education

For FI associated with chronic diarrhea, For FI associated with chronic diarrhea, bulking andbulking and antidiarrheal agents as antidiarrheal agents as Loperamide can be used.Loperamide can be used.

For FI associated with chronic constipation, For FI associated with chronic constipation, bulking agentsbulking agents and laxativesand laxatives can be used.can be used.

TREATMENT OFTREATMENT OF FIFI Rehabilitation:Rehabilitation:

It is considered the first line option in treating It is considered the first line option in treating FI in patients who have not responded to FI in patients who have not responded to simple dietary advice or medication. The simple dietary advice or medication. The rehabilitative techniques include:rehabilitative techniques include:

1( Biofeedback therapy: consists of pelvic 1( Biofeedback therapy: consists of pelvic floor strengthening exercises.floor strengthening exercises.

2( Pelviperineal Kinesitherapy:2( Pelviperineal Kinesitherapy: selectively selectively aims at the levator ani muscles.aims at the levator ani muscles.

TREATMENT OFTREATMENT OF FIFI

3( Sensory Retraining:3( Sensory Retraining: to increase rectal to increase rectal sensation.sensation.

4( Electrostimulation: not a clinically 4( Electrostimulation: not a clinically effective as it is passive therapy.effective as it is passive therapy.

TREATMENT OFTREATMENT OF FIFI Radiofrequency:Radiofrequency:

This procedure is used with a weak or This procedure is used with a weak or thinned anal sphincter complex. Patients thinned anal sphincter complex. Patients with a history of inflammatory bowel with a history of inflammatory bowel disease, extensive perianal disease or disease, extensive perianal disease or chronic diarrhea should not be offered this chronic diarrhea should not be offered this treatment. treatment.

The radiofrequency generator produces heat The radiofrequency generator produces heat by a high frequency alternating current by a high frequency alternating current causing tissue heating and collagen causing tissue heating and collagen contraction that tightening the tissue.contraction that tightening the tissue.

TREATMENT OFTREATMENT OF FIFI Hyperbaric oxygen:Hyperbaric oxygen: It has several physiologic effects on It has several physiologic effects on

damaged nerves in animal models, which damaged nerves in animal models, which lead to an improvement in neurologic lead to an improvement in neurologic function. function.

It may used with idiopathic FI secondary to It may used with idiopathic FI secondary to pudendal neuropathy.pudendal neuropathy.


Anal plugs and devices:Anal plugs and devices:

It may be useful for patients with impaired It may be useful for patients with impaired anal canal sensation, neurological disease anal canal sensation, neurological disease and in bed-ridden patients.and in bed-ridden patients.

TREATMENT OFTREATMENT OF FIFISurgical treatment:Surgical treatment: SphincteroplastySphincteroplasty Postanal pelvic floor repair Postanal pelvic floor repair Dynamic Graciloplasty Dynamic Graciloplasty Gluteoplasty Gluteoplasty Artificial Bowel Sphincter Artificial Bowel Sphincter Sacral Nerve Stimulation Sacral Nerve Stimulation Injectable Bulking Agents Injectable Bulking Agents Rectal Augmentation Rectal Augmentation Antegrade Colonic Enema Antegrade Colonic Enema StomataStomata

TREATMENT OFTREATMENT OF FIFI Sphincteroplasty:Sphincteroplasty:

Indicated in obstetrical tears that occur in Indicated in obstetrical tears that occur in the anterior midline and in sphincter the anterior midline and in sphincter damage arising from other anorectal damage arising from other anorectal procedures.procedures.

Successful outcomes between 70% and Successful outcomes between 70% and 80%.80%.


Sphincteroplasty: In prone Sphincteroplasty: In prone jack knife position, jack knife position, Incision around the Incision around the anterior portion of the anterior portion of the anus over the perineal anus over the perineal body: body: A. A. Dissection Dissection begins with lateral begins with lateral mobilization of muscle mobilization of muscle edges, which are then edges, which are then B. B. secured with secured with mattress sutures mattress sutures through the existing through the existing scar and healthy muscle scar and healthy muscle in order to in order to C. C. recreate recreate the sphincter complex.the sphincter complex.


wound closure wound closure with V-Y with V-Y advancement.advancement.

TREATMENT OFTREATMENT OF FIFI Postanal pelvic floor repair:Postanal pelvic floor repair:

It is performed on patients with idiopathic FI It is performed on patients with idiopathic FI with no evidence of sphincter defect on with no evidence of sphincter defect on EAUS. EAUS.

The patients expected to benefit most from The patients expected to benefit most from postanal repair are women with a history of postanal repair are women with a history of multiple vaginal deliveries.multiple vaginal deliveries.

Successful outcomes between 80% and 88%.Successful outcomes between 80% and 88%.


Postanal pelvic floor repairPostanal pelvic floor repair. . In prone jack knife In prone jack knife position,position, Incision is curvilinear posterior to the anal Incision is curvilinear posterior to the anal canal, canal, Dissection in the intersphincteric plane to Dissection in the intersphincteric plane to reveal PR and levator ani.reveal PR and levator ani.


Sutures in the upper levator ani are loosely tied to Sutures in the upper levator ani are loosely tied to create a lattice behind the rectum,create a lattice behind the rectum, Approximation of pubococcygeus,Approximation of pubococcygeus,


Approximation of EAS and PR,Approximation of EAS and PR, skin closure.skin closure.

TREATMENT OFTREATMENT OF FIFI Dynamic Graciloplasty (DGP):Dynamic Graciloplasty (DGP):It is a major procedure and must be It is a major procedure and must be

reserved for the most severe forms of FI, reserved for the most severe forms of FI, as in patient with severe trauma that as in patient with severe trauma that cannot be treated with other methods. cannot be treated with other methods.

Contraindications of DGP are Contraindications of DGP are intussusception, rectocele, enterocele, and intussusception, rectocele, enterocele, and rectal prolapse. rectal prolapse.

Success rates from 45% to 80%. Success rates from 45% to 80%.


DGP diagrams. In lithotomy position, skin incision in DGP diagrams. In lithotomy position, skin incision in medial aspect of thigh then gracilis muscle is exposedmedial aspect of thigh then gracilis muscle is exposed and isolated, perianal tunnel is prepared by 2 incisions,and isolated, perianal tunnel is prepared by 2 incisions,


Gracilis muscle has been transposed in perianal Gracilis muscle has been transposed in perianal space, the tendon is sutured to periosteum of space, the tendon is sutured to periosteum of contralateral pubic bone.contralateral pubic bone.


Overview of the end result of DGP: )Overview of the end result of DGP: )11( implantable ( implantable neurostimulator;neurostimulator; ))22( anode and cathode; )( anode and cathode; )33( position of ( position of the neurovascular bundle; )the neurovascular bundle; )44(( attachment of the attachment of the tendon of the gracilis.tendon of the gracilis.

TREATMENT OFTREATMENT OF FIFI GluteoplastyGluteoplasty::

Gluteoplasty has the same indications as Gluteoplasty has the same indications as graciloplasty, but graciloplasty is more graciloplasty, but graciloplasty is more frequently performed.frequently performed.

FI secondary to spina bifida or FI secondary to spina bifida or myelomeningocele are absolute myelomeningocele are absolute contraindications to gluteoplasty.contraindications to gluteoplasty.

Successful outcomes about 72%. Successful outcomes about 72%.


Bilateral Gluteoplasty:Bilateral Gluteoplasty: A A In prone jack knife In prone jack knife position, sigmoid incision near the position, sigmoid incision near the infragluteal crease,infragluteal crease, B B Perirectal incisions are Perirectal incisions are made,made, anterior and posterior tunnels are anterior and posterior tunnels are developed, the gluteus is detached, developed, the gluteus is detached, CC The The gluteal slips are brought to the contralateral gluteal slips are brought to the contralateral ischial tuberosity and secured. ischial tuberosity and secured.

TREATMENT OFTREATMENT OF FIFI Artificial Bowel SphincterArtificial Bowel Sphincter (ABS):(ABS): The best indications for the ABS are the anal The best indications for the ABS are the anal

sphincter lesions inaccessible to local sphincter lesions inaccessible to local repair, neurological incontinence and not repair, neurological incontinence and not responsive to sacral nerve stimulation test.responsive to sacral nerve stimulation test.

Contraindications to implantation of an ABS Contraindications to implantation of an ABS are excessive perineal descent, severe are excessive perineal descent, severe constipation, irradiated perineum, perineal constipation, irradiated perineum, perineal sepsis, anal agenesis and anal coitus. sepsis, anal agenesis and anal coitus.


The ABS comprises 3 parts: perianal The ABS comprises 3 parts: perianal occlusive cuff, control pump )implanted in occlusive cuff, control pump )implanted in subcutanous tissues of the scrotum or subcutanous tissues of the scrotum or labium( and pressure-regulating balloon labium( and pressure-regulating balloon )implanted in a pocket created in the )implanted in a pocket created in the subperitoneal space(.subperitoneal space(.

Success rates from 69%-83%.Success rates from 69%-83%.


Overview of the ABS: Anal opening is achieved by Overview of the ABS: Anal opening is achieved by transferring the pressurized fluid from perianal cuff transferring the pressurized fluid from perianal cuff toward the balloon by means of the control pump. toward the balloon by means of the control pump.

TREATMENT OFTREATMENT OF FIFI Sacral Nerve Stimulation (SNS):Sacral Nerve Stimulation (SNS):Indications for permanent SNS are FI due to a Indications for permanent SNS are FI due to a

deficiency of the smooth muscle of the IAS and deficiency of the smooth muscle of the IAS and to functional deficits of both sphincters, as in to functional deficits of both sphincters, as in scleroderma, degeneration or disruption of the scleroderma, degeneration or disruption of the IAS and idiopathic sphincteric weakness. IAS and idiopathic sphincteric weakness.

Contraindications included spina bifida, skin Contraindications included spina bifida, skin disease at the area of implantation, disease at the area of implantation, pregnancy, and presence of cardiac pregnancy, and presence of cardiac pacemaker. pacemaker.

Success rates about 95%.Success rates about 95%.


A permanent SNS system: consisting of an A permanent SNS system: consisting of an electrode, connecting cable and pulse generator.electrode, connecting cable and pulse generator.

TREATMENT OFTREATMENT OF FIFI Injectable Bulking AgentsInjectable Bulking Agents::The bulking agent should be non-migratory, The bulking agent should be non-migratory,

non-allergic, non-immunogenic, non-non-allergic, non-immunogenic, non-carcinogenic and easy to inject.carcinogenic and easy to inject.

Injectable PTQ )polydimethylsiloxane( Injectable PTQ )polydimethylsiloxane( implant appears to be the most effective implant appears to be the most effective injectable agent available. injectable agent available.

Injection of muscle-derived stem cells or Injection of muscle-derived stem cells or couple of magnets are still at a preliminary couple of magnets are still at a preliminary stage.stage.

TREATMENT OFTREATMENT OF FIFISuccess rates are about 68% of patients at 1 Success rates are about 68% of patients at 1

year after injection. year after injection.

Injection is directed into the intersphincteric Injection is directed into the intersphincteric space in the four quadrants. If there is a space in the four quadrants. If there is a defect of the IAS, three injections are defect of the IAS, three injections are directed into the defect, with the fourth directed into the defect, with the fourth injection into the contralateral site to injection into the contralateral site to provide symmetry.provide symmetry.

TREATMENT OFTREATMENT OF FIFI Rectal Augmentation (RA)Rectal Augmentation (RA)::

RA is a new surgical technique that RA is a new surgical technique that normalizing rectal capacity, compliance normalizing rectal capacity, compliance and improve rectal reservoir function in and improve rectal reservoir function in patients with severe fecal urgency. patients with severe fecal urgency.

It is done through longitudinal division of the It is done through longitudinal division of the anterior rectal wall, followed by anterior rectal wall, followed by augmentation of this defect with an ileal augmentation of this defect with an ileal patch using a linear cutting stapler.patch using a linear cutting stapler.

TREATMENT OFTREATMENT OF FIFI Antegrade Colonic Enema (ACE)Antegrade Colonic Enema (ACE)::

This technique is an effective surgical option This technique is an effective surgical option to treat patients with combined FI and to treat patients with combined FI and severe constipation and recommended as a severe constipation and recommended as a last option before colostomy. last option before colostomy.

ACE through an appendicostomy originally ACE through an appendicostomy originally described for FI in children. The appendix is described for FI in children. The appendix is connected to the umbilicus and through connected to the umbilicus and through which the enema can be administered.which the enema can be administered.


Another technique using the terminal ileum Another technique using the terminal ileum as a conduit with a side-to-side ileocecal as a conduit with a side-to-side ileocecal anastomosis. anastomosis.

Success rates about 90%.Success rates about 90%.

TREATMENT OFTREATMENT OF FIFI Stomata:Stomata:

A number of patients in whom the surgical A number of patients in whom the surgical procedures described above are procedures described above are inapplicable or not lead to satisfactory inapplicable or not lead to satisfactory bowel control should be offered a bowel control should be offered a permanent colostomy.permanent colostomy.

CONTINENT CONTINENT STOMATASTOMATA

CONTINENT STOMATACONTINENT STOMATAPatients with an end colostomy are Patients with an end colostomy are

confronted with very severe problems confronted with very severe problems from a social and esthetic viewpoint.from a social and esthetic viewpoint.

An external device may used to plug or An external device may used to plug or occlude the colon following an abdominal occlude the colon following an abdominal colostomy.colostomy.

CONTINENT STOMATACONTINENT STOMATAMany surgical trials were done to make the Many surgical trials were done to make the

stoma continent, such as:stoma continent, such as: Kock technique )nipple valve(Kock technique )nipple valve( Autotransplantation of the PylorusAutotransplantation of the Pylorus Kock pouch Kock pouch T-pouch T-pouch Skeletal muscle slips Skeletal muscle slips Free-muscular colonic graft Free-muscular colonic graft Simultaneous cecostomy and ileostomySimultaneous cecostomy and ileostomy Continent stoma rectus sheath tunnel.Continent stoma rectus sheath tunnel.

Thank youThank you

fecal incontinence

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