Fecal incontinence

Junaidi .AR
FK UNSRI

The anatomy of the rectum and anus

The muscular arrangement of the levator ani muscles

Factors necessary for maintenance of fecal continence

Triple loop mechanism of external anal sphincter

Introduction
Common medical problem that is underreported to physicians
Second leading cause of nursing home
placement, more common than dementia
Some degree of fecal incontinence will
develop in 3% of women who give birth
by vaginal delivery

Pathophysiology and etiology

Partial incontinence loss of control
to flatus and minor soiling
Major incontinence frequent and
regular deficiency in the ability to
control stool of normal consistency

Four basic physiologic factors:

stool consistency,
rectal compliance,
rectal and anal sensation
pelvic floor function
can lead to a defective continence mechanism

Incontinence with normal pelvic

floor function
Altered stool consistency
Inflammatory bowel disease
Infectious diarrhea
Laxative abuse
Radiation enteritis
Short bowel syndrome
Malabsorption syndrome

Incontinence with normal pelvic

floor function - 2
Inadequate rectal compliance
Inflammatory bowel disease
Absent rectal reservoir (ileoanal, low ant.
resection)
Rectal ischemia
Collagen vascular disease (scleroderma,
amyloidosis, dermatomyositis)
Rectal neoplasms

Incontinence with normal pelvic

floor function -3
Inadequate rectal sensation
Dementia, CVA, MS, brain or spinal cord
injury/neoplasm, sensory neuropathy,
tabes dorsalis
Overflow incontinence
Fecal impaction leading cause of
incontinence in institutionalized elderly
patients

Diabetes multifactorial, impaired rectal

sensation is important

The reflex responsiveness of the anal region

Fecal incontinence associated with spinal cord injury

Incontinence with abnormal pelvic

floor function
Anatomic sphincter defect internal or
external
Traumatic
Obstetric injury prolonged difficult labor with
forceps application, episiotomy complications,
third or fourth-degree lacerations
Anorectal surgery anal fistula surgery most common operative procedure that
results in fecal incontinence;
hemorrhoidectomy

Incontinence with abnormal pelvic

floor function - 2
Pelvic floor denervation degenerative
neurogenic factors are a common cause
of non-surgically related incontinence
Primary (idiopathic neurogenic
incontinence)
Pudendal neuropathy 80%. Denervation of
the puborectalis muscle and external anal
sphincter muscles results in an impaired
ability to maintain the anorectal angle and
prevent gross incontinence

Fecal incontinence associated with pudendal neuropathy (a)

Fecal incontinence associated with pudendal neuropathy (b)

Fecal incontinence associated with pudendal neuropathy (c)

Fecal incontinence associated with pudendal neuropathy (d)

Incontinence with abnormal pelvic

floor function - 3
Descending perineal syndrome results
from constant straining during defecation
that causes a traction neuropathy of the
nerves running along the pelvic floor
muscles. Both the puborectalis and external
anal sphincter muscles become denervated
Vaginal deliveries

Secondary
Injuries to spinal cord, cauda equina
Diabetic neuropathy

Incontinence with abnormal pelvic

floor function - 4
Congenital abnornmalities
Spina bifida
Myelomeningocele

Miscellaneous
Rectal prolapse 60-70% incontinence.
Aging anal canal pressure and rectal
compliance are decreased

Diagnostic evaluation
History
Few patients will volunteer the
symptom on their own
embarrassment, chronic diarrhea
Use terms as leakage, soiling or
accidents to facilitate
communication
Incontinence grading scale

Physical examination
Search for hemorrhoids, scars from
previous surgery, skin tags, fissures,
fistulas
Signs of rectal prolapse or descent of the
perineum
anal wink
Rectal examination obtain estimation of
resting anal sphincter pressure/external
anal sphincter strength; fecal impaction

Diagnostic studies for fecal incontinence

TABLE 5 - 3. DIAGNOSTIC STUDIES FOR FECAL INCONTINENCE

Tes ts

Information Obtained

Sigmoidoscopy

Inflammation, s trictures, tumors

Anorectal manom etry

Sphincter pressures
Rectal sensation, compliance
External s phincter res pons es

Pelvic floor neurophys iology

External s phincter electrom yography

Puborectalis electromyography
Pudendal nerve conduction

Proctography

Rectal capacity
Anorectal angle
Perineal des cent
Retention of contrast

Anal ultrasonography

Anal sphincter integrity

Anorectal manometry
Measurement of both resting and voluntary
sphincter squeeze pressure
Incontinent patients low resting and
voluntary squeeze pressure
The study cannot discriminate between
primary muscle and neuronal defects
Estimate threshold for rectal
sensation/compliance, rectoanal inhibitory
reflex

Anorectal manometry in fecal incontinence (a)

Anorectal manometry in fecal incontinence (b)

Electrophysiologic tests
EMG needle electrodes into the
superficial portion of the external sphincter
or puborectalis muscle myoelectric
activity
Pudendal nerve terminal motor latency
measures the delay between the
application of an electrical stimulus and
external sphincter muscle response.
Prolonged pudendal neuropathy

Defecography
Videodefecography barium thickened to
the consistency of stool is introduced into
the rectum.
Evacuation is monitored with flouroscopy
Assessment of the anorectal angle at rest
and during defecation
Excessive perineal descent, failure of the
puborectalis muscle to relax, rectocele and
internal intususception

Rectocele (a)

Anal Endosonography
An ultrasound probe is placed in the
anal canal or transvaginally to detect
sphincter injuries and to evaluate
pelvic floor structures

Normal anatomy as viewed by anal endosonography (a)

Normal anatomy as viewed by anal endosonography (b)

Normal anatomy as viewed by anal endosonography (c)

Treatment
Improving stool consistency
Increase intake of bulking agents bran,
psyllium
Antidiarrheal agents 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 therapy
Patients looks at a polygraph tracing
while attempting to contract the external
anal sphincter
Through visual feedback of looking at
anal canal pressures during contraction
and verbal guidance, patients can learn
to appropriately contract the external
sphincter in response to the sensation of
rectal distension

Biofeedback (a)

Biofeedback (b)

70% restoring continence

90% reduction in incontinent episodes
Best outcome after anorectal surgery
Lowest success spinal cored injury

Biofeedback is superior to pelvic floor

strengthening exercises
1974-1990, 13 studies incontinent
pts treated with biofeedback
success rates between 50% and 92%

Number of sessions to achieve

symptomatic improvement varied
among studies
Deterioration over the long term
Many patients require intermittent
biofeedback therapy at regular
intervals

Biofeedback therapy inexpensive, quick

and safe option
Success dependent on the expertise of the
clinician and the motivation and the ability
of the patient to understand and cooperate
Dementia, absent rectal sensation, inability
to contract the external sphincter are the
least likely to respond

.Surgery

INKONTINENCIA ALVI
Peristiwa yg tidak menyenangkan
,dan tak terelakan
IU disertai IA % 50 30
Patofisiologi IU & IA

Difinisi ( suatu proses fisiologi)

Koordinasi susunan syaraf pusat &
perifer disertai sistim reflek
Kontraksi yg baik otot polos & otot
serang lintang yg terkait
Kesadaran & Kemampuan untuk
mencapai tempat BAB

Hal penting mekanisme

Sudut ano rectal 100 derajat. 1
Sfringter anus externa. 2
Bentuk anus. 3

Klinis
feses cair. 1
feses padat. 2

Penyebab
IA Konstipasi. 1
IA Simptomatik penyakit usus. 2
besar
IA gg kontrol persyarafan (IA . 3
neurogenik)
IA hilangnya reflek anal. 4

IA Konstipasi
Perubahan sudut ano rectal
Kemampuan sensor menurun
Feses cair merembes
Iritasi dan produksi cairan mucus
Anamesis dan pemeriksaan colok
dubur
Terapi hilangkan penyebab

Causes of constipation
diet low in bulkand fluid. 1
poor toilet habits. 2
immobility, 3
lacantive abuse. 4
collorectal disorders.5
depression. 6
drugs. 7
endocrine metabolic.8

IA simpiomatik
. gastro entrits/Divertikulitis.Kolitis
Ca rsinomaa
Foto colon . Colonoskopi
Kelainan metabolik
Sfingter rusak ok post operasi
hemoroid prolaps recti
obat spt besi

IA Neurogenik
Cvd , inhibisi cortek cerebri
Feses berbentuk
Test kontrol neurogenik
Obat neurogenik & enema

IA hilangnya reflek anal

Hlkangnya unit motorik sfingter dan
fubo- rectal
Berkurang sensasi usus . Menurun
tonus anus
Prolaps rectum
Tekanan intra- abdominal

penutup
IA < IU
Defekasi proses fisiologi
Menua meningkat
Penampilan klinis sesuai dgn
.;penyebab ; pengelolaan supportif
obat operetif
Psiko- sosial dan ekonomi
Sembuh dan dikurangi