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HELLO I AM:

Amazing Argie T. Marpuri

FECAL INCONTENCE

FECAL INCONTENCE

Involuntary passage of stool from the


rectum.
Recurrent uncontrolled passage of faecal
material in an individual with a
developmental age of at least 4 years.

NORMAL CONTINENCE

Interaction of anal function:


Rectal compliance
Sphincter function
Anorectal sensation
Stool consistency
Stool volume
Mental allertness

INCONTENCENCE - TYPES

Sensory

Patient not aware of it


Neurophatic, rectal prolapse

Motor

patient not aware, but cannot prevent

Urgency

Radiation, IBD
Poor reservoir

Soiling

Ana scarring, impaction

FUNCTIONAL

Impaired rectal reservoir

Ulcerative colitis/Crohns disease


Radiation

Reduced Rectal Reservoir

Low colorectal anastomosis or coloanal


anastomosis

Diarrhoea/diarrhe
Overflow

SPHINCTER DEFECT

Congenital
Imperforate anus
Spina bifida

Trauma

Obstetric
Fistulotomy
Haemorrhoidctomy
Sphincterotomy
Anal stretch

Disease
Tumor
Rectal prolapse

TRAUMA
WOWNESS!
Its
FABULOUS!
Oh wait my
chin hurts a
bit

OBSTETRIC INJURY

Sphincter injury on EUS


35% primips
44% multips
Up to 80% after forceps

Pudental neuropathy
May be asymtomatic worsen
with time

Neurological

Pudendal neuropathy
Diabetes
Degenerative
Spinal cord injury

idiopathic

ASSESSMENT - HISTORY

Details of incontinence
Frequency
Nature solid, liquid & gas

Associated symptoms- blood, mucus etc


Previous anorectal trauma
Previous surgery
Obstetric history (episiotomy, tear, laceration,
forceps)
Comprehensive drug history
Continence scores

CONTINENCE SCORING
SYSTEM

EXAMINATION

Underwear, pads
General physical
Perineal deformity, scars
Perineal descent
Prolapse
Rectal exam
Resting + squeeze pressure

Perineal sensation

INVESTIGATION

Colonoscopy
Manometry
EUS
MRI
PNTML

ENDOANAL
ULTRASONOGRAPHY

MRI

multi-planar capability
Higher inherent
Contrast resolution than EUS
Not operator dependent
More expensive
IAS hyperintense, EAS hypointense
Good for EAS atrophy

MANOMETRY

Sphincter

Resting pressure (>40mmHg)


Squeeze pressure (>100 mmHg)
Sphincter asymmetry

Rectal balloon

Sensation
Compliance
Capacity
RAIR

CONSERVATIVE
MANAGEMENT

After stool consistency (bulking


agents, loperamide)
Sphincter exercises
Biofeedback (70% improvement in
symptoms)
Enema programme
Topical phenylephrin
Increase resting sphincter tone
Improve continence

SURGICAL OPTIONS

Sphincter repair
Injectable agents
Sacral nerve stimulation
Dynamic graciloplasty
Artificial sphincter
Stoma
ACE

ANTERIOR SPHINCTER
REPAIR

EAS defect
Overlapping vs
direct apposition
80% improved
Function
deteriorates with
time

INJECTABLE AGENTS

IAS pathology
Silicone
biomaterial
Submucosal vs
intersphincteric
Approx 50 to 70%
gain >50%
improvement

SACRAL NERVE
STIMULATION

Weak but intact


sphincter
Mechanism poorly
understood
2 stages
PNE trial electrode
2/52, diary
Permanent implant

Good results up to
90% report
improvement

DYNAMIC GRACILOPLASTY

Severe sphincter injury,


congenital
malformations
Convert fast-twitch
muscle to slow twitch
Variable results (35 to
85% continence)
Congenital
malformations do worse
Complications in 50%
(30% infection)

ARTIFICIAL BOWEL
SPHINCTER

Good results with


successful implant
High
complications
rates
Infection (up to
50%)
Erosion
Pain

Not recommended
for routine use
Only in cases of

STOMA

not without
complication

Parastomal hernia
Mucus leakage
Diversion colitis

MANAGEMENT OF FECAL
INCONTINENCE

NURSING ASSESSMENT

Obtain history of congenital defect,


trauma and disease

NURSING DIAGNOSIS

Bowel incontinence related to


inability to control defecation
Bowel incontinence related to lack
of voluntary sphincter control
Bowel incontinence related to

PATIENT EDUCATION AND


HEALTH MAINTENANCE

Teach the client and family to perform a


bowel stimulated program or other
strategies to manage fecal incontenence
Teach the client about common dietary
sources of fiber as well as supplemental
fiber or bulking agents as indicated

IF YOU WANT TO GO FAST, GO ALONE.


IF YOU WANT TO GO FAR, GO
TOGETHER.

FI

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