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Assessment of Fecal Incontinence
and Constipation in the
Female Patient
Mahmoud Barrie, MD
Assistant Professor
Department of Gastroenterology/Hepatology
Atlanta VAMC/EUH
Atlanta, GA
December 9, 2008
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Outline
Anatomy- Anorectum
Mechanism of continence
Fecal incontinence
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Epidemiology, etiology, clinical presentation
Diagnostic studies
Assessment Algorithm
Mechanism of defecation
Constipation
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Epidemiology, etiology, clinical presentation
Diagnostic studies
Assessment Algorithm
Summary
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Objectives
Anatomy- Anorectum
Mechanism of continence
Fecal incontinence
– Epidemiology, etiology, clinical presentation
– Pertinent radiographic and non-radiographic
testing
Mechanism of defecation
Constipation
– Epidemiology, etiology, clinical presentation
– Pertinent radiographic and non-radiographic
testing
Summary
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Epithelial nerve endings of the
rectum and anus
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Anorectal function
Continence
Defecation
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Continence mechanisms
Anorectal angle
Rectal accomodation/compliance
Rectal sensation
Anal sensory nerves
Internal anal sphincter
External anal sphincter
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Continence Mechanisms:
Anorectal Angle
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Continence Mechanisms:
Rectal Accommodation
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Continence Mechanisms:
Compliance
Ratio of pressure to volume at different
volumes of distention
Decreased compliance with
– Inflammation
– Fibrosis
– Surgical replacement with sigmoid colon
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Continence Mechanisms:
Rectal Compliance
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Continence Mechanisms:
IAS & EAS
Fecal Incontinence
Continuous or recurrent passage of
fecal material (>10ml) for at least one
month in a person older than 3/4 years
of age
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Epidemiology
A US study of outpatients found an
overall prevalence of 18·4%
Incontinence occurred daily in 2·7% of
patients, weekly in 4·5%, and monthly
or less in 7·1%
Symptomatic fecal incontinence
occurs in 21% of women presenting
with urinary incontinence, pelvic-organ
prolapse, or both
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Causes of Fecal Incontinence
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A greater proportion of cases of faecal
incontinence are acquired
Sphincter disruption resulting from
vaginal delivery= most common
sphincter injury
Sphincter atrophy due to advanced
age
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Vaginal delivery injury risks
Forceps delivery
Primiparous: giving birth to a baby weighing over 4
kg- Traction injury to the pudendal nerve
third-degree obstetric lacerations
Incidence of both flatus and stool:
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6-25% in new postpartum
3-27% in known sphincter tears
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Assessment
Essential elements of the history:
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Onset
Type of incontinence (flatus, liquid, or solid stool)
Frequency of episodes
Pertinent findings in the physical exam include:
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A thinned or deformed perianal body and scars from
previous surgery or trauma.
Breakdown of the perianal skin is a consequence, not a
cause of incontinence
Gaping of the anus suggests rectal prolapse, which can
usually be demonstrated with Valsalva’s manoeuvre.
Diminished perianal sensation and the absence of an anal
wink suggest a neurogenic cause
Digital exam- weak sphincter squeeze
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Diagnostic Studies
Function
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Anorectal manometry
EMG: Action potentials of sphincter muscle
PNTL
Defecography: anorectal angle, perineal descent
Anatomy
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Flexible sigmodoscopy/proctosocpy
Defecography: rectoceles
Anal sonography: Sphincter defect
Barium enema
MRI
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Function: Anorectal manometry
in fecal incontinence
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Function: EMG
Electromyography — Electromyography of the
external anal sphincter and pelvic floor muscles is
performed for three purposes:
To identify areas of sphincter injury by mapping
the sphincter.
To determine whether the muscle contracts or
relaxes (by the number of motor units firing).
To identify denervation-reinnervation potentials
indicative of nerve injury.
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Function: EAS EMG
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Function: EAS EMG
Nerve sprouting
Variations of
intervals b/w motor
unit potentials
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Function: Pudendal n. Latency
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Child Birth
Neurologic evidence
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PNTL prolongation
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42% of postpartum women (Snooks et al )
cesarean delivery performed in late labor (cervical dilation 8
cm or greater)
EMG of the anal sphincter: increased fiber density in
multiparous women
(Allen RE et al.)
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Anatomy: Defecography
Evacuation proctography: process, rate and
completeness
Assessing ano-rectal angle
Structural and functional alterations: rectocele,
internal rectal intussusception, external rectal
prolapse, enterocele and pelvic floor dysfunction,
or dyssynergia.
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Anatomy: Rectal Ultrasound
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Anatomy: Endoanal Coil MRI
Sphincter atrophy
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89% sensitivity
94% specificity
89% positive predictive value
94% negative predictive value
Defect(atrophy) in levator ani m.
May not be as good in detecting sphincter tear.
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Anatomic evidence
Endoanal MRI:
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20% of primiparous women: defect in the levator ani
muscle (Delancey et al )
Endoanal ultrasound for sphincter disruption
(Abramowitz L et al)
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35% of primiparous
44% of multiparous
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Summary of diagnostic
studies
Anorectal manometry: Good
EMG/PNTML:
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good but limited to specialized centers
Defecography:
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Not as good
Anal endosonography
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good
Endoanal Coil MRI
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:
New and promising
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Constipation
Straining ≥1/4 of defecation;
Lumpy or hard stools ≥1/4 of defecation;
Sensation of incomplete defecation ≥1/4 of
defecation;
Sensation of anorectal
obstruction/blockage≥1/4 of defecation;
Manual maneuvers to facilitate ≥1/4 of
defecation (example: digital evacuation,
support of the pelvic floor);
Less than three defecations per week.
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Defecation
Epidemiology
Prevalence 2-34%
F:M 3 to 5x
Increase >65yo
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Types of constipation
Normal transit and normal pelvic floor
function
Slow transit (colonic inertia)
Dyssynergic or obstructive defecation
or anismus
Structural abnormalities: Enteroceles
and Rectoceles
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Assessment of Constipation
H&P
– digital dysimpaction, pelvic and/back
pain, bleeding, urinary incontinence,
renal insufficiency
Colonic scintigraphy
Anorectal manometry/Balloon
expulsion
Surface EMG
Evacuation proctography
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Colonic transit
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Balloon Expulsion
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Rectal pressure & EMG in
PFD
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Defecography
Evacuation proctography involves imaging of the
rectum with contrast material and observation of
the process, rate, and completeness of rectal
evacuation using fluoroscopic techniques.
Structural and functional alterations can also be
observed and include rectocele, internal rectal
intussusception, external rectal prolapse,
enterocele and pelvic floor dysfunction, or
dyssynergia.
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History and exam
History
– Digital pressure in the vagina
Exam
– Bulging of the posterior vaginal wall may
be an enterocele or a rectocele.
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Symptoms/Signs
Intractable vaginal mucosal ulcerations
Urinary retention (renal failure)
A pulling sensation or lower back pain
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Worse w/prolong standing
Improves w/laying down
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Rectocele
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Enterocele
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Summary
Fecal incontinence
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Constipation
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H&P very important
Anal endosonography
Anorectal manometry
EMG
Defecography? (controversal)
Colonic transit (-)
Dynamic MRI w/endoanal coil
H&P very important
Colonic transit study
Anorectal manometry
Defecography: r/o PFD/enteroceles/rectoceles
EMG(+/-) to r/o PFD
Enteroceles/Rectoceles
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Beware of surgical treatment except for recurrent vaginal mucosal
ulceration or ovarian tension
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Q & A Session
Evaluation
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References
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If you have any technical issues, please contact 404-969-0387 or email [email protected]
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