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Faecal incontinence is a relatively common and debilitating condition. The exact
incidence in the population is difficult to calculate but it is more common among
certain groups such as multiparous women and the elderly.
We describe as incontinence the inability to control with the anal sphincters
gas, liquid faeces or formed stools.
Continence, or control of the anal sphincters depends on a number of factors.
Those factors are
• The integrity of the anal sphincter muscles.
There are two anal sphincters, the internal (which provides a constant
involuntary muscle “tone” or contraction) and the external which is under our
voluntary control.
Both muscles can be damaged from
a)trauma
b)surgery
c) sepsis.
Damage of the internal sphincter does not usually cause incontinence for
faeces. However it can produce incontinence for wind. This is a common
complication of “internal sphincterotomy”. Sometimes even faecal incontinence
can occur as the result of damage of the internal sphincter if other factors co-
exist.
Damage of the external sphincter carries a very high risk of incontinence.
Particularly the ability to “squeeze” and control is incapacitated. At the first
stages the patient experiences “urgency incontinence” which means that the
individual has to rush urgently to the toilet to avoid an “accident”. This can
develop into “passive incontinence” which consists of loss of stools without the
patient’s awareness. This can happen either during the day or during sleep.
Incontinence is aggravated by prolonged standing, exercise, coughing etc.
• The condition and function of the whole pelvic floor muscles.
In females faecal incontinence often coexists with a general relaxation and
prolapse of the whole pelvic floor muscles. This causes bladder problems (urine
incontinence or inability to empty the bladder) or prolapse of the uterus. There
can be a combination of rectocele (a prolapse of the rectum into the uterus) or
a cystocele (a prolapse of the bladder into the uterus).
• Pathologies of the anus and rectum
Conditions such as rectal prolapse, very large haemorrhoids, ulcerative colitis,
mucous-secreting tumours, radiation proctitis etc. can cause incontinence of
variable degrees. Many of these conditions do not cause genuine incontinence
but either “urgency” or minor soiling which disappears when the underlying
cause is treated.
- Neuropathy
On occasions the anal sphincter muscles are intact but they don’t work well
because they suffer from neuropathy. This can be the result of prolonged
severe diabetes, neurological diseases such as Multiple Sclerosis etc.
Incontinence from neuropathy is very difficult to treat. Lately Sacral Nerve
Stimulation (SMS) has shown some promising results.
SMS involves the placement of a small electric pacemaker which is implanted
under the skin and is connected to the sacral nerves which control the muscles
of the pelvic floor. A temporary pacemaker is initially placed for a few weeks
and if it improves symptoms it is replaced by a permanent one.
SMS is used when trauma or defect of the anal sphincter cannot be identified.
Investigations for incontinence
Colonoscopy
This is to check the presence of colitis or other pathology of the colon and
rectum which might cause diarrhoea, oversecretion of mucous etc. and would
contribute to incontinence.
Endorectal Ultrasound
With the endorectal ultrasound we check the integrity of the anal sphincters.
This is particularly important on women who have had vaginal deliveries of
babies and have suffered perineal tears.
Defaecation (Evacuation) Proctography
This is a procedure during which a contrast paste is injected in the rectum and
then the patient evacuates it under video-radiography. This dynamic
investigation gives very useful information on what happens at the time of rectal
and anal contraction: there can be evidence of rectal prolapse which is only
internally obvious (intususception), an acute abnormal angulation od the
rectum (anismus) or rectocele which prevents the rectal evacuation. In some
cases incontinence is produced by incomplete evacuation of the rectum and
subsequent leakage.
Anorectal Physiology
This consists of anorectal manometry ( a test which measures the pressures in
the anal canal during rest, squeeze and cough), measurement of anorectal
sensation, ability to perform a balloon expulsion test, pudendal nerve latency
(which estimates the nerve function –this is often deficient in cases of injury or
neuropathy) and EMG – Electromyography (also checks the normal function of
the nerves which may be compromised in diabetes or other neuropathy).
Medical and Physical Treatments of Incontinence
In most cases, and if a surgical cause such as injury of the sphincters, is not
suspected, initial treatment if incontinence is by means of medical or physical
treatments.
The most simple of those is diet modification. The patient is encouraged to
keep a food diary and observe the impact of various foods. Foods which
produce a lot of gas or contain irritant spices or are extremely fatty are
sometimes responsible for exacerbations.
A simple medication regime such as a combination of loperamide (an anti-
diarrhoea capsule) with fibre supplements, is often helpful. The fibre
supplement is useful to give bulk and solid nature to stools, people with
incontinence find t much easier to control formed stools rather than loose
watery pellets.
Anal Plugs in the form of synthetic sponges are available. It is a very simple
idea but it works! Even though it does not of course treat the causes it can be a
very simple measure to make the patient confident to be able to go out of the
house for a few hours. Most patients prefer them than wearing pads.
Injections of synthetic particles such as microspheres, hyaluronic, coaptite, and
even silicone have been used to either raise the mucosa , thus giving a better
"seal" of the anus , or to replace internal sphincter defects. There are some
good results in case series but so far randomised trials to provide high grade
evidence are still lacking. However these treatments are likely to become more
popular because they are safe and minimally invasive.
Pelvic Floor Exercises (sometimes in the form of pilates) are widely used.
Women are more keen to use them, particularly f they had pre vious beneficial
experience with urinary strss incontinence or gynaecological pelvic floor
problems. There is no objective evaluation and the quality of the treatment and
the outcome are likely to vary widely according to the therapist and patient.
However there are many reports by patients that they are beneficial and they
certainly are a reasonable treatment to try in cases of mild ncontinence or as a
"bridge" before more major treatments.
Biofeedback Treatment
This is a physcal therapy which consists of training of the patient to modify the
contraction of the pelvic floor muscles and the sphincters in a way to improve
either incontinence or succesful evacuation of the rectum. The patient is
connected with electrodes which monitor the contraction and relaxation of the
muscles and give feedback to the patient by way of visual and audio signals
directing thus to correction of inapproprote or inefficient contractions.
Biofeedback takes some considerable training by specialist nurses and
although it is not always successful there are very good results on some
patients. Since it is a non invasive technique with no side effects there is always
a case for trying it before more invasive treatments.
PTNS - Percutaneous Tibial Nerve Stimulation
Recent reports indicate that a new minimally invasive neuromodulation
treatment is helpful in urinary and faecal incontinence. This is PTNS which
consists of an electrical stimulation with a needle electrode which is inserted
into the medial aspect of the ankle where the tibial nerve passes by. It has been
shown that electrical stimulation of the tibial nerve results in mprovement of
urinary and faecal incontintinence. The mechanism is not 100% understood but
it s likely to generate reflex contracton of the pelvic floor muscles in a similar
way to Sacral Nerve Stimulation. The obvious advantage is that PTNS is much
less invasive since it involves only a needle in the leg. The treatment needs to
be repeated 1-2 times a week for 12 weeks or more. Further research is
conducted on PTNS. At King's College Hospital we provide PTNS for both
urinary and faecal incontinence.
Endorectal
ultrasound showing
intact internal
sphnicter (dark ring
around probe) and
external sphincter
(white cloudy ring
around internal
sphincter).
ultrasound showing
intact internal
sphnicter (dark ring
around probe) and
external sphincter
(white cloudy ring
around internal
sphincter).
Incontinence
A PTNS device used for neuromodulation of
ncontinence.
ncontinence.
A BIofeedback Treatment device
Anorectal Manometry equipment
-digital box and computer which can be
used with water perfused catheters
pump or with digital solid state
catheters.
-digital box and computer which can be
used with water perfused catheters
pump or with digital solid state
catheters.