210 - Fecal Incontinence

Question 1

Fecal Incontinence definition

Answer 1

involuntary loss of solid or liquid stool or mucus from the rectum

Question 2

What is dyssenergia (WRT fecal incontinence)

Answer 2

when the anal sphincter, pelvic floor muscles, or both, do not relax appropriately with attempts at defecation, and the resultant incomplete emptying and evacuation difficulties lead to overflow incontinence

Question 3

Prevalence of fecal incontinence in community-dwelling women? Age 20-29? Age 70+? Prevalence of fecal incontinence in nursing home women?

Answer 3

Community: 8.3%! (liquid stool > mucus > solid stool) 20-29: 2.6% 70+: 15.3% Nursing home 40-70%

Question 4

Common non-neurologic causes of fecal incontinence?

Answer 4

Question 5

Risk factors for fecal incontinence

Answer 5

lose/watery stools, frequent stools (>21/w), 2+ chronic illnesses, urinary incontinence, obesity, smoking, increasing age, decreased physical activity, anal intercourse, history of OASIS, history of pelvic irradiation, and other medical comorbidities, such as diabetes mellitus and inflammatory bowel disease

Question 6

Medications associated with fecal incontinence

Answer 6

Question 7

Treatment options for fecal incontinence

Answer 7

Question 8

Who should be screened for fecal incontinence?

Answer 8

age 50 years and older; residence in a long-term care facility; prior OASIS; history of pelvic irradiation; engagement in anal intercourse; or the presence of urinary incontinence, chronic diarrhea, diabetes, obesity, or rectal urgency

Question 9

What is the initial workup of fecal incontinence?

Answer 9

History: RFs (especiall ymodifiable), symptoma assessment including impat on life and Bristol scale

Physical: visual exam, DRE, look for Dovetail sign (loss of anteiror puckering indicating anal sphincter injury)

Labs: not needed unless infection suspected

Tests: if exam is abnormal, “referral for ancilary testing considered”

Question 10

What are the different Bristol stool descriptions?

Answer 10

Question 11

Who requires evaluation for colon cancer among women with fecal incontinence?

Answer 11

Changes in bowel habits, especially when accompanied by any “red flag” symptoms, including unexplained weight loss, abdominal pain, rectal bleeding, melena, or anemia

Question 12

In what % of fecally incontinent women did 16g daily fibre help, and how to dose it per age group?

Answer 12

50% (compared to 10% placebo) to decrease

19-30: 28g/d

30-50: 24g/d

50+: 22g/d

increase 5g/d every 1-2w to prevent bloating/gas

Question 13

Loperamide for fecal incontinence? Dosing?

Answer 13

Yes

start 1/2 tab/d, use prn to max 16mg/d

titrate prn

Question 14

Medical rx of overflow fecal incontinence associated with constipation/impaction?

Answer 14

Osmotic laxatives;

• PEG (polyethylene glycol aka miralax)
• Lactulose

Question 15

Has pelvic floor PT been shown to be helpful in fecal incontinence? What about biofeedback? What about electrical stimulation?

Answer 15

Yes

With biofeedback is better

One study said stim + bio > bio > PT alone, but AHRQ 2016 review concluded that biofeedback with electrical stimulation was no more effective than pelvic floor biofeedback alone and that up to 9% of participants may experience discomfort

Question 16

Devices for anal incontinence? how efficacious are they?

Answer 16

• Anal plug
• Vaginal bowel control devie (baloon pushed on rectum from inside vagina, deflate to have BM)

Both have about 78% success in decreasing incontinence episodes by 50%

Question 17

How effective are anal sphincter bulking agents for the treatment of fecal incontinence?

Answer 17

50% had >50% reduction in incontience episodes (but placebo had 30%), but doesnt last and may get worse

Question 18

Whos is a surgical candidate for fecal incontinence

Answer 18

First line for fistula and rectal prolapse

For other conditions not first line and associated with many complications and failure

Question 19

Neuromodulation for fecal incontinence? What are the long term success rates?

Answer 19

1st line for conservative-refractor patients, with or without anal sphincter injuries.

50% decrease in incontinence episodes in:

• 63% in the short term (6–12 months)
• 58% in the medium term (17–36 months)
• 54% in the long term (44–118 months)
• At 56 months, 20% of patients reported complete continence, with a 10% decrease in efficacy within 5 years

Question 20

What is the success rate of anal spincter repair for anal incontinence? Which method is best? What is the most common complication?

Answer 20

85% have improvement in symptoms. 50% have continence after 5-10 years but 75% are still satisfied with results.

End-to-end or overlapping is the same outcome

MC complication is wound infection: 6-35%

Question 21

Radiofrequency Anal Sphincter Remodeling?

Answer 21

Works by scarring and fibrosing the mucosa.

Not recommended because no high quality studies. 20% risk of bleeding.

Question 22

Other surgical techniques for feval incontinence?

Answer 22

gracilis muscle transposition, artificial anal sphincter placement, and diverting colostomy