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Continence 2.2 > Lesson 15: Fecal Incontinence > Flashcards

Lesson 15: Fecal Incontinence Flashcards

1
Q

Factors Affection Bowel Function - Colonic Transit Time

A

Goal = delivery of softened formed stool to rectum at intervals

Peristaltic Stimulants
- Activity
- Colonic distension
- Cholinergics
- Caffeine
- Eating

Peristaltic inhibitors
- Inactivity
- Low fiber diet
- Meds
- Age >65

Innervation
- Enteric nervous system
- Autonomic nervous system modulates
- Parasympathetic stimulates
- Sympathetic inhibits

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2
Q

Factors Affection Bowel Function - Sensory Awareness

A

Rectal distension + delivery of stool
- Stretch receptors in rectal walls + perirectal muscles
- Activated by low levels of distension

Anoderm
- Receptors in anal canal distal to the dentate line
- Ability to differentiate between solid, liquid, and gas

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3
Q

Factors Affection Bowel Function - Sphincter Function

A

Internal anal sphincter (IAS)
- Surrounds proximal anal canal and anorectal junction
- Normally closed; relaxes in response to rectal distension
- 5 - 20 mLs causes transient relaxation
- 60 mLs causes persistent relaxation

External Anal Sphincter (EAS)
- Surrounds IAS and anal canal
- Partially contracted at rest
- Rectal distension causes increased reflex tone
- Must voluntarily relax sphincter for defecation
- Continuous with puborectalis muscle

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4
Q

Factors Affection Bowel Function - Rectal Capacity + Compliance

A

Ability to relax around bolus of stool + store stool at low pressures

Continence is dependent on
- Interruption of mass movements
- Relaxation of rectal walls

Normal function (in sequence)
- Contraction of EAS increases anal pressures
- Blocks rectal emptying + interrupts mass movements
- Rectum relaxes to provide temporary storage
- Voluntary defecation involves relaxation of EAS + abdo muscle contraction
- Ultimately facilitates evacuation

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5
Q

Factors Affection Bowel Function - Environmental/Psychosocial Factors

A
  • Availability + accessibility to toileting facilities
  • Impact of social taboos + restrains
    — Causes subconscious withholding of stool
  • Involuntary defecation
    — When rectal pressures exceed anal canal pressures
    — Impaction causes constant relaxation of IAS
    — Permits leakage
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6
Q

Risk Factors

A
  • Diarrhea
  • Impaction with overflow incontinence
  • Neurologic disorders
  • Dementia
  • Anorectal trauma or surgery
    • Traumatic vaginal delivery
  • Restricted mobility
  • Inadequate toileting facilities
  • Conditions affecting rectal capacity/compliance
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7
Q

Etiologic Factors

A

alterations in peristaltic activity
- High volume diarrhea = rapid rectal distension
- Overrides sphincter function

Reduced sensory awareness of rectal filling
- No warning or response time

Impaired sphincter function
- No ability to delay

Reduced rectal capacity

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8
Q

Patient Assessment - History

A
  • Onset + severity of fecal incontinence
  • Impact on lifestyle + quality of life
  • Exacerbating + relieving symptoms

Systems review
- GI: IBD, IBS, anorectal trauma
- Neuro: spinal cord injury, lower back injury, MS, TBI
- Gyne: GTPAL

Medication review
- Both rx and OTC
- Laxatives, softeners, opioids, antidiarrheals
- Not obvious offenders
— Antacids
— Anticholinergics
— Cardiovascular meds
— Oral hypoglycemics
— Alzheimer’s meds

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9
Q

Patient Assessment - Diet

A
  • Fiber and fluid intake
  • consumption of sorbitol
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10
Q

Patient Assessment - Specific Questions

A

Peristaltic function
- # of stools, volume, consistency, peristaltic inhibitors/stimulants

Sensory awareness
- Do you know when you have to go?
- Can you differentiate between solid, liquid, and gas?

Sphincter function
- Ability to delay elimination?
- How long can you delay?

Rectal capacity/compliance
- Ability to delay for more than 1-2 minutes
- Any frequency or urgency associated with bowel movements?

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11
Q

Patient Assessment - Physical

A

Abdo inspection with percussion + palpation
- R/o colonic distension

Sphincter function
- Anal tone at rest
- Sensory awareness on digital exam
- Ability to voluntarily contract sphincter
- Sphincter strength + endurance
- Ability to perform Valsalva
- Retained stool in rectum?

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12
Q

Patient Assessment - Bowel Chart

A
  • Frequency
  • Volume
  • Consistency
  • Voluntary vs incontinent stools
  • Food + fluid intake
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13
Q

Diagnostics

A

Endoanal ultrasound/MRI
- Detects problems with structural damage

Anorectal manometry
- Assess sensory awareness + sphincter function
- Catheter with 3 pressure-sensitive balloons inserted into anal canal
— Intrarectal pressure
— IAS pressure
— EAS pressure

Sphincter EMG
- Assesses innervation + contractility

Defecography

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14
Q

Transient Fecal Incontinence

A
  • Caused by large volume liquid stool overwhelming continence mechanism OR
  • Altered mental status affecting patient’s ability to recognize/respond to rectal distention

Management
- Correction of etiologic factors
- Correction of factors causing altered mental status
- Containment + skin care

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15
Q

Episodic Fecal Incontinence

A
  • Some degree of sphincter damage is present
  • Damages sphincter is competent for formed stool but not liquid

Management
- Manage underlying conditions
- Sphincter strengthening exercises
- Containment products PRN

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16
Q

Chronic Incontinence d/t Altered Mental Status

A
  • Reduced ability to recognize/respond to rectal distention
  • Incontinence in response to mass movements
  • May have superimposed constipation d/t meds or diet

Management
- Stimulate defecation on routine basis
- Containment products PRN

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17
Q

Chronic Incontinence d/t Loss of Sensorimotor Innvervation

A

Neurologic process that results in
- Diminished sensory awareness of rectal distension
- Diminished ability to contract EAS
- Profound constipation d/t reduced activity

Management
- Normalize stool consistency
- Stimulation defecation on routine basis to provide control of fecal elimination

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18
Q

Passive Incontinence

A
  • Unrecognized leakage of stool
  • Leakage occurs but patient is aware
  • D/t loss of sensory function or dementia
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19
Q

Urge Incontinence

A
  • Leakage of stool associated with intense fecal urgency
  • Patient aware of rectal distention but unable to effectively delay defecation
    — Damaged or weak EAS
    — Motility disorder
    — Loss of rectal compliance
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20
Q

Seepage and Soiling

A
  • Leakage of small amounts of stool without conscious awareness
  • Occurs in between normal bowel movements
  • D/t IAS weaknesses or diminished sensory awareness
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21
Q

Flatus Incontinence

A
  • Loss of control of flatus
  • Stool continence maintained
22
Q

Management - Correct Stool Consistency

A

Colonic distension/constipation
- Clean out with laxatives and/or enemas/suppositories
- Fiber + fluid to normalize stool consistency

Diarrhea
- Correct etiologic factors
- Dietary modifications
- Medications PRN
- Improve sensory awareness

23
Q

Management - Improve Sensory Awareness

A

Biofeedback programs
- Balloon-tipped catheter inserted into rectum and inflated until patient senses balloon
- Repeated inflated + deflated

Abnormal rectal sensitivity
- Inflate balloon until patient perceives urgency
- Leave in place and have patient practice deep breathing until urgency subsides

24
Q

Management - Strengthening Muscles

A

If pelvic trauma
- Surgical consult if repair is indicated

Weak pelvic muscles but ability to contract muscles + cognitively intact
- Sphincter exercises

25
Q

Management - Improve ability to delay + control urgency

A

Freeze-Squeeze-Breathe until urgency subsides

Supportive counseling to reduce anxiety

26
Q

Management - Initiate Stimulated Defecation Program

A

For patients with total loss of sensory awareness + sphincter control

Goal to stimulate defecation on routine basis before rectum fills + causes involuntary defecation
- Patient cannot sense rectal distention or control sphincter to delay
- Must stimulate peristalsis to deliver stool to rectum
- Reduce risk of incontinence overtime

Steps
- Disimpact PRN
- Colonic clean out to eliminate retained stool
- Measures to establish soft, formed stool
- Establish schedule for stimulated defecation
- Select peristaltic stimulus

27
Q

Stimulus Options - Digital Stimulation

A

Gloved finger inserted to stimulate nerves in anal canal + anorectal junction

Causes reflex relaxation of IAD + peristalsis in left colon

28
Q

Stimulus Options - Suppositories

A

Placed against wall of rectum and retained long enough to melt
- Used with digital stimulation

29
Q

Stimulus Options - Mini-Enemas

A

4 mL ampules with twist-tops
- Contain docusate + soft soap
- Instilled slowly and retained for 10 mins

30
Q

Stimulus Options - Tap Water Enemas

A
  • Given via balloon-tipped catheter
  • Lukewarm water administered via catheter to distend the bowel
  • Pt transferred to toilet and balloon deflated to permit returns
31
Q

Stimulus Options - Transanal Irrigation

A
  • System composed of rectal balloon, water reservoir, and handheld unit
  • Allows patient to inflate balloon and control water instillation
  • Pump propels water proximally to promote effective evacuation
32
Q

Management - Improve Rectal Compliance and Capacity

A

Environmental
- Bedside commode
- Improve mobility
- Clothing modifications

Absorbent products
- Adult briefs are best option
- Provide appropriate skin care

33
Q

Surgical Intervention - Repair of EAS

A

For obstetric trauma

Ends of sphincter overlapped and sewn together

Successful if IAS remains innervated + intact

34
Q

Surgical Intervention - Sphincter Plication

A

Best approach to manage incontinence associated with IAS

Continence deteriorates overtime

35
Q

Surgical Intervention - Malone Antegrade Continence Enema

A

Continent stoma created into proximal colon

Self-administration of high volume irrigations at regular intervals

36
Q

Surgical Intervention - Artificial Anal Sphincter

A

Anorectal cuff connected to reservoir + controlled by pump

37
Q

Surgical Intervention - Injectable Bulking Agents

A

Collagen, silicone, or carbon-coated beads

38
Q

Surgical Intervention - Sacral Nerve Stimulation

A

Surgically implanted wires and stimulator

Wires places adjacent to sacral serves

Only if patient has failed behavioral or pharmacologic therapy

39
Q

Surgical Intervention - Fecal Diversion

A

Colostomy

Best option for uncorrectable fecal incontinence
- Neurologic process causing loss of sensory awareness + sphincter function
- Poor results from stimulated defecation program

40
Q

Encopresis

A

fecal soiling usually associated with functional constipation

41
Q

Primary encopresis

A

child who never gained fecal continence

42
Q

Secondary encopresis:

A

child who was continent x1 year and then became incontinent

43
Q

Retentive encopresis

A

soiling associated with stool retention

44
Q

Non-retentive encopresis

A

soiling not associated with stool retention

45
Q

Pathology non-retentive encopresis

A

caused by organic disorder or emotional stressors

46
Q

Pathology retentive encopresis

A

Caused by psychological issues
- Coercive/permissive toilet training
- Toileting fears
- Painful/difficult defecation
- Social taboos
- Lack of privacy

47
Q

Encopresis Presentation

A
  • Stool accidents
  • Abdominal pain
  • Lack of awareness of incontinence episodes
  • No awareness of fecal odor
48
Q

Encopresis - Assessment

A

History
- Med-surg and developmental history
- Onset + duration of encopresis
- Impact on child + family relationship

Physical
- Neurological lesions
— Observe gait
— Check base of spine
- Abdo exam re: retained stool
- Inspect perineum for skin breakdown

49
Q

Encopresis - Diagnostics

A
  • Abdo imaging for severity of retained stool
  • Transit study
  • Defecography and anorectal manometry
50
Q

Encopresis - Management

A

Education + counseling
- To eliminate blame + guilt

Bowel cleansing
- To eliminate all stained stool

Bowel program
- To establish regular elimination of soft formed stool
- Softeners + laxatives
- Fiber + fluids
- Age (in years) + 5 OR 0.5 g/kg/day

Routine toileting
- Child sits on toilet 10-15 mins BID after meals
- Taught to respond promptly to “urge to go”

Continence 2.2 (14 decks)

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