​Kembara Xtra - Medicine - Fecal Incontinence

​Kembara Xtra - Medicine - Fecal Incontinence 
Continuous or recurrent involuntary fecal material passage through the anal canal for more than a month in a person who is at least 4 years old Involves recurrent, involuntary feces loss Demands a careful rectal exam to assess rectal tone, voluntary squeeze, and rule out overflow incontinence from fecal impaction
The easiest, most accurate, and least invasive way to find anatomic anal sphincter abnormalities is with endorectal ultrasonography (EUS). The purpose of treatment is to improve quality of life or regain continence.
The uncontrollable passing of excrement is known as major incontinence.
Flatus-related incontinence and/or sporadic seepage of liquid feces are examples of minor incontinence (fecal soilage).

Aspects of Geriatrics
Fecal incontinence is more common as people age.
Idiopathic fecal incontinence is more prevalent in older women, and it is a significant factor in elderly people being placed in nursing homes.


Prevention Incidence

Fecal incontinence is frequently a "silent affliction" in patients who are not particularly asked about it. The number of patients affected is probably vastly understated.
Prevalence
"Women over men"
7% of adults, 15% of individuals over the age of 90, 56-66% of elderly hospital patients, >50% of nursing home residents, and 50-70% of patients with urine incontinence also have fecal incontinence are affected.
pregnant women's issues
Incontinence caused by obstetric pelvic floor damage can be either transient or ongoing.


Aspects of Geriatrics
Older individuals frequently experience fecal impaction and overflow diarrhea that results in fecal incontinence.
A history of surgery, especially anal surgery, such as hemorrhoidscissor removal, anal fissure repair (sphincterotomy), anal dilatation, or previous pelvic floor procedures

Pathophysiology and Etiology 

The intricate coordination of the pelvic musculature, nerves, and reflex arcs is necessary for continence.

In order to maintain fecal continence, several factors must be present. These include stool volume and consistency, colonic transit time, anorectal sensation, rectal compliance, anorectal reflexes, external and internal sphincter muscle tone, puborectalis muscle function, and mental capacity.
● The most prevalent metabolic illness, diabetes, causes pudendal nerve neuropathy, which results in fecal incontinence.
Spina bifida, myelomeningocele, and spinal cord injury are congenital conditions.

 Trauma, such as anal sphincter injury after vaginal birth or surgical treatments
Medical conditions include diabetes mellitus, stroke, spinal cord injury, degenerative nervous system diseases, inflammatory bowel diseases, and rectal neoplasia.

Risk Factors include: neuropsychiatric diseases (depression, dementia), multiple sclerosis, spinal cord injury, stroke, diabetic neuropathy, older age, female sex, obesity, and limited physical activity. Prostatectomy and radiation therapy are also risk factors.
injuries: Occipitoposterior presentation, a protracted second stage of labor, assisted vaginal delivery (with forceps or vacuum-assist), and episiotomy are risk factors for perineal injuries at the moment of vaginal birth.
Constipation, menopause, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and diarrhea
Congenital anomalies, such as imperforate anus/rectal prolapse, Fecal impaction, and a possible link to child maltreatment and sexual abuse

Prevention 

 Behavioral and lifestyle adjustments: Modifiable risk factors include obesity, insufficient exercise, a bad diet, and smoking.
Postmeal bowel routine: frequently defecate after meals to maximize the effect of the gastrocolic reflex.
Pelvic floor exercises before, during, and after pelvic surgery
 Up your daily fiber intake (to at least 30 g).

Accompanying Conditions 

Ageing (>65 years), urinary incontinence, pelvic organ prolapse, chronic medical conditions like diabetes, dementia, stroke, spinal cord compression, depression, immobility, COPD, IBS, and IBD, perineal trauma from childbirth, anorectal surgery, and a history of pelvic/rectal radiation are all risk factors.


Diagnoses Diagnoses are made based on physical observations and past experiences.

Patients rarely voluntarily disclose their fecal incontinence histories. Asking direct questions is crucial.
The problem-specific past comprises the following information: - Severity of feces soiling by liquid or gross feces incontinence - Onset and duration (recent onset vs. chronic)
- The frequency and occurrence of diarrhea or constipation; thorough medication review
Review your nutrition, health history, obstetric history, way of life, and mobility.
Examine depression and social disengagement.

clinical assessment 

Check the perineum for sarcopenia of the pelvic musculature, chemical dermatitis, hemorrhoids, fistulas, surgical scars, skin tags, rectal prolapse, soiling, and ballooning of the perineum.
A patulous anal orifice could be a sign of myopathy or a neurological condition.
Assess the external sphincter's reaction to anal winking, which stimulates the perineal skin. There may be neuropathy absent.
Request that the patient bear down while standing so that you can check for rectal prolapse.
Digital rectal examination to determine the presence of hemorrhoids, diarrhea, distal fecal impaction, anal canal pressure, sphincter tone, and rectal bleeding
An assessment of the entire nervous system, including the perianal sensation
Analyze your mental state.

Anorectal disorders, inflammatory/infectious gastrointestinal illnesses, bowel neoplasms, radiation proctitis, ischemic colitis, and fistulas are among the differential diagnoses.
- Rectal prolapse; prolapsed internal hemorrhoids
Obstetrical, surgical, radiation, accidental, and sexual trauma
Neurologic conditions such as diabetes mellitus, multiple sclerosis, pudendal neuropathy, dementia, neoplasms, stroke, and/or diseases altering degree of awareness
IBS, laxative misuse, IBD, small bowel syndrome, myopathies, aging and frailty, collagen vascular disease, infectious diarrhea, fecal impaction and overflow, psychological and behavioral issues

Laboratory Results 

Fecal incontinence in older people should be treated with a tailored, minimally invasive strategy that is also practical. Usually, a diagnosis can be made with the help of the history and physical examination. If doubt persists, take into account the following:
The most accurate and less intrusive test for identifying anatomic flaws in the puborectalis muscle, rectal wall, and external and internal anal sphincters is the EUS. The therapeutic response to sphincteroplasty can be accurately predicted by EUS.
Plain abdominal x-ray for constipation and fecal impaction
Colonoscopy, anoscopy, and sigmoidoscopy (for tumors, colitis, and hemorrhoids)

Initial examinations (lab, imaging)
Consider stool tests if there is a history of travel, antibiotic use, tube feedings, or sepsis symptoms:
the cultural
- Parasites and the ova
- Assay for Clostridium difficile toxin
Thyroid-stimulating hormone (TSH), electrolytes, and BUN in elderly patients. EUS may show structural abnormalities of the anal sphincters, rectal wall, or puborectalis muscle. EUS may find a sphincter injury in more than one-third of vaginal deliveries in primiparous women and almost half of vaginal deliveries in multiparous women.

Tests in the Future & Special Considerations
Defecography can assess pelvic descent, quantify anorectal angle, and find hidden or overt rectal prolapse.
MRI defecography (dynamic MRI) can clarify the anatomy of the pelvic floor.
The rectoanal inhibitory reflex, the threshold of conscious rectal feeling, rectal compliance, and anorectal pressures during straining are only a few of the parameters that anorectal manometry measures.
Pudendal nerve terminal motor latency (PNTML), which depends on the operator and has a weak connection with clinical and histologic findings, assesses the neuromuscular integrity between the pudendal nerve and the anal sphincter.
Electromyography can be used to evaluate myopathic/neurogenic damage.

Management 

Scheduled (or prompted) defecation is successful in ambulatory individuals, especially in those with overflow incontinence.
Kegel exercises to bolster pelvic floor muscle
Schedule osmotic or stimulant laxatives for constipation if you're going to be in bed.
Enemas, laxatives, and suppositories may assist affected individuals empty their bowels more completely and reduce postdefecation leaks.
Using deodorants for stools (Peri-Wash, Derifil, Devrom)

Medication 

There is little evidence to support the effectiveness of antidiarrheals (loperamide, codeine) and medications that improve sphincter tone (phenylephrine gel, sodium valproate) (2)[B].
Amitriptyline can occasionally be helpful for idiopathic fecal incontinence. Cholestyramine and colestipol are helpful in diarrhea following malabsorption or cholecystectomy.
Initial Line
Fecal continence may be improved by specialized treatment for the underlying condition (such as infectious diarrhea/IBD).
Next Line
In milder cases of fecal incontinence, increasing dietary fiber alleviates symptoms. High-fiber diets, psyllium products, or methylcellulose are all examples of stools-bulking substances.
Adsorbents or opium derivatives are examples of antidiarrheal medicines that may lessen diarrhea-related incontinence.
Removing the burden from individuals with fecal impaction and overflow incontinence and treating them with a bowel regimen to stop a recurrence

Further Treatments 
In motivated patients with some voluntary sphincter control, biofeedback is a first line of treatment. It trains patients to notice rectal distension and contract the external anal sphincter while maintaining low intra abdominal pressure.
Patients with systemic neurologic diseases, anal abnormalities, or recurrent episodes of incontinence respond poorly to biofeedback and electrical stimulation of the anal sphincters.

Surgical Techniques 

Surgery should only be thought of after nonsurgical measures have failed.
Patients with severe symptoms and an external anal sphincter defect should be offered sphincter repair.

For patients with internal anal sphincter dysfunction, injectable treatment (tissue-bulking substance injected into the anorectal submucosa or the intersphincteric region) seems safe and successful (40% effectiveness).

Patients with severe fecal incontinence and irreversible sphincter injury may be candidates for artificial anal sphincter implantation or dynamic graciloplasty, which involves gracilis muscle transposition into the anus as modified sphincter. 

When other available therapeutic approaches have failed or if the patient prefers it, stoma (colostomy/ileostomy) construction may be necessary for people with disabling fecal incontinence. A less radical technique allows these individuals to flush their colons via an antegrade continence enema: a continent stoma made utilizing the appendix or cecum as the point of entry.

Anal plugs reduce fecal leakage in patients who do not respond to other forms of therapy, particularly those who are immobile, in institutions, or have neurological disabilities; however, the plugs are frequently poorly tolerated.
Especially in individuals with a coexisting sphincter dysfunction, sacral nerve stimulation (neuromodulation) through the implantation of SC electrodes that administer low-amplitude electrical stimulation to sphincter muscles improves overall rectal tone.

 The SECCA operation (radiofrequency anal sphincter remodeling), which results in tissue injury, scarring, and anal canal narrowing by delivering temperature-controlled radiofrequency energy to the anorectal junction distal to the dentate line. ambulatory, minimally invasive technique for mild to moderate fecal incontinence.
Magnetic anal sphincter (MAS) devices, a flexible ring that surrounds the external anal sphincter 3 to 5 cm from the anal margin, consist of a series of interconnected, titanium beads (14 to 20) with internal magnetic cores. The beads split during feces expulsion, enabling evacuation. With moderate to severe incontinence, the beads come close to closing the channel after evacuation.

 An 86% success rate for a vaginally implanted bowel control device that the patient inflates to stop leaking and deflates to feces.

Other recent developments in managing fecal incontinence include the TOPAS pelvic floor repair system (self-fixating polypropylene mesh placed behind the anorectum to support the puborectalis) and percutaneous posterior tibial nerve stimulation at the ankle for 30 minutes each week for 12 weeks (50% efficacy).


Admission 
Avoid catharsis and, if fecal impaction is the cause, perform manual fecal mass evacuation following lubrication with lidocaine jelly.
No enemas with hydrogen peroxide, hot water, or soap
Outpatient treatment

Follow-Up Routine rectal examination
patient observation
If a patient with fecal incontinence has less than one bowel movement every other day, consider impaction.


High-fiber (20–30 g/day) and fluid-dense (1–1.5 L/day) diet; avoid precipitants (caffeine).


Education of Patients 
Exercises to train the kegel/sphincter are beneficial but insufficient for addressing fecal incontinence.

Reimpaction is likely if the bowel regimen is stopped, and there is a 50% failure probability over the next five years after overlapping sphincteroplasty.

Complications include depression and social isolation, skin ulcers, and problems with the artificial bowel sphincter's mechanical function.