Diagnosis and therapy of fecal incontinence

Fecal incontinence is not a diagnosis, but a symptom which can have multiple causes. The aim of any therapy should be to treat the underlying disorder. This requires a detailed diagnostic procedure in each patient. If no underlying disorder can be found, therapy becomes symptom oriented. Besides drug treatment anal biofeedback training is the most important form of medical therapy. Except for special situations surgery is indicated only if medical therapy has failed.     

Diagnosis and management of fecal incontinence in elderly patients

Fecal incontinence is a physically and psychologically disabling condition that affects millions of Americans, especially those over the age of 65 years. The pathophysiology is often multifactorial, with decreased anorectal sensation, reduced rectal compliance. anal sphincter dysfunction, altered stool consistency and immobility playing significant roles. A detailed history and a thorough physical examination are always necessary in patients with fecal incontinence and physiologic tests, including anorectal manometry, cinedefecography and electromyography, may be required for proper diagnosis and treatment. In most patients fecal incontinence is initially treated with conservative measures, such as biofeedback training or alteration of the stool consistency (if appropriate). If conservative management fails, surgical intervention, such as sphincteroplasty or gracilis muscle transposition, may be considered.     

Antegrade continent enema management of chronic fecal incontinence in children

BACKGROUND/PURPOSE: Fecal incontinence impedes social and psychological development in children. Conventional bowel management with rectal enemas, medication, and biofeedback frequently will provide intervals free of fecal soiling sufficient for children to be socially continent. METHODS: This report details the improvement achieved by antegrade irrigation of the colon when conventional bowel management programs have failed to provide satisfactory intervals free of fecal soiling. Twenty-three children had conduits performed to administer antegrade continent enemas in the colon from December 1993 to May 1997. RESULTS: Twenty of the children were available for evaluation. One child was lost to follow-up, and two were noncompliant with the irrigation program. Fourteen of the 20 children are out of diapers. Four of the six wearing diapers, do so for urinary, not fecal incontinence. Two patients (10%) still require diapers for fecal incontinence. Parents were pleased with the efficacy of antegrade irrigation and the decrease in family stress with the elimination of fecal soiling. CONCLUSIONS: Ninety percent of the children available for follow-up benefited from antegrade irrigations of the colon. The antegrade irrigations were an improvement over conventional bowel management programs because a predictable interval free of soiling could be established. This allowed families to plan activities and improved the self-esteem of their children.     

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.     

Biofeedback training is useful in fecal incontinence but disappointing in constipation

BACKGROUND: Successful biofeedback therapy has been reported in the treatment of fecal incontinence and constipation. It is uncertain which groups of incontinent patients benefit from biofeedback, and our impression has been that biofeedback is more successful for incontinence than for constipation. PURPOSE: This study was designed to review the results of biofeedback therapy at the Lahey Clinic. METHODS: Biofeedback was performed using an eight-channel, water-perfused manometry system. Patients saw anal canal pressures as a color bar graph on a computer screen. Assessment after biofeedback was by manometry and by telephone interview with an independent researcher. RESULTS: Fifteen patients (13 women and 2 men) with incontinence underwent a mean of three (range, 1-7) biofeedback sessions. The cause was obstetric (four patients), postsurgical (five patients), and idiopathic (six patients). Complete resolution of symptoms was reported in four patients, considerable improvement in four patients, and some improvement in three patients. Manometry showed a mean increase of 15.3 (range, -3-30) mmHg in resting pressure and 35.7 (range, 13-57) mmHg in squeezing pressure after biofeedback. A successful outcome could not be predicted on the basis of cause, severity of incontinence, or initial manometry. Twelve patients (10 women and 2 men) with constipation underwent a mean of three (range, 1-14) biofeedback sessions. Each had manometric evidence of paradoxic nonrelaxing external sphincter or puborectalis muscle confirmed by defography or electromyography. All patients could be taught to relax their sphincter in response to bearing down. Despite this, only one patient reported resolution of symptoms, three patients had reduced straining, and three patients had some gain in insight. CONCLUSIONS: Biofeedback helped 73 percent of patients with fecal incontinence, and its use should be considered regardless of the cause or severity of incontinence or of results on initial manometry. In contrast, biofeedback directed at correcting paradoxic external sphincter contraction has been disappointing.     

Urinary and fecal incontinence in geriatric facilities in the Czech Republic

BACKGROUND: Incontinence represents one of the common problems in long-term care geriatric facilities and nursing homes. However, in the Czech Republic data on prevalence, severity and incontinence-associated factors for nursing home residents are not available. The aim of the study was to report the prevalence of urinary (UI) and bowel incontinence (BI) in different geriatric facilities and to identify factors positively associated with incontinence. METHODS AND RESULTS: In a sample of 1162 residents of 18 long-term care facilities UI has been found in 684 residents (63.3%). Health and social care facilities did not differ significantly (60.7 vs 65.6%). Of the incontinent 294 residents (27.2%) suffered from permanent/daily incontinence, 390 (36.1%) from occasional transitory UI. Prevalence of BI reached 54.4%, as well as double incontinence (45.9%). Cognitive impairment, self-care ADL and/or mobility dependency and bed rest are factors significantly associated with UI (for all P < 0.001). However, age, gender and urinary tract infection did not reach the statistical significance (P = 0.280-0.069). Risk adjustment/stratification for UI revealed the prevalence of 33.0% in the low risk group. In the high risk group (high ADL dependency and severe cognitive impairment) the prevalence came up to 96.0%. CONCLUSIONS: Our study presents the first results focused on incontinence problem in long-term care geriatric institutions in the Czech Republic. High prevalence of this condition makes incontinence an important medical, nursing and economical yet neglected problem.     

Percutaneous cecostomy: a new technique in the management of fecal incontinence

A pilot study on the percutaneous introduction of a cecostomy tube for colonic irrigations in the treatment of children with fecal incontinence is described. The results were good, and the technique is recommended for certain patients.     

Are special investigations of value in the management of patients with fecal incontinence?

PURPOSE: The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone. METHODS: Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography. RESULTS: In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy. CONCLUSIONS: Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.     

Combined Mitrofanoff and antegrade continence enema procedures for urinary and fecal incontinence

PURPOSE: Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children undergoing major reconstructive urological operations. To treat double incontinence or the combination of wetting and severe constipation, we constructed a Mitrofanoff conduit and a channel for antegrade continence enemas in 18 patients between 1989 and 1995. We review the underlying pathological conditions, various surgical techniques and outcomes of these operations. MATERIALS AND METHODS: Underlying abnormalities mainly included spinal lesions, bladder exstrophy, imperforate anus and various cloacal anomalies. Patient age ranged from 2 to 18 years (average 8.4). In 13 patients both procedures were done simultaneously. The appendix was used to construct the antegrade continence enema channel in 8 cases and the Mitrofanoff channel in 5. It was long enough to be divided and used for both procedures in 2 cases but it was missing or unsuitable in 3. Alternative antegrade continence enema conduits were cecal flap in 7 patients and ileum in 1, while the ureter, ileum and detrusor tube were used to establish Mitrofanoff channels in 5, 5 and 1, respectively. Stomas were constructed according to the V-flap or V. Z. Q. technique and situated in close proximity in the right lower abdominal quadrant in 13 cases. RESULTS: Convalescence was uneventful except for 1 abscess near an antegrade continence enema stoma. Ten patients needed dilation or minor revisions due to difficulty in catheterizing the antegrade continence enema (5), Mitrofanoff (3) or both conduits (2). Subsequently 3 patients underwent repeat operations for reconstruction of 2 antegrade continence enema channels (cecal flap and ileum) and 1 detrusor tube Mitrofanoff channel. Currently 15 patients are dry on regular clean intermittent catheterization using 10 to 12F catheters. Outcomes of the antegrade continence enema channels are satisfactory in 15 patients who are clean or rarely soil. Failure occurred in 1 patients with severe constipation necessitating colostomy and 2 (1 noncompliant who stopped catheterizing regularly) in whom the channels subsequently closed. CONCLUSIONS: Synchronous construction of antegrade continence enema and Mitrofanoff channels is successful in the majority of doubly incontinent patients. Selection of patients with high motivation is important to obtain satisfactory results.     

Toilet tales: stool toileting refusal, encopresis, and fecal incontinence

In the present study, we examined the specific binding of IGF-I and IGF-II to their receptors in C6 glioma cells taken during different growth phases in culture: phase A, early stage of the exponential growth (48 h after seeding); phase B, late stage of the exponential phase (96 h after seeding); phase C, confluent phase (at 144 h after seeding); and phase D, stopped at 48 h post-confluence. Scatchard analysis revealed higher Ka values for the IGF-IR during the exponential phases (A and B). The affinity of IGF-I for its receptor during the post-confluent phase (D) decreased to about half that at phase A (p < 0.01). Although lower at the later phase (D), the number of binding sites of the IGF-IR in the different tested growth stages in culture (A, B, and C) was not statistically different (p > 0.05). Conversely, the number of binding sites of the IGF-II/mannose-6-phosphate receptor appeared to increase during time in culture. The Ka values of the IGF-II/mannose-6-phosphate receptor decreased significantly during the culture time, phase D showing the largest decrease (50%) as compared with phase A (p < 0.005). These binding data suggest that IGF-I and IGF-II receptors are differentially expressed in rat C6 glioma cells in culture and are a function of the growth phase.     

Abdominal sonography for the diagnosis of bowel obstruction

Minimally invasive thoracoscopic staging for lung cancer was compared with re-staging by open thoracotomy in seventeen patients to evaluate whether videoimaged thoracoscopic staging was accurate. Seventeen patients underwent thoracoscopic staging initially with a closed videoimaged technique. These same patients then underwent an open thoracotomy and re-staging with a therapeutic resection for lung cancer. All patients underwent pleural evaluation and biopsy if indicated, thoracic hilar and mediastinal lymph node sampling, and then resection of the parenchymal lesion via a wedge resection, lobectomy or pneumonectomy. There was complete TMN stage correlation between the closed videoimaged thoracoscopic and open thoracotomy techniques. This preliminary study suggests minimally invasive videoimaged thoracoscopic staging is an accurate method to assess the stage of lung cancer to guide rational management.     

One-sample pregnancy diagnosis in elk using fecal steroid metabolites

In utero hypoxia may affect the development of the brain and result in altered respiratory responses postnatally. Using a barometric plethysmograph, we examined the effects of exposing pregnant guinea pigs to 200 ppm carbon monoxide (CO) for 10 h/d from d 23-25 of gestation until term (approximately 68 d) on the ventilatory responses of their 4-5-d-old neonates at rest, and during progressive asphyxia and steady state hypercapnia. Exposure to this concentration of CO produced significantly higher levels of carboxyhemoglobin (COHb) in maternal (8.53 +/- 0.6% versus 0.25 +/- 0.1%) and fetal blood (13.0 +/- 0.4% versus 1.6 +/- 0.1%) from CO-treated animals when compared with controls. Hematocrit was significantly higher in the CO-treated neonates (46.3 +/- 1.0% versus 41.3 +/- 0.9%) at 5-6 d of age, although no difference existed between the groups for COHb at this time. There was no difference between the groups for length of gestation, litter size, or birth weight, but CO-treated neonates were significantly smaller at 4 d of age (102.4 +/- 3.7 g) compared with controls (132.0 +/- 5.0 g). At 4-5 d of age there was no difference between the groups for either tidal volume (VT), respiratory frequency (f), or minute ventilation (VE) at rest, but during steady state hypercapnia (4 and 6% CO2) the CO-treated neonates had a significantly greater VT and VE (but not f) than did controls. During progressive asphyxia, CO-treated animals had a significantly greater VT than did controls from 1-8% CO2. There was a significant fall in f at 1 and 3% CO2 in CO-treated animals; however, this effect did not persist, resulting in a significantly increased VE from 3 to 8% CO2. The inspiratory flow rate (VT/expiratory time) was significantly increased in the CO-treated neonates during progressive asphyxia; this occurred in the absence of a difference in inspiratory time between the groups. These results indicate that prenatal exposure to CO increases CO2 sensitivity in 4-5-d-old guinea pigs. This may be due to developmental alterations in the areas of the brainstem responsible for respiratory control.     

Surgical repair of fecal incontinence. Correlation of sonographic anal sphincter integrity with subjective cure

We examined the relationship between left ventricular hypertrophy (LVH) and renal and retinal damage in 174 untreated patients with essential hypertension. As an index of renal and retinal damage, we examined proteinuria and retinal vascular change. LVH was diagnosed according to left ventricular mass obtained from echocardiography. Of the hypertensive patients, 111 patients (64%) had LVH. The incidences of proteinuria and advanced retinal vascular change were higher in patients with LVH than in those without LVH. In a multiple regression model, there was a significant positive correlation between left ventricular mass and proteinuria, as well as diastolic blood pressure, sex, age and body mass index. In conclusion, proteinuria is related to elevated left ventricular mass in patients with essential hypertension.