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Colorectalsurgery.com.auFaecal incontinence has traditionally been thought to be more common in women because of the incidence of obstetric trauma. However, recent population studies have shown this not to be true. COLANTA has published an interesting article in the Medical Journal of Australia in January, 2002 in which over 10,000 self administered questionnaires were distributed and about 640 of the people sent questionnaires responded. There was a report of a 1.4 per cent incidence of major faecal incontinence and of these about half of those reported said it had a major impact on the quality of life. Not surprisingly there was an increased prevalence in older age groups but there was no sex difference identified.
In the same article, liquid faecal incontinence was reported at a rate of about 11 per cent, tinence i
of which in the total population of women, almost 9 per cent complained of liquid faecal incontinence and roughly the same number in the male population. Of these, about one third reported significant substantial soiling with faecal incontinence this was a significant problem in that population. Solid faecal incontinence was somewhat less in the female population with about one per cent and in the male population about 3 per cent. Of these only one person suggested it was causing significant problems. Now with the male population, faecal incontinence is due to a number of factors, with obstetric injury not being one of them. The most common factor is trauma to the anal sphincters, either caused by perianal trauma or perineal surgery. Now COLANTA’s article suggested that radiation injury and diabetes were not involved, but I will speak about that more later in the talk.
Perianal surgery that causes sphincter damage is usually such operations as Haemorrhoidectomy, Sphincterotomy for anal fissure or incidences of trauma such as occur in motor vehicle accidents, particularly motor cycle accidents. Anal ultrasound is an extremely good method of assessing anal sphincters for injury and in a study by Chen published in the Annals of Surgery, 1999, 37 men were studied who had problems with incontinence. 27 per cent of those had major incontinence. Damage was revealed by ultrasound in 9 patients and manometry revealed that these 9 patients had significantly lower maximal resting and squeeze pressure than the other patients. There was 92 per cent improvement with conservative measures in patients without sphincter damage, so that is if the ultrasound does not reveal any sphincter damage then the majority of patients will improve without any operative intervention. Operative intervention would be direct sphincter repair or Graciloplasty, as in the case of a patient of Andrew Hunter’s, who destroyed the sphincter mechanism around the anal canal in a motor bike accident and had a successful reconstruction or artificial anal sphincter which I have not had much experience with.
In patients with diabetes approximately 20 per cent of Type 1 diabetics will develop faecal incontinence during their life and the severity of the problem is related to the duration of the disease. The cause is multi-factorial. One of the problems is that of autonomic neuropathy which would develop and impinges on the function of the internal anal sphincter and rectal sensation. In association with this, the so-called diabetic diarrhoea occurs, which adds an extra load to the sphincter mechanisms and peripheral motor neuropathy impinges on the action of the external anal sphincter. There is also evidence that the recto-anal inhibitory reflex is impaired. In another very large group of male patients with incontinence are those whose rectum and anal canal and sphincters are affected by radiotherapy. Radiotherapy is used to treat a number of cancers in males, but the significant ones are prostate cancer, rectal cancer both pre and post-resection and anal squamous cell carcinoma. Prostate cancer has a high incidence in Australia, with almost 10,000 new cases being diagnosed Australia wide each year, causing 2,500 deaths each year. Radiotherapy causes injury to both cancer and normal cells by causing damage to cellular DNA and particularly those cells which are rapidly dividing, such as tumour cells, but also cells of the rectal mucosa. Radiation is given in fractions, that is, small amounts each day, and the maximum tolerated dose that can be given to the rectal area is about 45 - 50 greys and this is expected to result in a complication rate of about 5 per cent of serious complications within 5 years. So this would give an estimated complication rate of about 100 - 200 patients experiencing significant radiotherapy related rectal injury per year. The symptoms that these patients complain of are that of significant diarrhoea, faecal urgency, PR bleeding and faecal incontinence. About 75 per cent of patients undergoing pelvic radiotherapy experience acute ano-rectal symptoms. 20 per cent will experience so-called late phase radiation proctitis, that is symptoms that persist after 3 months, and about 8 per cent of patients over 10 years will have problems with proctitis, enteritis or ano-rectal strictures, and about 3 per cent will have very severe problems with proctitis or small bowel obstruction or fistula formation. There is no question that patients with diabetes or patients who are having combination chemotherapy, suffer increased complications.
To look at the function of the anal sphincters, patients who have radiotherapy for anal carcinoma obviously have the radiotherapy directed mainly at the anal sphincters and the level of incontinence is about 25 per cent. Studies on this are poor, but it is thought that the internal anal sphincter, the anal epithelium and the haemorrhoidal cushions all suffer damage and cause incontinence. Patients who have these problems and undergo ano-rectal manometry are tinence i
found to have the resting anal canal pressures decreased and the physiological sphincter length decreased. So in other words the internal anal sphincter has been compromised. This is thought to be due to damage to the myenteric plexus within the internal anal sphincter.
Treatment options. Well there have been numerous attempts to give patients drugs during radiotherapy to decrease the effect of the radiotherapy on normal tissue and these have basically failed, although Misoprostol is currently under investigation. Sucralfate enemas are about the only thing that have been found to decrease faecal urgency in patients with radiotherapy and for bleeding, 4 per cent Formalin enemas or argon beam coagulation have been found to be effective. Results of surgery are in general poor. Moving to another topic now. The patient who I think we all see and have trouble treating are men who have no obvious cause for incontinence. In fact their incontinence is mainly faecal seepage, often complaining they have to wipe the perianal area a number of times per day and also complaining of skid marks. The patient is usually middle aged, overweight, have a very busy lifestyle and complain of minor leakage and pruritus. There have been some studies on this and Paradella in 1998, published the results of anal manometry on a group of these patients and rather paradoxically found that these patients had a long physiological anal sphincter and abnormally high resting I think the way to treat these patients is to exclude ano-rectal and colonic pathology by digital rectal examination, proctoscopy, sigmoidoscopy and colonoscopy. If there are haemorrhoids there then treat them preferably by banding rather than Haemorrhoidectomy. Take a very detailed dietary history as this can, I think, relate very importantly to their problems and particularly look at their fibre intake and the intake of caffeine. The physiological effects of coffee and caffeine are interesting. It does not affect gastric emptying. It does stimulate motor activity of the transverse and distal colon and I think this is important when we are dealing with faecal incontinence as many of these patients drink up to 8 - 10 cups of coffee per day and are always stimulating the colon and it does cause pruritus ani by a break down of the products in coffee to a chemical which does cause significant itching.
So, in summary, if a male patient presents with faecal incontinence it is very important to take a significant history, particularly about episodes of past perianal surgery, look for diabetes, ask about pelvic radiotherapy and check the patient’s diet. For investigations, check there is no ano- rectal or colonic pathology. Anal ultrasound is an extremely useful tool and anal manometry less useful. Treatments start with dietary manipulation. Try various medications such as Imodium and Lomotil. Pelvic floor rehabilitation I think remains the mainstay of treatment in these patients and surgery, if an anatomical defect is found on ultrasound, may prove useful.
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