bowel symptoms faecal incontinence: ‘tear’ assessment and ... · urinary incontinence/prolapse...
TRANSCRIPT
24-May-16
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Sydney Colorectal + Pelvic Floor Centre
Faecal Incontinence: Assessment and Management
Professor Marc A Gladman MBBS DFFP PhD MRCOG FRCS (UK) FRACS
Professor of Colorectal Surgery
Sydney Colorectal + Pelvic Floor Centre
Mrs PK; 56 yrs; Married; 2 children
• Bowel symptoms – IBS with loose stools
• Para 2 x VD - #1 forceps with ‘tear’
• Back injury 15 years ago – microdiscectomy
• Working for the Federal Government in Canberra
• Dramatic impact on work/social/psychological well-being
• >10 years of incontinence to faeces / flatus
• Initially monthly episodes – now weekly
• Associated faecal urgency – 5 mins max
• Embarrassment – didn’t seek help for 5 years
Sydney Colorectal + Pelvic Floor Centre
What is incontinence?
‘Any accidental or involuntary loss from the bladder or bowels’
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Urinary Incontinence
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Faecal incontinence (FI): bowel leakage
‘Involuntary or uncontrolled passage of bowel motion, faeces or wind from the bowel’.
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How common is bowel leakage?
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Sydney Colorectal + Pelvic Floor Centre
Australian Health Survey 2011-13
Diabetes Mellitus
Osteoporosis
Cancer
_____________________________________________
Diabetes Mellitus 4.0%
Osteoporosis 3.4%
Cancer 1.6%
_____________________________________________
9%
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FI: extent of the problem
12% reported FI - half moderate/severe
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FI: extent of the problem
Sydney Colorectal + Pelvic Floor Centre
FI
FI afflicts more adults than DM (4.0%),
osteoporosis (3.4%) and cancer (1.6%)
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Stigmatisation of FI
Sydney Colorectal + Pelvic Floor Centre
Take Home Message 1
‘Bowel leakage affects 1 in 8 of your patients’
‘Two-thirds will NOT volunteer it’.
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Sydney Colorectal + Pelvic Floor Centre
Overview
The role of the GP: GPMP
Identification, assessment & treatment of sufferers
When symptoms persist – what next?
The multidisciplinary team - when & where to refer
Latest Treatments – Sacral Neuromodulation
What every GP needs to know
Sydney Colorectal + Pelvic Floor Centre
Overview
The role of the GP: GPMP
Identification, assessment & treatment of sufferers
When symptoms persist – what next?
The multidisciplinary team - when & where to refer
Latest Treatments – Sacral Neuromodulation
What every GP needs to know
Sydney Colorectal + Pelvic Floor Centre
The role of the GP
Identification in primary care
Screening questions A.I.M. & ‘hi-risk’ patients - C.O.N.T.R.O.L
Assessment priorities
Red flags & Reversible factors
Treatment options in primary care
L.E.A.K.A.G.E
Chronic disease management plans
GPMPs & TCAs
Sydney Colorectal + Pelvic Floor Centre
Screening questions: general approach
“I’ve noticed that many people in your situation suffer with a problem that they feel embarrassed talking about”
“Do you mind if I ask you some personal questions that will help me determine if you also have the same trouble as lots of others?”
“Please don’t be embarrassed to tell me all about the problem….once I know all the details, we can start to improve the problem”
Sydney Colorectal + Pelvic Floor Centre
Screening: 3 simple questions: A.I.M
Anxious: “Are you ever anxious because you think you might lose control of bowel?”
In time: “Do your bowels sometimes start to empty before you get to the toilet?”
Mess: “Do you ever notice staining in your underwear from bowel leakage?”
Sydney Colorectal + Pelvic Floor Centre
Take Home Message 2
A.I.M to screen patients for leakage:
AnxiousIn-timeMess
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Hi-risk groups: C.O.N.T.R.O.L
Cognitive impairment
Older people
Neurological / spinal problems
Trauma – colorectal / anal surgery*
Runny stools – diarrhoea from any cause
Obstetric trauma*
Light bladder leakage / pelvic floor prolapse*
Sydney Colorectal + Pelvic Floor Centre
Sydney Colorectal + Pelvic Floor Centre
1st Degree 2nd Degree
3rd Degree 4th Degree
OASIS: Obstetric Anal Sphincter InjurieS
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OASIS: Obstetric Anal Sphincter InjurieS
35% occult anal sphincter injury
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HaemorrhoidectomyAnal Fistula
Anal surgery and bowel leakage (FI)
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Colorectal surgery and FI
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Urinary incontinence/prolapse and FI
21% of patients with urinary incontinence, prolapse or both had faecal incontinence
Sydney Colorectal + Pelvic Floor Centre
The role of the GP
Identification in primary care
Screening questions & ‘hi-risk’ patients - C.O.N.T.R.O.L
Assessment priorities
Red flags & Reversible factors
Treatment options in primary care
L.E.A.K.A.G.E
Chronic disease management plans
GPMPs & TCAs
Sydney Colorectal + Pelvic Floor Centre
Assessment priorities
Exclusion of organic pathologyRed Flag symptoms
Identify / treat reversible factorsGastrointestinal / extra-gastrointestinal
Symptom assessment / impact on QoLTypes of incontinence / impact on daily activities,
function, interaction
Sydney Colorectal + Pelvic Floor Centre
Red flags ABCD
A – age
>60yrs: ‘B’ OR ‘C’; >40yrs: ‘B’ AND ‘C’
B – bleeding PR
Typically >6/52 WITHOUT anal symptoms
C – change in bowel habit
Typically to loose, frequent stools
D – deficiency
Unexplained Fe deficiency anaemia
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Reversible factors
GI
constipation / faecal loading – FIBRE / FLUID
diarrhoea (e.g. infective, IBD, IBS) - Loperamide
rectal prolapse or third-degree haemorrhoids
ExtraGI
acute disc prolapse/cauda equina syndrome
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Assessment priorities: summary
‘Faecal incontinence is a symptom nota diagnosis
It is important to exclude / Rx other serious / benign GI / non-GI conditions’
Sydney Colorectal + Pelvic Floor Centre
The role of the GP
Identification in primary care
Screening questions & ‘hi-risk’ patients - C.O.N.T.R.O.L
Assessment priorities
Red flags & Reversible factors
Treatment options in primary care
L.E.A.K.A.G.E
Chronic disease management plans
GPMPs & TCAs
Sydney Colorectal + Pelvic Floor Centre
Treatment Options: L.E.A.K.A.G.E
Loperamide (Gastro-Stop 2mg PRN max 16mg daily)*
Exercise
Assessment of bowel habit / stool consistency* - FIBRE
Kegal exercises*
Assessment of diet*
Garment protection*
Encourage weight loss
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Loperamide
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Assessment of stool consistency:fibre demystified
Sydney Colorectal + Pelvic Floor Centre
Assessment of stool consistency:fibre demystified
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Fibre: insoluble and soluble
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Kegel Exercises
8 second lift / squeeze
8x repetitions
8 weeks
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Assessment of diet: food allergens
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Garment protection: anal plugs
Peristeen plugs: coloplast.com.au
Sydney Colorectal + Pelvic Floor Centre
Take Home Message 3
‘Significant improvements can be made to patients’ symptoms with simple interventions’
‘L.E.A.K.A.G.E’
Sydney Colorectal + Pelvic Floor Centre
The role of the GP
Identification in primary care
Screening questions & ‘hi-risk’ patients - C.O.N.T.R.O.L
Assessment priorities
Red flags & Reversible factors
Treatment options in primary care
L.E.A.K.A.G.E
Chronic disease management plans
GPMPs & TCAs
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Sydney Colorectal + Pelvic Floor Centre
Chronic disease management plan
Preparation of a GPMP – 721Initial assessment, goal setting, treatment
Review of a GPMP – 732
At 3 months undertake review
Coordination preparation/review of TCAs: 723/732GP, physiotherapist, dietician, psychologist
Sydney Colorectal + Pelvic Floor Centre
Chronic disease management plan
‘Faecal incontinence is a chronic disease. Patients have MDT needs’
‘GPMP’
Sydney Colorectal + Pelvic Floor Centre
Overview
The role of the GP: GPMP
Identification, assessment & treatment of sufferers
When symptoms persist – what next?
The multidisciplinary team - when & where to refer
Latest Treatments – Sacral Neuromodulation
What every GP needs to know
Sydney Colorectal + Pelvic Floor Centre
Specialist referral
Troublesome symptoms
Impact on QoL
Failed simple measures
Long-term compliance is problematic
High risk
Post partum (traumatic); perianal pathology / surgery
Sydney Colorectal + Pelvic Floor Centre
The multidisciplinary team
Complex patient needs
Dietary; psychological; physiotherapist; medical; surgical
Evolving technology for physiological assessment
Hi-resolution anorectal manometry; 3D endoanal US
Rapidly expanding spectrum of interventions
Biofeedback; PTNS; SNS; ESGN
Sydney Colorectal + Pelvic Floor Centre
Anorectal physiology
“Bowel urodynamics”
Provides objective physiological measures of function
Anorectal manometry
Canal pressures; rectal sensation; rectoanal reflexes &coordination
Endoanal ultrasound
Morphological information about the internal / externalsphincters
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Sydney Colorectal + Pelvic Floor Centre
Conventional anorectal manometry
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Conventional anorectal manometry
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Hi-Resolution Manometry Hi-Resolution Manometry
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3D endoanal US
Sydney Colorectal + Pelvic Floor Centre
ineffective anal squeeze pressures
normalrestingtone
minimal squeeze increment generated
Urge faecal incontience / external sphincter weakness
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Sydney Colorectal + Pelvic Floor Centre
2 sessions of biofeedback – now impressive squeeze pressures
normalrestingtone
strong, well-sustained (30 sec) squeeze
increment generated
Following physiotherapy
Sydney Colorectal + Pelvic Floor Centre
Overview
The role of the GP: GPMP
Identification, assessment & treatment of sufferers
When symptoms persist – what next?
The multidisciplinary team - when & where to refer
Latest Treatments – Sacral Neuromodulation
What every GP needs to know
Sydney Colorectal + Pelvic Floor Centre
Sacral Neuromodulation
Terminology
Sacral Nerve Stimulation Sacral Neuromodulation
Aim
Recruitment of residual function of a functionallydeficient anorectum by modulation of its nerve supply
Principle
Impacts upon neural interfaces to produce benefit
Sydney Colorectal + Pelvic Floor Centre
More than 100,000 patients worldwide have received SNS
SNM for Bowel Control
‘Like a cardiac pacemaker for the nerves of the bowel’
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SNM: surgical phenomenon
Neuromodulation-fast growing area of medicine
20 years experience
Procedure: bridging the divideConservative & potentially hazardous surgery .
Evidence-based Medicine
RCT; unprecedented attentive / prolonged FU
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SNM: patient info
The procedure: try before you buy
day-case; minor procedure; 2 stage (test / permanent implant)
Safety
“Zero” mortality Low morbidity; day-case; minor procedure
Effective
80% success rates – preserved in long-term
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Test Implant
SNM: try before you buy
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S 1
S 2
S 3
S 4
The procedure: S2-4
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SNM – XR position
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SNM: patient info
The procedure: try before you buy
day-case; minor procedure; 2 stage (test / permanent implant)
Safety
“Zero” mortality Low morbidity; day-case; minor procedure
Effective
80% success rates – preserved in long-term
Sydney Colorectal + Pelvic Floor Centre
SNM: outcomes
50% reduction
100% continent
Short-term (12/12) 79 (69-83) 42 (21-66)
Medium-term (24/12) 80 (65-88) 40 (5-74)
Long-term (56/12) 84 (75-100) 35 (4-52)
Sydney Colorectal + Pelvic Floor Centre
Take Home Message 4
‘Persistent leakage-refer to an expert
SNS – minor, safe, success in 8/10’
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Sydney Colorectal + Pelvic Floor Centre
Summary: take home messages
Incontinence is a COMMON, debilitating condition
FI: 1 in 8 YOUR pts; 2 of 3 WON’T admit; coexist with UI
ACTIVELY screen patients for leakage / target ‘hi-risk’ groups
A.I.M & C.O.N.T.R.O.L
SIMPLE interventions lead to SIGNIFICANT improvements
L.E.A.K.A.G.E
Patients DON’T have to live with incontinence
Specialist MDT is crucial; safe treatments with high success rates
Sydney Colorectal + Pelvic Floor Centre
Further information
web: www.bowelproblems.solutions
email: [email protected]