conservative treatment of faecal incontinence jim hill manchester royal infirmary
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Conservative treatment of Conservative treatment of faecal incontinencefaecal incontinence
Jim HillJim Hill
Manchester Royal InfirmaryManchester Royal Infirmary
Why should we be interested?Why should we be interested?
Common problemCommon problem
Requires understanding ARPRequires understanding ARP
Results of surgery frequently imperfectResults of surgery frequently imperfect
Post operative – anterior resection, ileo Post operative – anterior resection, ileo anal pouch anal pouch
Can be iatrogenicCan be iatrogenic
Impacts on Quality of lifeImpacts on Quality of life
OptionsOptions
Drug treatmentDrug treatment
BiofeedbackBiofeedback
Rectal irrigationRectal irrigation
Anal plugsAnal plugs
Internal sphincter bulking agentsInternal sphincter bulking agents
Drug treatmentDrug treatment
Little evidence to guide clinicians in the Little evidence to guide clinicians in the selection of drug therapiesselection of drug therapies
Focus of most of the trials has been on the Focus of most of the trials has been on the treatment of diarrhoeatreatment of diarrhoea
Anti-diarrhoeal drug versus placebo Anti-diarrhoeal drug versus placebo or no active treatment – four or no active treatment – four
randomised trialsrandomised trialsFewer bowel actions (4)Fewer bowel actions (4)More full continence (3)More full continence (3)Lower stool weights (2), incontinence Lower stool weights (2), incontinence scores (1) scores (1) Fewer episodes faecal incontinence (1), Fewer episodes faecal incontinence (1), faecal urgency (1), unformed stools (1), faecal urgency (1), unformed stools (1), pads (1)pads (1)Longer gut transit times (1)Longer gut transit times (1)Increase side effects (2)Increase side effects (2)
LoperamideLoperamide
ReducesReduces– stool weightstool weight– small bowel motilitysmall bowel motility– sensitivity of the rectoanal inhibitory reflexsensitivity of the rectoanal inhibitory reflex
Slight increase in resting anal pressureSlight increase in resting anal pressureInitially small doses (2-4mg) titrated Initially small doses (2-4mg) titrated Combination with codeine phosphateCombination with codeine phosphateCo-phenotrope (diphenoxylate with Co-phenotrope (diphenoxylate with atropine) high incidence of side effectsatropine) high incidence of side effects
Drugs enhancing anal sphincter Drugs enhancing anal sphincter tone versus placebo – four tone versus placebo – four
randomised trialsrandomised trials
Passive incontinence Passive incontinence
Phenylepinephrine improved maximum Phenylepinephrine improved maximum anal resting tone and continence anal resting tone and continence symptomssymptoms
30-40% > 10-20%30-40% > 10-20%
Localised dermatitis, stinging/burningLocalised dermatitis, stinging/burning
Criticisms of drug trialsCriticisms of drug trials
Long term benefits not assessedLong term benefits not assessed
Not analysed on an intention to treat basisNot analysed on an intention to treat basis
Blind outcome assessors to treatmentBlind outcome assessors to treatment
Relevant primary outcome measures (no. cured Relevant primary outcome measures (no. cured or improved)or improved)
If cross over data at end of first arm treatment, If cross over data at end of first arm treatment, within individual comparison of treatment and within individual comparison of treatment and include adequate washout periodinclude adequate washout period
Follow CONSORT guidelinesFollow CONSORT guidelines
Biofeedback - principlesBiofeedback - principles
Improve contraction of Improve contraction of the striated muscles of the striated muscles of the pelvic floor (strength the pelvic floor (strength training)training)
Enhance the ability to Enhance the ability to perceive and respond to perceive and respond to rectal distension (sensory rectal distension (sensory training) training)
To combine sensory and To combine sensory and strength training strength training (coordination training)(coordination training)
Randomised controlled trial of Randomised controlled trial of biofeedback in faecal incontinence – biofeedback in faecal incontinence –
Norton et al Gastroenterology Nov ‘03Norton et al Gastroenterology Nov ‘03
1)1) Advice – diet, fluids, techniques to Advice – diet, fluids, techniques to improve evacuation, bowel training improve evacuation, bowel training programme, anti-diarrhoeal medicationprogramme, anti-diarrhoeal medication
2)2) Anal sphincter exercises taughtAnal sphincter exercises taught
3)3) Computerised biofeedback – sensory Computerised biofeedback – sensory and strength trainingand strength training
4)4) Home biofeedback deviceHome biofeedback device
Outcome measuresOutcome measures
Patients own view of effectivenessPatients own view of effectiveness
Change in bowel symptomsChange in bowel symptoms
Change in continence scoreChange in continence score
QOL assessmentQOL assessment
ARPSARPS
ResultsResults
All groups significant improvement in All groups significant improvement in outcome measures (67% improved outcome measures (67% improved overall)overall)
No significant difference between four No significant difference between four groupsgroups
Only age and BMI predictors of outcomeOnly age and BMI predictors of outcome
Sphincter pressures improved in all groupsSphincter pressures improved in all groups
Continence scores median 15 to 13Continence scores median 15 to 13
Conclusions from Norton paperConclusions from Norton paper
Majority of patients with symptoms of faecal Majority of patients with symptoms of faecal incontinence may be subjectively improved by incontinence may be subjectively improved by nurse-led managementnurse-led management
Anal sphincter exercises, computer assisted Anal sphincter exercises, computer assisted biofeedback and home biofeedback did not biofeedback and home biofeedback did not enhance treatmentenhance treatment
Patients with sphincter disruption not excludedPatients with sphincter disruption not excluded
Patients should be offered the choice of Patients should be offered the choice of conservative managementconservative management
Colonic irrigationColonic irrigation
Colonic irrigation-Kessel et al Colonic irrigation-Kessel et al Dis Colon Rectum 1997Dis Colon Rectum 1997
Faecal soiling and faecal incontinence Faecal soiling and faecal incontinence 500mls – 1 litre normal saline 5-10 mins 500mls – 1 litre normal saline 5-10 mins after first stoolafter first stool10-90 mins for washouts10-90 mins for washouts32 patients, 22 still performing washouts at 32 patients, 22 still performing washouts at 18 months18 monthsResults soiling (79%) > faecal Results soiling (79%) > faecal incontinence (38%)incontinence (38%)
Colonic irrigation physiologyColonic irrigation physiology
Irrigation fluid reaches on average just Irrigation fluid reaches on average just beyond the right colic flexurebeyond the right colic flexure
Antegrade segmental transport induced in Antegrade segmental transport induced in all colonic segmentsall colonic segments
Almost complete emptying of the Almost complete emptying of the rectosigmoid and descending colonrectosigmoid and descending colon
Conveen plugsConveen plugs
Anal continence plug – Mortenson Anal continence plug – Mortenson & Humpreys Lancet 1991& Humpreys Lancet 1991
10 patients – 10 patients – incontinent liquid/solidincontinent liquid/solid
1 withdrew1 withdrew
Worn 12 hoursWorn 12 hours
No incontinence in No incontinence in 82% during time plug 82% during time plug in placein place
11 plugs/week11 plugs/week
Internal sphincter bulking agentsInternal sphincter bulking agents
No randomised No randomised trials/no control trials/no control groupsgroups
Submucosal or Submucosal or intersphincteric planeintersphincteric plane
Symptomatic Symptomatic improvementimprovement
Variable effect on Variable effect on ARPSARPS
Bulking agentsBulking agents
Essential supportEssential support
ConclusionsConclusions
Almost never harmfulAlmost never harmful
Almost all patients appreciate the effort Almost all patients appreciate the effort
Specialist nurse support essentialSpecialist nurse support essential
Worthwhile maximising medical therapy Worthwhile maximising medical therapy prior to any surgeryprior to any surgery
IndicationsIndications
Post surgery Post surgery – Sphincter repairSphincter repair– SphincterotomySphincterotomy– Anterior resection and pouch surgeryAnterior resection and pouch surgery
Idiopathic faecal incontinenceIdiopathic faecal incontinence
Biofeedback trialsBiofeedback trials
Reported success rates 60-90%Reported success rates 60-90%
Absence of well designed randomised Absence of well designed randomised controlled trialscontrolled trials
Do not allow a reliable assessment which Do not allow a reliable assessment which elements of biofeedback therapy have a elements of biofeedback therapy have a therapeutic effecttherapeutic effect
Biofeedback Biofeedback
Norton and Kamm; Gastroenterology 2003Norton and Kamm; Gastroenterology 2003171 patients171 patientsBiofeedback vs standard careBiofeedback vs standard careDiary, symptom questionnaire, continence Diary, symptom questionnaire, continence score, QOL, psychological status, anal score, QOL, psychological status, anal manometrymanometryImproved 53% biofeedback, 54 % Improved 53% biofeedback, 54 % standard carestandard careResults largely maintained at 1 year Results largely maintained at 1 year