In this episode of PodMD, Colorectal & General Surgeon Dr David Lam will be discussing the topic of faecal incontinence, including what faecal incontinence is, the causes of faecal incontinence, the types of treatment available, any warning signs to look out for, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr David Lam.
David is a Colorectal & General Surgeon based in Melbourne. He is passionate about all areas of both colorectal and general surgery but has particular expertise in colorectal pelvic floor disorders.
David completed his medical degree with honours at the University of Melbourne in 2007 and qualified as a General Surgeon in 2016. He subsequently completed four years of Colorectal Surgery subspecialty training, 3 in Australia and 1 in Oxford, United Kingdom. Whilst at Oxford, he worked in the internationally renowned Pelvic Floor unit.
David holds appointments in Colorectal Surgery at Austin Health, Pelvic Floor Surgery at The Women’s Hospital Melbourne, and General Surgery at Eastern Health. His private practice is based in the Eastern suburbs of Melbourne.
Today, we’ll be discussing the topic of Faecal Incontinence.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
David, thanks for talking with us on Pod MD today.
David: Thank you for having me.
The topic of today’s discussion is Faecal Incontinence. David, Can you describe for our listeners what Faecal Incontinence is?
David: Yeah, so I think there’s a very simple definition. I guess it can be defined as the inability to control the passage of faeces or flatus from the anus. It’s a very common condition. Australian data shows that it can affect, you know, up to 12% of the older population. And I think this is actually probably lower than what is the actual case. There’s significant underreporting because of either cultural or emotional barriers. And the same study shows that it’s not just females. In this study, about 2/3 of females, but that’s, you know, 1/3 of males who have this condition as well.
How would a patient with Faecal Incontinence typically present?
David: So there’s two main sets of symptoms. The first is faecal urgency and this is this describes an ability to hang on to the stools, so normal people should be able to hold onto their stools for 15 minutes once they have a sensation, and so the people with faecal urgency will have the sensation that they want to go to the toilet but they feel like can’t make it to the toilet in time and these are the patients who are always looking for a toilet when they go out.
The 2nd symptom is passive incontinence and that describes an involuntary loss of faeces, that is, they have no price sensation. The first thing they notice is that they’ve soiled themselves, and this can often be when they do physical activity such as jogging. Or it can be they’ve used their bowels think that they’re completely empty and then a couple of minutes later, they noticed that they’ve had an accident.
These symptoms can be quite severe and when they are, they can really be disabling, and now I have had patients who are trapped at home, even crippled by anxiety because of their faecal incontinence.
What causes faecal incontinence?
David: Defecation is a complex mechanism that involves an interplay between many factors, but one way to think about it would be an anatomical perspective. And from that you would need healthy sphincters, a healthy rectum and healthy nerves. Sphincters firstly, there’s an internal sphincter which is responsible for passive tone, and the external sphincter which is more under voluntary control, which gives an extra squeeze.
When you have a disruption of the sphincters then you may end up with feacal incontinence and that may occur due to obstetric injury that may occur due to sphincter injury from a hemorrhoid procedure or a fistula operation, and can you be due to degeneration with older age.
You need a compliant healthy rectum to be able to store the faeces and so in in conditions such as inflammatory bowel disease where you have a non-compliant rectumand also loose stools or if you’ve had part of the rectum removed for example from surgery, from a rectal cancer or if you have a rectal or if you actually have a rectal cancer or rectal prolapse this can cause loss of control of defecation as well.
And finally, there’s somatic nerves, as well as autonomic nerves that control defecation, and these can be affected by conditions such as diabetes with the autonomic dysregulation, as well as strokes, Parkinson’s disease and multiple sclerosis, just to name a few.
What are the treatment options?
David: So when I see a patient who has faecal incontinence, the first step is to perform a thorough assessment to delineate the cause is as we described above, and often times the causes may be multifactorial, so I would perform a history to characterise their incontinence, assess their stool, consistency and also assessment of severity and how it affects their quality of life.
I would then perform a physical examination to have a look at their perianal skin. Do a digital rectal examination to assess their sphincters clinically, as well as to make sure that there’s no mass there. I may also do a rigid sigmoidoscopy in the rooms. In terms of investigations, the first step would be to go and exclude any rectal conditions are with a direct viewing and that maybe through a flexible sigmoidoscopy or a colonoscopy. A lot of my patients will then undergo dedicated anorectal physiology testing and what this involves is a combination of an endoanal ultrasound to assess sphincter integrity.Analrectal manometry which can measure their sphincters pressures at rest as well as when they squeeze as well as assess their rectal compliance and finally our pudendal nerve testing.
Once I performed an assessment, then I can tailor the treatment to the patient. Treatment broadly can be classified into conservative and surgical approaches. Conservative approaches aim to improve the stool consistency to reduce the frequency of their faecal incontinence episodes and the 2nd mainstay of Conservative management is pelvic floor physiotherapy, and that includes dedicated pelvic floor exercises to improve their sphincter function, as well as bio feedback to improve their defecation dynamics.
Traditionally, the role of surgery for faecal incontinence has been quite limited. If patients have an obvious sphincter defect on their annual ultrasound, they might be a candidate for a sphincter repair. For patients who have a lot of passive leaking due to a gaping anus there is a role for a new injectables to bulk up the annual canal and always colostomy, to divert the faeces has been a really a last resort treatment for faecal incontinence.
Have there been any developments in treatment in the last years or are there any in trials or development now?
David: Yeah, so sacral neuromodulation, which is also known as sacral nerve stimulation or SNS is has been a real game changer for the treatment of faecal incontinence. The first years of SNS came out in about 1995, but in Australia it’s had more widespread use in the last 10 years. What SNS involves is a thin lead with some electrodes at the end of it is placed at the S3 nerve root to stimulate the sacral nerve and what this does in, it modulates the afferent signals that affect rectal sensation, as well as the efferent signals which control the somatic and autonomic control of the sphincters.
The contribution of SNS into you know whether it’s more affluent or whether it’s more efferent, that is not entirely known, but we definitely know that it has both these components. Logistically how SMS works, it’s done in two stages. So there’s a test procedure initially for two weeks to determine whether it’s an effective treatment and if so, then we would go and proceed with a permanent implantation where the lead is connected to a battery, much like a pacemaker.
SNS has been shown to be really effective for those who have a test that works, then in terms of their permanent implantation, there’s probably an 85 to 90% effectiveness rate, and we define effective effectiveness as a more than 50% reduction in their incontinent episodes.
Over the last couple of years there’s been some modifications to SNS which makes it more attractive, for example smaller batteries as well as MRI compatibility which has been a problem in the past.
Are there any warning signs a GP or their patient can look out for?
David: Definitely, most patients are with faecal incontinence have been putting up with this problem for a long time, so these patients may not necessarily have any rectal pathology per say. However, there’s two groups of patients who need urgent referral. And these are either patients with new or rapid onset of their featuring consonant symptoms and the second group is those who have associated rectal symptoms such as pain or rectal bleeding. And the reason why these patients need urgent referral is that this is these are potential red flags for rectal malignancy.
What role does the GP play in the treatment of the condition?
David: GPs actually have a very integral role in the treatment and assessment of faecal incontinence. I think the first thing to note is that GPs often are the ones who detect the problem patients might find that their faecal incontinence is embarrassing, or they feel that nothing can be done about it because it’s just a part of getting older. And so they might not tell anybody. The first person they would tell is their GP.
Secondly, GPs have a very important role in giving advice regarding conservative management. We know that conservative management is effective in more than 50% of patients with faecal incontinence, so examples of what the GP can do is to give advice about dietary modification, for example avoiding certain foods that cause diarrhoea, such as diet, dairy or caffeine.
The patient may be started on some fibre supplementation and these can be just over the counter simple measures such as some metamucil or some normafibre or some psyllium husk. For patients who still have loose motions despite dietary modification and fibre supplementation, some low dose anti diarrheal medications such as loperamide can be useful, especially for those patients who just want a little bit more confidence to make sure that they don’t have any accidents, for example when they’re going out.
When should a GP refer?
David: We briefly discussed red flags before, but in reality any patient who wants help with their faecal incontinence should be referred. It’s important to note that despite this being oftentimes not a dangerous condition, it really does have a significant impact on patients’ quality of life and it’s amazing to see how patients, you know, just often with simple measures who can have a really vastly improved confidence to go out and either socialise or exercise and this reaps huge benefits for their overall health.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Faecal Incontinence.
David: Certainly. So the first one is to say that faecal incontinence is a very common condition and it’s underreported. So if you don’t ask, the patient won’t necessarily volunteer. Secondly, conservative management can really make a big difference and this is something that GPs can instigate even prior to a referral to a colorectal surgeon. And thirdly for patients whose who failed conservative management, sacral neuromodulation or SNS is the way of the future and has the capacity to benefit a whole lot of patients with faecal incontinence
Thanks for your time and the insights you’ve provided.
David: Thank you