Transcript m62 2004JimHill

Conservative treatment of
faecal incontinence
Jim Hill
Manchester Royal Infirmary
Why should we be interested?
Common problem
Requires understanding ARP
Results of surgery frequently imperfect
Post operative – anterior resection, ileo
anal pouch
Can be iatrogenic
Impacts on Quality of life
Options
Drug treatment
Biofeedback
Rectal irrigation
Anal plugs
Internal sphincter bulking agents
Drug treatment
Little evidence to guide clinicians in the
selection of drug therapies
Focus of most of the trials has been on the
treatment of diarrhoea
Anti-diarrhoeal drug versus placebo
or no active treatment – four
randomised trials
Fewer bowel actions (4)
More full continence (3)
Lower stool weights (2), incontinence
scores (1)
Fewer episodes faecal incontinence (1),
faecal urgency (1), unformed stools (1),
pads (1)
Longer gut transit times (1)
Increase side effects (2)
Loperamide
Reduces
– stool weight
– small bowel motility
– sensitivity of the rectoanal inhibitory reflex
Slight increase in resting anal pressure
Initially small doses (2-4mg) titrated
Combination with codeine phosphate
Co-phenotrope (diphenoxylate with
atropine) high incidence of side effects
Drugs enhancing anal sphincter
tone versus placebo – four
randomised trials
Passive incontinence
Phenylepinephrine improved maximum
anal resting tone and continence
symptoms
30-40% > 10-20%
Localised dermatitis, stinging/burning
Criticisms of drug trials
Long term benefits not assessed
Not analysed on an intention to treat basis
Blind outcome assessors to treatment
Relevant primary outcome measures (no. cured
or improved)
If cross over data at end of first arm treatment,
within individual comparison of treatment and
include adequate washout period
Follow CONSORT guidelines
Biofeedback - principles
Improve contraction of
the striated muscles of
the pelvic floor (strength
training)
Enhance the ability to
perceive and respond to
rectal distension (sensory
training)
To combine sensory and
strength training
(coordination training)
Randomised controlled trial of
biofeedback in faecal incontinence –
Norton et al Gastroenterology Nov ‘03
1) Advice – diet, fluids, techniques to
improve evacuation, bowel training
programme, anti-diarrhoeal medication
2) Anal sphincter exercises taught
3) Computerised biofeedback – sensory
and strength training
4) Home biofeedback device
Outcome measures
Patients own view of effectiveness
Change in bowel symptoms
Change in continence score
QOL assessment
ARPS
Results
All groups significant improvement in
outcome measures (67% improved
overall)
No significant difference between four
groups
Only age and BMI predictors of outcome
Sphincter pressures improved in all groups
Continence scores median 15 to 13
Conclusions from Norton paper
Majority of patients with symptoms of faecal
incontinence may be subjectively improved by
nurse-led management
Anal sphincter exercises, computer assisted
biofeedback and home biofeedback did not
enhance treatment
Patients with sphincter disruption not excluded
Patients should be offered the choice of
conservative management
Colonic irrigation
Colonic irrigation-Kessel et al
Dis Colon Rectum 1997
Faecal soiling and faecal incontinence
500mls – 1 litre normal saline 5-10 mins
after first stool
10-90 mins for washouts
32 patients, 22 still performing washouts at
18 months
Results soiling (79%) > faecal
incontinence (38%)
Colonic irrigation physiology
Irrigation fluid reaches on average just
beyond the right colic flexure
Antegrade segmental transport induced in
all colonic segments
Almost complete emptying of the
rectosigmoid and descending colon
Conveen plugs
Anal continence plug – Mortenson
& Humpreys Lancet 1991
10 patients –
incontinent liquid/solid
1 withdrew
Worn 12 hours
No incontinence in
82% during time plug
in place
11 plugs/week
Internal sphincter bulking agents
No randomised
trials/no control
groups
Submucosal or
intersphincteric plane
Symptomatic
improvement
Variable effect on
ARPS
Bulking agents
Essential support
Conclusions
Almost never harmful
Almost all patients appreciate the effort
Specialist nurse support essential
Worthwhile maximising medical therapy
prior to any surgery
Indications
Post surgery
– Sphincter repair
– Sphincterotomy
– Anterior resection and pouch surgery
Idiopathic faecal incontinence
Biofeedback trials
Reported success rates 60-90%
Absence of well designed randomised
controlled trials
Do not allow a reliable assessment which
elements of biofeedback therapy have a
therapeutic effect
Biofeedback
Norton and Kamm; Gastroenterology 2003
171 patients
Biofeedback vs standard care
Diary, symptom questionnaire, continence
score, QOL, psychological status, anal
manometry
Improved 53% biofeedback, 54 %
standard care
Results largely maintained at 1 year