Mrs PK; 56 yrs; Married; 2 children Faecal Incontinence: Assessment and Management Professor Marc A Gladman MBBS DFFP PhD MRCOG FRCS (UK) FRACS Professor of Colorectal Surgery >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 Working for the Federal Government in Canberra Dramatic impact on work/social/psychological well-being No other bowel problems Para 2 x VD - #1 forceps with tear Back injury 15 years ago microdiscectomy What is incontinence? Urinary Incontinence Any accidental or involuntary loss from the bladder or bowels Faecal incontinence (FI): bowel leakage How common is bowel leakage? Involuntary or uncontrolled passage of bowel motion, faeces or wind from the bowel. 1
Australian Health Survey 2011-13 FI: extent of the problem Diabetes Mellitus 4.0% Osteoporosis 3.4% Cancer 1.6% 9% 12% reported FI - half moderate/severe FI: extent of the problem FI FI afflicts more adults than DM (4.0%), osteoporosis (3.4%) and cancer (1.6%) Stigmatisation of FI Take Home Message 1 Bowel leakage affects 1 in 8 of your patients Two-thirds will NOT volunteer it. 2
Overview The role of the GP: GPMP Identification, assessment & treatment of sufferers When symptoms persist what next? The multidisciplinary team - when & where to refer 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 Latest Treatments Sacral Neuromodulation What every GP needs to know 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 Screening questions: general approach I ve noticed that many people in your situation have trouble 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 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? Take Home Message 2 A.I.M to screen patients for leakage: Anxious In-time Mess 3
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* OASIS: Obstetric Anal Sphincter InjurieS 1 st Degree 2 nd Degree 3 rd Degree 4 th Degree OASIS: Obstetric Anal Sphincter InjurieS 35% occult anal sphincter injury Anal surgery and bowel leakage (FI) Colorectal surgery and FI Anal Fistula Haemorrhoidectomy 4
Urinary incontinence/prolapse and FI 21% of patients with urinary incontinence, prolapse or both had faecal incontinence 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 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 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 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 Treatment Options: L.E.A.K.A.G.E Loperamide (Gastro-Stop 2mg PRN max 16mg daily)* Exercise Assessment of diet* Kegal exercises* Assessment of bowel habit / stool consistency* - FIBRE Garment protection* Encourage weight loss 5
Loperamide Assessment of diet: food allergens Kegel Exercises 8 second lift / squeeze Assessment of stool consistency: fibre demystified 8 seconds rest 8x repetitions 8 weeks Assessment of stool consistency: fibre demystified Fibre: insoluble and soluble 6
Garment protection: anal plugs Take Home Message 3 Significant improvements can be made to patients symptoms with simple interventions L.E.A.K.A.G.E Peristeen plugs: coloplast.com.au 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 Chronic disease management plan Preparation of a GPMP 721 Initial assessment, goal setting, treatment Review of a GPMP 732 At 3 months undertake review Coordination preparation/review of TCAs: 723/732 GP, physiotherapist, dietician, psychologist Chronic disease management plan Faecal incontinence is a chronic disease. Patients have MDT needs GPMP 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 7
Specialist referral Troublesome symptoms Impact on QoL Failed simple measures Long-term compliance is problematic High risk Post partum (traumatic); perianal pathology / surgery 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 / external sphincters Hi-Resolution Manometry 3D endoanal US Urge faecal incontience / external sphincter weakness Following biofeedback strong, well-sustained (30 sec) squeeze increment generated normal resting tone minimal squeeze increment generated normal resting tone ineffective anal squeeze pressures 2 sessions of biofeedback now impressive squeeze pressures 8
Overview The role of the GP: GPMP Identification, assessment & treatment of sufferers When symptoms persist what next? The multidisciplinary team - when & where to refer Sacral Neuromodulation Terminology Sacral Nerve Stimulation Sacral Neuromodulation Aim Recruitment of residual function of a functionally deficient anorectum by modulation of its nerve supply Latest Treatments Sacral Neuromodulation What every GP needs to know Principle Impacts upon neural interfaces to produce benefit SNM for Bowel Control Like a cardiac pacemaker for the nerves of the bowel More than 100,000 patients worldwide have received SNS SNM: surgical phenomenon Neuromodulation-fast growing area of medicine 20 years experience Procedure: bridging the divide Conservative & potentially hazardous surgery. Evidence-based Medicine RCT; unprecedented attentive / prolonged FU SNM: patient info SNM: try before you buy The procedure: try before you buy day-case; minor procedure; 2 stage (test / permanent implant) Test Implant Safety Zero mortality Low morbidity; day-case; minor procedure Effective 80% success rates preserved in long-term 9
The procedure: S2-4 SNM: patient info The procedure: try before you buy S 1 S 2 S 3 S 4 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 SNM: outcomes Take Home Message 4 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) Persistent leakage-refer to an expert SNS minor, safe, success in 8/10 Summary: take home messages Further information 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 web: www.bowelproblems.solutions email: prof@scopecentre.com.au Patients DON T have to live with incontinence Specialist MDT is crucial; safe treatments with high success rates 10