GYNECOLOGY

3.2 ANAL INCONTINENCE DIAGNOSIS AND MANAGEMENT

Doc Yvonne Nacis

o Innervated by direct branches from S3 and S4

TABLE OF CONTENTS
I. ANAL INCONTINENCE .................................................... 1
A. Introduction ............................................................. 1
B. Anorectal Disorders ............................................... 1
C. Fecal Incontinence ................................................. 2
II. RECTOVAGINAL FISTULAS ........................................... 3
A. Anovaginal Fistula .................................................. 4
III. KEY POINTS..................................................................... 4
I. ANAL INCONTINENCE
A. Introduction
NORMAL
• As a bolus of stool or gas passes from the sigmoid colon
to the rectal canal, receptors in the wall of the
puborectalis sense the distention of the rectum
• As long as the pressure in the anal canal is maintained
at a higher level than the rectal pressure, continence
is maintained
and, to a lesser degree, from the pudendal nerve
o Constant contraction of the puborectalis creates
a 90-degree angle between the rectum and anal
canal, known as the anorectal angle
BOTH THE PUBORECTALIS AND EAS
• Contain a majority of type I, or slow-twitch muscle
fibers, which are ideally suited to maintaining a constant
contraction or tone
• Each muscle group also contains a small proportion of
type II, or fast-twitch, fibers that allow for quick
responses to rapid increases in intra-abdominal
pressure
ANTERIOR RECTAL WALL
• Acts as a plug

ANAL CANAL PRESSURE

• Depends on a competent internal anal sphincter (IAS)
and external anal sphincter (EAS)

IAS
• A thickened continuation of the circular muscle of the
colon and provides 75% to 85% of the resting tone of
the anal canal, but there is a lower rectal sphincter RECTOANAL INHIBITORY REFLEX (RAIR)
pressure when the anal canal is distended with stool • IAS
o IAS, under autonomic control, maintains the o Has a reflex relaxation that allows for colonic
high pressure zone or continence zone contents to be sampled by the anal canal to
o Passive incontinence distinguish solid, liquid, and gas forms of fecal
material
EAS o After the sampling, the ias contracts and the
• Keeps the anal canal closed fecal material is pushed back into the rectum
o Absent in patients with hirschsprung
• Almost cylindrical as it encircles the anal canal
disease
o Provides the voluntary squeeze pressure
o Inhibited by chronic dilation of the anus with
▪ Prevents incontinence with increasing
fecal impaction and can lead to incontinence
rectal or abdominal pressure and is
related to urge incontinence • Rectal Normal Compliance
o Innervated by the hemorrhoidal branch of the o If the rectum has normal compliance and the
pudendal nerve from the S2-S4 nerve roots person chooses to defer defecation, the IAS and
o Contraction of the EAS, voluntarily or through EAS sphincters and puborectalis remain
spinal reflex, increases the anal canal pressure contracted until the appropriate time to eliminate
by 25%, but this tone cannot be maintained
indefinitely because these are fatigable, fast- B. Anorectal Disorders
twitch muscles DEFINITION
• Anal incontinence
PUBORECTALIS MUSCLE o General term that refers to loss of gas or fecal
• Third muscular component of the sphincter complex material via the anus
o Originates from the pubic bone on either side of o Inability to defer the elimination of stool or gas
the midline, passes beside the vagina and until there is a socially acceptable time and place
rectum, and fuses posteriorly behind the to do so
anorectal junction to the form the U-shaped sling • Fecal incontinence
that cradles the rectum while sending some o Inability to prevent loss of stool from the anus
fibers onto the walls of the anal canal until desired
o Maintains a constant muscle tone that is o Fecal soiling
directly proportional to the volume of the rectal • Accidental bowel leakage
content and pressure, and it relaxes at the time
of defecation
1
Transcriber: AhjuicyMD2024
INCIDENCE • Colonoscopy
• Common (Distressing BUT reluctant to discuss: o Any woman with chronic diarrhea to evaluate
embarrassment) for inflammatory bowel disease and infectious
• 9% to 16%, age: 47 and 55 years diarrhea
• 10% asymptomatic o Detects mucosal disease or neoplasia
• >30%: urinary incontinence with fecal incontinence effectively
known as dual incontinence o Acceptable bowel screening for any woman
• Second leading cause of nursing home placement older than 50 years
• Electromyography EMG
ETIOLOGY o Used for mapping the EAS defect and for
determining the presence and degree of
• Pregnancy and delivery: most common
neuropathy, denervation, and reinnervation
• Increases with age: postmenopausal women
o Evaluates the bioelectrical action potentials
generated by the depolarization of skeletal
C. Fecal Incontinence striated muscle
DEFINITION ▪ Consists of systematic examination of
• Inability to defer the elimination of stool spontaneous activity, recruitment
• Subdivided into three groups: patterns, and the waveform of the motor
o Fecal urge incontinence unit action potentials (MUAPs)
▪ Loss of fecal contents despite attempts to • Pudendal nerve terminal motor latency nerve
avoid defecation conduction studies
o Passive incontinence o Measure the time from stimulation of a nerve
▪ Involuntary discharge of feces without to a response in the muscle it innervates
awareness or sensation o Normal PNTML is 2.0 ± 0.2 milliseconds
o Fecal seepage o Most sensitive predictor of functional
▪ Most often defined as the involuntary outcome of overlapping EAS repairs
leakage of small amounts of stool • Dynamic cystoproctography or defecography
o used as an adjunct to physical examination in
PATHOPHYSIOLOGY patients with chronic constipation and pelvic
• Significantly affected by floor defects or hernias that may be contributing
o Stool inconsistency and volume to their fecal incontinence
o Colonic transit time • Magnetic resonance imaging of the anal sphincters
o Rectal compliance o Evaluate muscular and connective tissue
o Innervation of the pelvic floor and anal sphincter supports of the pelvis
o Interplay among the puborectalis muscle,
rectum, and anal sphincters

DIAGNOSTICS
• Endoanal Ultrasonography
o Poor squeeze anterior sphincter defect and
chronic third degree laceration of the EAS
o Delineate defects of the IAS and EAS. EAUS
VAGINAL DELIVERY
o Simplest and least expensive
o Most often informed management decisions • Mechanical disruption or separation of the IAS, EAS, or
o Best first-line test both
• Anal Manometry or Anal Sphincter Ultrasound • Damage to the muscle innervation by stretching or
o Baseline assessment to which post treatment crushing the pudendal and pelvic nerves
assessment or function can be compared • Most common
▪ Rectal sensation, anal canal pressures, • Increased with midline episiotomy, instrumented
and the RAIR delivery, vaginal delivery of larger infants, and
▪ Prior surgery to the anorectal canal or persistent occiput posterior
radiation therapy
✓ Normal values include an initial OTHER RISK FACTORS
sensation of 20 mL • Increasing maternal age, prolonged second stage
✓ Urge to defecate at 80 to 120 mL (longer than 2 hours), epidural anesthesia, and clinically
✓ Maximum tolerable capacity at diagnosed sphincter laceration at the time of delivery
200 to 250 mL • Diabetes mellitus
✓ The RAIR is a reflex response to
increased pressure in the rectum INCIDENCE
from gas or stool • 13% of primiparas
▪ Normal resting pressure: 60-80 mmHg
• 23% of multiparas
▪ Normal squeeze pressure: 120-180
mmHg
2
Transcriber: AhjuicyMD2024
PE o Loperamide
• Dove tail sign ▪ Antidiarrheal agent that slows small and
o Loss of anterior perineal folds in the EAS or large bowel peristalsis, thereby
chronic third-degree laceration increasing transit time
• Clitoral-anal or Bulbocavernosus reflex ▪ Appears more effective than
o Test innervation of the EAS diphenoxylate for fecal urgency– related
o Procedure incontinence
▪ Using a cotton swab, a gentle, quick o Amitriptyline
touch beside the clitoris over the ▪ Tricyclic antidepressant
bulbocavernosus muscle should elicit a ▪ Increases colonic transit time
contraction of the EAS o Hyoscyamine
▪ Intact ▪ Recommended for women with fecal
✓ Pudendal nerve afferents and incontinence after meals
rectal or external hemorrhoidal • Surgery
branch of the pudendal efferent o Sacral neuromodulation
nerves are functional o Repair of rectal prolapse
✓ Unlike men, who should always o Anal sphincteroplasty
exhibit this reflex, approximately o Radiofrequency treatment of the anal canal
10% of women lack this reflex o Injectable perianal bulking materials
naturally o Anal sphincter neuromuscular flaps
▪ Absent o Implantation of artificial sphincters
✓ With presence of fecal SECCA procedure, or Delivering temperature-controlled
incontinence, further neurologic radiofrequency anal radiofrequency waves to the anal canal
testing is indicated sphincter remodeling resulting in denatured collagen and
✓ Sensation in the S2-S4 change to tissue compliance potentially
dermatomes should be screened by narrowing the anal canal
by dull and pinprick discrimination Anterior Common surgical treatment for
Sphincteroplasty persistent anal incontinence after
when touching the perineum
obstetric anal sphincter lacerations
• Rectal examination
Sacral nerve ▪ Chronic fecal incontinence
o Assess resting (IAS function) and squeeze stimulation ▪ First-line surgical treatment of
(EAS) tones of the anal canal fecal incontinence
Neosphincters ▪ Gracilis
DIAGNOSTICS ▪ Artificial Silastic cuff
• Endoanal ultrasound
o Occult external anal sphincter disruption after
vaginal delivery determined: 11% to 35%
• Pudendal nerve conduction prolongation

TREATMENT
• Biofeedback
o 90% reduction in incontinence
o Rectal balloons
▪ “retrain” to perceive rectal distention
while squeezing external sphincter in
response to rectal distention

• Electrical Stimulation Therapy

o Improve fecal incontinence in patients with a
weakened pelvic floor who are unable to
contract their EAS or puborectalis on command
o Reserved for patients who are unable to respond
II. RECTOVAGINAL FISTULAS
to traditional biofeedback protocols
DEFINITION
o Most protocols recommend high-frequency
stimulation at a maximum tolerable stimulation • NOT a true source of fecal incontinence
of 50 Hz for 15 to 20 minutes twice daily • Abnormal connection between the vagina and rectum
o Response to therapy is usually seen in 6 weeks,
with maximum improvement by 12 weeks ETIOLOGY
• Medications • Obstetric injuries: most common cause
o No specific medication is approved for fecal
incontinence except for antidiarrheal
medications
3
Transcriber: AhjuicyMD2024
INCIDENCE o Colostomy
• 0.1% of vaginal births ▪ Delay of 8 to 12 weeks to heal
o Martius fat pad graft
▪ To increase the vascular supply

III. KEY POINTS

• Estimates of fecal incontinence range from 11% to 15%
of community-dwelling women older than 64 years
• Over 30% of women reporting urinary incontinence also
report fecal incontinence, known as dual incontinence
• The IAS, under autonomic control, maintains the high-
pressure zone or continence zone and, along with the
EAS, keeps the anal canal closed
• The EAS provides the voluntary squeeze pressure that
prevents incontinence with increasing rectal or
abdominal pressure. The EAS is innervated by the
hemorrhoidal branch of the pudendal nerve from the
S2-S4 nerve roots
• A common cause of fecal incontinence is damage to the
anal sphincter at the time of vaginal delivery, with or
without neuronal injury. Prevention of these injuries is
critical
• The incidence of occult external anal sphincter
A. Anovaginal Fistula disruption after vaginal delivery determined by
DEFINITION endoanal ultrasound ranges from 11% to 35%. The
• Fistula occurring caudad or adjacent to the EAS chance of muscular injury is increased with midline
episiotomy, instrumented delivery, and vaginal delivery
ETIOLOGY of larger infant
• Obstetric injury • Approximately 1 in 10 women will develop some fecal
• Lower third of the vagina incontinence or fecal urgency after one vaginal delivery
• Sphincter defect in the EAS • At a tertiary colorectal referral clinic, a prospective study
showed that further evaluation, including radiologic and
SIGNS AND SYMPTOMS physiologic tests, altered the final diagnosis or the
• Depending on the size and location of the fistula, the cause of fecal incontinence in 19% of cases
woman may be almost asymptomatic • Biofeedback for patients with fecal incontinence shows
o Low small fistula a similar reduction in incontinence episodes after
▪ Complain of a small amount of flatus intense education with a nurse specialist on the
passing into her vagina subjects of bowel care, medications, and dietary and
o Large fistula fluid management. This highlights the importance of
▪ Formed stool coming through the vagina conservative management techniques
with every bowel movement, causing • Overlapping anterior anal sphincteroplasty provides
significant distress and hygiene problems symptomatic control of incontinence in 60% to 80% of
• Rectal bleeding patients initially, but long-term outcomes are not nearly
o Neoplastic process or post-pelvic radiation as successful

DIAGNOSTICS
REFERENCES
• Transnasal ultrasound or EMG
• Comprehensive gynecology 7th edition
o To map any defects prior to surgical treatment
• Colonoscopy
o Suspicion of inflammatory bowel disease
• Anoscopy or proctoscopy
• Barium enema – high fistulas
• Vaginography – dilute barium solution may help
identify a fistula

TREATMENT
• Opening the fistula tract, curetting the tract, and leaving
the tract open to heal secondarily
o Waiting time
▪ 3 months

4
Transcriber: AhjuicyMD2024