Investigations for faecal incontinence and constipation

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Investigations for faecal incontinence and
constipation

• Anorectal physiology and endoanal ultrasound

Caroline Short
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Anorectal Physiology Indications

• Faecal incontinence passive or urge
• Faecal urgency
• Constipation
• Assessment of sphincter prior to colostomy
  reversal

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Role of Anorectal Physiology

• A technique that allows the measurement of
  pressure with time
• Assessment of anal sphincter resting and squeeze
  pressure
• Assessment of RAIR
• Assessment of rectal sensation

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Pre Test Anorectal Physiology

• No prep necessary
• Empty bowels if possible
• Calibrate equipment

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Anorectal Physiology Procedure

• Take history, explain procedure, patient removes
  clothes from waist down
• Ask patient to lie on right hand side, position
  well lubricated solid state catheter (4 or 5
  transducers)
• Usually well tolerated
• Locate best high pressure zone
• Cough and squeeze measurements

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Rectal Distension Study

• Insert rectal balloon alongside catheter
• Inflate until first sensation
• Note RAIR
• Inflate until maximum tolerated
• Sterilise catheter using perisafe

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Pitfalls

• Low resting pressure difficult to detect RAIR,
  probe may slip out
• Cyclic waves difficult to obtain accurate
  pressure measurement
• Loaded rectum

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Analysing Graph

• Resting pressure
• Squeeze pressure peak plateau and duration
• Cough pressure
• HPZ length
• First aware volume
• Maximum tolerated volume
• RAIR

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Calibration check
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Rest and squeeze pressures
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RAIR
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Normal values

• Resting pressure male 50 120 mm Hg
• Resting pressure female 30 100 mm Hg
• Squeeze pressure male 140 400 mm Hg
• Squeeze pressure female 75 250 mm Hg
• Volume first aware 10 30 ml
• Maximum tolerated volume 100 300 ml

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EAUS Indications

• Faecal incontinence passive or urge
• Faecal urgency
• Post op assessment of sphincter following third
  degree tear
• Anal pain
• Fistula

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Role of EAUS

• Assessment of internal and external sphincters
• Detects defects which may be surgically repaired.
• Provides information to aid decisions

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EAUS Procedure

• Take history, explain procedure, obtain verbal
  consent
• Patient removes clothes from waist down
• Position covered probe in rectum
• Gradually withdraw probe
• Take images high, mid and low anal canal
• Take 3D images

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Female, high canal
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Female, mid canal
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Female, low canal
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EAS overlap repair
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EAS defect mid canal
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IAS defect previous stretch
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IAS defect
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Defect in IAS and EAS
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EAS defect
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Rectal prolapse
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Conclusion

• Since the 1960s anorectal manometry has played a
  major role in the physiological investigation of
  anorectal functional disorders. It is a simple
  and minimally invasive procedure, usually well
  tolerated.
• Along with 3D U/S imaging we can provide a useful
  tool to aid diagnosis.