9 Incontinence and Defecation Disorders9 Incontinence and Defecation Disorders.pptVIP

Evaluation of Incontinence and Defecation Disorders Clues From The History Associated Diseases Activities that Precipitate Episodes Consistency of Stool Prior Warning or Absence of Sensation ?Associated Urinary Incontinence (40% have “double incontinence”) Know Disease Associations !!! Obstetrical Injury Idiopathic Previous Anal Surgery Diabetes Mellitus Proctitis Anorectal Trauma Radiation Injuries Neurologic Disorders Central Peripheral IBS Miscellaneous (inc. chronic straining at stool) Exam Clues – Possible Meaning Perianal dermatitis – bile salt seepage Perineal scarring – episiotomy/sphincterotomy Perineal descent - neuropathies Anal wink absent - ?spinal process Anal sensation absent – Qtip sharp/dull/mapping Anal canal deformity (post-repair/keyhole) Anorectal angle at rest (difficult to guesstimate) Resting pressure – lax/tight/focal defects Squeeze pressure – technique/fatigue/focal defects ?relaxation of PRM/EAS with straining ?rectocele/prolapse Anal Endosonography Endosonography - Normal Endosonography – S/P 4th degree tear EUS – Thin anterior EAS ?A Promising New Technique ANAL MRI External MRI Probe Dynamic Pelvic Floor MRI Defecography Defecography Pelvic Floor EMG Pelvic Floor EMG Pudendal Nerve Latency Pudendal Nerve Latency PNTML - prolonged Anorectal Manometry Anorectal Manometry A rigid probe for recording the rectal-anal inhibitory reflex. (From Schuster, MM, et al: Simultaneous manometric recording of the internal and external anal sphincter reflexes. Bull Johns Hopkins Hospital 116:79, 1965) Solid State Probe without Balloon Tip Evaluation of Incontinence Dyschezia Emphasize anatomy and physiology Inquire about possible diseases that may be contributing to or causing the symptoms Select appropriate testing to answer the questions of cause and what to do about it USE YOUR GOLD STANDARD FULLY! St.Mark’s Electrode Perfused multilumen probe for balloon reflex manometry. The balloon, positioned 10 to 15 cm above the anal ver