Fecal incontinence in the elderly
Introduction
Introduction Fecal incontinence or anal incontinence refers to defecation and deflation that are not controlled at least twice or more per day. It is a clinical condition with various pathophysiological basis caused by various reasons. symptom. The incidence of the elderly is about 1%, and older inpatients are more common, and more women than men.
Cause
Cause
Changes in stool characteristics:
Normal bowel movement requires proper anorectal sensation. The pelvic floor receptor is considered to be very important in detecting the presence of feces in the rectum. Fecal block and overflow fecal incontinence patients have reduced rectal sensation, traumatic and idiopathic In patients with incontinence (idiopathic fecal incontinence), there may be an abnormality of the anal canal, idiopathic fecal incontinence or neurogenic fecal incontinence, which is due to the control of the pelvic floor striated muscle and the external anal sphincter for progressive neurological damage and internal sphincter function. Caused by the decline. Such as irritable bowel syndrome, inflammatory bowel disease, infectious diarrhea, abuse of laxatives, malabsorption syndrome, short bowel syndrome, radiation enteritis.
Abnormal intestinal capacity or compliance:
Inflammatory bowel disease. Rectal volume defect. Rectal ischemia. Collagen vascular disease. Rectal tumors. External rectal compression. The cause of fecal incontinence in the elderly may be due to fecal blockage, abnormal rectal sensation, decreased anal sphincter pressure, neuromuscular dysfunction, dementia, iatrogenic and so on.
Rectal sensation abnormality:
Nervous system lesions. Overflow incontinence.
Sphincter or pelvic floor dysfunction:
Sphincter anatomy defect. The pelvic floor muscles lose their innervation. Congenital anomalies.
Pathogenesis
Normal defecation activity is a random activity of conditioned reflex under neuroendocrine regulation. It is a complex physiological process involving multiple systems. Feces or gas in the colon, after the involuntary movement of colonic rhythmic contraction and gastric colon reflex reaches the lower rectum. Stimulate the rectal wall baroreceptor. When the intracavity pressure reaches a certain threshold, the sympathetic nerve is excited, the rectum is dilated, the internal sphincter is contracted, and the anal crypt is stimulated to produce a sensation. This impulse is along the visceral afferent nerve sacral parasympathetic nerve into the lumbar medulla. The defecation center is re-introduced into the sensory and motor areas of the cerebral cortex. When the cerebral cortex is relieved of defecation, the external sphincter and the puborectalis muscle are relaxed, and defecation activity can occur.
The mechanism of fecal incontinence is not fully understood. The control of normal bowel movement depends on many factors: the function of the brain, the volume and consistency of the feces, the transmission of the colon, the expansion of the rectum, the function of the anal sphincter, and the sensitivity of the anorectum. And anorectal reflex, etc., any one or more of these factors may cause fecal incontinence.
Examine
an examination
Related inspection
Colonoscopy blood electrolyte examination
Partial inspection
Anal examination can be used to understand the presence or absence of local factors leading to fecal incontinence.
(1) Visual inspection: pay attention to the presence or absence of fecal contamination, ulcers, eczema, skin scars, mucosal prolapse, anal expansion and so on.
(2) refers to the diagnosis: attention to anal sphincter contractility, anorectal ring tension and so on.
(3) Endoscopy: Observe the color of the rectal mucosa, with or without ulcers, inflammation, bleeding, tumors, stenosis and anal fistula.
2. Laboratory examination
The function of the anorectal has a complex mechanism that includes many different factors that allow defecation and maintenance of self-control at any time. Therefore, a special examination can test one aspect of this mechanism, and clinical evaluation must be considered based on various examination results. Common diagnostic tests for evaluating pelvic floor and sphincter function include:
(1) Anorectal manometry: including the resting pressure controlled by the internal anal sphincter, the maximum pressure when the external sphincter contracted freely, and the perceptual threshold of stimulation during diastole, and the anal resting pressure and maximum pressure decreased during fecal incontinence.
(2) Electromyography: It is an objective basis for reflecting the physiological activities of the pelvic floor muscles and sphincters, and understanding the location and extent of nerve and muscle injuries.
(3) Defecation angiography: The dynamic changes during defecation can be recorded, and the state of the puborectal muscle and the degree of injury can be estimated by the change of the rectal angle.
(4) Saline enema test: When sitting, 1500ml of normal saline was injected into the rectum, and the leakage amount and maximum retention amount were recorded to understand the self-control ability of defecation, and the retention amount decreased or zero when the stool was incontinence.
(5) Anal canal ultrasound map: can accurately determine the location and asymmetry of the anal sphincter defect, measuring the thickness of the internal sphincter.
Stool bacteriological examination, looking for pathogens.
Abdominal plain film, barium enema, colonoscopy, and finding the cause of fecal incontinence can help.
Diagnosis
Differential diagnosis
diagnosis
Careful interrogation and physical examination can identify the cause of most fecal incontinence, pre-treatment radiology and physiology can confirm the diagnosis, related gastrointestinal dysfunction and detection of anal sphincter defects can provide objective basic information.
1. Consultation
50% of patients with fecal incontinence do not take the initiative to complain of symptoms. Unless asked in detail, it is an art to ask about medical history. When a patient visits, it is the responsibility of the doctor to encourage the patient to elaborate the medical history and guide or directly ask about the situation.
(1) Medical history: to understand whether there are surgery, birth injury, history of trauma, course of disease and treatment.
(2) Symptoms:
1 self-control ability of defecation, whether it is inconvenient, the number of stools per day, self-care conditions;
2 anorectal symptoms, such as abnormal urination, spinal condition, intelligence, mental and mental status.
Differential diagnosis
Clinically, it must be differentiated from diarrhea caused by intestinal inflammation, ulcerative colitis, proctitis, and anal fistula.
