Fecal incontinence
Introduction
Introduction Incontinence of the fetus, copracrasia refers to the inability of feces and gas to be controlled at will, and involuntarily flows out of the anus. It is a symptom of defecation dysfunction, also known as fecal incontinence. The incidence of anal incontinence is not high, but it is not uncommon. Although it does not directly threaten life, it causes physical and mental pain to the patient and seriously interferes with normal life and work.
Cause
Cause
Anal congenital malformation:
1. Nervous system developmental defects: congenital lumbosacral sacral bulging or spondylolisthesis may be associated with anal incontinence, the patient's external sphincter and puborectalis muscle lose normal innervation, have no contractile function, are in a state of relaxation, and because of the sensory and motor system All affected, the rectal mucosa lacks the sense of swelling when the feces are filled, can not cause the intention and initiate the defecation movement, the feces in the rectum are discharged at any time, such diseases are often accompanied by urinary incontinence.
2. Anorectal malformation: the anorectal itself and the pelvic structure are changed, and the higher the rectal blind end, the more obvious the change, the more complicated, the high blindness of the rectum is located above the basin, and the puborectalis muscle shortens, obviously The anterior superior displacement; the internal sphincter is absent or only in the primordial state; the external sphincter is mostly loose, filled with adipose tissue, and the muscle fibers are abnormally disordered. Some 225 anorectal malformations were followed up by the author, 80 cases (35.5%) There are different degrees of filth or incontinence. The higher the deformity position, the higher the incidence of incontinence. The cause is mainly related to the deformity accompanied by the defects of sensory and motor tissue structure, and also has obvious relationship with surgical injury and surgical errors. In the past, when treating high-level malformation abdominal abdomen anusplasty, the rectum did not pass the puborectal muscle ring, but fell behind it, anorectal malformation, especially high malformation with humeral deformity, and neurological deficits are not uncommon, according to Jiehioiiikhh Analysis, about 10% of postoperative anal incontinence belong to this cause, anal incontinence after middle and low deformity, the main cause is surgical injury, Infection and other factors, such as cloaca malformation, mainly for the rectal anal canal of the baby girl, urethra, vaginal acupuncture, and high incontinence infants often have fecal incontinence, congenital dementia, meningocele, multiple hard Fecal incontinence can occur in skin diseases and the like.
trauma:
As a result of trauma, the anorectal ring is damaged, causing the sphincter to lose its sphincter function and to incontinence, such as stab wounds, cuts, burns, frostbite and laceration (mainly for perineal tears during maternal delivery), and anal canal Injury of rectal surgery, such as anal fistula, hernia, rectal prolapse, rectal cancer, etc., damages the anal sphincter and causes incontinence.
Anorectal disease:
The most common are anorectal tumors; such as rectal cancer, anal canal cancer, Crohn's disease invading the anorectal rectum and involving the anal sphincter, or ulcerative colitis caused by long-term diarrhea causing anal canal, or rectal prolapse The anal relaxation caused by the anus and the severe scar of the perianal area affect the anal sphincter, which can cause fecal incontinence when the anus is insufficiency.
Nervous system lesions:
More common in brain trauma, brain tumors, cerebral infarction, spinal cord tumors, spinal tuberculosis, cauda equina injury, etc. can lead to fecal incontinence.
Pathogenesis
Pathophysiology
Defecation is a process in which multiple systems of the human body participate in coordination and uniformity. The feces reach the rectum. First, the rectum must have a certain compliance. The feces are accepted, and the normal is 250ml. After the rectal contents reach a certain amount, the rectal receptors are stimulated. Into the nerve fiber afferent center, and then through the efferent nerve fiber to the external sphincter and levator ani muscle, the central judgment conditions permit, at this time the external sphincter relaxation, increased intra-abdominal pressure to complete defecation, for some reason does not allow defecation, then The external sphincter compresses the internal sphincter by random contraction, and the internal sphincter reverse-reflexively inhibits rectal contraction, thereby rectal dilatation, volume enlargement, or pushing the feces back to the sigmoid colon by rectal peristalsis, which disappears freely. This external contraction of the external sphincter Stimulation of the internal sphincter reverse inhibition of rectal contraction is called random inhibition, defecation is a very complicated process, any link can be damaged can cause fecal incontinence, such as low compliance of the rectum can lead to serious increase in stool frequency, and even fecal incontinence , high compliance, can increase the rectal volume Patients with constipation, such as fecal incontinence, as well as abnormal rectal receptor inhibition reduce the arbitrariness may also occur, or damage to the external sphincter fecal incontinence may occur, in short, many reasons for fecal incontinence, but also to be further explored.
2. Classification
(1) Classification by degree: according to different degrees of fecal incontinence: can be divided into complete and incomplete anal incontinence 2, 1 incomplete anal incontinence: rare stool and gas can not be controlled, but dry stool can be controlled, 2 complete Sexual anal incontinence: dry stools, loose stools and gas can not be controlled.
(2) Classification by nature: according to the nature of anal incontinence, divided into sensory incontinence and exercise incontinence, 1 sensory anal incontinence: normal morphology of the anal sphincter, but lack of sensation in the lower rectum, such as spinal cord or central nervous system dysfunction Anal incontinence; or anal incontinence caused by severe rectal compliance, severe stool frequency, 2 motor anal incontinence: mainly damage to the anorectal sphincter damage the anorectal ring, resulting in patients unable to control Anal incontinence caused by stool.
Examine
an examination
Related inspection
Rectal examination for rectal examination
1. Digital rectal examination: the examiner feels that the anus has no urgency and is in a relaxed state. When the ankle patient contracts the anus, the anal sphincter contraction is not obvious or has no contraction force; if the anus has a history of injury, it can be scarred and scarred. The patient can touch the side of the anal canal with a sense of contraction, while the other side has no sense of contraction, and pay attention to whether there is a lump in the anorectal rectum, tenderness, etc., after the finger exits the anus, observe whether the finger cuff has mucus and blood.
2. Endoscopy: observation of anorectal or colon with or without deformity, scar, anal canal and rectal mucosa with or without erosion, ulcer, rectal mucosa with or without congestion, edema, rectal polyps, rectal cancer and anorectal cancer.
3. Defecation angiography: through the dynamic observation of forced defecation, levator ani, resting, etc., to understand the function of the anal sphincter, such as the sputum filled into the rectum can be retained by the levator, indicating that the anal sphincter has certain functions; The tincture into the rectum involuntarily flows out, indicating anal incontinence.
4. Anorectal rectal pressure measurement: patients with fecal incontinence showed a decrease in pressure in the anorectal rectum, the frequency slowed or disappeared; the anal canal systolic blood pressure decreased; the rectal anal canal inhibition reflex disappeared, such as ulcerative colitis caused by fecal incontinence patients rectum Compliance is significantly reduced.
5. Rectal sensation measurement: a 4 cm × 6 cm large balloon with a catheter is placed in the rectum, and then water or air is injected into the balloon. The sensory threshold of the normal rectum is 45 ml ± 5 ml, such as neurological fecal incontinence. In patients, their rectal sensation threshold disappeared.
6. Balloon ejection test: If the rectum is dull, the normal volume can not cause bowel reflex, and the balloon cannot be discharged. This test can be used to judge whether the rectum feels normal or not, and can also judge the function of the anal sphincter, such as anal sphincter. The damage has no sphincter function, and the balloon can slide out of the anus by itself, or the balloon can be discharged after slightly increasing the abdominal pressure.
7. Pelvic EMG examination: This examination can understand the location and extent of the sphincter defect.
8. Anorectal ultrasonography: The anorectal ultrasound can clearly show the various levels of the anorectal rectum, the internal sphincter and its surrounding tissue structure, can assist in the diagnosis of anal incontinence, such as whether the internal sphincter is intact, Whether the sphincter has a defect, and the location and extent of the defect, the test can not only assist in the diagnosis, but also provide a basis for the choice of surgical incision.
Diagnosis
Differential diagnosis
diagnosis
The diagnosis of this disease can be established through the analysis of medical history, including the symptoms and the clinical analysis of the primary cause. The visual examination can be seen that there is abnormal surgery of the original anus or traumatic scar, and there is fecal contamination. The anal examination shows anal canal relaxation or The sphincter systolic function is poor, the clinical diagnosis can be established, the primary disease is in the nervous system and the colon, and it is established through the nervous system examination of barium enema and endoscopy. In recent years, there have been some new developments in the anorectal function test. Including electromyography, muscle tension is abnormal, anal reflex latency is prolonged, anal skin reflex and rectal distension are normally reflected, and abnormal pressure map can be seen in anorectal cavity airbag manometry. Defecation X-ray angiography can be seen in anorectal rectum. The angle disappears, etc. These tests help to distinguish between lesions, causes and appropriate treatments.
Differential diagnosis
It is mainly related to the occasional loss of control of stool in patients with diarrhea such as acute bacillary dysentery and acute enteritis, but the stool of these patients can be controlled freely in most cases, and patients often have abdominal pain and pus and bloody stools or watery stools. The relief of diarrhea symptoms, stool formation, and occasional fecal incontinence disappeared, fecal incontinence is mainly the identification of the cause, including neurological disorders and injuries, muscle dysfunction and damage, congenital diseases.
