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1. Continence and the Pelvic Floor
Julie Cornish
General Surgical SpR

2. faecal incontinence
• affects 2-5% of population
• increases with age
• incidence in >50yrs age
– 11% men
– 26% women
• significant social stigma

3. Causes of incontinence
• Structural damage to muscles
• Nerve disruption
• Marked intestinal hurry

4. causes
• If sphinctor normal
– faecal impaction (immobility, medication,
parkinsons)
– IBD, IBS
• If sphinctor abnormal
– Disruption of sphinctor ring due to trauma
– Surgical trauma (haemorrhoidectomy)
– Complete rectal prolapse
– LMN lesion
– Muscle atrophy
– Congenital abnormality (anorectal atresia)

5. Obstetric causes
• 10-30% women post VD have signif sphinctor
injuries
• Full thickness tears –rare
• Prolonged childbirth assoc with damage to
pudendal nerve
• Denervation of pelvic floor leads to sphinctor
atrophy in later life

6. investigation
• Hx
– Detailed obstetric hx
– Past perianal operations
– Defaecation hx
– Incontinent to gas/liquid/solids
– Urinary incontinence
– review medications (e.g. laxatives)
• Examination (don’t forget pr)

7. investigations
• Anal manometry
• Endoscopy
• Endoanal USS
• Pudendal nerve terminal motor latency
studies
• Defacating proctogram
• MRI – spine /pelvis

8. Anorectal manometry
• Use
– sensory or muscular defects
– functional weakness of internal and external
sphinctor
• measures pressure of sphinctor muscles,
sensation in the rectum and anal reflexes
• can use water or air filled balloons

9. Anal manometry 2
• Resting and squeeze pressures over anal canal
• HPZ – high pressure zone
• = length of the anal canal through which the
pressures >50% of the average maximum
• Normal values
– 40-70ml (threshold)
– 60-130 ml (urgency sensation)
– Maximum tolerated volume 150-230ml

10. Pudendal nerve latency studies
• St Marks pudendal electrode
• Mounted on volar side of index finger
• Four cables emit electrical stimulation
• Latency (ms) = from onset of stimulus to first
deflection
• Normal values = 2.0 +/- 0.2ms

11. Non operative management
• medication (bulking agents, anti-diarrhoeals)
• specialist dietary assessment
• pelvic floor exercises
– bowel retraining (education about how the bowel works, and
training to modify bowel function)
– biofeedback (this includes aspects of bowel retraining and also
physical treatments to improve bowel and pelvic floor coordination)
• rectal irrigation
• anal plugs
• repair of a localized sphincter defect

12. Injection of bulking agents
• Used for weakened or deficient internal
sphinctor muscle
• Only limited evidence for use currently
• Trials ongoing for PTP and collagen implants

13. Sacral nerve stimulation
• temporary/permanent
• lead threaded down to S3 via spinal needle
• GA
• Current 0.5 – 3mA at 15 pulse/second
• Temporary - 3 weeks
• change to permanent if >50% improvement in
incontinence episodes + subjective
improvement in symptoms

14. When do you operate?

15. When do you operate?
• Correction of some congenital abnormalities
• Complete rectal prolapse
• Simple disruption of external sphinctor
(sphinctor repair)
• Severe incontinence
– implantation of artificial bowel sphinctor
– graciloplasty
– stoma

16. When might you consider a stoma?

18. stoma
• Complex Crohns
• Rectovaginal fistula
• Extensive injury (e.g cloacal)