Jovi:
Good evening everybody and welcome to tonight’s webinar, Advances in the Diagnosis and Management of Anorectal Disorders and Colorectal Cancer: A Comprehensive Update. My name is Jovi, and I am your host for this evening.
Before we continue, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal or Torres Strait Islander colleagues that have joined us online tonight. I myself have joined from Cammeraygal land in Sydney’s north shore.
So, I would like to formally present our presenters tonight. Our panel this evening comprises of Dr Henry Cheung and Dr Tim Senior. Dr Rebecca Lendzion was unfortunately not able to attend in person due to last minute, unforeseen circumstances, however, she was very keen at the opportunity to present to you all and was able to pre-record her segment of the presentation to us. Dr Cheung will be fielding any questions that we receive that relate to Rebecca’s presentation tonight.
So I will just move onto the bios. We have got Dr Cheung, who is a colorectal surgeon and member of the Colorectal Society of Australia and New Zealand. Dr Cheung specialises in the management of colorectal cancers, diverticular disease and inflammatory bowel disease, common anorectal conditions such as haemorrhoids, anal fissure and anal fistula of all causes. Dr Cheung has expertise to perform surgeries using minimally invasive approaches, and up to date techniques.
Dr Rebecca Lendzion’s practice includes all facets of open and laparoscopic colorectal surgery, hernia and abdominal wall reconstruction, diagnostic and therapeutic endoscopy and colonoscopy. Rebecca has a special interest in the surgical management of inflammatory bowel disease, pelvic floor disorders, and the early detection and management of colorectal cancer.
We are also joined tonight by Dr Tim Senior, who is our facilitator for this webinar. Tim is a GP at the Tharawal Aboriginal Corporation at South West Sydney. He is also Medical Advisor to the RACGP and Aboriginal and Torres Strait Islander Health and is a Clinical Senior Lecturer in General Practice and Indigenous Health at the University of Western Sydney.
So welcome to all our speakers tonight. I will hand you over to Tim, who will go over the learning objectives. Over to you, Tim.
Tim:
Thank you very much. Good evening, everyone. I hope you are all keeping well. I am joining you from Tharawal Country south west of Sydney. So these are our learning objectives, which is educational speak for what we hope to get out of this evening. So by the end of this online CPD activity, we should all be able to review common anorectal disorders and their aetiology, symptoms and risk factors. Review interventions and management of common anorectal disorders, discuss the changes that are occurring in the epidemiology, prevention, diagnosis and management of colorectal cancers, and discuss how to manage common problems that patients present to their GP following commencement of treatment for colorectal cancer. So, I will just hand over straight away to our live presenter this evening, Dr Henry Cheung. Thanks very much for joining us.
Henry:
Thank you very much, Tim. Good evening. Tonight I am going to talk about some advances in the world of colorectal cancers. Whilst there is a lot of exciting innovative research going on, I wanted to focus on things that we actually encounter clinically. Even though colorectal cancer is predominantly within the domains of specialist care, the GP plays a critical role in a patient’s cancer journey, right from diagnosis, management, surveillance, and providing support along the way.
I hope by tonight’s webinar, you will have an opportunity to appreciate the changes that are occurring in the various aspects of colorectal cancers, and also I want at the end to go through some common problems that patients may have once they have started their cancer journey.
To set the scene of the current context around colorectal cancer, bowel cancer is still one of the most common cancers diagnosed in Australia, behind breast, prostate and melanoma. Bowel cancer is the most common diagnosed cancer that affects both males and females. Around 15 thousand Australians are diagnosed each year. In New South Wales, 91% of bowel cancers were found in people 50 years or over. One in 12 men will be diagnosed with bowel cancer during their lifetime, and one in 16 females will be diagnosed with bowel cancer in their lifetime as well.
Bowel cancer is a silent killer, because it can develop without any noticeable symptoms and can hence reach an advanced stage. Around five thousand Australians die from bowel cancer each year. It is the second deadliest cancer in men, and the third deadliest cancer in women behind lung and breast.
Over the past four decades, the mortality rate has decreased significantly and the survival has significantly been increasing as well. One of the main updates is early onset bowel cancer, where, it is now recognised that bowel cancer is increasingly being diagnosed in younger people. Currently, one in 10 bowel cancers diagnosed is in those under the age of 50. It is the deadliest cancer and sixth leading cause of death amongst Australians between 25 to 44 years of age. There is a trend is more left-sided colon cancers and rectal cancer in particular. Hence they are more likely to experience symptoms, which has often been attributed to other things such as haemorrhoids, food intolerances, results of living a hectic lifestyle, or stress. As a result, they are also more likely to be diagnosed at a later stage.
So, what is increasing the risk of early onset bowel cancers? In addition to traditional risk factors such male gender, smoking, excessive alcohol, diabetes, family history, these are some of the recognised associations postulated to increase the risk of early onset bowel cancers. Having a westernised diet of red meat, processed meat and low fibre, sure can lead to obesity and insulin resistance. Gut dysbiosis my affect various processes in the body, and also increase the number of mutations found in these cancers without an actual family history.
So what about in the arena of diagnosis? Whilst we all know about National Bowel Cancer Screening Program and the target age of 50 to 74, patients between 45 and 59 can request or be offered FOBT following counselling about the risk and benefits of the test. A question that often gets asked by patients is what if they have a family history of bowel cancer, and the relevance of doing the FOBT? Screening recommendations were updated a few years ago and advice is screening should begin at 10 years younger than the age of first diagnosis of colorectal cancer in their family, but there is no published evidence to support this. Based on the patient’s risk, patients can start FOBT at an earlier age. Colonoscopy screening, it is recommended if you are in the medium to high risk category from age 50 and 45 respectively. Patients are also recommended to start low dose aspirin if there are no contraindications. Genetic testing is only recommended if one is in the high risk category.
Another question I often get asked is, is there still value in doing FOBT if the patient also has PR bleeding history? In this recent large population study in the UK of over 9 thousand patients, they found faecal occult blood testing is negative in 56% of patients with rectal bleeding. FOBT can rule out colorectal cancer in 99.9% of patients with rectal if the test is negative. However, if a test is positive, colorectal cancer is present in around 10% of those with rectal bleeding. Therefore, there is still value in doing the FOBT. I probably do not stamp all distal if they can actually see bright red blood.
In the next section, I want to talk about some updates in the management of colorectal cancers. So, the first is malignant polyp. With increased screening and increased awareness as well as better endoscopic techniques, we are finding earlier cancers in the form of malignant polyps. These are adenomas which have neoplastic cells that have invaded into the submucosa within the polyp, so they are essentially an early stage bowel cancer or stage 1 bowel cancer. Malignant polyps represent 5% of all adenomas and up to 60% of stage 1 colorectal cancers. The question becomes whether an endoscopic resection alone is sufficient treatment or if surgical resection of the affected bowel segment with lymph node clearance is necessary. We look for presence of these risk factors, such as inadequate excision margin, poorly differentiated grade, having a cribiform architecture, histology showing tumour budding and lymphovascular invasion, as well as looking at the depth of invasion by whether they are pedunculated or sessile type of polyp, and the width of the invasion. If we look at the pedunculated polyp with Haggitt 4 invasion for example, it will have a greater than 25% risk of lymph metastases already.
However, ultimately the decision is not that straight forward. In addition to considering the risk of residual cancer, both locally and in the draining lymph nodes, we also need to consider the surgical risk, which might be okay if it is a caecal polyp that requires a right hemicolectomy but it may not be a okay as an ultra-low anterior resection of abdominoperineal resection if the polyp is involved in the low rectum, because these procedures have a high risk of complications and long term impact on the patient, and most importantly, it is also is based on the patient’s choice. Each patient has a different acceptance of risk.
When it comes to surgery, it is still the main curative treatment for cancers. And one of the major advances in colorectal cancer surgery is minimally invasive surgery. Laparoscopic surgery is the standard of treatment in most colorectal units for appropriate patients these days. However, there is also emerging evidence for robotic surgery in colorectal cancers. Some of the advantages is because of the increased dexterity articulating instruments as well as better visualisation. It can be having benefits of less blood loss, shorter hospital stay, faster recovery, lower conversion rate to open surgery. Some of the disadvantages includes longer operating time, and also cost to the health system, although at present, there is limited evidence to show differences in oncological outcomes, risk of complications or overall survival rates between robotic surgery.
As we are pushing the boundaries of treatment for colorectal cancer patients, on the other end of the spectrum, there are maximally radical surgical options to improve survival in those with advanced disease after careful selection. Pelvic exenteration is an example with en bloc resections of pelvic organs such as the distal sigmoid colon, rectum, anus, along with the bladder, prostate, urethra in males or uterus, ovaries, vagina, bladder, urethra in females. It has been performed for very locally advanced rectal cancers and also recurrent rectal cancers.
In this last series of over one thousand pelvic exenterations preformed, it demonstrated a five year survival benefit of up to 66% for advanced primary rectal cancers. And 44% of those were diagnosed with locally recurrent cancer. Much higher than if they did not have these treatments.
The other type of radical surgery is peritoneal malignancy surgery, commonly known as peritonectomy. It is performed for peritoneal carcinoma carcinomatosis, which is cancer involvement of the peritoneum. The rationale behind such radical surgery is that peritoneal disease is considered a regional disease, as opposed to distant metastases. Peritonectomy involves partial reductive surgery, which is removal of peritoneum and any associated macroscopically diseased organs. Patients are then given heated intraperitoneal chemotherapy. The systemic chemotherapy does not reach the peritoneum that well. PIPAC is a new minimally invasive way to give aerosolised chemotherapy agents in a peritoneal cavity to shrink tumours within the peritoneum. It is a form of palliative treatment. It can be used on patients who are not considered a viable candidate for HIPEC. After receiving PIPAC, the tumours may shrink enough to make HIPEC a possibility. It has been shown to achieve five year survival of up to 30-40% in very carefully selected patients. The down side to these radical surgeries is morbidities which are undoubtedly high.
I also want to touch on some other treatment modalities. These are increasingly being used on patients and no doubt you will come across patients who are undergoing some of these treatments. For locally advanced rectal cancers, it is now the standard treatment to give radiation up front before surgery, with the main benefit in reducing the risk of local recurrence after surgery. We now know that up to 20% may develop what we call complete clinical response. That is, the tumour is no longer clinically evident, following long course neoadjuvant chemoradiotherapy. And whilst not the standard of care, we do accept that patients now can choose to watch and wait, rather than have surgery to remove the rectum. However, patients will need to undergo intensive and regular monitoring if they decide to watch and wait. And this includes regular digital rectal examination, flexible sigmoidoscopies, MRIs every three months, and these are performed intensively for the first two years, as that is the period with the highest rates of regrowth and this can happen in up to a quarter of patients who are undergoing watch and wait. However, if regrowths do occur, salvage surgery does seem to confer any inferior oncological outcomes.
An extension of neoadjuvant treatment is what we call now total neoadjuvant therapy for locally advanced rectal cancers, where patients undergo all their radiation treatment as well as systemic chemotherapy, and this is the proper systemic chemotherapy treatment, not the chemo radio-sensitising treatment. So they get all this treatment before surgery. The benefits include higher rates of pathological complete response, down-staging and down-sizing effects, as well as improved chemotherapy completion than if they were to have the chemotherapy after surgery.
I also want to talk about immunotherapy quickly. It is one of the most exciting treatments at present for what we call MSI High colorectal cancers. These cancers have a high number of mutations in their DNA, which lead to the production of proteins that are not normally found in the body. In very simple terms, immunotherapy helps the immune system to recognise and attack cancer cells by blocking interactions that help cancer cells evade the immune system. Recently, there was a published study of 12 patients with rectal cancers who had immunotherapy, and all patients had complete response following treatment. In my institution, we are now routinely checking for these mutations on biopsy specimens at the time of diagnosis.
In this last section, I wanted to discuss some common post-treatment problems that patients might present to their GPs with. And please do include any questions you have in the chat, as what I am going to go through is definitely not a comprehensive list of everything that the patient might experience. One of the most common symptoms after surgery, is alteration in bowel habits. And this can happen for a number of reasons. This may include shortening of the bowel, it may also involve gut dysbiosis, and also other things such as bowel passive malabsorption, such as in a right hemicolectomy. However, most importantly, most patients will adapt over time and it is a matter of educating them and warning them and also supporting them when they have these symptoms. This may include use of cholestyramine if we think it is a bile acid malabsorption. Or maybe we can add some fibre to the patient’s diet in order to improve the form and bulk of the stool.
Low anterior resection syndrome is a complex and multifactorial syndrome that occurs in those who have surgery for rectal cancers. LARS is exacerbated by factors such as colonic dysmotility, which can happen as a result of increased proximal denervation of the sigmoid and loss of distal inhibition, rectal reservoir dysfunction, anal sphincter dysfunction and also caused by the impact of radiotherapy. A recent international consensus stated that patients will require at least one of the symptoms in the table and one consequence to be recognised as having LARS. So, these symptoms include having variable, unpredictable bowel function, they have often changes in their stool consistency, they get what we call fragmentation and clustering, that is the urgency to go and then once they have been, then they feel that they have to break down the bowel motions into multiple very sort of closely related episodes. They may get pain, swelling, incontinence. And these can all have significant impact on their everyday activities. The treatment is largely based on symptoms. But in some cases, they may even go off for pelvic physiotherapy and in very selective cases, sacral nerve stimulation and also trans-anal irrigation. Up to 40% patients who have very low rectal cancers following treatment may develop low anterior resection syndrome in the long term.
Another issue is that patients can present with a variety of stoma issues. And these may include high stoma output. They may present with peristomal skin issues, they may have problems with fitting of the appliances, and also developing abnormal bulges and hernias after surgery. Most important of all is to have contacts of your nearest stomatherapy team, and they are usually found in most tertiary or regional hospitals. And they can make a huge difference in trouble shooting stoma problems following surgery.
Other treatment issues can include local symptoms. So for example, radiotherapy can lead to problems such as dysuria, urinary frequency, they may get skin irritation and redness and pain in the perineum. They may get faecal urgency and incontinence as well as diarrhoea, constipation, mucus discharge and PR bleeding. In the long term, as I mentioned before, they may develop low anterior resection syndrome, sexual and urinary dysfunctions. With systemic chemotherapy, they can present with a variety of symptoms such as infections, nausea, vomiting. However, much of these effects can be also related to specific agents.
In this last slide, what is important after having started the treatment of cancers is that we need to recognise symptoms that may represent recurrence. Unfortunately, most of the time, these symptoms tend to present late. So, it is important that the patients are followed up regularly, with the recommended surveillance, CT scans of the chest, abdomen and pelvis, as well as tumour markers and also colonoscopy surveillance. Patients who have developed cancer once, are also at increased risk of developing metachronous cancers in the future. So therefore, even though the recommended normal surveillance regime is about five years, these patients sometimes will need ongoing monitoring and education about symptoms in order to be able to find these metachronous cancers in the future.
And this concludes my part of the presentation tonight.
Tim:
Thank you very much indeed, that was really good. If anyone does have any questions, feel free to put them into the chat box. We are just going to be loading up Dr Lendzion’s presentation now, in order to present that to you. But feel free to put questions into the chat box and we may get some time to answer those at the end. So, I think we are starting Dr Lendzion’s presentation now. Thank you.
Rebecca:
My name is Rebecca Lendzion. I am a general surgeon and a colorectal surgeon working at Concord Hospital and Macquarie University Hospital in Sydney. My plan is to talk to you today about common anorectal disorders that you may see and refer on to us as colorectal surgeons. So the five I was going to focus on were haemorrhoids, anal fissure, proctalgia fugax which while not being exceedingly common, is interesting and I think a little bit of a diagnostic dilemma, obstructed defecation and faecal incontinence.
So, in terms of haemorrhoids, the diagnosis is almost always a clinical one, and the main point of obtaining a medical history is really to identify those symptoms which suggest underlying haemorrhoid disease and risk factors for the development of haemorrhoids. So, those patients that are constipated or spend a large amount of time on the toilet with their iPhone in particular. And this is then followed by a focussed exam. Haemorrhoids are classically defined by painless bleeding with bowel movements, with intermittent protrusion. And classically what we see is painless PR bleeding, people often describe as bright red blood on the toilet paper, that also drips into the bowel or sprays the bowel, or can be placed on top of a bowel motion. The focus of the history should be essentially on the extent of severity and duration of symptoms, so often I see patients who say they have had, you know, haemorrhoids since the birth of their children in the last 10 years, but things are getting worse, in particular, symptoms of hygiene, perianal hygiene. So they may talk about bleeding and prolapse, which is generally often, I think associated, people confuse prolapse with skin tags. Issues of perineal hygiene, which can usually lead to over-wiping with toilet paper and this can precipitate further bleeding, and the presence or absence of pain. So the presence of pain may suggest an underlying fissure or a thrombosed haemorrhoid. I will then always assess the patient’s fibre intake. So, whether they had only been taking fibre after being prescribed by the GP, or whether they had been having either dietary or supplementary fibre before this started. Looking at bowel habits, so frequency, consistency and ease of evacuation. So I am always asking about whether people push or strain on the toilet, and realising that constipation often predisposes patients to haemorrhoidal disease.
So the examination is typically done either in the prone position or can be done knee to chest, or lateral decubitus position. My preference is lateral decubitus. I generally start with a visual inspection of the anus, so looking for circumferential skin tags, also trying to exclude any other rarer causes of PR bleeding such as an anal SCC, and often in older women who have had past their childbearing years, I will always assess their perineum, looking for evidence of any scarring, and that may also prompt a discussion about incontinence. And typically laboratory investigations are not required for diagnostic purposes, but patients will often come to the rooms with iron studies having been performed.
So, while haemorrhoids are the most common cause of PR bleeding, other causes of PR bleeding can be colorectal cancer, or IBD, ulcerative colitis Crohn’s disease, diverticular and angiodysplasia. And while most patients with PR bleeding will not have colorectal cancer, rectal bleeding attributed to haemorrhoids represents one of the most common missed opportunities to establish a cancer diagnosis. And even polyps. From time to time, I have taken patients to theatre for a colonoscopy and found a pre-malignant polyp. And often in that situation, you know, haemorrhoids have saved the patient’s life. It is also important to establish personal and family history and any risk factors for bowel cancer. And then you can perform a proctoscopy in the rooms and / or endoscopy to identify high risk patients that will require more extensive evaluation. And this table below is from the American Society, and there are the recommendations they provide for patients who present with PR bleeding, as to who should undergo endoscopic investigation. And I guess, that group does not include iron deficiency anaemia, which I think is also a reasonable group to include for a scope.
So, in terms of medical treatment, constipation and abnormal bowel habit will play a significant role in symptomatic haemorrhoids, and I often say to a lot of patients that people do not learn to defecate in the correct position, and that is something that I spend a lot of time talking about in my consultations. It is also important to increase both fibre and fluid intake, because it is ineffectual to dump a whole lot of fibre into the gut without supplementing it with fluids. And medical treatment of haemorrhoids can improve symptoms in those patients with mild to moderate prolapse and bleeding, and a Cochrane Review from I think 2019 that includes seven randomised control trials, compared patients who were prescribed fibre versus those who were in a non-fibre group. And they found that fibre had a beneficial effect in the treatment of symptomatic haemorrhoids and also had an effect on bleeding. Interestingly, symptoms such as prolapse, pain and itching showed no effect. I generally prescribe most people Benefiber, because I think it is tolerable. I think often people start off with Metamucil or psyllium husk and they really struggle to get it down and it impacts their compliance. The Metamucil Firbrecaps certainly help with that. But Benefiber is my sort of go-to.
So patients need to also be counselled about the way to maintain a proper bowel habit. So, they need to avoid straining and also limiting time on the toilet. So, I tell all patients to purchase a foot stool, which they can buy on the internet from Amazon or get them from Bunnings or Kmart, just a little child’s foot stool, and that essentially allows the correct position for the puborectalis to allow easier bowel evacuation. And even some women who I see for faecal incontinence, allowing them to completely evacuate their rectum in the squatting position, reduces the number of incontinence episodes that they have. IPhones are the biggest cause of haemorrhoids I think. And when I was googling someone sitting on the toilet with their phone, this add came up. And it said, the best iPhone games to play on the toilet, Todd’s top five. And I bet your bottom dollar, Todd has got really bad haemorrhoids, because haemorrhoids are held in position by ligaments, and excessive relaxation, straining and pushing on the toilet can cause issues with the development of haemorrhoids. I tell patients going to the toilet is simply for going to the toilet. They should go to the toilet, evacuate their bowels, feel comfortable after they have done so, and leave without spending an excessive amount of time on the toilet.
So, once you send the patients to a colorectal surgeon, the treatment of their haemorrhoids we discuss, one option is rubber band ligation. This is a really popular and effective treatment and involves ligating haemorrhoidal tissue with a rubber band, and it results in ischemia and necrosis of any prolapsing mucosa, this is followed by scar fixation to the rectal wall. And it is typically very well tolerated. I usually tell most patients they might feel uncomfortable for a day or so, and when it is placed in the correct position above the dentate line, where there is no somatic sensitivity, patients should not have pain. The main risk of this procedure is bleeding. So, at that sort of 10 to 14 day mark where that rubber band falls off, I have had a few patients who have had a bleed, and they are always patients who are non-compliant with their postoperative fibre intake. They do not use a foot stool, they allow themselves to become constipated. So a lot of the time I spend with patients is talking to them about the expectations after the procedure.
So a large case series of about 750 patients with grade 2 and 3 haemorrhoids, reported a cure rate of 93% and a recurrence rate of 11% after two years. So that is quite good.
Sclerotherapy is another option. This can be done by some proceduralists in their rooms. And the most used sclerosing agents are phenol in almond or vegetable oil. I think at Macquarie, we used almond oil. And this involves a submucosal injection of the sclerosant which causes fibrosis and subsequent fixation of haemorrhoidal tissue. The scelosant cannot be injected anteriorly in the male due to the risk of prostatic abscess, and so in that situation, some proceduralists may choose to band that haemorrhoid. There is limited data on the efficacy and not surprisingly, there is better results in those patients with grade 1 haemorrhoids versus those patients with grade 2.
So, in terms of thrombosed external haemorrhoids, I think this is something that GPs and ED physicians will see a lot. Unsurprisingly, there is a paucity of studies that are generally available, but also, of those studies that are available, there are very few with high levels of evidence. Surgery might be superior to conservative management, but there is no evidence regarding the optimal period of conservative management. And the main thing is, most patients treated non-operatively, will eventually experience resolution of their symptoms, mainly pain. Excision of thrombosed external haemorrhoids may result in more rapid symptom control, lower recurrence rate and longer remission intervals. So it is not unreasonable to offer that in the first instance, but I also will educate or inform patient that I think in the instance that we remove a thrombosed external haemorrhoid, I think their risk of post-procedural bleeding is probably slightly higher, and that is just anecdotally. When surgery was compared with incision and evacuation of the thrombus versus conservation, essentially patients were quicker to experience resolution of symptoms in the surgical group versus the conservative group. So, I mean, there is quite a delta there between the two types, so I think if patients are wanting to avoid surgery, it is not unreasonable, but they just need to be aware that they can have symptoms grumbling on for quite some time before they get resolution. In terms of surgical options, this is just for haemorrhoids, including I guess thrombosed haemorrhoids. An open haemorrhoidectomy and a Doppler guided or assisted haemorrhoid artery ligation. But that is sort of beyond the scope of this talk today.
So, anal fissure is another common perianal symptom that we see and I think often patients present with painful PR bleeding and it is put down to haemorrhoids, but often it is a fissure. So, a fissure is a longitudinal tear within the anal canal, and it typically extends from the dentate line toward the anal verge. It is often precipitated by constipation and diarrhoea, and the primary symptom is anal pain, and that is anal pain that is provoked by defecation and lasts for several hours. Patients can describe lying on the floor in agony after a bowel motion that can last from minutes to hours with no relief, and often they will describe sitting in a warm bath and as soon as they get out of the bath, the pain recurs. In terms of their location, most are in the posterior midline, 90%. In terms of the anterior midline position, this is more common in females than males, and if you have enough bad luck to have both an anterior and posterior fissure, that incidence is about 3%. Those patients with a lateral fissure or multiple fissures are considered atypical, and it is at that time that we need to start thinking about alternative diagnoses such as HIV or Crohn’s disease. And with Crohn’s disease, you may get other features, such as you know, that typical watering can anus with multiple fissures, fistulas, which are complex, syphilis, TB and hematologic malignancies, typically CLL.
So, an acute fissure is defined as a fissure that has been present for less than eight weeks. And a fissure of longer duration will generally manifest one of more stigmata of chronicity, which means when the patient presents to the rooms, we see signs that they have had their symptoms for longer than eight weeks. Often, you see a sentinel tag at the distal aspect of the fissure, so the lower border of the fissure, and these tags often need to be removed, because the problem with them is that they cause trapping of faecal material in the fissure, which A) causes pain and B) impacts the ability of the fissure to heal. You may see hypertrophied anal papilla at the proximal aspect of the fissure, which again, would surgical need to be removed because they cause the same problem with the sentinel tags. And you may also see exposed muscle within the base of the fissure. One thing I have not included here is that some patients can also develop a fissure fistula, so they can develop a superficial fistula through that sentinel tag as well, which can give them symptoms of you know, perianal discharge in between bowel motions.
So in terms of treatment. So, reassuringly, almost 50% of patients with an acute fissure will have resolution of their symptoms with non-operative management. And most of the interventions are typically well tolerated with minimal to no side effects. So, treatment with sitz baths and fibre supplementation can be associated with a superior degree of pain relief when compared to the topical anaesthetics and topical hydrocortisone. I think with the sitz bath, it is not so much the salt that provides the relief, it is more so the warmth. Often patients get out of the warmth of a bath and find that their symptoms flare up.
So, GTN is associated with healing in approximately 50% of chronic anal fissures and based on a pooled analysis of studies, there was a 13.5% improvement in the absolute rate of healing and a 38% relative improvement in the rate of healing compared to placebo or lignocaine. The problem is the side effects, where patients will complain of headaches or just about 30% of patients will, which is quite high, which is why Rectogesic now have these finger protectors. And about 50% will develop recurrent fissures, which is significantly higher than the surgical option. And I think this is a reasonable first line management, and often patients will have been having GTN by the time they come to see me. My preference is to prescribe a topical calcium channel blocker. My preference is diltiazem and I send the patients off to a compounding pharmacy where they may up an ointment with diltiazem and lignocaine. And that has quite good healing rates of 65 to 95%, and the mechanism of action is to lower anal resting pressure by relaxing the internal anal sphincter, and as expected, there are significantly less side effects when compared with topical GTN. And the data suggests that the cure rates are increased with increasing frequency of application, so I typically tell most patients to particularly in the acute phase, you know, have a shower or a warm bath after they have had a bowel motion in the morning, use of fibre supplementation and their foot stool. Have a warm bath, get clean, and then apply the diltiazem after that. And I tell them to do that twice per day. And I think these patients are fairly motivated because the pain is so crippling.
So, one other option surgically, or one option surgically, is injection of Botox. Most of the studies that evaluate the use of Botox typically involve comparison with topical GTN, and a lot of the studies are prospective and retrospective studies, and they suggest equivalent outcomes between the two. So Botox is associated with a modest but consistently reported improvement in healing rates, and in most studies, this is defined as resolution of anal pain. The problem in these studies is that there are several limitations, particularly given the variety of dosages, so one bottle of Botox will have 100 units, and we usually mix that up to one mil, so we add a mil of normal saline. And you can inject up to 100 units, but the other issue is there is variation in the number of injections and injection sites. So, some people will inject into the intersphinteric space, others into the internal anal sphincter. And then the location of the injections is variable, so I typically inject, if I was seeing a male, I inject the whole 100 and I inject them into three, six and nine o’clock positions, and I inject them into the muscle. And I think at the time of the injection, you can generally almost feel the muscle relaxing. If it is a smaller woman with a shorter muscle, I might inject a bit less, like 60 or 80 units, but still in the same location.
One RCT demonstrated that topical diltiazem was equivalent to Botox in terms of healing and pain relief. But this was after three months of treatment and I think anecdotally, the Botox probably gives them relief a bit earlier. And small retrospective studies evaluating Botox as second run therapy following unsuccessful treatment with GTN have suggested an improved symptomatic relief and avoidance of a surgical sphincterotomy at follow up.
So a lateral internal sphincterotomy was first introduced in the fifties, and provides fairly prompt symptomatic relief, as it reduces the elevated pressures within the anal canal and it involves dividing a portion of the internal anal sphincter. Multiple RCTs have confirmed the superiority of the lateral internal sphincterotomy when compared to GTN calcium channel blockers or Botox, with healing rates that radiate to 100%, but the issue is the risk of faecal incontinence. So, one study looked at following up patients for six years, and found that incontinence rates were 8-30%, and I think this is a tricky operation, because you have to divide enough muscle to allow elevated pressures within the anal canal to reduce, but not so much that you cause incontinence. So, it is a bit of a fine balance.
Proctalgia fugax is an interesting anorectal condition, and it is part of a spectrum of functional GI disorders, characterised by the Rome III criteria. It affects twice as many females as males, typically at 50 years, and it is pain that commonly occurs, rectal or anal pain, once a month as a sudden pain with no trigger. I find patients present with it at night, but the studies say it is diurnally as often as nocturnally. Patients can describe pain as severe as an anal fissure and when you get them up onto the table, you kind of pray you find an anal fissure, and then when you do not, you have to start thinking about something like this. But, it is non-radiating crampy pain. It can be spasmodic or stabbing, without any concomitant symptoms and is quite severe after about 15 minutes, and then will decline spontaneously. And, again, these patients will often present having said they woke up in the middle of the night feeling that they need to have a bowel motion, but when they go and have a bowel motion, they are unable to evacuate their rectum, because it is empty. And then they commonly have quite severe pain, will have a warm bath, they get relief, and then they get out of the bath and it comes back again. The cause of proctalgia fugax is unclear. And spasm of the anal sphincter is commonly implicated, but it is I think in a lot of ways a diagnosis of exclusion. So you need to exclude other things like fissure before this.
Most treatments will act by relaxing the anal sphincter mechanisms, so patients can be prescribed oral or topical diltiazem, topical GTN, but again, you have to manage the symptoms of headache or nerve blocks. The effectiveness of a lot of the treatments are only in case reports or case series, but one RCT looked at the use of salbutamol which found a good result. So, it is a really hard thing to follow patients up with. So, often I prescribe salbutamol, so I usually say, you know, two puffs every 10 minutes for a maximum of six puffs over 30 minutes, to see if they get a resolution of their symptoms at the time, because it is not something you can do to prevent the pain from occurring. But that is one option. Another surgeon I work with will often prescribe diltiazem, and I ask the patients to go away and keep a record of when the episodes happen and what they did and what worked and what did not work, just so that we can sort of work out the best thing for them.
Obstructive defecation is something often seen in my older female group of patients, and this is again, difficulty passing stool, with ineffectual straining with preserved urge to defecate. So, patients will go to the toilet, have their bowels open, then sometimes they walk away and they feel like they have emptied completely, they walk away, come back, feel that they need to empty again, but they are unable to. And it is essentially characterised by difficulty, infrequent and / or incomplete defecation. And some patients will talk about having to do manual manoeuvres to assist with the evacuation, so some people talk about actually digitating the rectum to sort of scoop out the bowel motion. Other women describe putting pressure on their perineum or their buttock to allow them to have a bowel motion. The Robe IV criteria is the most prominent diagnostic criteria used for functional GI disorders, but I do not have a category for obstructive defecation. Everyone seems to use this criteria for functional constipation diagnosis.
So, it is fairly common. So in the UK, the rates are as high as 10% and in the US, they are as high as 18%. It is more frequently seen in multiparous peri or postmenopausal women, and is more frequent after a hysterectomy. So, I think it is those patients that have a hysterectomy that are often seen because they do not have their uterus to sit there as a barrier for the small bowel to enter the pelvis. So, we need to be seeing these patients, exclude any red flags that may be associated with a rectal cancer as the cause of their obstructive defecation, so looking at things like any unintentional loss of weight, bleeding or recent change in bowel habit that may indicate an underlying malignancy. When seeing these patients, you need to take a complex pelvic floor assessment looking at quantifying the stool frequency and consistency, and the severity of their symptoms. Because often faecal incontinence will happen in the setting of obstructive defecation, and that is because you know, they share a lot of the same risk factors. And an obstetric history is essential and I will come to that later.
So, the features of obstructive defecation will often include prolonged time on the toilet. Digitation which may be vaginal, perineal, or anal, but I think can also be buttock, to be inner buttock towards the anus. Features of incomplete defecation and encore defecation. So, those are the repeated trips to the toilet that I described before. And anismus is associated with obstructive defecation and there are high rates or prior sexual abuse described in these patients. So, I think it is important to try, and it is hard when you see these patients and you have only got a short consultation, to build a relationship with them where you both feel comfortable to ask and answer this question. So, I often give these patients a double appointment as well, so that you have some time to build rapport.
So, in terms of the examination, specific to obstructed defecation, you may see several findings. So, the first thing you may see is paradoxical puborectalis contraction. So this can be elicited by asking the patient to bear down or strain during a digital rectal exam. In a normal scenario, the pelvic floor, which includes your external anal sphincter and puborectalis, should relax. If it does not, or it contracts, it may suggest paradoxical contraction. And this finding is useful for excluding it, but it is poorly specific, because it is hard to ask patients in that artificial position to try and mimic what they are doing on the toilet. Patients with paradoxical puborectalis contraction will often require anal manometry and a proctogram to confirm the diagnosis.
Rectal prolapse. So, this is an impression of an internal or external rectal prolapse, is appreciated by asking the patient to bear down as a proctoscope is withdrawn. And sometimes patients, it is not always easy to elicit a rectal prolapse in the rooms, and sometimes patients will present with a photo, and that can be quite helpful. And you may observe a rectocele.
In terms of investigations, this is where blood tests come in. So, calcium and thyroid function tests are required to exclude any metabolic causes for constipation symptoms, and a colonoscopy should be performed to exclude any alternate pathology. I send patients for a defecating proctogram. This is a dynamic study, and it is invaluable in distinguishing the main pathological causes for obstructive defecation. And it also gives you a lot of information about organ prolapse. So we are looking at the three compartments, so you know, the bladder, the uterus and the rectum. At Macquarie University within our imaging department, we book patients in for a consultation with a radiologist and she is excellent, so she sits with the patient and has a discussion with them about their symptoms to try and work out what she is looking for as well to assist with her report. They are about 600 odd dollars, but they are very, very helpful. Anal manometry is used as well, again we perform that at Macquarie University and also Concord Hospital. And in obstructive defecation, you may see rectal hyposensitivity. And an endoanal ultrasound can also be used to look for a hypertrophied internal anal sphincter, which can indicate rectal prolapse or solitary rectal ulcer syndrome.
And this is just an example of a dynamic MRI, and this is what the radiologist is looking at. And you can see here that the small bowel is prolapsing anterior to the uterus.
So in terms of management, I like to do a really good trial of non-operative management in these patients. So, I put them on either a fibre or osmotic laxative, so Movicol is usually well tolerated, it is very safe to leave patients on, they do not become dependent on it. Microlax enema is another one I use both in obstructed defecation and in faecal incontinence. So, often these patients if they have either assistance to completely empty their rectum, or they are able to completely empty their rectum, then they will not have symptoms for the rest of the day. I advise them to lean forward with their feet elevated on a foot stool, to again relax the puborectalis and allow for an easier bowel motion. I restrict diet soft drinks and artificial sweeteners, and try and limit their caffeine intake to one cup per day, so that they do not hate you. And I also ask them to start using a stool diary to get more of an indication. Some people are really good, and they can really pin point exactly when and where and what triggers their symptoms, and others are so distressed the acuity of their symptoms, that it is really hard to get a sense for what their pattern is like. And I think without having that clear pattern, it is difficult to work out the best treatment for them. Pelvic floor physiotherapy with biofeedback is successful, and the rates are up to 50 to 100%, in least 12 published series. And that is irrespective of whether the patient has a prolapse or intussusception. But the biggest thing here is compliance. So I often say to patients, you know, you need to see a pelvic floor physiotherapist, and I write the referral, and I send them to somebody, because I think if they have got a referral in their hand with a number to call, they will make the appointment. And often they will say to me, oh, I know how to do pelvic floor, because you know, they have read it in New Idea or Women’s Day magazine two years ago, but the clear answer is that no one really knows, except the pelvic floor physios. So a lot of people will evacuate their bowels using their rectus abdominis muscles and push and strain, but really they need to be using their lateral abdominal wall, and their pelvic floor a lot better. So, I think sending them to a good pelvic floor physiotherapist is very helpful.
So, biofeedback works by operant conditioning, and it corrects dyssynergia and improves the coordination of the abdominal muscles and pelvic floor during defecation. And it can also help improve the perception of rectal filling in patients with impaired rectal sensation. So, those patients with the rectal hyposensitivity that I talked about earlier.
The operative management of obstructive defecation is really aimed at correcting the anatomical contribution to the symptoms. So, that could be from a rectocele or an enterocele. The literature says it is controversial, but I think most surgeons would advocate an extensive trial of conservative measures and biofeedback. But I think it is a combination of everything. So, I generally see patients for the first time, talk to them about conservative measures, and then usually book them in for a colonoscopy or flexible sigmoidoscopy if they have had a recent colonoscopy, with anal manometry, then by about four weeks after that, so that gives them enough time to implement the changes I have asked them to, to see whether that is making a difference. Hopefully by then they have had their MRI as well, and it is at that point that you can decide whether or not they need to have surgery to correct the anatomical problem, or whether they have had a good enough response that they can push on and have biofeedback. But even the patients that proceed to surgery should have biofeedback as well, because often they have disordered toileting that needs to be fixed.
Faecal incontinence is my last topic, and I see a lot of women for this. It is the involuntary passage or inability to control discharge of faecal material through the anus, in individuals older than the age of four. It is fairly common. The prevalence is almost 8% and it is more common with increasing age and female patients. And it has significant negative psychological affects and reduced quality of life. And I think these patients are more distressed than patients that have cancers. And if you can help them, I think they are more grateful than patients that have cancers, because there is just such a stigma associated with it. So, the clinical sub-types. There is passive incontinence, and that is involuntary passage of faeces or flatus without awareness. So, a lot of patients will describe going to the shops and they will have a bowel motion come away from them. Urge incontinence. So, that is characterised by passage of faecal material inside of them, trying to hold onto it. So patients are home, they have their breakfast, their gastrocolic reflex runs into gear, and they feel as though they need to have a bowel motion, but they do not make it to the toilet on time. I think most people I see probably have a mix of passive and urge. And faecal seepage is the leakage of stool following an otherwise normal evacuation. And I think they are the patients that really do well with an enema in the morning to allow them to completely evacuate their bowel.
So, there are multiple aetiological factors in terms of cause, but the underlying cause is almost always multifactorial. There are congenital or acquired anatomical abnormalities and neurological dysfunction. Obstetric trauma with injury involving the external anal sphincter, the internal anal sphincter, the pudendal nerve or a combination of all three, is for me probably the most common. And approximately 20% of women will develop some degree of faecal incontinence after a vaginal delivery, and 51% of women having a vaginal delivery will have a grade 1 or 2 tear, and 30 to 35% will have evidence of a sphincter disruption on their endoanal ultrasound. Other causes are anal dilatation or sphincter damage during surgery. So, examples of that would be haemorrhoidectomy, more so with staple haemorrhoidectomy which has sort of gone out of fashion now, if the sutures for a staple haemorrhoidectomy are not placed quite high enough into the rectum, then patients can inadvertently have damage typically to their external anal sphincter. So patients may describe weakness rather than incontinence.
So in terms of taking a history, you need elicit what they mean when they report incontinence. So you are looking at passive seepage, urge or stress incontinence. You need to characterise the degree, so is it stool, is it liquid, it is flatus, do they experience mucous or any passage of blood? The number of pads that they wear per day, whether they change any pads at night, or whether they need to wear any sort of adult diapers. The onset of symptoms and their duration, so I had a woman who I saw who developed incontinence in the last 18 months after she stopped her HRT therapy with menopause, so that is one interesting one. The severity of their symptoms and the timing. And any precipitating events such as surgery in the younger group. The stool consistency and the urgency. So, some people will describe incontinence only with a loose bowel motion or diarrhoea but they do not have it with a solid bowel motion, and that group is really easy to fix, because you can generally just start them on a bulking fibre to make it better. And then clinical sub-types we discussed before.
Often people will have concurrent urinary incontinence, or rectal or vaginal prolapse, and it is also important to elicit whether they have had any back injuries. Obstetric history, so you need to take a history for each baby. So I look at the number, the mode of delivery. So, often it is an issue with vaginal deliveries. The size of each baby, the length of the labour. So mainly we look at a prolonged second stage that lasts for more than 60 minutes. And looking at their presentation, so if it is an OP or posterior, whether they have had use of forceps, or an episiotomy, whether they have had any turs, and the details of any repair. So, often women cannot remember whether they have had, the degree of the tear. So often I ask them you know, did you have your tear sutured in the room, or did you have to have an anaesthetic. And that will usually give you an idea of whether it was a grade 2 or 4 versus if it was just a grade 1. I look at the dietary caffeine intake, including tea. I look at use of any artificial sweeteners. And also look at other medical conditions. So, other conditions in the past medical history that might contribute, including inflammatory bowel disease. So if they have got any evidence of proctitis, diabetes or prior radiation, which is again evidence of proctitis.
So, in terms of assessment tools, these are clinical ones, there are a lot of them, but none of them have been validated. So the scores generally correlate well with our clinical impression and are reproducible basically from studies. So that is really where they are most helpful. As I said earlier, I send patients off with a stool diary, and I ask them to note the timing of their bowel motions, the consistency, the presence or absence of incontinence, any urgency or the use of pads, and the use of any medication. And basically, the diary is more accurate than the patient recall, and that is most beneficial for the patients that really have an acuity to their symptoms, because they are so distressed and they are really not able to give you a good history. And in addition to severity scores, you can also look at quality of life assessment tools, but again, that is more reproducible for studies, and I do not use those.
So in terms of a physical examination, you need to perform a comprehensive inspection of the perineum. And you are looking for the presence of faecal matter, because that gives you an idea about hygiene. Thinning of the perineal body and any scars from previous surgery or obstetric injuries, skin excoriation, because that gives you an idea if they are having you know, passive faecal incontinence. And to treat that, you can often prescribe a topical hydrocortisone. Any prolapsing haemorrhoids or skin tags. I look for anal gaping or a patulous anus, and excessive perineal descent or rectal prolapse can be demonstrated by asking the patient to bear down. So I ask patients to bear down. I also ask patients to squeeze their muscles together to get an idea of the strength.
A DRE should also be performed to look for any masses or tumours. And it also allows you to assess their resting sphincter tone and their anal canal length. And you can also assess for a rectocele, an enterocele or rectal prolapse. And a comprehensive abdominal and urological exam should also be performed. So, endoscopy should also be performed to make sure that there are no other mucosal disorders or neoplastic conditions that may be contributing. So, the ones I mentioned before like proctitis associated with ulcerative colitis or Crohn’s disease, or that you might see following radiation in patients that have had prostate cancer. Stool culture should also be performed in patients that have unexplained diarrhoea, and I would also generally send them off for a faecal calprotectin as well. Endoanal ultrasound gives you a good idea of the anatomy of the sphincter, and can show some quite dramatic features, particularly if there is a defect in the midline involving the sphincter complex in patients with obstetric history. Anal manometry is a procedure that I do again at Macquarie University Hospital. It takes about 15 minutes. It involves inserting a probe into the patient’s rectum. The probe has 15 pressure sensors on it, and basically, allows us to measure the pressures within the rectum, and also various sensations. I then perform neurophysiology. So this involves assessing the pudendal nerve and we can also do defecating proctograms using either MRI or x-ray.
So, the endoanal ultrasound as discussed, provides an assessment of the thickness and structural integrity of the anal musculature. And it is really important in women who have had children or who have described issues with injuries. I saw a woman recently who had quite a small baby, but what sounded like a very dramatic birth. She had a grade 3 tear, and on day 1 postpartum, all of her sutures fell out. And she told me she just had packing, like wound packing in hospital for 12 days, and then after discharge, and her baby was in a posterior presentation and the proceduralist used the forceps to turn the baby, so she would have torn from that. And she had immediate postpartum incontinence. And so she has now presented with incontinence years later. And that is quite an impressive story. But most women will often sort of describe long labours, forceps, big babies. And ultrasound, as I described before, can reveal an occult injury in 35% of women following a vaginal delivery. It is really the gold standard for sphincter evaluation. It is a simple, well tolerated, cheap technique, and we typically do it in conjunction with anorectal manometry. And you can see from the image on the right hand side of your screen, that there is an anterior defect.
So, anal manometry is the preferred technique for assessing the function of the muscle and for detecting abnormal rectal sensation. So like that hypotonic rectum that we see with obstructive defecation. It can also assess the anal sphincter length and rectal compliance and rectoanal reflexes. So often what happens is the first part of the test is I get women to squeeze for five seconds, like they are trying to hold onto a bowel motion, and again for 30 seconds. And you know, young women with normal continence would be able to maintain high pressures in their rectum the whole time. But women with faecal incontinence and a significant obstetric history will often fatigue really quickly, and because they fatigue really quickly, they are unable to hold onto a bowel motion. We use a solid-state probe, and it allows for high resolution anorectal manometry. And it can provide information on the anorectal sensory motor responses such as the rectoanal inhibitory reflex.
So this is what the probe looks like on the left hand side of the screen. It is quite thin. At the tip of this transducer, we put a balloon, and that balloon is inflated during the test to mimic, you can see in this image here on the right, the balloon has been inflated, and that mimics a bowel motion in the rectum. And these little grey dots are the little pressure transducers. And this is the platform that we use that gives us the report using the London protocol.
And yes, this is the London protocol. This is the classification system that we use, high resolution anal manometry and all the steps involved. And essentially, we do the test and everything gets plugged into the machine and they sort of give us an answer. I think the most helpful finding is the patients that fatigue quickly. I think a lot of it is academic, because most patients end up you know, all having the same treatment.
Pudendal nerve terminal motor latency testing investigates the neuromuscular integrity between the terminal portion of the pudendal nerve and the anal sphincter. So, the pudendal nerve innervates the anal sphincter complex. This is the St. Mark’s probe. So, it involves using a finger electrode and it applies a small current to the pudendal nerve and records the time to contraction of the external anal sphincter, and we test both the right and the left nerves in the lateral decubitus position. And a prolonged latency will suggest pudendal neuropathy. And that is longer than 2.2 milliseconds.
So in terms of the management goals of faecal incontinence, we want to improve the continence but we also want to improve patient quality of life. So, often these patients will come to me and they will not go to the shops, they will not go out and see their grandchildren, they will not travel to see family interstate, because they are too embarrassed. So if you can do that, then you give them back a lot. The strategies can be divided into conservative and there are surgical options.
So in terms of lifestyle and dietary modification, often it is really simple, making some simple changes. So you can manipulate their dietary intake and avoid the foods that can cause diarrhoea or urgency. I send every patient to a dietician. We have one in our rooms. And as soon as I give them a referral on the spot, ask them to make an appointment straight away. And often patients benefit from being on a FODMAP diet if they are not sure what food triggers there are, and that often helps. Caffeine reduction, so generally I am happy for them to have one per day, but no supplementary artificial sweeteners. It is amazing, so women will come to you and they will say, I only have symptoms when I have my cappuccino when I go out when I go out every week for a coffee with my girlfriends. And you say to them, well you need to stop doing that, but it just I think sometimes they are just so distressed by the new onset of symptoms that it does not occur to them. Adding fibre to their diet can improve the consistency of their stools, so going from a soft liquid stool to a bulkier stool that they have more control over. And there is no benefit in patients that already have a normal or hard stool, you are really targeting that group of patients that has a lose stool.
So a food and symptom diary can again, so in addition to the stool diary, I ask them to look at whether they have had any foods and you know, some people will describe you know, apricots and peanuts, and they are the thing that causes their problem, and if that is good, then that is great. Other supportive measures include the timely recognition of soiling and maintaining the perianal hygiene, so I tell patients they can use baby wipes or flushable wipes, particularly those with barrier cream. So if you use like a Calmoseptine baby wipe, it usually helps with bad excoriation they get around their skin. And very acutely, you can give them topical hydrocortisone.
So in terms of pharmacological management, so anti-diarrhoeals such as loperamide, Lomotil and codeine are some of the mainstays. Codeine is generally poorly tolerated and that is because of the side effects of drowsiness and confusion. I generally prescribe most people loperamide, so some people I will say to them have it the night before you leave the house, you know, the next day for an appointment, or you could have it the morning of. Patients with Crest syndrome and scleroderma, they usually benefit from having one tablet every second day. I am not really sure why, but it definitely helps them. That is just anecdotal. So, loperamide is a synthetic opioid and it acts to reduce intestinal motility and secretions. So, you are really just stopping them from having a bowel motion, but you are not necessarily fixing the problem. High doses can obviously cause constipation, so that is the other caveat to it, but the patients can say, well, yes it worked, so I was not incontinent, but I was constipated and had pain. And codeine as I said, has good results but can cause drowsiness.
Biofeedback. So, that is again with the pelvic floor physio. So a pressure sensitive or sponge probe is used and the pressure or muscle activity of the anal sphincter contracting around the device is measured, and the aim is to improve sphincter strength, muscle coordination and enhance their sensory perception. So, you are trying to teach patients to become more aware of a bowel motion in the rectum so that they are then able to use their stronger sphincter muscle and their coordination to hold onto a bowel motion. It is most successful in patients with a weak sphincter or impaired rectal sensation. The range is variable and as I said to you before, it is variable because of issues with compliance. So, if I ever see a patient with incontinence, I never just say to them, okay, here is your referral, go and see a pelvic floor physio, I do not need to see you again. I get them to come back. So, if you get the patients to come back and see you at sort, I usually give them a good amount of time, like four or five months, it creates that expectation that they should have done what they were supposed to do. So, it makes them accountable, because they know they are coming back to see you, and you then also get some feedback about the physio that you have referred them to. So, a Cochrane Review from 2012 concluded that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect. A recent systematic review concluded that twice the number of patients regain continence with biofeedback compared to pelvic floor. And a combination biofeedback and electrical stimulation can be superior to any monotherapy, so like tibial nerve stimulation.
So, surgical options can be a sphincter repair, so that you might do an anterior overlapping sphincter repair in patients that have had quite a significant sphincter injury. Sphincter augmentation, so you can use bulking agents, which involve injection of silicone in between the internal and external sphincter. Neuromodulation, so sacral nerve stimulator, and faecal diversion, which sounds dramatic, but it can really give the patients back their lives if you just give them a functioning colostomy. Some people are just resound to the fact that that is just what they need.
So, sacral nerve stimulator is an effective treatment for faecal incontinence, and there is new evidence coming out to say that it is even effective and beneficial in patients that have an untreated sphincter injury, so an anatomical defect. It is a two stage procedure, so patients will have an initial peripheral nerve evaluation with temporary wires, which are inserted as a day case procedure. They usually stay in for 10 to 14 days and we have a look to see whether they have any benefit. So then subsequent permanent stimulator placement is inserted if there is a detectable benefit during the initial evaluation. And cross over studies have shown that up to one third of patients will have a complete improvement, 70 to 80% of patients will have more than a 50% reduction in their episodes of faecal incontinence. And that improvement continues over time. And 90% of patients will show improvement at five years.
So, this image on the left is showing you the anatomy of what is happening on the right. So it involves inserting, this is the guidewire or electrical temporary probe that we insert to stimulate one of the sacral nerves, and then we look to see whether the patients have any contraction of their sphincter. This is what it looks like. It is pretty small. The one on the left hand side of the screen is probably one of the earlier ones. They are much smaller now, they are probably I would not say the size of a 50 cent piece, maybe a little bit bigger, and this is the wire that inserts into the spine. And they are not compatible with MRI, I am quite sure.
This is the App that patients can use on their phone to control the degree of stimulation of the muscles. So, previously patients would have to come in, see the rep, the rep would then have to program the stimulator externally, but now patients can have more control over it, which gives them another degree of autonomy. That can be challenging in the elderly group of patients, who are not so tech savvy.
So the complications of the sacral nerve stimulators can be infection, so the rates quoted are about 2 to 10%, and they can be quite impressive, so I saw a lady at the beginning of this year who had one inserted about 15 years ago, and she developed osteomyelitis and had to have the device removed. Pain, but I think that is uncommon. 16 to 54% of patients will need reoperation to replace the electrode after a technical failure, and 8 to 20% of patients will eventually have the equipment explanted because of, you know, technical failure, pain or discomfort, but I think overall, it is generally a very well tolerated option for people with incontinence. Thank you.
Tim:
Thank you very much, Henry, for answering all those questions that came through as well, that was really helpful. Superb, I think everyone got something out of that. So these are the learning objectives for the evening. So we can just look at those and see if we have covered all of those tonight. So, those are the same ones that we saw at the beginning. And we have got a few minutes if you do have any urgent questions, you may be able to just type them into the chat box, but we are nearly done. At the end of activity, when we close it, you will come to the evaluation as well, and you will need to do the evaluation to get the CPD points. Jovi will tell us more about that in a minute. But I would just like to thank Dr Cheung very much for his presentation and for going through all the questions that people put in, that was really useful. And we send our heartfelt thanks to Dr Lendzion as well for actually doing her presentation even though she could not make it tonight, that is very much appreciated by everyone, too. Jovi.
Jovi:
Perfect. Thank you so much, Tim, and thank you, Henry. I would like to thank everyone that has joined us online for this presentation. We hope you have enjoyed it. Just also if you missed any parts of this webinar, this webinar is recorded and will be uploaded on the RACGP website in the following week. So, just a reminder that as Tim said, it is an accredited activity, and to be allocated your CPD hour, you must finish the survey following this webinar. Thank you, everyone, and have a good night.
Tim:
Thank you very much. Good night.