Functional fecal incontinence

　　The etiology of functional fecal incontinence is unknown, 96% of insomnia have a history of constipation or fecal impaction. Most of them have anal rectal motor disorders, manifested as rectal sensory abnormalities, increased rectal minimum sensitivity, defecation threshold, and maximum tolerance.

　　Fecal impaction can change the tension and adhesion-elasticity characteristics of the intestinal wall or change the mechanical sensitivity, and the change in sensation may be the result of fecal impaction. The sensitivity of the anal rectum decreases, causing fecal incontinence before the patient perceives feces in the rectum by producing a reflex inhibition threshold of the anal internal sphincter. Psychological factors such as mental distress, sadness, fear, and lack of self-confidence may also be one of the factors causing the disease, but some studies believe that these manifestations are the result of fecal incontinence.

　　Functional fecal incontinence can cause various complications, the most common of which are perineal, sacral tail skin inflammation, and pressure ulcers (bed sores). The incidence of fecal incontinence in the elderly, critically ill patients, and bedridden patients reaches 46.0% to 54.4%. Due to the stimulation of feces, the perineal skin is often in a moist and metabolite-eroded state, prone to redness, swelling, ulceration, and pain. Skin ulcer infection can extend to the muscle layer or even to the scrotum, labia, inguinal region, etc., and pollute the urinary and vaginal orifices, causing retrograde infection. This not only aggravates the patient's suffering but also brings difficulties to clinical nursing work. Due to the frequent stimulation of feces, the perianal skin may develop erosion, itching, ulceration, and pain, and a few patients may restrict their diet to reduce defecation, leading to weight loss and weight loss.

　　When fecal incontinence occurs, the patient cannot control the excretion of feces and gas at will, leading to long-term dampness and uncleanliness of the perianal area, soiling of clothing, and affecting daily life and work.
　　Mild fecal incontinence patients exhibit varying degrees of fecal or flatus incontinence due to the different severity of fecal incontinence. The underwear may be soiled occasionally, and there is sometimes a loss of control over flatus and liquid feces. Mild incontinence is quite common in elderly people with low rectal sensitivity, and many patients also experience it occasionally. The vast majority of these patients report diarrhea.
　　Severe fecal incontinence refers to the inability to control formed feces, with the frequency of feces leakage ranging from occasional to frequent (several times a day).
　　Fecal incontinence is often accompanied by symptoms such as urgency, constipation, and urinary incontinence. Fecal incontinence has a profound psychological impact on patients, and patients often hide their symptoms, becoming more and more isolated, and frequent urination. Some patients may experience increased fecal incontinence after meals and are often unwilling to dine in public places.

　　To prevent functional fecal incontinence, it is necessary to actively participate in mild sports activities, enhance physical fitness, improve the vitality of various organs of the body, strengthen the exercise of anal function, and prevent constipation. The elderly should actively treat chronic bronchitis and other long-term diseases that increase abdominal pressure. Develop the habit of regular defecation, defecate at a fixed time every day and empty the bowels completely, and reduce the stimulation of the rectal mucosal receptors. When elderly patients have constipation, they should not take any laxatives or defecation-inducing drugs on their own, but should take medication under the guidance of a doctor to avoid damaging the function of the colon.

　　The clinical examination for functional fecal incontinence in hospitals is as follows: rectal examination, endoscopic examination, defecation radiography examination, anal canal and rectal pressure measurement, rectal sensation measurement, balloon expulsion test, pelvic floor electromyography examination, and anal canal and rectal ultrasonography. The specific details are as follows.

　　1. Rectal examination:The examiner feels that the anal canal is relaxed without any sense of urgency. When the patient is asked to contract the anal canal, the anal sphincter muscle does not contract significantly or has no contraction power at all. If the patient has a history of anal injury, scars can be felt. Some patients may feel a contraction on one side of the anal canal while the other side has no contraction sensation. Pay attention to whether there are tumors, tenderness, and other symptoms in the anal canal and rectum, and observe whether the finger gloves are stained with mucus and blood after the fingers are withdrawn from the anal canal.

　　2. Endoscopic examination:Observe whether there are malformations, scars in the anal rectum or colon, whether the anal skin and rectal mucosa have erosion, ulcers, whether the rectal mucosa has congestion, edema, rectal polyps, rectal cancer, and anal rectal cancer, etc.

　　3. Defecation radiography examination:By observing the dynamic changes of defecation, anal contraction, and rest, understand the function of the anal sphincter. If the barium灌入rectum can be retained by anal contraction, it indicates that the anal sphincter has certain function; if the barium灌入rectum is involuntarily discharged, it indicates anal incontinence.

　　4. Anal and rectal pressure measurement:Patients with fecal incontinence show a decrease in pressure, a decrease in frequency, or the disappearance of pressure in the anal and rectal canal, a decrease in anal sphincter systolic pressure, and the disappearance of the rectal anal inhibitory reflex. For patients with ulcerative colitis causing fecal incontinence, the rectal compliance is significantly reduced.

　　5. Rectal sensation measurement:Insert a balloon with a catheter into the rectum, then inject water or air into the balloon. For patients with neurogenic fecal incontinence, the rectal sensation disappears.

　　6. Balloon expulsion test:If the rectum is insensitive, the normal volume cannot cause a defecation reflex, and the balloon cannot be expelled. This examination can be used to judge whether the rectal sensation is normal and to judge the function of the anal sphincter. If the anal sphincter is damaged and has no sphincter function, and the balloon can slip out of the anus by itself, or can be expelled by slightly increasing abdominal pressure, it indicates that the balloon can be expelled.

　　7. Pelvic floor electromyography examination:This examination can understand the location and extent of the anal sphincter defect.

　　8. Transrectal endoscopic ultrasound examination:Transrectal endoscopic ultrasound can clearly display the various layers of the anal and rectal canal. The internal anal sphincter and its surrounding tissue structure can assist in the diagnosis of anal incontinence. Such as observing whether the internal anal sphincter is intact, whether the external anal sphincter has a defect, and the location and extent of the defect. This examination not only assists in diagnosis but also provides a certain basis for the selection of surgical incisions.

　　Functional fecal incontinence requires improving dietary structure, and it is advisable to consume high-protein, high-calorie, easy-to-digest, and high-fiber foods to facilitate smooth defecation. Increase the content of dietary fiber in the diet, with an average daily supply of 6.8g. Dietary fiber is not absorbed by the body, but it can increase the volume of feces, stimulate intestinal peristalsis, help restore intestinal function, strengthen the regularity of defecation, and effectively improve the condition of anal incontinence. Specific as follows.

　　1. Maintain smooth defecation; drink plenty of water every day, especially a large glass of warm water in the morning. Pay attention to diet regulation, eat more vegetables and fruits rich in fiber. Avoid drinking alcohol in large quantities and avoid spicy, dry, and irritating foods.

　　2. Choose underwear and toilet paper scientifically; underwear should be made of soft and thin cotton fabric, avoid wearing coarse cloth or synthetic products. Toilet paper should be thin, soft, and have even folds. Avoid using waste newspapers or waste paper with ballpoint pen writing, as the ink can cause perianal diseases due to long-term irritation.

　　3. Do not ignore anal cleaning: Clean the anus twice a day, once immediately after defecation and once before going to bed to avoid soiling the underwear.

　　4. Regularly do sitz baths: Sitz baths are a good method for anal health and treatment. Sitz baths can have a significant effect on mild anal disorders. The water temperature should not be too hot to avoid burns, but also not too cold to be ineffective. The sitz bath time should generally not be less than 20-30 minutes, during which hot water can be added appropriately to promote perianal blood circulation and accelerate the absorption of inflammation.

　　5. Pay attention to doing perineal exercises: Do perineal exercises twice a day, morning and evening, to make a contraction and relaxation movement of the perineum, 50 to 100 times each time, which can promote the return of venous blood in the anal-rectal area.

　　With the understanding of the importance of human defecation and fecal control, the treatment of fecal incontinence has paid attention to the adjustment of intestinal dynamics, rectal and colonic storage function and sensory function, pelvic floor muscle coordination movement function, and neural and reflex function. Over the years, overflow incontinence caused by constipation of various causes has received great attention from clinicians. Specifically as follows.

　　1. General treatment:Dietary adjustment (limiting dairy products and foods with water and fiber content), increasing physical activity, and the elderly should appropriately strengthen physical exercise. For overflow fecal incontinence, efforts should be made to cultivate the patient's regular defecation habits, using the原理 of gastrocolic reflex, encouraging defecation 30 minutes after meals. For children with overflow fecal incontinence, the first step in treatment is the education of the family and parents, guiding the child not to hold in stool and to regularly empty the rectum in the toilet, and clean enema can be used when necessary, once a week. For anal chemical dermatitis, patients should be helped to master the hygienic techniques to avoid physical injury to the anal and perianal skin, and use mild cleansers to clean the anus and ointments for protection.

　　2. Drug therapy:Regardless of the function of the anal-rectal tract, for diseases with diarrhea, efforts should be made to control diarrhea, such as using high-volume fiber substances like psyllium (psy11ium), or non-specific antidiarrheal agents such as diphenoxylate. For diseases caused by dysfunction of intestinal motility, drugs such as codeine, benzylpiperazine, and loperamide (loperamide) can be used. Loperamide can improve the frequency and urgency of daily bowel movements, increase the control of bowel movements, and the common dose is 2-4mg per day at night, with a maximum of 16mg/d. Attention should be paid that the drug may cause serious constipation and other adverse reactions when taken in large doses. Incontinence of formed stools may worsen symptoms if anticholinergic drugs are used. For diarrhea incontinence caused by bile salt reasons, cholestyramine can change the consistency of stool, which has a significant effect on many patients, but there is still no strict clinical trial to prove this effect. Osmotic laxatives are suitable for overflow incontinence, such as elderly patients can take 10ml of lactulose twice a day, and add one clean enema per week, with an effective rate of over 90%. For patients with obvious constipation, appropriate use of mild laxatives or stool softening drugs is recommended. After cleaning the intestines, about 60% of children can achieve complete self-control within one year, and another 23% of patients have a significant reduction in the frequency of stool overflow.

　　3. Psychological Treatment:The purpose of psychological treatment is to clarify and change tension factors, or change the patient's attitude towards tension factors. Such patients must first overcome psychological barriers, as fecal incontinence patients often worry about others knowing, do not want to be with others, some are ashamed to seek medical help, and delay the condition. In Western and European countries, patient encouragement groups are set up to help patients overcome shyness. For those with obvious psychogenic factors, systemic desensitization test treatment can be adopted if necessary. In addition, patients can be advised to wear elastic tight pants to increase defecation control ability.

　　4. Pelvic Floor Muscle Electrical Stimulation:Through pelvic floor muscle electrical stimulation, induce anal contraction, treat fecal incontinence. The results of efficacy reports in literature vary greatly, and most believe it is ineffective.

　　5. Biofeedback Therapy:Biofeedback therapy for fecal incontinence mainly adopts electromyographic biofeedback and anal canal pressure biofeedback. By analyzing the anal and rectal function through electromyography or manometric technology, the training method is adopted to treat fecal incontinence. Each biofeedback treatment takes about 50 minutes, during which 50 defecation training sessions are conducted once a week, for 1 to 6 weeks, usually depending on the individual situation and specific treatment effect to determine the duration of the course. The effectiveness of biofeedback therapy for fecal incontinence is 50% to 90%. Long-term follow-up shows that most patients maintain good spontaneous defecation for more than one year after biofeedback therapy. Biofeedback therapy is painless, non-invasive, without drug adverse reactions, and not affected by factors such as age, with a high success rate and low recurrence rate, and is a safe and effective method for treating FFIC.