Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 494

In the majority of older adults with faecal incontinence, an accurate diagnosis can be made and management plan instituted based on the history and examination alone, and diagnostic tests are often unnecessary. In all older adults, the decision to proceed to invasive testing should be balanced with the individual’s level of frailty and willingness to accept such investigation and the appropriateness of any subsequent invasive treatment.

In those at risk of, or with a history suggestive of, faecal impaction but no evidence of this on rectal examination, a plain radiograph can be used to demonstrate or exclude high impaction. In those with a new change in bowel habit, anaemia, and/or blood in the stool, a flexible sigmoidoscopy or colonoscopy (in those able to tolerate the procedure) can be useful in the diagnosis of colitis and other inflammatory bowel conditions or malignancy.

Table 19.2 The assessment of faecal incontinence.

History
Chronic Medical Condition
Diabetes and chronic diarrhoea or constipation
Cerebrovascular accidents or cord compression
Dementia and depression
Immobility
Trauma during childbirth
Surgical History
Haemorrhoidectomy
Sphincterotomy
Fistulectomy
Colon resection and dilatation
Radiation to the prostate or cervix for carcinoma
Review of medications such as antipsychotic, sorbitol‐based medications (theophylline)
Physical examination
Abdominal and rectal exam Vaginal exam in women
Neurological examination
Cognitive and functional assessment

In those with impaired or reduced anal tone, in particular multiparous women or those with a history of surgery to the anus, anal ultrasound is a useful and minimally invasive technique to assess the structure and function of the anal sphincter complex and correlates well with both surgical and electromyographic findings.⁵¹ Magnetic resonance imaging (MRI) has been shown to give superior spatial resolution and better contrast for lesion identification versus ultrasound⁵² but is more expensive, and availability may be limited. Defecography is a technique where a viscous barium contrast (usually, barium liquid mixed with mashed potato, oatmeal, or flour) is injected into the rectum and then defecated into a commode with X‐ray or MRI recording; it is of limited value except in the diagnosis of rectal introsusception. The advent of laparoscopic ventral rectopexy has given a useful treatment option for rectal intussusception, leading a resurgence in interest in the imaging technique.⁵³ Neurophysiological testing using electromyography, pudendal terminal motor latency, or somatosensory evoked potentials are of limited value in faecal incontinence and are not generally recommended.⁵⁴