Faecal Incontinence Month: Diagnosis in Faecal incontinence - what should we know?
An interview with Dr José de Assunção Gonçalves
Dr Jose de Assunção Gonçalves (Dr JAG) (right) currently works at Hospital da Luz – Lisboa and is a member of the Executive
Committee of the Portuguese Society of Coloproctology and
of the of the Portuguese Neurourology and Urogynecology Association.
In this interview, Dr JAG speaks to Dr Miguel Cunha and explains what we should know about diagnosing faecal incontinence.
MC: Firstly, let me thank you for agreeing to participate in this interview! It is a pleasure to interview you and get to know more about your view on the diagnosis of Faecal incontinence. As mentioned in the ESCP Guidelines, clinical history is crucial for adequately evaluating faecal incontinence patients. What would be a good clinical history format, or in other words, how do you usually do it? Which scales do you use? How do you assess bowel habits?
Dr JAG: I usually say that approximately 95% of the information you need to evaluate and treat a patient with faecal incontinence is provided at the clinic appointment’s office with a good clinical history and a thorough physical examination. This would be an evidence level V statement if you consider me an expert. I think it is eloquent to stress its significance. Pelvic floor disfunctions are probably one of the last fields in medicine that rely so much on a doctor-patient relationship.
I started my specialization in pelvic floor disorders when I worked as honorary clinical assistant to Ms Vaizey at St. Mark’s Hospital (London). Her mentorship was pivotal in my practice and to this day an inspiration. I use the St. Mark’s clinical history of anorectal functional pathology. This questionnaire fits in an A4 sheet (front and reverse) and addresses all the things you need to know. I strongly recommend having copies at the appointment office and focus on identifying the main complain (don’t forget that one can be incontinent and constipated at the same time).
At some point you will remember all those questions but if you’re just starting, I believe this questionnaire will be your best friend. In it you’ll find the Bristol Stool Chart and the St. Mark’s/Vaizey Score for faecal incontinence. I prefer the latter to the Wexner Score because it adds two points (ability to defer and using of pad). In short, the most important thing is to use always the same scale (be it Vaizey or Wexner) for follow-up.
MC: I believe this evaluation will be very much dependent on the relationship you develop with the patient and how you get him/her to feel confident to share his/her symptoms and concerns. Do you agree with this? Do you have any tips or tricks you usually use to work on this relationship?
Dr JAG: I cannot think of another disease that affects so much the dignity of a human being as faecal incontinence does. Both in our social and sexual condition. It’s absolutely devastating and people suffer in silence. When a patient reaches our office there is huge load of problems and high intense feelings that need to be taken care of. It is not the typical 3-steps situation that the surgeon was trained to: disease-surgery-cure. And such patients will usually need more of your time than what is booked for. You will need a longer appointment than usual and you’ll need flexibility sensitivity and cleverness to be able to fill all the questions of the clinical history. Empathy is the key word. Show (and feel) compassion and hide your stress because that patient has “ruined” your morning or afternoon schedule. That’s the only way I know to gain the patient’s trust, confidence and hope. Let the patient speak but then be assertive and focus on the problems. At the end of the day, medicine is a science and you need objectiveness. Otherwise you risk an one hour appointment and still be clueless of what to do. Last but not least, even when you don’t know what to do, there is one strong message you really need to pass on to the patient (and to yourself): “Faecal incontinence has a solution and we will take care of you”.
MC: Regarding the workup to evaluate the anorectal function and integrity, which complementary exams do you usually ask for? Do you believe one size fits all? Or is your workup different on a case-by-case basis?
Dr JAG: There are 5 reasons for asking complementary exams:
- Clinical purposes (when the results of the exams affect the decision of the treatment you will implement);
- Academic (research studies purposes);
- Defensive clinical practice (forensic purposes);
- Patient’s power of persuasion;
- Postponement of a decision.
All are plausible. Most of the times you will only need common sense. Regarding faecal incontinence, for functional testing I perform anorectal manometry testing following the IAPWG protocol and for sphincter integrity assessment I perform endoanal ultrasound (2D – axial). Not all patients will need these exams for you to choose the best treatment.
T. Kocher said that “a good surgeon is a doctor who knows how to operate and when not to operate”. I think that applies to complementary exams as well. Apart from guidelines and recommendations which are exactly that - lines that guide you and recommend good practices - I think you’ll achieve being a good doctor when you know which patients really need and benefit of complementary exams.
MC: What about to multidisciplinary meetings? Do you believe they are important to discuss every and each case? How do you do it in your practice?
Dr JAG: I’m all in for a multidisciplinary approach. On history taking we ask for urinary symptoms, pain, pelvic organ prolapse and sexual life. Then we perform the physical examination. If there’s any issue to be addressed we take the case to the team. I work in a private hospital with a high-volume maternity. There we have dedicated urogynecologists, urologists, physiatrists and general (colorectal) surgeons. Personally, I think the biggest achievements of the pelvic floor multidisciplinary team in my hospital has been raising awareness of the colorectal disorders to the gynaecologists/obstetricians and urologists (therefore optimizing their referencing to us) as well as optimizing the patient circuit with the Rehabilitation Service. It also provides an excellent opportunity to discuss the various therapeutic options.
MC: What advice would you give to young Colorectal Surgeons interested in the field of faecal incontinence? How can they improve and implement a dedicated practice in this field?
Dr JAG: First of all; be aware and inquisitive towards the patient. Then empathy. Think of it on the history of pelvic surgeries namely on rectal resection. Ask for obstetric history and search for eventual injuries. Ask for current medication (sometimes you will only need to substitute metformin). Try and ask first for urinary incontinence. Suspect of physical, psychological or even sexual abuse. Be prepared for grief, rage and resentfulness. Don’t feel that the patient is retarding your busy schedule. Instead, view it as a big challenge and that you will make a huge difference in someone’s life. And be prepared for treatment failure and setbacks.
Bond with the urogynecologists, obstetricians and urologists of your hospital. They have a longer dedication to this field than we do, are usually much more experienced than we are and will probably be our biggest “providers” of patients.
I feel that faecal incontinent patients are the most grateful of all (even more than oncologic patients that carry on fearing the sword above their head for some years). That will make your day and your job as a doctor worth it.
MC: Thank you so much for sharing your knowledge with us.
