| Summary: | Objective: Up to 0.5–1.0% of adults will experience varying degrees of faecal incontinence that affects their quality of life. The management of a patient with faecal incontinence is often difficult in spite of a diversity of treatment options for such patients. Material & Methods: By conducting a randomised control trial, using the Sealed Envelope Randomisation Technique, a sample size of 40 patients was arbitrarily chosen to evaluate the feasibility of implementing an Integrated Rapid Assessment and Treatment (IRAT) Pathway and assess its influence on patient‘s outcome measured using FI severity score and quality of life score. We then evaluate the reliability of these assessment tools by measuring the inter- and intra-rater test-retest reliability. Furthermore, we assessed the correlation between anorectal physiology study results and patients‘ symptoms measured with FI severity score to understand the role and limitation of these investigations. Finally we perform a systematic review on injectable bulking agents and report our experience with Permacol ® injections which is the main intervention offered in our unit when conservative managements fail. Results: The Implementation of IRAT pathway did not improve objective patients‘ outcome measures compared to Standard Care Pathway. However, patients were more satisfied with their management which may reflect the support and thorough education these patients received. All assessment tools used to measure patients‘ outcomes (SMIS, CCIS & FIQoLS) showed a good level of reliability. The same can not be said about anorectal physiology studies which demonstrated weak correlations with patients‘ symptoms. However, some of these studies (MMRP, MMSP, rVV and sVV) were significantly different when compared in patients with and without FI, and among subgroups of incontinent patients (urge, passive and mixed FI). Our systematic review of the published literature on injectable bulking agents has identified methodological variation between studies. The technique is safe but complications can occur. Some 70 per cent of patients have an early clinical response but less than 50 per cent of patients are able to maintain this response on maximum follow-up. The choice of material is likely to influence the outcome and the use of a general anaesthetic during the procedure and laxatives in the postoperative period are associated with favourable outcomes. Trans-submucosal Permacol® injection is associated with 72% and 63% improvement in St. Mark‘s Incontinence Score in patients with idiopathic faecal incontinence at short and medium term follow-up respectively. However only 39% and 27% of patients achieve a 50%, or more, improvement in St. Mark‘s Score in the short and medium term follow-up. Conclusions: Despite widespread enthusiasm for critical pathways, rigorous evidence to support their benefits in health care is limited. However, understanding what evidence-based information is, and translating this information into practice using reminder systems or other effective implementation strategies, can potentially improve care, reduce costs, and enhance safety. CCIS, SMIS, and FIQoLS, all have good test-retest reliability and adequately reflect the global disease burden. Therefore, they are appropriate tools to objectively measure symptoms and compare the various management modalities. Physician should understand the limitation of anorectal physiology studies when they are used in the assessment of patients with defective continence mechanism. The current success rate and durability of symptomatic control with the use of IBA makes it an acceptable option for managing faecal incontinence owing to the simplicity, minimal invasiveness, safety and low cost. Unlike artificial anal sphincter, stimulated graciloplasty and SNS, IBAs can be implemented in units with limited resources, experties and infrastructure, making a potential treatment of FI more widely available and contributes to the overall improvement in the quality of care provided. Routine maintenance and follow-up is not needed and therefore IBAs may be more suitable for elderly patients and patients with comorbidities or impaired mental capacity who constitute the major group among those with faecal incontinence.
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