Nisan 2016

24-25

Levent FİLİK

Department of Gastroenterology, Education and Research Hospital, Ankara

Sarkopeni, ilerlemiş yaşa bağlı kas kütlesi ve fonksiyonlarındaki azalmadır. Yaşam kalitesini etkileyen bir faktör olan sarkopeni, anal sfinkter fonksiyonlarında da azalma ve fekal inkontinense neden olabilir. Bu olgu sunumunda eksternal anal sfinkter yorgunluğuna neden olarak fekal inkontinens gelişmiş bir vaka sunulacaktır.

Anal manometri, inkontinens, anal sfinkter

Sarcopenia, defined as loss of skeletal muscle mass and function, is associated with impaired quality of life in elderly age (1). Accordingly, elderly persons are particularly susceptible to faecal incontinence (FI) due to ageing of neuromuscular system (2). FI is an important health burden on elderly patients and their families, nurses, physicians and health-care system (3). Polypharmacy and comorbidity plays an additional negative effect on anal sphincter dysfunction due to ageing. External anal sphincter (EAS) is naturally subject to fatigue. Voluntary contraction failure of the EAS is an important factor in FI. The fatigue rate (FR) is a computerized system parameter to show the sustained voluntary contraction of EAS in anorectal manometry (ARM), considering the squeeze pressure and the EAS fatigability. Although FR is thought to be a practical index to reveal the patients with anal sphincter dysfunctions, there is no enough data for elderly individuals. In this clinical case study we present a 62 year-old male patient. He had a complaint of fecal soiling although his anal sphincter resting pressure was normal.

Based on the above-mentioned data of our patient, anal sphincter pressures were adversely affected in elderly age. The patient did not have any neurological disease or colorectal surgery that might cause anal sphincter dysfunction. EAS is important in faecal continence and may be susceptible to fatigue in elderly men due to sarcopenia. Nevertheless, fatigability is not routinely measured in anorectal examinations. Several studies state conflicting results regarding the fatigue rate of EAS (2-5). Nockolds et al. stated that females with anal incontinence have a weaker but more fatigue-resistant EAS compared to women with constipation. This difference was proposed to be linked with presence of higher proportion of slow-twitch muscle fibres (3). We propose that the different results are likely due to different pelvic floor anatomy of women and men. No doubt, further studies are necessary to clarify this issue. Nevertheless, new studies on muscle fibers (slow twitched and fast twitched) should be gender and age specific. Herein, the issue of concern is underestimation of subclinical faecal incontinence of elderly individuals. Therefore, longterm personal and social problems due to mild incontinence in elderly patients often go unrecognized. In conclusion, anal incontinence should be considered as an adverse effect of ageing due to sarcopenia in elderly with otherwise normal resting anal sphincter pressure. It should not be underestimated and motility study should be done even if subclinical FI has been suspected in elderly. Also, long squeeze pressure recording is necessary in elderly patients even if the resting pressure is normal. Further studies are necessary to clarify the impact of age and gender on anal continence problems. Finally, new studies regarding geriatric sarcopenia should address anal sphincter dysfunctions.

Based on the above-mentioned data of our patient, anal sphincter pressures were adversely affected in elderly age. The patient did not have any neurological disease or colorectal surgery that might cause anal sphincter dysfunction. EAS is important in faecal continence and may be susceptible to fatigue in elderly men due to sarcopenia. Nevertheless, fatigability is not routinely measured in anorectal examinations. Several studies state conflicting results regarding the fatigue rate of EAS (2-5). Nockolds et al. stated that females with anal incontinence have a weaker but more fatigue-resistant EAS compared to women with constipation. This difference was proposed to be linked with presence of higher proportion of slow-twitch muscle fibres (3). We propose that the different results are likely due to different pelvic floor anatomy of women and men. No doubt, further studies are necessary to clarify this issue. Nevertheless, new studies on muscle fibers (slow twitched and fast twitched) should be gender and age specific. Herein, the issue of concern is underestimation of subclinical faecal incontinence of elderly individuals. Therefore, longterm personal and social problems due to mild incontinence in elderly patients often go unrecognized. In conclusion, anal incontinence should be considered as an adverse effect of ageing due to sarcopenia in elderly with otherwise normal resting anal sphincter pressure. It should not be underestimated and motility study should be done even if subclinical FI has been suspected in elderly. Also, long squeeze pressure recording is necessary in elderly patients even if the resting pressure is normal. Further studies are necessary to clarify the impact of age and gender on anal continence problems. Finally, new studies regarding geriatric sarcopenia should address anal sphincter dysfunctions.

1. Bosaeus I, Rothenberg E. Nutrition and physical activity for the prevention and treatment of age-related sarcopenia. Proc Nutr Soc 2015;1:1-7. 2. Bilali S, Pfeifer J. Anorectal manometry: are fatigue rate and fatigue rate index of any clinical importance? Tech Coloproctol 2005;9:225-8. 3. Nockolds CL, Hosker GL, Kiff ES. Fatigue rate of the external anal sphincter. Colorectal Dis 2012;14:1095-100. 4. Telford KJ, Ali AS, Lymer K, et al. Fatigability of the external anal sphincter in anal incontinence. Dis Colon Rectum 2004;47:746-52. 5. Paganotti B, Miasato M, Kardoch FP, et al. Fatigue rate index is higher in children with functional constipation and retentive fecal incontinence. J Pediatr Gastroenterol Nutr 2015;61:525-6.