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FecalIncontinenceTreatment&Management
TREATMENT

MedicalTherapy
Conservativetreatmentoptionsforfecalincontinenceincludebulkingagentsandbiofeedback.After
historyandphysicalexaminationfindingshavehelpedexcludesystemicdiseaseandlocalanal
pathologyasthesourceofthepatient'sproblem,theprovidercaninitiatetreatment.

Thegoalofmedicaltherapyistoreducestoolfrequencyandimprovestoolconsistency.Aregular
bowelregimenincludingdailylaxativesshouldbeestablished.Ifimpacted,manualdisimpactionanda
dailytapwaterenemamayhelppreventreaccumulation.Theetiologyofdiarrheashouldbe
diagnosedandtreatmentinitiated.Mildincontinencecanoftenbeimprovedbyinitiatingsimple
conservativemeasures.Forpatientswithinfrequent,lowvolumestools,bulkingagentsarehelpful,as
formedstoolsareeasiertocontrolthanliquidstools.Methylcellulose(Citrucel)orpsyllium(Metamucil,
Fiberall,Hydrocil)canbetakendaily.Additionalfirmingofthestoolcanbeobtainedbyrestrictingfluid
withintakeofthebulkingagent.Thismaybehelpfultherapyinthepatientwhohasincontinenceof
softstoolorliquidstool.

Inpatientswithdiarrheaduetononinfectiousetiologiesorwithreducedrectalcompliancedueto
radiationproctitisorinflammatoryboweldisease,agentsthatslowthemotilityofthegutmaybe
helpful.Loperamidehydrochlorideincreasesguttransittime,allowingforincreasedabsorptionof
waterfromthevolumeofstool.Thisresultsinafirmer,moreeasilycontrolledstool.Themaximum
dailydosageis16mg.Theusualdoseregimenis24mgtwiceorthreetimesdailytocontrol
symptoms.Anadditionalbenefitoftheopiatederivativeloperamide(Imodium)isthatitincreases
internalanalsphinctertoneandmayimproverectalcompliance.[51]Diphenoxylate
hydrochloride/atropine(Lomotil)hasalsobeenusedhowever,diphenoxylatehydrochloridecancause
dependenceandisascheduleVmedicationundertheControlledSubstanceAct.

Biofeedbackisasafe,minimallyinvasivebehavioraltechniquethatusesauditoryorvisualfeedback
toreeducatethepelvicfloormusculature.Althoughmanydifferenttherapieshavebeenused,several
studiesthathavedemonstratedasignificantimprovementinfecalincontinencebytreatmentwith
biofeedback.[52,53]Otherdata,includingarecentCochranereview,doesnotprovideclearevidence
oftherapeuticbenefit.[54]Themostcommonlyusedtechniquesarerectalsensitivitytrainingandanal
sphincterstrengthtraining.

Duringrectalsensitivitytraining,arectalballoonisgraduallydistendedwithairorwaterandthe
patientisaskedtoreportfirstsensationofrectalfilling.Oncethisthresholdvolumeisdetermined,
repeatedreinflationsoftheballoonareperformedwiththeobjectivebeingtoteachthepatienttofeel
thedistensionatprogressivelylowervolumes.Therationaleisthatsomepatientsarefoundtohave
highthresholdvolumesandifthepatientdetectsstoolarrivingsooner,thereismorepossibilityto
eitherfindatoiletoruseananalsqueeze,orboth.Conversely,thesametechniquehasalsobeused
toteachthepatienttotolerateprogressivelylargervolumesinthosewithurgencyanda
hypersensitiverectum.[54]

Biofeedbacktechniqueshavealsobeenusedtodemonstrateanalsphincterpressuresoractivityto
thepatient,therebyenablingteachingofanalsphincterexercisesandgivingfeedbackon
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performanceandprogress.ThiscanbeachievedbyusingEMGskinelectrodes,manometric
pressures,intraanalEMG,oranalultrasonography.Thepatientisencouraged,byseeingorhearing
thesignal,toenhancesqueezestrengthandendurance.Thereisnoconsensusonanoptimum
exerciseregimenforuseathomebetweensessions,noronthenumberofsqueezes,frequencyof
exercises,ortreatmentduration.Differentauthorsmaydescribeverydifferentprograms.[54]

Biofeedbackrequiressomerectalsensationandtheabilitytovoluntarilycontractthesphincter.It
appearstobeeffectiveforneurogenicandidiopathicanalincontinenceandforincontinencerelatedto
disruptionofanalsphincters[53],butarecentCochranereviewdidnotdemonstrateconclusive
therapeuticbenefits.[54]Biofeedback'ssuccessseemstodependonimprovingrectalsensation,
becausemanometricstudieshavenotshownconsistentimprovedsphincterpressure.Personalunits
arenowavailable(withoutprescription)forhomeuseafterinitialclinicalinstruction.Theyusea
vaginallyplaced,airfilledsensorthatprovidesinformationonforceanddurationofcontractions.
Resultsfrombiofeedbackcandiminishovertime,buthomedevicesprovidethepatientthe
opportunityforaprolongedcourseoftherapyandintermittentreeducationinaprivatesetting.

Ina2012randomized,doubleblindstudy,3monthsoftreatmentwithtranscutaneouselectricaltibial
nervestimulation(TENS)wasnotsignificantlybetterthanshamtreatmentinimprovingthenumberof
incontinenceandurgencyepisodesin144patientswithfecalincontinence.[55]

A2015summaryofthetreatmentoffecalincontinencefromthe2013NationalInstituteofDiabetes
andDigestiveandKidneyDiseases(NIDDK)Workshophasbeenpublished.[3]

SurgicalTherapy
Oncemedicaltherapyhasbeenmaximized,minimallyinvasiveandsurgicaltherapiesmaybe
considered.Inselectpatients,injectablematerialsmayprovideimprovementinanalsphincter
function.

Severalreportshavedescribedinjectionofvariousmaterialstoaugmentthefunctionoftheinternal
analsphincter.Injectablesiliconehasbeenshowntobeeffective.Inastudyof82patientswithsevere
fecalincontinenceandalowanalrestingpressurecausedbyinternalanalsphincterdysfunction,
patientswererandomizedtosiliconeinjectionintotheintersphinctericspaceandinternalanal
sphincterwith(GroupA,n=42)orwithout(GroupB,n=40)guidancebyendoanalultrasonography.
Resultsshowthatfecalincontinenceimprovedsignificantlyinbothgroupswithupto12monthsof
followupbuttoagreaterextentinthegroupinwhominjectionwasultrasonographicallyguided.No
seriouscomplicationsoccurred.[56]

Resultswithcarboncoatedmicrobeadshavebeenlesspromising.Inapilotstudyof33patients,the
submucosalinjectionofcarboncoatedmicrobeadsimprovedminorfecalincontinencebyincreasing
analpressurebutdidnotsignificantlyimprovequalityoflife.[57]Experiencewithcollageninjections
hasbeenmorelimited.

Severalsurgicalproceduresareperformedforthetreatmentofanalincontinence.Thetypeof
procedureusedisbasedonthepatienthistory,physicalexaminationfindings,andresultsof
diagnosticevaluation.Thecurrentphilosophyinpelvicreconstructivesurgeryisrestorationofnormal
anatomy.Usually,sphinctercomplexdefectsaresecondarytoobstetricinjury,fistularepair,orlateral
internalsphincterotomy.Thestandardprocedureforanalincontinenceduetoanalsphincterdisruption
istheanterioroverlappingsphincteroplasty.ThisprocedurewasfirstproposedbyParksetalin1971
andmodifiedbySladeetalin1977.

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Anteriorsphincteroplastyconsistsofdissectingouttheexternalanalsphincter,dividingthescartissue
inthemidline,andthenoverlappingthescarsothatmuscleisapproximatedtomuscleascloselyas
possible.Thesurgerycanbeperformedwiththepatientinthepronejackknifepositionorthedorsal
lithotomyposition.Controversyexistsastotheneedtoidentifyandplicatetheinternalanalsphincter.
Itsvalueinthecontinencemechanismhasbeendiscussed.Severalpostoperativestudieshave
demonstratedimprovementinrestingandsqueezepressures,whichsuggestthateithertheinternal
sphincterwasplicatedintentionallyorthattheinternalanalsphincterwasalsounintentionallyplicated
intheprocessofoverlappingthescarmass.Inanolderstudy,Fangandcolleaguessuggestnot
separatingtheinternalfromtheexternalanalsphinctershowever,theydonotdiscussthereasoning
forthis.[58]

Severalotherstudieshaveperformedultrasonographyofthesphincterspostoperatively,yetfew
specificallymentiontheconditionoftheinternalsphincter.Brieletalcompared2groupsofpatients
whounderwentsurgicalrepair.Onegrouphadsurgicalrepairofonlytheexternalsphincterbetween
1973and1989.Thesecondgroupunderwentsurgicalrepairconsistingofrestorationofthe
rectovaginalseptum,perinealbody,andrepairoftheexternalandinternalsphincters.Thesepatients
hadsurgicalrepairbetween1989and1994.Theyfoundthatthemorecomplexrepairconferredno
advantage.Themeasuredoutcomefocusedonanalcontinence,whichwasrestoredorimprovedin
63%and68%,respectively.[59]

Fortheinternalanalsphincterrepair,thesurgicalapproachrequiresdissectionalongthe
intersphinctericplaneandidentificationoftheinternalanalsphincter.Thesphincteristhendissected
freefromtherectalmucosaandmobilized.Thesurgicaltechniquevariesdependingonthebulkof
scartissue.Thescartissueiseitherdividedorleftintactasthesphincterisplicated.

AbouZeidperformedisolatedinternalsphincterrepairin8patientswithultrasonographicallyproven
defectsoftheinternalanalsphincter.Allpatientshadanalincontinenceofvaryingdegrees.Allhad
undergoneapriorsurgicalprocedure,suchashemorrhoidectomyorsphincterotomy,andhad
developedsymptomssubsequently.Allpatientsunderwentpreoperativeultrasonography,and6
patientsunderwentpostoperativeendoanalultrasonographytodocumentinternalsphincteranatomy.
Continencescoresimprovedinallpatients,and2patientsachievedcompletecontinence.[14]The
smallnumbersofthiscasesseriesareencouraging,butdonotallowfordefinitiveconclusions.

Mostreconstructivesurgeonsperformcolporrhaphyandperineorrhaphyaspartoftheoverallrepair.
Numerousarticlesdescribethephysiologicandsupportiveroleoftherectovaginalseptumand
perinealbody.Inastudyof143women,Weberandcolleaguesfoundthatdefectsintheposterior
compartmentoftencoexistwithbowelsymptomshowever,theywereunabletoshowadirect
correlationbetweenstageofprolapseandseverityofbowelsymptoms.Thisstudydidnotproceed
withsurgicalrepairandevaluateforsymptomspostoperatively.[60]WexnerandOliverasupportthe
philosophyofrepairofalldefectsandsuggestthatfailuretorecognizeandrepairconcomitantinjuries
oftheanalsphinctermechanismisusuallyaccompaniedbycontinuedanalincontinence.[61]

Pudendalnerveneuropathyisassociatedwithahigherfailurerateaftersphincteroplasty.As
discussedpreviously,Gillilandfoundthattheonlyfactorpredictiveofsuccessfuloutcomeof
overlappingsphincteroplastywasbilaterallyintactPNTML.[46]Sangwanetalfoundthatpatientswith
unilaterallyintactpudendalnerveshadalessfavorableoutcomethanthosewithbilaterallynormal
latencies.[47]Chenetalevaluatedpatientswhohadnormal(1),unilateral(7),orbilateral(4)
prolongationofPNTMLwithpreoperativeandpostoperativeincontinencescores.Theyfound
significantimprovementinincontinencescoresamongallgroups.Theseresultsweresustainedat20
to72monthfollowup.

Differentstudieshavedemonstratedthatanterioroverlappingsphincterrepaircanimprovecontinence
scores,restingpressures,andsqueezepressuresregardlessofpudendalnervelatenciestherefore,
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ifsphincterdisruptionispresent,repairshouldbeoffered.Counselingpatientsregardingsurgical
outcomesandrisksisimperative.

Someresearchersperformpostanalrepairinpatientswithanalincontinencefromaneurogenicor
idiopathiccause.Thistypeofanalincontinenceisoftenassociatedwithdenervationofthepelvicfloor.
Patientshaveadecreasedabilitytosenseimpendingdefecationandmayinitiallybecomeawareof
theneedforabowelmovementonlyaftertheyhavepassedstoolandnoticetheodororsensationof
fecalmaterialaroundtheanus.Theinternalandexternalanalsphinctersareusuallyintact.Evaluation
oftendemonstratesanincreaseintheanorectalangle,whichhasalsobeendescribedasa
"flattening"oftheanorectalangle.

Theoriginaltheorybehindpostanalrepairwasrestorationoftheanorectalangleandlengtheningof
theanalcanal.Theincisionismadeposteriortotheanalcanalandcarriedtothelevatorplate.The
dissectioniscarriedintheintersphinctericplanebetweentheinternalandexternalanalsphincters.
Onceidentified,theileococcygeus,puborectalis,andpubococcygeusmusclesareplicatedposterior
totherectum.Theinternalanalsphincter,externalanalsphincter,orbothcanalsobeplicatedduring
theprocedure.ThisapproachwasfirstdescribedbySirAlanParks,whoseinitialserieshadan83%
successrate.Manysubsequentseriesbydifferentinvestigatorshavebeenunabletomatchthis
originalsuccessrate.

Inanattempttobetterunderstandthemechanismofpostanalrepair,severalinvestigatorshave
performedpreoperativeandpostoperativephysiologicevaluationofpatients.Inareviewof30
patientswhohadundergonepostanalrepair,SettiCarraroetalfoundthat19ofthe30patientshad
breaksintheinternalanalsphincter(6),theexternalanalsphincter(4),orboth(9)onendoanal
ultrasonography.[62]MatsuokaandcolleaguesperformedpreoperativePNTML,EMG,and
manometryandfoundnopredictivefactorintheoutcomeofpostanalrepair.[63]Scottetalperformed
manometrypriortopostanalrepairandwereunabletoshowanycorrelationbetweenmanometryand
successfuloutcome.

Laurbergetalperformedextensivepreoperativeandpostoperativeevaluationincludingmanometry,
perinealdescent,PNTML,andsinglefiberEMG.Theyfoundminimalcorrelationwithpreoperative
physiologictestingandsuccessfulsurgicaloutcome.Ofinterestinthisstudyisthefindingof
increasedfiberdensityandprolongedPNTMLinthosepatientswhoimprovedwithsurgery,
suggestingdamageasaresultofpostanalsurgicalrepair.[64]SettiCarraroetalalsofound
postoperativeprolongationofPNTML,from2.2millisecondsto2.85milliseconds,inpatientswitha
successfulsurgicaloutcome.Theyfoundthattheonlypreoperativefactorpredictingsuccessful
outcomewasintactPNTML.[62]OthersalsofoundthatintactPNTMLisassociatedwithbetter
surgicaloutcomes.Thesefindingsseemtoindicatethatthepatientwithidiopathicfecalincontinence
andnormalPNTMLhasabetterchanceofsuccesscomparedtoapatientwithaneurogeniccauseof
incontinence.

BothLaurbergetalandSettiCarraroetalhavefoundthatpostanalrepairmaycausetraumatothe
pudendalnervesthatdidnotexistpreoperatively.Thepotentialconsequencesofthisarenotknown.
Jamesonetalevaluatedpatients2yearsfollowingpostanalrepairandfoundadecreaseinthe
numberofpatientswhohadsomebenefit(83%to53%),withonly28%whoweremarkedlybetterat2
years.[65]

Theeffectofpostanalrepairontheanorectalanglehasalsobeenevaluated.Bartoloandcolleagues
haveshownthatrestorationoftheanorectalangledoesnotcorrelatewiththesuccessofpostanal
repair.Failureofpostanalrepairtorestoretheanorectalanglehasbeenconfirmedbyother
investigators.Womacketalhadimprovementin70%of16patientsandfoundnosignificantchange
intheanorectalanglewhenmeasuredradiographically.Theyrecommendthattheprocedurenotbe
limitedtothosepatientswithwideningoftheanorectalangle.[66]
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Inacomparisonofanteriorsphincteroplastyandpostanalrepair,Orromandcolleaguesfoundno
postoperativeadvantageforeitherprocedure.[67]Theyfoundthatpatientswhohadundergone
postanalrepairhadnochangeinanorectalangle,whereasthosewhohadundergoneanterior
sphincteroplastywithanteriorplicationofthelevatorshadamoreobtuseanorectalangle.They
concludedthatrestorationoftheanorectalanglewasnotimportant,andtheirgrouphasabandoned
thepostanalapproach.Matsuokaetalconcludedthatalthoughthesuccessrateforpostanalrepair
waslow(~35%),itisavalidtherapeuticapproachbecauseoflowmorbidityandtheabsenceof
mortality.[63]Thealternativeforthesepatients,inwhomothermodalitieshavefailed,istolivewith
thisverydisablingcondition,undergodivertingcolostomy,orundergomuscletransfer.

Musclewraptechniqueshavebeendevelopedinwhichstriatedmusclesfromthegracilisorgluteus
musclesaretransposedandwrappedaroundtheanalcanaltoincreasetone.Theuseofthegluteus
musclehaslargelybeenreplacedbygracilistransfer.Thesetechniquescreateaneosphincterwhen
thereisnotenoughmusclepresenttorepair.Theproceduremaybeindicatedinpatientswhohave
congenitalabsenceoftheanalsphincterorinthosewhohavelosttheanalsphincterasaresultof
disease,althoughsomehaveundertakenthisprocedureafterattemptsatsphincterrepairhavefailed.

Toperformgracilistransfer,themuscleismobilizedwhilemaintainingtheproximalattachmentsand
theneurovascularbundle.Caremustbetakentopreventdevitalizationofthemuscle.Themuscleis
tunneledandthenwrappedaroundtheanus.Thedistalendissuturedtothecontralateralischial
tuberosity.Implantationofanervestimulatortothetransposedmuscletoaidinlongtermcontraction
isdescribed.Resultshavebeengood,withasuccessrateof66%inaseriesof139patients.[68]
However,theprocedurehasahighcomplicationrateandisusuallyperformedintheresearchsetting.
[69] Inpatientswithsevereanalincontinenceorthoseinwhomotherprocedureshavefailed,muscle

transpositionmayofferanimprovementinqualityoflife.[70]

Theartificialbowelsphincter(ActiconNeosphincter)wasdesignedtoactasapatient'sownanal
sphincterincasesofseverefecalincontinence.ThisimplantabledeviceisproducedbyAmerican
MedicalSystemsandisavailableintheUnitedStates.Theinflatablecuffisplacedaroundtheanus,
andaninflationreservoirisplacedinthespaceofRetzius.Asthepatientfeelstheneedtohavea
bowelmovement,acontrolpumpissqueezedandforceswateroutofthecuffandintothereservoir.
Thisallowsthepatienttohaveabowelmovement.Thecuffslowlyrefillsoverseveralminutes.Itsuse
inpatientswithfecalincontinencehasbeensomewhatlimitedandrecentlongtermdatahasbeen
disappointing.Inastudyof25patientswhowerefollowedforamedianof50months,only3hadgood
functionalresultswiththesystem.Complicationsincludedinfection,erosion,chronicpain,and
obstructeddefecationthedeviceremovalratewasapproximately50%inthisseries.[71]

Whenfecalincontinencepersistsaftermedicalandsurgicaltherapieshavefailed,acolostomymay
beconsidered.Thisconvertsaperinealstomaintoamanageableabdominalstomaandremovesthe
constantfearofpublichumiliation.

Formorerecentinformation,thereaderisencouragedtoreviewthe2015summaryofthetreatment
offecalincontinencefromthe2013NationalInstituteofDiabetesandDigestiveandKidneyDiseases
(NIDDK)Workshop.[3]

SacralNerveStimulation
Sacralnervestimulation(SNS)isanestablished,FDAapproved,minimallyinvasiveprocedureforthe
treatmentoffecalincontinence.TheneurostimulatordeviceisknownastheInterStimSystem,
manufacturedbyMedtronics.SNShasbeenshowntobenefitpatientswithfecalincontinencecaused
byminoranalsphincterdefectsorduetoneurologicdisordersresultinginrectalhyposensitivity,as
wellasthosewithintactsphincterswhohavefailedconservativetherapies,includinglowresiduediet,
medications,andbiofeedbackphysiotherapy.
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InterstimSNSisatwostepprocessthatbeginswiththeplacementofatemporaryexternal
electrodeintothesacralforamentoprovidelowamplitudeelectricalstimulationoftheS3sacralnerve
roots.Itlikelyworksatthepelvicafferentand/orcentrallevelratherthanprimarilyperipheralmotor
neurostimulation.[72]SNSthenreducessymptomsoffecalincontinencebyimprovingtherestingand
squeezepressuresoftheanalsphincter,rectalsensation,andcolonicmotility.[72,73,74,75]Patients
whorespondtoa2weektrialsubsequentlyundergoplacementofapermanentelectrodeconnected
transcutaneouslytoanembeddedneurostimulator.Bothstepsareperformedintheoperatingroom
andrequiregeneralorlocalanesthesia.Thepracticeofemployingatemporary,percutaneousSNS
fora2to3weekperiodallowspractitionerstoidentifypatientswhoaremostlikelytorespond
positivelytoapermanentimplant.[76]Percutaneousnerveevaluation(PNE)isanalternative,office
basedprocedurethatallowsthetemporaryneuromodulatorleadtobeplacedunderlocalanesthesia.
Ifthisinitial,temporaryphaseissuccessful,theInterStimdeviceisimplantedintheoperatingroom.
Studieshaveshownsuperiorityofthe2stagedtrialascomparedtoPNE.[77,78]

SeveralclinicalstudieshaveshownthatSNSachievesgreaterrateofcontinenceamongpatientswith
fecalincontinencecomparedtoplaceboortooptimalmedicalmanagement.Goodoutcomeswere
firstreportedin1995,andsincethen,numeroustrialsintheUnitedStatesandinEuropehaveyielded
evidencesuggestingthatSNScanimprovecontinenceinaproportionofpatientswithfecal
incontinence.[76,73]

Severalauthorshavealsoshowngoodoutcomesamongpatientswithfecalincontinencecausedby
anteriorresectionandchemoradiationforrectalcancer,[79,80]systemicsclerosis,[81,82]andCrohns
disease.[83]Studiessuggestthatafterimplantation,41to75%ofpatientsachievecompletefecal
continenceand75to100%experienceimprovementinincontinenceepisodes.[84]Importantly,the
therapeuticeffectandimprovedqualityoflifeforfecalincontinenceismaintainedforatleast5years
afterSNSimplantation,with89to92%having>50%improvementand36to48%havingcomplete
continence.[85]However,10to35%ofpatientswithfecalincontinencedonotrespondafter
permanentimplantation,eitherimmediatelyorlater,despiteinitiallysatisfactoryteststimulationfor
reasonsyetunknown.Severalcohortstudieshavenotbeenabletoidentifyspecificpredictivefactors
duringpreoperativeevaluationforsuccessfuloutcomeswiththepermanentSNSimplant.[86,87,88]

A120patientprospectivemulticentercohortstudywithanFDAapprovedinvestigationalprotocol
revealedthat83%and85%ofsubjectswithapermanentneurostimulatorachievedtherapeutic
success(definedas50%reductionsofincontinentepisodesperweek)at12and24months,
respectively,and41%ofpatientsachieved100%continenceat24months.Incontinentepisodes
decreasedfromameanof9.4perweekto1.9at12monthsand2.9at24months.[89]

InarandomizedstudybyTjandraandcolleagues(2008),120patientswithseverefecalincontinence
wererandomizedtohaveSNSorbestsupportivetherapy,whichinvolvedpelvicfloorexercises,
bulkingagent,anddietarymanipulation.Duringa12monthfollowupperiod,fullassessmentincluded
endoanalultrasound,anorectalphysiology,a2weekboweldiary,andfecalincontinencequalityof
lifeindex.Comparedtothecontrolgroup,theSNSgroupexperiencedasignificantdecreaseinmean
incontinentepisodesperweekfrom9.5to3.1andinmeanincontinentdaysperweekfrom3.3to1,
aswellasasignificantimprovementinfecalincontinencequalityoflifeindex.Fortysevenpatients
(39%)achievedperfectcontinencewithSNS.[90]

InamulticenterstudycomparingSNStoplacebo,Leroiandcolleagues(2005)randomized27
patientswithSNSinadoubleblindcrossoverdesigntostimulationONorOFFfor1monthperiodsfor
upto8months.Patientswhoreceivedstimulationreportedasignificantreductioninfrequencyof
fecalincontinenceepisodesandsymptomseverity,preferenceforONphase,andanimprovementin
theabilitytopostponedefecation,thequalityoflife,analsphincterfunction.Continencewasfully
restoredin5ofthe19(26%)patientswhoactuallyreceivedstimulation.[91]
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A5yearprospectivestudybyBoyleandcolleagues(2011)wasfirsttoreportdatawithintentionto
treatinanattempttoassessthetrueefficacyofSNSforfecalincontinence.Among50patientswith
fecalincontinence,13patients(26%)didnotrespondduringthefirst,temporaryimplantationstageor
weredissatisfiedwiththeresult.Tenadditionalpatients(20%)didnotachievea>50%reductionin
symptomsfollowingpermanentimplantation.Nevertheless,27patients(54%)experienced>50%
reductioninsymptoms,including13(26%)whoachievedapparentcontinence.SNSresultedina
significantreductionoffecalincontinenceepisodespernightfrom14to2,andinanimprovementin
theabilitytodeferdefecation.Therefore,whilegoodoutcomeswerecomparabletoaforementioned
studies,thisstudyrevealedthatsymptomsoffecalincontinencecontinueinthemajority(74%)of
patientswhenanalyzedbyintentiontotreat.[92]

Amongtheabovementionedstudies,analyzedinarecentCochraneReview,adverseeventsoccurred
among1225%andincludedpain,hematoma,and/orseromaattheimplantsite,leadmigration,
paresthesia,changeinthesensationofstimulation,andinfection.Therewerenosepticevents.[76]
Faucheronandcolleagues(2010)alsorecentlyinvestigatedreasonsforneurostimulatorimplant
revision,thuselucidatingSNSassociatedmorbidity.Among87patientswhoreceivedthe
transcutaneousneurostimulatorimplant,36(41%)requiredsurgicalrevisionofthedeviceduetosite
infection,painoradversestimulation,electrodedisplacement,electrodebreakage,totalorpartialloss
ofclinicalefficacy,devicedysfunction,andbatterydepletion.[93]

DuelandJakobsenandcolleagues(2012)exploredalternativeneurostimulatorsettingsina
randomizeddoubleblindcrossoverstudywith15patientswhohavesustainedlossofefficacy.By
alteringpulsefrequenciesandpulsewidths,theauthorsfoundapreferredsettingforeachindividual
thatultimatelyachievedsignificantimprovementintheFecalIncontinenceQualityofLifeScale.They
notedatrendtowardhighestpatientsatisfactionandimprovedtreatmentoutcomewithhighfrequency
stimulation,whichwaspreferredby8ofthepatients,whichwassustainedat3monthfollowup.[94]

Sacraltranscutaneouselectricalnervestimulation(STENS)isanoninvasive,cheap,simpleand
promisingalternativetothetranscutaneousSNSwithInterstimSystem.Asmallprospectivestudy
byChewandcolleagues(2011)showedoptimisticresultsamong17patientswithidiopathicfecal
incontinencewhousedTENS.Treatmentincluded2hoursofdailyS3nervestimulationfor3months.
Sixtyninepercentofthesubjectsshowedimprovementinthefecalincontinenceseverityindex,witha
decreaseinthenumberofgasand/orstoolincontinenceepisodesperweek.Allpatientsreported
subjectiveimpressionofimprovement,and88%scored>6/10forbowelcontrol.Themeanrectal
volumeoffirstsensationandfirsturgefell,andthemaximumtolerablevolumerose.Thesatisfaction
scorewas>6/10inallpatients.[95]However,morestudiesarenecessarytoevaluateitsefficacy.

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TheInterStimSystemneurostimulatormanufacturedbyMedtronicshowninplace.CourtesyofMedtronicInc.
ViewMediaGallery

TheInterStimSystemneurostimulatormanufacturedbyMedtronic.CourtesyofMedtronicInc.
ViewMediaGallery

Injectableanalbulkingagent

Solesta(OceanaTherapeutics,Inc.)isabulkingagentconsistingofadextranomerstabilizedin
hyaluronicacidthatwasapprovedbytheFDAin2011forthetreatmentofpassivefecalincontinence
inpatientswhohavefailedotherconservativetherapies.InEuropeandCanadaitisknownas
NASHADxorZuidex.Dextranomer/hyaluronicacidisabiocompatiblebulkingagentinjectedunder
theanalsubmucosa.Four1mLinjectionsareadministeredintothedeepsubmucosaintheproximal
partofthehighpressurezoneoftheanalcanal,approximately5mmabovethedentateline.Ifthe
responseisinadequateafteraminimumof4weeks,treatmentcanberepeatedasecondtime.By
expandingtheanaltissue,theproximalanalcanalnarrows,thuspreventingfecalleakage.
Dextranomer/hyaluronicacidinjectioncanbeadministeredinanoutpatientsettingwithoutanesthesia.
[96]

Recentstudiessuggestthatjustoveronehalfofpatientsachieve>=50%reductioninnumberof
fecalincontinenceepisodesat6months,andthiseffectissustainedforupto3years.Furthermore,
patientsreportsignificantimprovementfrombaselineinmostofthedomainsoftheFecal
IncontinenceQualityofLifescalewithdextranomer/hyaluronicacidinjections.[97]A3yearcost
effectivenessmodelcomparingdextranomer/hyaluronicacidinjectionandsacralnervestimulation
followingfailedconservativemanagementrevealedthatdextranomer/hyaluronicacidinjectioniscost
effectiveandresultsinmoreefficientuseofresourcesforthetreatmentoffecalincontinencethan
sacralnervestimulation.[98]

Oneofthefirst,andmostcited,studiestosupporttheuseofdextranomer/hyaluronicacidforthe
treatmentoffecalincontinencewasarandomized,doubleblind,shamcontrolledtrialwith206
patientsbyGrafandcolleagues(2011).Ofthe136patientsreceivingdextranomer/hyaluronicacid
injections,71(52%)reported>50%reductioninthenumberofincontinenceepisodesat6month
followup,comparedto22(32%)ofthe70patientsreceivingshaminjections.Therewasnoblinding
from6to12months,andallremainingparticipantsreceiveddextranomer/hyaluronicacidinjection,
with57%achieving>50%reductioninsymptoms.Thenumberofincontinenceepisodesdecreased
from15atbaselineto6.2at12months,andthemeannumberofincontinencefreedaysincreased
from4.4atbaselineto7.9at12months.ThemeanFecalIncontinenceQualityofLifescoresforall
fouritemsimprovedsignificantlybetweenbaselineandmonth12.[99]
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Interestingly,thepercentageofsubjectsachievingatleast50%reductioninfecalincontinence
symptomsat6and36monthsremainedstable(52%),whilethepercentageofsubjectsachieving
100%reductionrosefrom6%at6monthsto13%at36months.Ofnote,themajorityofpatients
availableforanalysisat36monthshadreceivedasecondinjection1monthaftertheinitialtreatment.
Therefore,itappearsthattheachievedeffectofdextranomer/hyaluronicacidinjectionissustainedfor
upto3years.[100]

AnopenlabelstudybyLaTorreanddelaPortilla(2013)producedcomparableresultsforefficacyof
dextranomer/hyaluronicacidat24months.Ofthe83individualswhocompleted24monthfollowup,
63%experienceda>=50%reductioninthetotalnumberofepisodesoffecalincontinence,withthe
mediannumberofepisodesdecliningby69%.Thenumberofincontinencefreedaysincreasedfrom
15atbaselineto22at24months.[101]

Amongtheseandotherstudies,mosttreatmentrelatedadverseeventsweremildtomoderate,self
limitedandresolvedwithin1monthofinjection.Theseincludeproctalgia,rectalhemorrhage,
constipation,injectionsitebleeding,rectaldischarge,analpruritus,proctitis,painfuldefecation,and
fever.Threeseriousadverseeventswerereported,representingatotalof1.3%ofalladverseevents
relatedtodextranomer/hyaluronicacidinjection:Escherichiacolibacteremiaand2minorabscesses.
[102]

VaginalBowelControlDevice

AnewdevicereceivedFDAapprovalin2015.TheEclipseSystemoffersaconservative,safe,and
effectiveoptionforthemanagementoffecalincontinencewithnoreportedseriousadverseoutcomes.
Itisavaginalinsertthatisintendedtotreatfecalincontinenceinwomen18to75yearsoldwho
experienceatleast4incontinenceepisodesina2weekperiod.Thedeviceincludesaninflatable
balloon,whichisplacedinthevagina.Uponinflation,theballoonexertspressurethroughthevaginal
wallontotherectalarea,therebyreducingthenumberoffecalincontinenceepisodes.Thedeviceis
initiallyfittedandinflatedbyaclinician(withtheuseofapump),andafterproperfitting,thepatient
caninflateanddeflatethedeviceathomeasneeded.Thedeviceshouldberemovedperiodicallyfor
cleaning.

Arecentstudypublishedlookedat61of110(56%)participantsfrom6clinicalsitesthatwere
successfullyfitandenteredtreatment.At1month,intentiontotreatsuccesswas79%(48/61)per
protocolsuccess,86%(48/56)consideredbowelsymptomsverymuchbetterormuchbetter.
TherewassignificantimprovementinallFecalIncontinenceQualityofLifeandModifiedManchester
subscales.Successrateat3monthswas86%.[103]Similarly,anothermulticenter,openlabel,
prospectivetrialshowedthat62%ofthe91intenttotreatsubjectsachieveda>50%reductionin
incontinencefrequency.Meanfecalincontinenceseverityscoresimprovedby32%,and78%of
completerswereveryorextremelysatisfiedwiththedevice.[104]

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EclipseSystem(vaginalinsert)fromPelvalon.CourtesyofPelvalonInc.
ViewMediaGallery

PreoperativeDetails
Oncethedecisionhasbeenmadetoproceedwithsurgicalrepair,mechanicalbowelcleansingis
performed.Thiscanbeperformedwithavarietyofagents.Fullmechanicalbowelpreparationwith
largevolumesofsolutionisprobablyunnecessary,althoughithassomebenefitsforpostoperative
management.Smallervolumesofsolutionarebettertoleratedbypatients,withsomesurgeonsusing
onlyFleetenemaspriortorepair.Thevalueofamorethoroughpreparation,suchasGoLYTELY,isin
thepostoperativeperiodwhenmostsurgeonsareconcernedaboutdelayingmechanicalstretchtothe
newlyrepairedsphincter.

Antimicrobialprophylaxisforcolorectaloperationscanconsistofanoralantimicrobialbowel
preparation,preoperativeparenteralantimicrobials,oracombinationofboth.Oralprophylaxis
consistsofneomycinpluserythromycin,orneomycinplusmetronidazole,startednomorethan1824
hoursbeforesurgeryalongwithamechanicalbowelpreparation.Currentrecommendationsfor
parenteralantibioticprophylaxisincludeathirdgenerationcephalosporinwithmetronidazole.Asingle
preoperativeparenteraldoseofantibioticissufficientandshouldbeadministeredwithin1hourprior
toincision.[105]

IntraoperativeDetails
Tominimizetheriskofsurgicalsiteinfections,careshouldbetakentokeeptheoperativefieldclean
fromcontamination.Preoperativeantibioticsshouldbeadministeredpriortobeginningtheprocedure.

Duringoverlappingsphincteroplasty,maintainingthescartissueonthemusclebellyandusingthisto
decreasethelikelihoodofsuturepullthroughhasbeenoneofthemostimportantfactorsimproving
surgicaloutcomes.Theadequatemobilizationoftheexistingscartissueandseparationofthescarin
themidlinetoallowforoverlapisalsoimportant.Thejudicioususeofcauterytoprevent
devascularizationisalsowise.
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PostoperativeDetails
Postoperativemanagementaftersurgicaltreatmentforfecalincontinencevariessignificantly
accordingtoprovider.Agreementexistsabouttheuseofpostoperativestoolsoftenersanddietary
fiber,andseveralproductsareavailable(seeMedicaltherapy).Mineraloilmaybeusedforashort
periodoftimepostoperatively,butlongtermuseisassociatedwithabsorptionproblems.

Specificdietaryrestrictionsarecommonlyusedpostoperatively.Manysurgeonsdelayfeedingand
keeppatientsonclearliquiddietsorsoftfoodsforseveraldays.Othersallowamoreliberaldietand
usestoolsoftenersandmineraloiltodecreasestoolfirmness.Ifamechanicalbowelpreparationis
used,thetimetofirstbowelmovementwillbedelayed,especiallyifthepatientiskeptNPOforthe
immediatepostoperativeperiod.Manyencouragepatientstousesitzbathsasameansofdecreasing
perianaledemaandtoassistwithcleanliness.However,somebelievethatosmoticgradientsactually
allowformoreswellingandtissuemaceration,andtheypromotetheuseofperibottlestowashthe
perineumandrectum.Inthesecases,showeringisacceptableastheperineumisnotsubmergedin
water.

Theuseofpostoperativeantibioticsiscontroversial.Duetothelocationandnatureofthetissues,
infectionofthesurgicalsiteisariskhowever,thebloodsupplytothisareaisrichand,unless
compromisedwithextensiveelectrocautery,theneedforpostoperativeantibioticsisquestioned.

Followup
Duetothenatureandlocationofthesurgicalrepair,paincontrolisanimportantissue.Patients
shouldhaveadequateaccesstotheirsurgeonforadditionalmedicationsasnecessary.Becausethe
rateofseparationofsuperficialtissuesisashighas25%andbecauseofthepotentialforinfection,
patientconcernsandsymptomsmustbetakenseriously.Evaluationbytrainedproviders,ifonlyto
reassurethepatient,allowsthesurgeontodetectseriouscomplicationsearly.

Postoperativeevaluationshouldbescheduledfor46weeksaftertheprocedure.Atthistime,most
postoperativeswellingandtissuedistortionisusuallyresolved.Ahistoryofthepatient'sbowelhabits
shouldbetakenandproblemsaddressed.Ifmodificationofthestoolsoftenerregimenisrequired,it
canbedoneatthistime.Mineraloilregimensshouldbestoppedifthepatienthascontinuedthese
medicationspostoperatively.Additionalfollowupcanbescheduleddependingontheindividualneeds
ofthepatientandpracticeofthesurgeon.

Complications
Thecomplicationratefromsurgicalrepairoftheanalsphinctervariesbasedontheseriesreviewed.
Thepatientpopulationrequiringsurgicalrepairmayhavesignificantcomorbiditiesthatpredispose
themtopostoperativecomplications.Areviewofseveralseriesforbothpostanalrepairandanterior
sphincteroplastyrevealsthatmostpatientsareinthefifththroughseventhdecadeoflife.Underlying
medicalconditions,suchasobesity,diabetes,orheartdisease,canincreasethepostoperativeriskof
myocardialinfarctionordeepveinthrombosis.

Themostcommoncomplicationissuperficialseparationofskinandsubcutaneoustissues,andthe
frequencyrateisashighas25%insomeseries.Caremustbetakentoplaceaslittletensionas
possibleonthesetissues.ConversionofthecurvilinearincisionintoaYshapedincisionatthetimeof
closurecanplaceagreatdealoftensionontheperinealskinandpredisposeittoseparation.
Plicationofthebulbospongiosusandsuperficialtransverseperineummusclescanremovetension
fromtheoverlyingskinandservetorestoreanatomy.Devascularizationofthevaginalorrectal
mucosacanresultinnecrosisofthesetissues.

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Riskofinfectionis35%.Openingthewoundtoallowfordrainageandtreatmentwithantibioticsmay
allowthephysiciantosalvagethesurgicalrepair.Fistulaformationoccursinfewerthan1%ofthe
seriesreviewed,butitismorecommoninthosecasesinwhichinfectiondevelops.

Bleedingandhematomaformationarealsopossiblecomplications.Bleedingcanusuallybecontrolled
withpressureachievedwithpacking.Hematomaformationintotheperirectalspacecangounnoticed
andresultinthesequestrationoflargeamountsofblood.Treatmentrequiresevacuationofthe
hematomaandsurgicalhemostasis.

Othercomplicationsincludeanalstricture,fecalimpaction,andpain.Painmaybeassociatedwith
bowelmovementsandintercourse,leadingtoagreatdealoffrustrationforboththeproviderand
patient.Manyoftheseproblemsimprovedwithtime.Mostcomplicationsthatarisedonotaffectthe
sphincterrepair.Althoughpatientsmaybedistressed,theyshouldbereassuredthattheriskoffailure
oftheprocedureisnotincreased.

OutcomeandPrognosis
Initialoutcomeaftersphincteroplastyis6490%withshorttermfollowup.[67,106]Thesuccessrate
startstofallafterthefirstfewyearsandcontinuestofallwithlongerfollowup.Twolongtermstudies
demonstratethatonlyhalfofthepatientshavesatisfactorycontinenceat6980months
postoperatively.[107,108]

Asecondaryanalysisofdatafromamulticenterstudyevaluatingadaptivebehaviorsamongwomen
withfecalincontinenceinthePelvicFloorDisordersNetworkrevealedsignificantimprovementsin
symptomseverityandconditionspecificqualityoflifeat3and12monthsfollowingtreatment.[109]
Treatmentwasnonsurgicalin78%ofthewomen22%underwentanalsphincterrepair.

FutureandControversies
Thedisappointingresultsoftheartificialanalsphincterhaveledinvestigatorstoexploreother
therapiesforseverefecalincontinence.

Sacralspinalnervestimulationhasbeenusedsuccessfullyforthetreatmentoffemalepatientswith
urinaryincontinenceassociatedwithoveractivebladderandnonobstructiveurinaryretention.The
MedtronicInterStimdevice(Medtronic,Inc,Minneapolis,MN)isFDAapprovedintheUnitedStates
forthisindication.InEurope,sacralspinalnervestimulationhasgivenpatientswithfecalincontinence
anoptionthatisminimallyinvasiveandappearstooffersignificantimprovement.Arecentrandomized
controltrialof120patientswithseverefecalincontinencedemonstratedasignificantimprovementof
incontinencesymptoms,decreasingfrom9.5to3.1meanincontinenceepisodesperweekwhen
comparedwithoptimalmedicaltherapythatcomprisedbulkingagents,pelvicfloorexercises,and
dietarymanagement.Theseresultsareevenmoreencouraginggiventhathalfofthepatientshad
evidenceofasphincterdefectandtwothirdshadevidenceofpudendalneuropathy.

Interestingly,neitherthemaximalrestingpressure,squeezeanalpressures,orpudendalnerve
terminallatencyhadanyassociationwithimprovement.Inadditiontoasustainedfunctional
improvement,qualityoflifewassignificantlyenhancedasmeasuredbyfecalincontinencequalityof
life(FIQL)scores.MedtronicInterStimhasbeenthemodalityofchoiceofinvestigatorsinthisand
otherstudiestreatingfecalincontinence.[110]Longtermdataofgreaterthan5yearssince
implantationisreassuring.In52patientswhohadundergoneimplantation,atleast50%improvement
occurredinthreequartersofthepatients.[111]Successfulresultshavebeendemonstratedevenwith
significantanalsphincterdisruption.[112]

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