New Options Are Emerging for Treatment of Fecal Incontinence

FORT LAUDERDALE, FLA. — Anterior overlapping sphincter repair is commonly performed in patients with fecal incontinence secondary to an anterior defect in the sphincter complex, but long-term outcomes are questionable.

In the short term, 50%-75% of patients achieve good control of solid and liquid bowel movements. But few of the patients requiring such surgery—usually as a result of obstetric or iatrogenic trauma—have good long-term function, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.

In one study of 42 patients who underwent the surgery, half were continent after the surgery, and only 14% were continent at a 6-year follow-up. In another study of 191 patients, 40% had some continence, but only 6% had complete continence at 10-year follow-up, said Dr. Weiss of Cleveland Clinic Florida, Weston.

Neuropathy has emerged as a predictor of poor surgical outcome, he noted.

In patients who don't do well after surgery, consider whether the repair was successful from an anatomic standpoint. Ultrasound can help determine whether the sphincter repair is intact or if there is a persistent defect. A second attempt at surgical repair may be warranted in cases of persistent defect, but if the initial repair is intact, an alternative procedure should be considered, Dr. Weiss said.

Among the other surgical options available or under investigation are:

▸ The artificial anal sphincter. In a recent report on the North American experience with the artificial sphincter, nearly half of 112 patients required surgical revision of the device, and 37% had the device explanted (with successful reimplantation in 7 patients). Of those with a functioning sphincter at study completion, all had significant improvement in fecal incontinence and quality-of-life scores; the success rate in these patients was 85%, but the intention-to-treat success rate was only 53%. “When it works, it works well, but it takes a lot to get it to work well,” he said.

▸ Sacral nerve stimulation. Implantation of a device that stimulates nerves originating from the sacral nerve foramen was originally used to treat urinary incontinence, but it also has proved useful for concomitant fecal incontinence. Preliminary results of ongoing trials of its use for fecal incontinence look promising, with 40%-75% of patients achieving continence.

▸ The Durasphere procedure. Microscopic carbon-coated beads are injected into the anal canal and lower rectum as part of this experimental minimally invasive office procedure, thought to improve internal sphincter function by increasing tissue bulk. Results of small phase II studies are promising, with patients experiencing significant decreases in fecal incontinence and quality-of-life scores. Durasphere EXP Injectable Bulking Agent is approved for treating stress urinary incontinence due to intrinsic sphincter deficiency in women.

▸ Secca. The Secca System is an FDA-approved device that uses radiofrequency energy to deliver scarring to the anal canal to treat fecal incontinence by changing tissue tone. In a prospective multicenter study involving 47 patients, modest but significant improvements in fecal incontinence scores (from 14 to 11 on a 0-20 scale) were seen at 6 months, with a further decrease to about a score of 9 at long-term follow-up.

▸ Stoma. A patient who fails all other options may be a candidate for a stoma. This may seem like a terrible option, but properly counseled patients may handle a stoma very well and consider this approach preferable to wearing diapers, Dr. Weiss said.