Fecal incontinence: Help for patients who suffer silently

All 4 groups had similar improvement in symptoms, raising questions about the therapeutic value of biofeedback.³² Long-term studies have found that 60% to 80% of patients will continue to have episodes of incontinence after undergoing biofeedback. A Cochrane review of RCTs concluded that there is not enough evidence to judge whether sphincter exercises and biofeedback are effective in reducing fecal incontinence.³³Long-term studies have found that 60% to 80% of patients will continue to have episodes of incontinence after undergoing biofeedback.

Still no relief? Order tests and consider surgery

For patients with fecal incontinence refractory to conservative management, more sophisticated diagnostic studies can provide invaluable information for guiding further treatment.

Endoanal ultrasound is considered the gold standard diagnostic test for fecal incontinence. It is superior to electromyography in terms of availability, patient tolerance, and ability to assess the internal anal sphincter, except in cases in which nerve injury is suspected.³⁴

Other tests sometimes used to pinpoint the cause of fecal incontinence include an enema challenge (which can differentiate between liquid and solid incontinence) and anal manometry (which can quantify anal sphincter tone). Defecography (which makes it possible to visualize the rectal emptying process) can be helpful if a diagnosis of rectal prolapse is being considered.

Magnetic resonance imaging is among the most costly diagnostic studies associated with fecal incontinence. But it is the only modality that can depict the morphology of the external sphincter and the presence of muscle atrophy—providing information that has been shown to significantly improve the likelihood of successful sphincter repair.³⁵

A wider range of surgical options

When medical therapy and biofeedback fail to produce adequate results, referral to a colorectal surgeon is appropriate. (Although conservative management is frequently unsuccessful, health plans typically require that they be attempted before surgical intervention is considered.)

Sphincteroplasty, or anterior anal sphincter repair, addresses the most common cause of fecal incontinence—and is still a common surgical procedure.³⁶ Sphincteroplasty generally has good to excellent results, providing there is sufficient muscle mass for a successful repair.^37,38

The procedure involves dissecting the sphincter complex from the surrounding anoderm, then overlapping the edges of the sphincter muscle and suturing them together. Continence has been reported nearly 80% of the time, although a longer duration of fecal incontinence and incontinence secondary to operative injury of the sphincter are risk factors for poorer outcomes.^39,40

Recent studies have called into question the durability of anterior sphincter repair. A systematic review of 16 studies reporting short- and long-term outcomes for more than 900 patients found that all but one of the studies showed a decline over time in the number of patients who were happy with the outcome.³⁹

Sacral nerve stimulation is first-line surgical treatment
Sacral nerve stimulation (SNS) is the most promising development in the treatment of fecal incontinence. In the last decade, SNS has become the first-line surgical treatment for patients for whom medical and behavioral therapy are unsuccessful.⁴⁰

A minimally invasive procedure that involves an implantable device, SNS is always preceded by an effectiveness trial in which a finder needle is percutaneously inserted into the third sacral foramen. Stimulation should result in immediate contraction of the pelvic floor and external sphincter and plantar flexion of the big toe.

The next step is the insertion of a temporary stimulator lead, which remains in place for a 2- to 3-week test of low-frequency stimulation. If significant reduction in the number of incontinence episodes during the trial period occurs, the device is inserted (See “Sacral nerve stimulation: A case study” above).

Improvement in fecal continence has been reported to be as high as 100% in some cases, with up to 75% of patients achieving complete continence.⁴¹ While the mechanism involved remains unclear, multiple studies have confirmed its effectiveness.^42,43

Posterior tibial nerve stimulation is another recent development, in which a small, thin lead is placed at the posterior tibial nerve, then connected to a temporary stimulator. Less data are available for this treatment, but a recent review summarized the findings of 8 published studies and found success rates ranging from 30% to 83%.⁴⁴

The Secca procedure—a relatively new therapy that delivers radiofrequency energy to the anal sphincter—is another option, believed to work by reducing compliance of the sphincter complex and the level of tolerable rectal distension.⁴⁵ Procedures using injectable bulking materials and fat grafting around the sphincter complex have demonstrated some promise, as well.⁴⁶

A number of other surgical modalities are available, and often effective under certain circumstances. Among them are rotational and free muscle transfers, used only in cases in which the bulk of the sphincter complex has been destroyed.^47,48 Implantable anal sphincters (made from human muscle and nerve cells) are occasionally used, as well, but frequently need to be removed because of infection.^49-51