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Chapter 7 Neurogenic Urinary Incontinence
or weakened.Anal tone is decreased and the ability to squeeze it may be compromised.
However, in suprasacral spinal lesions these reflexes and anal tone may be enhanced.
The ability to squeeze the anal sphincter depends on the incompleteness of the lesion.
However, these findings do not always reflect what really happens during the emptying phase.
For the evaluation of neurogenic LUT disorders, urodynamic investigations are
mandatory to define the pattern of neurogenic detrusor-sphincter dysfunction in the
individual patient. Figure 7.1 shows the eight most frequent patterns observed in patients with neurogenic lower urinary tract dysfunction.
The underlying urodynamic pattern is decisive for selecting the treatment strategy,
which is also the case in incontinent patients to achieve continence with various conservative and operative therapeutic options. Last but not at least, the urodynamic pattern determines the risk for upper urinary tract function and morphology deterioration.
Nervous control of continence and micturition is organized on a cerebral, spinal
and peripheral level, all three are cross-linked,and the circuiting is complex and contentious.
As will be described, there are numerous treatment options, their application depends on the type of neurogenic LUT dysfunction,the etiology and the social situation
of the individual patient. In the following the clinical symptomatology and the treatment strategies are described in (1) suprapontine,(2) suprasacral spinal and (3) spinal
sacral and subsacral (cauda equina and peripheral nerve) lesions.
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Fig. 7.1. Patterns of neurogenic lower urinary tract dysfunction. Each of the drawings symbolizes the bladder and sphincter. Structures drawn with heavy lines symbolize overactivity, structures drawn with thin lines represent underactivity, those with intermediate lines normal function. The drawings represent the eight most frequent neurogenic dysfunctional patterns in the
lower urinary tract (for further explanations, see text).
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Helmut Madersbacher
7.3 Therapeutic Options for Neurogenic Urinary Incontinence
7.3.1 Urinary Incontinence Due to Suprapontine Lesions
The detrusor reflex to empty the bladder is a brainstem reflex that is controlled by various suprapontine centers including the frontal lobe and basal ganglia. Clinically, suprapontine lesions therefore cause frequency, urgency and incontinence due to detrusor overactivity caused by damage to cerebral inhibitory centers. Urodynamically we
see detrusor overactivity either of the phasic or more often of the terminal type (see
Fig. 7.2). During the storage phase, the urge to void comes up usually late without
warning and is accompanied by a uncontrollable detrusor contraction causing detrusor overactivity incontinence.
The coordination between detrusor and sphincter is located in the brainstem.
Therefore in suprapontine lesions,the coordination between detrusor and sphincter is
preserved and bladder emptying is without residual urine unless other reasons for infravesical obstruction such as an obstructive, enlarged prostate are present.
Unless the neurological disease causing LUT dysfunction cannot be eliminated,
neurourological therapy is mostly symptomatic or activates reserve functions to compensate the defect.
Terminal detrusor overactivity can only be brought under control by adequate
toilet training based on the records of a micturition protocol: the patient has to go or
has to be brought to the toilet regularly before the urge to void occurs. The exact
Fig. 7.2. Terminal detrusor overactivity.In the majority of elderly patients with symptoms of the
overactive bladder, terminal detrusor overactivity can be found. At a certain filling volume,
which may be small or large, suddenly,without warning, the urge to void comes up together with
the detrusor contraction, which the patient is unable to control: The consequence is overactivity
incontinence.
Chapter 7 Neurogenic Urinary Incontinence
timing is based on the records of the micturition protocol. The timing of micturition has to be adjusted to the bladder capacity and prompted voiding has to occur
before uncontrolled detrusor contractions cause incontinence. If the bladder capacity
is below 250 cc anticholinergic therapy is indicated in order to increase bladder
capacity.
A retrospective analysis in patients with Parkinson’s disease (Holliger et al. 2002)
reveals that detrusor overactivity increases and bladder capacity decreases with duration and severity of the disease. Only recently Seif et al. (2003) demonstrated in Parkinson patients with an implant for deep brain stimulation the inhibiting influence of
the basal ganglia on the detrusor reflex: STN stimulation normalizes detrusor hypersensitivity in Parkinson patients,whereas with stimulation off hypersensitivity occurs
again.
7.3.2 Suprasacral Spinal Cord Lesions
In suprasacral lesions (also known as upper motor neuron lesion or spinal reflex bladder) the sacral reflex arc (bladder → afferent neurons → S2-S4 sacral cord → efferent
neurons → bladder) remains intact.However, at least on the afferent side,this reflex is
mediated not as normally by A-delta afferent neurons but by unmyelinated C-fibers
(= Capsaicin sensitive), which originate in the vanilloid receptors within the bladder.
In complete suprasacral lesions, at a certain point the filling volume of the bladder
triggers the sacral micturition reflex. The patient himself has lost the ability to feel
bladder filling and the urge to void and is therefore unable to control it. The patient
suffers from neurogenic detrusor overactivity incontinence (previously called reflex
incontinence).As the reflex for bladder emptying is limited to the spinal cord,the coordination between detrusor and sphincter mediated in centers of the brainstem area
is lacking and detrusor-sphincter dyssynergia occurs. DSD presents a functional infravesical obstruction that may cause severe damage to the lower and upper urinary
tracts. A high-pressure situation within the bladder with ureterorenal reflux, hydronephrosis and pyelonephritis can result.
The therapeutic strategy is based (1) on regular bladder emptying before neurogenic detrusor overactivity occurs, achieved nowadays primarily by intermittent (self-)
catheterization,in some patients also by triggered reflex voiding; and (2) by inhibiting
the overactive detrusor with pharmacotherapy, electrical neuromodulation,sacral
deafferentation or bladder augmentation.
If incontinence persists,condom catheters in men and pads in women are useful.A
transurethral or suprapubic indwelling catheter should be avoided if possible.
Pharmacotherapy in neurogenic detrusor overactivity comprises (1) anticholinergics,which act in the periphery on the efferent side,(2) substances blocking the receptors of the afferent nerves within the bladder, primarily by blocking vanilloid receptors by instillation of capsaicin or resiniferatoxin into the bladder or by paralyzing the
detrusor muscle by injecting botulinum toxin A into the detrusor.
In incomplete lesions, noninvasive neuromodulation of the detrusor reflex prefer-
ably by stimulating the pudendal afferents via the dorsal penile or clitoridal nerve is an
alternative,especially when anticholinergics are either not effective or not tolerated in
adequate dosages.
In complete lesions caused by a spinal cord trauma, electrical stimulation of the anterior sacral nerves using the Brindley implant is another alternative; however, balanced voiding and continence can mostly only be achieved if this procedure is com-
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Helmut Madersbacher
bined with sacral deafferentation which means posterior sacral root rhizotomy of
S2–S5 bilaterally (see following paragraph).
For patients in whom neurogenic detrusor overactivity incontinence cannot be
managed adequately by conservative means, two operative options are available to
achieve the aims: One is sacral deafferentation (rhizotomy of the dorsal sacral roots
S2–S5 bilaterally), which abolishes any sacral reflex activity and therefore provides
continence. However,in order to empty the bladder the patient either has to perform
intermittent (self-) catheterization or at the time of operation simultaneously an anterior root stimulator (Brindley device) is implanted.According to our and others’ experience over the long term,85% of the patients became and remained continent and the
same percentage achieved balanced electrically driven micturition with tolerable
pressures.
In patients with incomplete lesions,sacral electrical neuromodulation is able to reduce detrusor overactivity with beneficial clinical effect in patients in whom the noninvasive technique is not effective: special electrodes are directly implanted to the S3
root after a trial period.
For both complete and incomplete lesions,bladder augmentation, preferably using
clam-ileo-cystoplasty, is an alternative with good long-term results to achieve continence; however,bladder emptying has to be accomplished by intermittent catheterization in almost all patients.
Transurethral sphincterotomy can relieve infravesical functional obstruction
caused by detrusor-sphincter dyssynergia; however, the second aim, the achievement
of continence, is not achieved.
7.3.3 Spinal Sacral and Subsacral Lesions
In complete spinal sacral and subsacral (cauda equina and peripheral) lesions (lower
motor neuron lesion), the detrusor and sphincter become underactive, resulting in
neurogenic detrusor acontractility and flaccid paresis of the pelvic floor musculature
and the striated sphincter.The problem for the patient again is twofold: there is a failure to empty and, because of flaccid paresis of the striated sphincter and the pelvic
floor,also a failure to store,resulting in neurogenic stress incontinence.
Bladder emptying is best achieved by intermittent (self-) catheterization.Emptying
by abdominal straining carries certain risks and demands careful urodynamic investigation before it can be recommended.
Conservative treatment is rarely successful in neurogenic stress incontinence; however, regular fluid intake and regular bladder emptying may improve the situation to a
certain extent. Pharmacological agents are not effective in this type of lesion. The
method of choice is still the implantation of the artificial urinary sphincter with a 90%
success rate, however, with the disadvantage of a 30% re-operation over time and a
change in the system between 10 and 15 years after implantation because of material
fatigue.
Sling procedures may be an alternative; however, no long-term results have been
published so far and there is almost no experience with suburethral slings of the new
type (tension-free vaginal tape and others) in patients with neurogenic stress incontinence. It is questionable whether the therapeutic concept for these slings, which is effective in non-neurogenic stress incontinence, also works in these patients.In incomplete lesions, electrical stimulation of the pelvic floor over several months may improve the situation, although no evidence-based data are available.
Chapter 7 Neurogenic Urinary Incontinence
7.4 Conclusions
Neurogenic lesions are a frequent cause of urinary incontinence,especially in the elderly. Numerous treatment options are available for neurogenic incontinence,but their
application depends on the underlying pathophysiology and the individual situation
of the patient in regards to disability and social situation.The mainstays for neurogenic detrusor overactivity incontinence in suprapontine lesions is behavioral treatment
combined with anticholinergic therapy if bladder capacity is reduced.In patients with
spinal lesions, mostly urinary incontinence is combined with an emptying problem;
therefore both aspects have to be looked after at the same time. In suprasacral spinal
lesions, intermittent catheterizations in combination with pharmacotherapy (anticholinergics, botulinum toxin A) is the method of choice; operative alternatives are in
complete lesions sacral deafferentation together with the implantation of the anterior
sacral root stimulator (Brindley) or in complete and incomplete lesions bladder augmentation.Some patients with incomplete lesions may benefit from noninvasive or invasive sacral neuromodulation.
In sacral and subsacral lesions, neurogenic stress incontinence can only be cured
thus far by operative procedures.The implantation of the artificial urinary sphincter is
the method of choice; alternatives may be sling procedures, although no long-term
data are available and there is almost no experience with suburethral slings of the new
type.
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Chapter 8
Chapter 8 Fecal Incontinence After Rectal and Perianal
Fecal Incontinence After Rectal
and Perianal Surgery
Alan G. Thorson
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8
Contents
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 104
8.2 At-risk Procedures . . . . . . . . . . . . . . . . . . . . . . 104
8.3 Procedure-specific Risks . . . . . . . . . . . . . . . . . . . 105
8.3.1 Procedures for Anal Diseases . . . . . . . . . . . . . . . . 105
8.3.1.1 Hemorrhoidectomy . . . . . . . . . . . . . . . . . . . . . . 105
8.3.1.2 Sphincterotomy . . . . . . . . . . . . . . . . . . . . . . . . 106
8.3.1.3 Operations for Fistula-in-ano . . . . . . . . . . . . . . . . 106
8.3.2 Procedures with Secondary Impact on Continence . . . . 109
8.3.2.1 Anterior Resection . . . . . . . . . . . . . . . . . . . . . . 109
8.3.2.2 Ileal Pouch Anal Anastomosis . . . . . . . . . . . . . . . . 111
8.3.2.3 Transanal excision . . . . . . . . . . . . . . . . . . . . . . 111
8.3.3 Procedures for Prolapse . . . . . . . . . . . . . . . . . . . 112
8.3.3.1 Abdominal Procedures . . . . . . . . . . . . . . . . . . . . 112
8.3.3.2 Perineal Procedures . . . . . . . . . . . . . . . . . . . . . 112
8.3.4 Miscellaneous Procedures . . . . . . . . . . . . . . . . . . 113
8.3.4.1 Rectocele Repair . . . . . . . . . . . . . . . . . . . . . . . 113
8.3.4.2 Sphincteroplasty . . . . . . . . . . . . . . . . . . . . . . . 113
8.4 High-risk Procedures . . . . . . . . . . . . . . . . . . . . . 113
8.5 Etiology of Postoperative Incontinence . . . . . . . . . . . 113
8.6 High-risk Patient Groups . . . . . . . . . . . . . . . . . . . 114
8.7 Decreasing the Risk of Fecal Incontinence
Following Rectal and Perianal Surgery . . . . . . . . . . . 115
8.8 Outcomes Data . . . . . . . . . . . . . . . . . . . . . . . . 115
8.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . 116
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
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Alan G.Thorson
8.1 Introduction
The following discussion will focus on several specific aspects of postoperative fecal
incontinence.We will first identify the most common anal and rectal operations that
are associated with the unintended consequence of fecal incontinence.We will next try
to quantitate the relative risks for incontinence for those procedures, identify specific
groups of patients who appear to be at particularly high risk and determine if there
are any procedures where some degree of incontinence should be an expected outcome.We will then look at the etiology of incontinence in these patients and evaluate
the current literature for contributing factors within these operations that could potentially be changed in order to decrease the risk of incontinence.Finally, any current
outcomes data with respect to specialist and volume data will be reviewed.
8.2 At-risk Procedures
Alterations in continence have been reported following many different procedures
performed on the anorectum. There are four general types of operations that have an
impact on continence.These include: (1) Procedures performed for anal diseases that
have a direct impact on the anal sphincter, (2) Procedures performed for colonic or
rectal conditions that secondarily impact continence, (3) Procedures for prolapse and
(4) Miscellaneous procedures, including those performed for the management of incontinence or other conditions.
The most obvious risks are associated with procedures done for controlling symptoms of anal pain and bleeding and the management of acute and chronic anal suppurative disease. The most common of these procedures related to postoperative incontinence include the many operations for hemorrhoidectomy (stapled and excisional),
sphincterotomy, anal dilatation, drainage of abscesses and the various operations for
anal fistula. The latter includes fistulotomy and fistulectomy with or without seton,advancement flaps and the use of fibrin glue.The operation of sphincterotomy and those
for fistula, which often entail an actual division of at least a portion of the sphincter,
are at particular risk for causing incontinence.
Procedures performed for colonic or rectal conditions that secondarily impact continence include those performed for cancer and inflammatory bowel disease. These
operations include low anterior resection, proctectomy with or without colonic Jpouch or coloplasty–anal anastomosis and ileal pouch anal anastomosis (IPAA). There
are also reports dealing with the effects on continence following the transanal excision
of rectal tumors, including the technique of transanal endoscopic microsurgery
(TEM).
The procedures for rectal prolapse can be divided into abdominal and perineal approaches. The abdominal approaches may have an impact on continence due to the
correction of a preexisting anatomic problem.This effect is usually positive, although
reduction of the intussusception, when chronic dilation of the prolapse has significantly weakened the sphincter mechanism and stretching of the pudendal nerves has
caused a neuropathy, may worsen continence. These approaches include the Loygue
procedure and rectopexy by suture,mesh (Ripstein) or Ivalon sponge and may be with
or without sigmoid colon resection. Generally, the abdominal approaches for prolapse
have less dramatic effects on continence than do the perineal operations.The Altemeier perineal rectosigmoidectomy results in a proctectomy, while the Delorme proce-
Chapter 8 Fecal Incontinence After Rectal and Perianal Surgery
dure represents a rectal mucosectomy with preservation of the muscular wall of the
rectum.
Miscellaneous procedures that can affect continence include rectocele repair and
anterior sphincteroplasty. The latter is an operation that is performed specifically for
the management of fecal incontinence but that has an incidence of incontinence as a
consequence.
8.3 Procedure-specific Risks
8.3.1 Procedures for Anal Diseases
8.3.1.1 Hemorrhoidectomy
The reported incidence of incontinence following hemorrhoidectomy is highly variable. Many factors confound the establishment of a true figure.These include the type
of procedure performed and the definition of incontinence utilized in the postoperative evaluation.No large studies have examined this question using the newer fecal incontinence scales that are now available. Randomized series comparing differing techniques are not common.
Having said this, in general complaints of significant continence issues following a
well-performed hemorrhoidectomy are low. The exception is for utilization of Lord’s
dilatation procedure for hemorrhoid management. In the long-term follow-up of 153
patients randomized between operative hemorrhoidectomy and Lord’s dilatation,
Konsten and Baeten (2000) found the risk of incontinence following dilatation to be as
high as 52% 17 years after the procedure. In a study evaluating transanal ultrasonographic evidence of sphincter injury following anorectal procedures, Stamatiadis
found a 76% incidence of internal sphincter injury and a 24% incidence of external
sphincter injury following anal dilatation (Stamatiadis et al.2002).
In comparing technical modifications,there is little difference whether a stapler,laser, ultrasonic scalpel, bipolar cautery, standard cautery or a cold blade is used. Ravo
described a 0.2% risk of flatus and fecal incontinence in a review of 1,107 patients from
12 Italian centers undergoing stapled hemorrhoidectomy (Ravo et al. 2002). In a randomized prospective trial of 119 patients undergoing stapled vs conventional hemorrhoidectomy, Ho found a minor incontinence rate of 3.7% for stapled hemorrhoidectomy and 3.2% for conventional hemorrhoidectomy at 3 weeks (Ho et al. 2000). At
3 months the residual rates were 0% and 1.6% respectively.
Khan examined the results of hemorrhoidectomy utilizing the ultrasonic scalpel.In
a prospective trial, 30 patients were randomized to either excisional hemorrhoidectomy using electrocautery or by ultrasonic device.Incontinence was compared to flatus
only and did not differ between the groups (Khan et al.2001).
McConnell and Khubchandani (1983) reported on closed hemorrhoidectomy in 441
patients. With follow-up of up to 7 years, they reported a lasting incontinence rate of
0.5%. Johannsson reviewed the long-term results of patients undergoing MilliganMorgan hemorrhoidectomy. Over a follow-up period ranging from 7 to 14 years, 507
patients reported a 33% incidence of impaired continence. However,only 29% of these,
or 8% of the total, said that their incontinence was directly related to the operation of
hemorrhoidectomy (Johannsson et al.2002).
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Alan G.Thorson
Overall the risk for incontinence is probably less with the stapled procedures as
there is minimal risk to division of the sphincter. Both conventional and stapled hemorrhoidectomies do result in some dilatation of the sphincter with a resultant undefined continence risk. Depending upon the patient population being studied and the
type of hemorrhoidectomy, continence risks range from 0% to an excess of 30%. However, when taking into consideration the size of the various studies, the overall rate of
incontinence following hemorrhoidectomy is probably somewhere between 0.5% and
5%.
8.3.1.2 Sphincterotomy
The operation of lateral internal sphincterotomy (LIS) entails the partial division of
the internal sphincter.With a planned division of the sphincter, it is not surprising that
there is a reported incidence of incontinence following the procedure. The extent of
the incontinence could be related to a number of variables,including the length of the
muscle divided, the preoperative manometric pressures and the operative technique
utilized.
Garcia-Aguilar compared the technique of open vs closed LIS. In a retrospective review of 864 patients, 90% expressed satisfaction with their operation; however, there
were statistically significant differences between the operations with respect to incontinence.With the open procedure,there was a persistent incontinence to gas in 30.3%,
soiling of underclothing in 26.7% and accidental bowel movements in 11.8%.The comparable figures for the closed procedure were 23.6% for problems controlling gas,
16.1% for soiling of underclothing and 3.1% for accidental bowel movements (p=0.062
for gas, less than 0.001 for soiling underclothing and accidental bowel movements).
These figures suggest a significant risk for continence issues following either operation (Garcia-Aguilar et al. 1996).
Three other studies have also shown a significant risk of continence issues with LIS.
Pernikoff and associates reviewed 500 patients in a retrospective manner. Although
the fissure healing rate was 99%, 8% of patients experienced “impaired fecal incontinence”(Pernikoff et al. 1994).In a retrospective review of 1,355 patients, Khubchandani found an incidence of incontinence to flatus of 35.1%, soiling 22% and accidental
bowel movements 5.3%.A significantly higher proportion of patients having accidental bowel movements were over age 40 (Khubchandani and Reed 1989). Lewis retrospectively reviewed 350 patients undergoing either open or closed LIS for anal fissure.
A total of 60 patients (17%) complained of incontinence to flatus or feces, which was
transient in two-thirds. Thus the long-term incontinence rate was about 6% (Lewis et
al. 1988). Overall, these studies suggest a risk of incontinence of at least some degree
following LIS, ranging generally from 6% to 30%.
8.3.1.3 Operations for Fistula-in-ano
The are many variables that confound attempts to assess the risk of continence following procedures for anal fistula.These include the type of fistula, the underlying disease
state and the operation utilized.
The type of fistula refers to the extent of muscle involvement by the tract as it extends from the internal to the external opening. Parks’ classification of anal fistula is
the most commonly used today. This classification includes submucosal fistulas (no
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