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Chapter 14 Medical and Behavioral Treatment of Fecal Incontinence
Fig. 14.2. First sensation thresholds (ml) before and after biofeedback training. From Chiarioni
(2002)
207
Fig. 14.3. Maximum squeeze pressures (mmHg) before and after biofeedback training. From
Chiarioni (2002)
squeeze pressures before and after training and demonstrates that biofeedback did
improve the strength of pelvic floor contractions. However, there was an overlap
between responders and non-responders to biofeedback and no significant difference
between the two groups either in their post-treatment squeeze pressures or their baseline squeeze pressures. These data suggest that sensory discrimination training is the
critical component to biofeedback training.
It is possible that the Chiarioni study (Chiarioni et al. 2002) overestimates that importance of sensory retraining and that there are some patients whose primary etiology for fecal incontinence is muscle weakness; these patients would be expected to
benefit more from strength training. The author advocates a pretreatment anorectal
manometry to assess both sphincter strength and sensory thresholds in order to direct
14
208
William E.Whitehead
the biofeedback training to the specific deficits the patient has. Nevertheless,
Chiarioni’s study suggests that biofeedback training must be able to address sensory
retraining as well as strength training in order to achieve optimal results.
14.3.5 Combining Biofeedback with Surgery
or Medical Management
Biofeedback operates through a different mechanism than surgery: Biofeedback depends on learning and acts through afferent and efferent nerve pathways to improve
continence,whereas surgery corrects morphological abnormalities in the pelvic floor
musculature. This raises the possibility that combining biofeedback with surgery (or
medical management) may improve outcomes over what can be achieved by either
technique alone.This is an emerging area of research.
14.4 Summary and Conclusions
Diarrhea and constipation are recognized risk factors for fecal incontinence, and the
first step in conservative medical management is to use antidiarrheal drugs or laxatives to try to normalize stool consistency.Education about the causes of fecal incontinence, including an attempt to identify specific precipitating events (e.g., coughing,
eating in public) and to teach ways of coping, should also be incorporated into conservative management. Conservative management with education and drugs to normalize stool consistency are effective in about 60%–90% of patients with constipation-related or diarrhea-related fecal incontinence (Table 14.3). Biofeedback is indicated
when patients have failed to respond to conservative management and when they have
weakness of the pelvic floor muscles or impaired ability to sense rectal distention as a
contributing cause of incontinence. Biofeedback appears to work primarily through
improving the ability to detect weak rectal distensions,but improved strength training
may be important to improve bowel control in some patients. The overall success of
biofeedback training is about 70% (Table 14.3). Biofeedback is often combined with
medical management because diarrhea or constipation may interact with sensory–motor defects in the anus and rectum to exacerbate incontinence.
Table 14.3. Treatment options for fecal incontinence
Treatment Indication Outcomes
Loperamide Diarrhea About 80% decrease
Habit training Constipation 60% of children
Plus laxative
Biofeedback Nerve injury or sensory loss 75% improve
50% cured
Surgery Muscle injury 68%
Chapter 14 Medical and Behavioral Treatment of Fecal Incontinence
Acknowledgements
This study was supported in part by Grant RO1 DK57048.
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14
Part V
Operative Therapy
of Urinary Incontinence
V
Chapter 15
Chapter 15 Innovative and Minimally Invasive Treatment
Innovative and Minimally Invasive
Treatment of Stress Urinary Incontinence
Christl Reisenauer, Konstantinos Gardanis, Diethelm Wallwiener
213
15
Contents
15.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . 214
15.2 Tension-free Vaginal Tape (TVT) – Operation . . . . . . 214
15.2.1 Surgical Technique . . . . . . . . . . . . . . . . . . . . . 214
15.2.2 Indications, Results and Complications . . . . . . . . . . 216
15.3 Other Tension-free Suburethral Slings
for Treatment of Stress Urinary Incontinence . . . . . . 218
15.3.1 Materials of Suburethral Slings . . . . . . . . . . . . . . 218
15.3.2 Approaches of Suburethral Slings . . . . . . . . . . . . . 221
15.3.2.1 Antegrade Suprapubic Approach . . . . . . . . . . . . . 221
15.3.2.2 Prepublic Approach . . . . . . . . . . . . . . . . . . . . . 222
15.3.2.3 Transobturator Approach . . . . . . . . . . . . . . . . . 224
15.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . 227
References . . . . . . . . . . . . . . . . . . . . . . . . . . 227
15
214
Christl Reisenauer,Konstantinos Gardanis,Diethelm Wallwiener
15.1 Introduction
Over the past decades many theories have been proposed to explain why women develop stress urinary incontinence. They have led to different, more or less successful
methods of treatment.
Two of these theories are relevant for an innovative and minimally invasive surgical
treatment of stress urinary incontinence by using tension-free mid-urethral slings.
The latter will be the subject of the following article.A second form of treatment, urethral injectable agents,however, will not be dealt with here as they are described in another chapter of this book.
One of these theories is the Hammock Hypothesis of DeLancey. This theory provides information on the structural support of the urethra and explains how it relates
to stress incontinence.
The urethra lies on a supportive layer that is composed of the endopelvic fascia and
the anterior vaginal wall. The layer gains structural stability by its lateral attachment
to the pelvic sidewall at the arcus tendineus fascia pelvis. The arcus tendineus fascia
pelvis is a tense fibrous band between the pubic bone and the ischial spine.
Coughing, for example, increases abdominal pressure and presses the urethra
against this hammock-like supportive layer. Consequently the lumen is closed, so that
discharge of urine is prevented. The stability of the suburethral layer depends on its
connection to the arcus tendineus fascia pelvis being intact. If the supportive layer is
unstable it cannot provide resistance against which the urethra can be compressed.
This is followed by a loss of urine (DeLancey 1994).
Another theory is the Integral Theory of Petros and Ulmsten. This theory demonstrates that stress urinary incontinence may occur because of a lack of support of the
mid-urethra. This is caused by a weakness of the pubourethral ligaments and the anterior vaginal wall (Petros and Ulmsten 1993).
According to both theories, the urethra is not properly closed in stress incontinent
women because of dysfunctions or defects in pubourethral ligaments and/or the suburethral vaginal wall. The TVT operation – as a form of a minimally invasive treatment
– intends to correct these dysfunctions and defects.
The tension-free vaginal tape (TVT) procedure, as described by Ulmsten, was introduced into clinical practice in 1994–1995 after extensive preclinical research. If conducted by experienced surgeons, it is a simple and effective procedure that can be
performed under local anesthesia and requires only a short operative and recovery
time.
15.2 Tension-free Vaginal Tape (TVT) –
Operation
15.2.1 Surgical Technique
The TVT operation is carried out using a specific two-component instrument comprised of a nondisposable metal handle to which two disposable metal needles are attached. A prolene tape covered by a plastic sheath is fixed to the needles. A catheter
guide introduced into a Foley catheter controls the urethra and the bladder at needle
insertion (Fig. 15.1).
Chapter 15 Innovative and Minimally Invasive Treatment
215
Fig. 15.1. Tension-free vaginal tape operation
216
Christl Reisenauer,Konstantinos Gardanis,Diethelm Wallwiener
After the patient is sedated, a transurethral Foley catheter is introduced and the
bladder is emptied. The local anesthesia is given. Two minimal incisions are made in
the abdominal skin above the superior edge of the pubic bone,4 cm apart. Another incision, 1.5 cm long, is made in the suburethral vaginal wall,starting 1 cm from the urethral meatus. Laterally from this incision, a minimal blunt dissection, 0.5–1.0 cm long,
is made with scissors to each side of the urethra. With a catheter guide introduced into
the Foley catheter, the urethra and the bladder neck are identified. Using the handle
with the needle attached, the tape is placed around the mid-urethra as follows: the tip
of the needle is inserted into the prepared paraurethral incision on one side of the urethra. The urogenital diaphragm is perforated and, then inside the cavum Retzii, the
needle tip is brought up to the abdominal incision in close contact with the back of the
pubic bone. As soon as the needle tip has reached the abdominal skin incision, its
proximal end is disconnected from the handle. The procedure is then repeated on the
other side. At this step of the operation, the patient undergoes cystoscopy to confirm
an intact bladder.Still covered by the plastic sheath,the tape is then brought into position by gently pulling the needles upward with the tape attached.
With 300 ml of saline in the bladder, the patient is then asked to cough vigorously,
to make sure that continence has been obtained.During coughing, the tape is adjusted
so that a few drops of urine are allowed to escape the urethra.When the tape has been
placed in an ideal U-shape around the mid-urethra, the plastic sheath is withdrawn.
The abdominal ends of the tape are cut with scissors below the skin surface in the subcutaneous tissue. Finally, the vaginal and skin incisions are sutured. The bladder is
emptied and no catheter is left in place (Ulmsten 2001).
15
15.2.2 Indications, Results and Complications
In a prospective long-term multicenter study, Nilsson et al. evaluated 90 patients who
had a tension-free vaginal tape operation because of primary stress urinary incontinence. The mean follow-up time was 56 months; 84.7% of the patients were completely cured, another 10.6% significantly improved and 4.7% of the operations were regarded as failures.Only a few complications during or after surgery occurred. In 1.1%
of the patients bladder perforation and in 3.3% intraoperative bleeding of more than
200 ml occurred. In 3.3% a retropubic hematoma formed. Postoperative voiding difficulties were experienced by 4.4% of the patients; 5.9% reported de novo urge symptoms and 7.8% experienced urinary tract infections during the first 2 months after operations (Nilsson et al.2001).
After a 7.6-year mean follow-up time, 81.3% of the women who had been treated
with the TVT procedure were cured,16.3% improved and 1.3% of the operations failed
(Nilsson et al.2003).
The TVT operation can also be recommended for the surgical treatment of female
stress urinary incontinence where previous incontinence operations have failed. The
operative success seemed not to be diminished by previous surgery (Rezapour et al.
2001). TVT surgery is less successful in stress incontinent women with a very low
resting urethral pressure and an immobile urethra (74% of patients were cured and
12% significantly improved after a mean follow-up time of 4 years) (Rezapour et al.
2001).
In the meantime, the tension -free vaginal tape has become one of the most popular surgical procedures for the treatment of stress urinary incontinence. Several re-
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