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21 Fecal Incontinence
the commode with or without giving an enema.
The goal is to check whether the rectum is protruding out of the anus.
Anorectal manometry can help in evaluating
pelvic oor function. Quantication of anal muscle strength during rest and squeeze can provide
valuable information. The capacitance of the rectum, the presence of a recto-anal inhibitory reex,
and electromyography (EMG) can also be
obtained as part of the anorectal manometry test.
Along with the physical exam, anorectal manometry aids in assessing pelvic oor muscle coordination. Sphincter pressures on manometry are
expected to be low in FI; however, high pressures
can be seen in patients with FI and should alert
the caregiver to rule out problems like animus or
overow incontinence. Patients with chronic
constipation and urgency may also have high anal
rest and squeeze pressures as a result of the
sequela of constant squeezing out of fear of having an accident.
Rectal hyposensitivity (a stretched-out rectum) may be seen in chronically constipated
patients with overow incontinence where the
rectum has reduced sensation and enlarges to a
point that it is lled with stool that can uncontrollably run out the anus. Rectal hypersensitivity
which can be thought of as similar to a stiff
walled rectum, more typically is noted in patients
with some forms of irritable bowel syndrome,
low anterior resection syndrome, inammatory
bowel disease, scleroderma and after pelvic radiation. The absence of a recto-anal inhibitory
reex is seen in patients with Hirschsprung disease and after some anorectal surgery. Pudendal
nerve terminal motor latency (PNTML) testing is
no longer recommended or performed as it adds
little to the evaluation and treatment plan. [1]
Ultrasound is a useful tool to assess sphincter
morphology in the setting of FI.In experienced
hands, ultrasound can also be used to diagnose
rectal intussusception and pelvic organ prolapse
(Fig.21.1).
Defecography can be performed dynamically
with uoroscopy or during an MRI.This allows
visualization of the pelvic structures during the
223
Fig. 21.1 Endoanal ultrasound: sphincter defect
simulated act of squeezing and then defecation.
For patients with FI, there is limited utility as
most patients will not be able to retain contrast to
complete the study. For patients who can retain
contrast, evaluation for rectal intussusception
may be useful as, if present, it may be associated
with a suboptimal response to treatments like
sacral nerve neuromodulation (SNM).
When to consider a colonoscopy is individualized for patients based on age, symptoms, and
family history of colon cancer. Colonoscopy is
recommended for anyone over 45 who has never
had a colonoscopy or for patients with a change
in their bowel habits. If there is a strong family
history, typically, a colonoscopy is recommended
when the patient is 10 years younger than the
youngest person in their family who had colorectal cancer. A colonoscopy is performed to exclude
pathology such as a malignancy or inammatory
bowel disease. For patients with diarrhea, random biopsies are performed to rule out microscopic colitis.
Survey tools to assess FI can be helpful. We
prefer the Cleveland Clinic Fecal Incontinence
Score (CCF FI 0–20 with 20 being totally incontinent) which is a validated tool that is helpful in
objective documentation of symptoms of fecal
incontinence and can be used to evaluate and follow FI after treatment.
224
BOWEL CARE PATHWAY - INCONTINCE
A. R. Spivak
Treatment
The goals of treatment include decreasing episodes of FI and improving quality of life.
Conservative treatment is the rst line of therapy and involves optimizing bowel function
with dietary modications, uid management,
correcting loose stools with bulking agents,
antidiarrheal medications, and pelvic oor
exercises, and incorporating behavioral
changes.
Dietary modications include eliminating caffeine, articial sweeteners, lactose, gluten, and
dietary supplements. The goal is to optimize
Fig. 21.2 Clinic bowel
care pathway
stool consistency and eliminate foods that contribute to loose stools and urgency. Maintaining a
diary, which documents food intake, bowel
movement frequency, and consistency, as well as
episodes of urgency and FI, can be extremely
helpful to pinpoint dietary agents that contribute
to bowel dysfunction.
Medical management utilizing medications
designed to slow colonic motility and optimize
stool consistency is also frequently started at this
stage. Figure 21.2 lists the commonly recommended medications.
Regiments designed to facilitate emptying the
rectum and left colon using scheduled enemas or
Conservative Therapy
Diet
Fiber
Pelvic Floor PT
Biofeedback
Kegel Exercises
12 weeks
Re-
evaluation
Advanced Therapy
Sacral
Neuromodulation
Evalution
Sacral
Neuromodulation
Therapy
Medications
Antidiarrheal
Probiotics
Device trail (7–10 days)
You should see
improvement by >50%
Device Implantation
(Outpatient surgery)
21 Fecal Incontinence
suppositories can aid in the management of
FI. There are some commercial products available to assist in this process. The Peristeen® anal
irrigation system can be purchased online and is
used in adults to improve quality of life symptoms. This device consists of a catheter with a
balloon, a pump, and a water container. Patients
are taught to insert the balloon via their anus into
their rectum and inate the balloon. They then
irrigate their rectum and colon with water.
Expelling the water with stool cleans out the left
colon. When the left colon is cleansed of stool, FI
cannot occur. Typically, this is performed several
times a week [12].
Pelvic oor physical therapy is used to rehabilitate pelvic oor in order to improve sensation,
muscle coordination, and anal strength. Ragadas
etal. found in 124 patients treated with physical
therapy, 50% demonstrated reduction in FI
scores. They noted that patients who were less
likely to respond had a CCF-FI score >10, a previous vaginal delivery, an anorectal or colon surgery, and were not able to maintain a squeezing
effort [13].
Anal skin care is a forgotten need in patients
with FI.It is important to counsel patients on correct use of barrier ointments (e.g., zinc oxide),
gentle soaps, avoiding over wiping, and use of a
bidet which all can improve irritated anal skin.
Patients are also cautioned that deodorants can
irritate the skin and that rubbing with perineal
pads can further lead to perineal skin breakdown
and irritation.
When conservative management does not sufciently improve the patient’s quality of life,
more advanced therapy is considered and will be
discussed next.
Anal Insertion Devices
Anal plugs can be used as an adjunct to conservative therapy. A plug is inserted into the distal part
of the rectum to provide mechanical obstruction
and prevent stool leakage. Plugs are no longer
225
Fig. 21.3 An anal plug
recommended in the guidelines published by the
American Society of Colon and Rectal Surgeons
[1] (ASCRS) due to variable results. Previous
studies have demonstrated a 50% improvement
in FI symptoms in 62% of patients over a 12-week
observation period [12] (Fig.21.3). There is little
drawback to trying an anal plug, and some
patients with limited FI may nd it extremely
helpful.
Vaginal Bowel Control Systems
Vaginal bowel control systems can also be used
as an adjunct to conservative therapy. A pessarylike device is introduced into the vagina. This has
an attached balloon. When the balloon around the
pessary is inated, there is impingement on the
rectovaginal septum, pushing the rectum toward
the sacrum and mechanically occluding the rectum temporarily. This prevents stool from passing beyond this point. The balloon needs to be
deated for defecation. In a multicenter study of
137 patients, 62% were able to be tted with and
tolerate such a device. Of those, 94% had a reduction of their FI symptoms over a 12-month period
[14] (Fig.21.4).
226
Fig. 21.4 A vaginal insertion device
Bulking Agents
Multiple types of bulking agents have been
injected into the anal region in an attempt to
increase the bulk of the anal sphincter with the
goal of improving FI.
Dextranomer/hyaluronic acid (Solesta®),
which is available in the United States, is a biocompatible bulking agent administered by submucosal injection. It is hypothesized to expand
the submucosal layer of the proximal anal canal,
thereby augmenting bowel control. Limited
studies comparing injections to patients injected
with a sham control demonstrated >25% reduction in FI symptoms over a 12-month period
[15]. Bulking agent injections are not routinely
recommended as treatment for FI in the updated
ASCRS practice guidelines [1] due to lack of
signicant FI improvement in most studies
(Fig.21.5).
A. R. Spivak
Fig. 21.5 Solesta® injection
Radio-Frequency Tissue Remodeling (SECCA®)
Radio-frequency tissue remodeling involves
delivery of radio-frequency energy into the
internal anal sphincter. This stimulates collagen
deposition and thickening of the muscularis propria, which leads to an increased bulk and outlet
resistance of the anal canal. Frascio et al.
reviewed the published outcomes from several
studies and found a 55–80% symptom improvement in patients with mild-to-moderate FI [17].
Long- term date is limited, and this treatment
has not been recommended for treatment of FI
in the most recent ASCRS practice guidelines
[1] again due to concerns of limited signicant
improvement.
21 Fecal Incontinence
Percutaneous Tibial Nerve Stimulation (PTNS)
Percutaneous tibial nerve stimulation (PTNS)
indirectly stimulates nerves supplying the pelvis
by electrically stimulating the tibial nerve. It
involves sitting with the stimulator over the tibial
nerve for about 30min several times per week for
up to 3 months. If there is improvement, then
occasional treatments will be needed to sustain
the response. An advantage of PTNS is that no
surgical procedure is required as the stimulator is
external. In a randomized double-blind trial performed in the United Kingdom, 115 patients
received PTNS and 112 sham stimulation. There
was no signicant difference between the two
groups after 12weeks of treatment [16].
Sacral Nerve Neuromodulation (SNM)
227
Fig. 21.6 Sacral nerve neuromodulation
Sacral nerve neuromodulation is currently the
recommended rst-line surgical option for
patients with FI—even in those with sphincter
defects. The SNM procedure is performed in two
stages. The rst stage is called peripheral nerve
evaluation (PNE) and involves inserting a wire
into the S3 sacral foramen. This is usually performed in the ofce. This wire is a temporary
lead and is attached to an external stimulator. The
patient tracks their episodes of FI.After about a
week, the wire is removed. If there has been a
50% improvement in symptoms, at a later date in
the operating room, a permanent lead is placed in
S3 and the stimulator implanted in the buttock.
For some patients, stage one is performed in the
operating room, and the permanent lead is
inserted during this phase. The stimulator is still
external during this modied phase one. If there
is 50% improvement, the stimulator is implanted
approximately a week later in the operating room
(Fig. 21.6). The United States multicenter trial
that led to Food and Drug Administration (FDA)
approval involved 120 patients. In all, 83% had
more than a 50% improvement in symptoms at
1year and 41% achieved 100% continence. This
stimulator is powered by a battery in the
implanted device. In the past, the stimulator was
not MRI-compatible. The most recent update to
the device has made it MRI-compatible and prolonged the battery life to 10years [18].
Surgical Sphincter Repair (Sphincteroplasty)
Damage to the anal sphincter most commonly
occurs during childbirth. Sphincter disruption
may be undiagnosed at the time. As a women
ages, weakening of the pelvic oor and a reduction in anal muscle bulk can occur. All these factors, combined with a remote obstetric anal
sphincter injury, may lead to FI decades after
childbirth. Sphincter disruption is typically diagnosed with anal ultrasound. When the disruption
is diagnosed within a year after childbirth, repair
of the sphincter may be an acceptable surgical
treatment of FI.Sphincter repair can also be considered as a treatment option for FI when SNM is
228
ab c
Fig. 21.7 (a) A dissected sphincter. (b) Overlapping sphincter repair. (c) Completed sphincteroplasty
not available [19]. Sphincteroplasty is performed
under general anesthesia either in the prone jackknife position or in lithotomy. A curvilinear incision is made in the perineum, the dissection is
carried laterally, and the ends of the anal sphincter are identied. Retaining the scar on the ends
for tissue integrity, the internal and external
sphincters are overlapped together in a vest-overpants-type conguration and secured with
absorbable sutures. This recreates the sphincter
complex (Fig.21.7).
Short-term published outcomes (<5 years)
after sphincteroplasty demonstrate improvement
of FI symptoms in 50–86% of patients. However,
repair deteriorates over time. In patients reassessed at 10years, none were totally continent.
Redo repair has limited success and is rarely recommended [20].
Fig. 21.8 Ventral mesh rectopexy
A. R. Spivak
Ventral Mesh Rectopexy (VMR)
FI improvement after VMR correction of intussus-
ception or external prolapse [21] (Fig.21.8).
External rectal prolapse or signicant rectal internal intussusception can add to FI. If present,
response to any other FI therapy will be limited
Other Treatments
and the anatomic abnormality needs to be surgically corrected. In VMR, the space between the
rectum and vagina is developed down to the pelvic
oor. Mesh is sutured to the rectum, and then the
other end is xed to the sacral promontory. This
lifts the posterior and middle compartments and
stabilizes the rectum. Multiple studies document
Other treatments have been performed in the
past for FI such as gracilis muscle transposition,
magnetic anal sphincter augmentation, and arti-
cial bowel sphincter. None of these are cur-
rently available or recommended in the United
States [1].
21 Fecal Incontinence
229
Antegrade colonic enemas can be an option
for a motivated patient who wants to avoid colostomy. This involves creation of appendicostomy
and daily high-volume irrigations through the
appendicostomy to cleanse the stool from the
colon.
In patients who still suffer from a poor quality
of life despite trying multiple FI therapies, a
colostomy is an option. This can provide patients
with the ability to leave their home without the
worry of FI.
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Operations forRectal Prolapse
JenniferShearer, BrookeGurland,
andCaitlinBungo
General Background
22
231
232
J. Shearer et al.
Preoperative Procedural Considerations
Abdominal Procedures forRectal
Prolapse
Table 22.1 Common complications of abdominal rectopexy by procedure type
22 Operations forRectal Prolapse
Table 22.1 (continued)
General Abdominal Surgery Complications
233