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250
ab
J. S. Beaty and C. A. Ternent
patients being seated on a toilet-like chair.
Disposable bilateral perianal surface EMG electrodes are connected to the EMG recording
device, which provides auditory and visual signals to aid patient observation of muscle activity.
Patients are then asked to squeeze, to bear down
as in defecation, and to relax the pelvic oor
with the goal of lowering the straining EMG
activity to a level close to the rest EMG activity.
Patients are then trained to expel the rectal balloon connected to a catheter in the lateral position and instructed to practice expulsion of rectal
contents while relaxing the pelvic oor during
straining at home. Anal canal sponge EMG and
surface EMG electrodes can be used to accomplish these goals in patients with PFD.EMG biofeedback tracings can also be used to help
patients with FI visualize anal sphincter and pelvic oor activity at rest and squeeze as part of
muscle strengthening therapy (Fig. 32.3).
Biofeedback training can also be performed with
an ARM probe placed in the distal rectum and
the anal canal. A balloon is attached to the tip of
the pressure transducer catheter, which is used
for training rectal evacuation in PFD and to help
regain rectal sensation and more complete evacuations (Fig.32.2). Squeeze and rest anal sphincter exercises based on real-time manometry
tracings can also be used to visualize pressure
tracings for the specic biofeedback needs of FI
patients.
Few studies have compared the different biofeedback protocols for PFD. A 2003 metaanalysis by Heymen etal. evaluating 38 studies
c
Fig. 32.3 EMG-based biofeedback sequences of a
patient with fecal incontinence performing rest and
squeeze repetitive exercises documenting magnitude of
the squeeze effort compared to rest. (a) Represents slow
rest- squeeze cycles to work on sustainability of the con-
traction. (b) Fast rest-squeeze cycles to work on endurance. (c) Biofeedback session with green tracing
representing optimal squeeze goal magnitude for the session and purple tracing representing real-time patient
squeeze and rest goal directed exercises
32 Pelvic Floor Conditions: Biofeedback
251
shows a mean success rate of studies using pressure biofeedback (78%) to be statistically superior (P = 0.018) to the mean success rate for
studies using electromyography biofeedback
(70%) although the clinical signicance of this
difference remains largely unknown. The mean
success rates comparing studies using intra-anal
EMG sensors to studies using perianal skin EMG
sensors were 69% and 72%, respectively, indicating no advantages for one type of electromyography protocol over the other (P=0.428).
The cognitive aspects of teaching pelvic oor
relaxation at strain for patients with PFD can be
challenging. One approach commonly employed
and taught by trained physical therapists is the
Franklin method. This program may be purchased
online from www.franklinmethod.com. This
method combines imagery, embodied anatomy
and teaching skills to help improve human movement. Essentially, patients are taught to shorten
and lengthen in counterbalance form the complementary sets of pelvic oor and spinal/abdominal
musculature. Once patients become knowledgeable in the isolation of these muscle groups then
the task of correction of the pathologic pelvic
oor activity such as dyssynergia is possible. The
visual cues of biofeedback are used to reinforce
optimal muscle behavior that can then be reproduced outside of the controlled ofce setting.
Another option is to work with PFD patients on
behavior modication techniques to isolate the
pelvic oor and work on decreased pelvic oor
muscle contractility during strain to less than 50%
of the squeeze activity and as close to the rest
activity as possible. All this should be facilitated
by visualizing pelvic oor muscle activity with a
biofeedback tracing such as that provided by
EMG surface electrodes or anal canal pressure
recordings. This latter technique focuses on
abdominal muscle and respiration coordination to
optimize the Valsalva maneuver while relaxing
the pelvic oor during rectal evacuation efforts.
Subtle cues by the therapist with the assistance of
biofeedback for relaxation of the pelvic oor in
PFD can help patients understand appropriate
behavior and modify pathologic tendencies. This
cognitive realization is crucial and not always
easy to overcome and maintain over time. Both
approaches to biofeedback therapy for PFD can
be effective as stand- alone or complementary programs and represent important elements of the
armamentarium to treat PFD.
D. Biofeedback for fecal incontinence may be
simpler to teach and involves a combination
of Kegel type squeeze exercises under surface
EMG feedback of the pelvic oor and rectal
resensitization if needed. The 2015 American
Society of Colon and Rectal Surgery Clinical
Practice Guidelines for the Treatment of
Fecal Incontinence recommend biofeedback
as an initial treatment for patients with fecal
incontinence and some preserved voluntary
sphincter contraction with 1B evidence grading, corresponding to strong recommendation
with moderate quality evidence and benets
clearly outweighing risks and burdens. The
objective benet reported in the literature has
shown substantial variability. Nonrandomized
prospective or retrospective case series report
64–89% improvement in incontinence episodes. Randomized trials have compared different approaches of biofeedback, pelvic
oor exercise advice and education, as well
as telephone treatment, but there are no randomized controlled trials of biofeedback to
sham therapy in FI.A recent meta-analysis of
35 studies of biofeedback therapy for FI identied a success rate for studies using
Coordination Training (i.e., coordinating pelvic oor muscle contraction with the sensation of rectal lling) of 67%, while the mean
success rate for studies using Strength
Training (i.e., pelvic oor muscle contraction) was 70%. Furthermore, the mean success rate for those Strength training studies
using electromyographic biofeedback was
74%, while the mean success rate for studies
using anal canal pressure biofeedback
Strength training was 64%. Finally, no patient
characteristics were identied that would
assist in predicting successful outcome. A
Cochrane Database Systematic review from
2012 found that while there is a suggestion
that some elements of biofeedback therapy
and sphincter exercises may have a therapeutic
252
J. S. Beaty and C. A. Ternent
effect for FI, this was not certain and larger
well-designed trials were recommended.
We routinely perform EMG-based biofeedback for FI although manometry-based can be
substituted if needed. Patients are typically
placed in the lateral decubitus or supine position
with lower extremity support so the pelvic oor
activity at squeeze, rest and strain can be easily
visualized. Sets of squeeze and rest exercises are
initially practiced under therapist supervision in
order to maximize the voluntary squeeze over
rest effort to the greatest magnitude on the monitor scale. Patients can then practice repeat sets of
short pelvic oor and external anal sphincter
squeeze and rest exercises while maximizing the
magnitude of the squeeze activity. Once this concept is mastered, patients move on to sets of longer squeeze efforts with similarly long recovery
times for endurance build-up (Fig.32.3). These
exercises that are learned with the assistance of
supervised ofce biofeedback sessions can then
be practiced at home with or without the help of
home biofeedback equipment depending on
patient and therapist preference and availability.
No specic biofeedback standards exist for
the optimal number of sessions, session time
length and frequency. One study did evaluate predictors of success for biofeedback in constipation. In 194 constipated patients, biofeedback
success rates improved after ve or more sessions and was signicantly related to patient willingness to complete therapy. In general, patients
undergo weekly up to 1-h sessions for 4–6weeks
with assessment of function and clinical progress. The clinical progress with the therapy and
patient symptomatology can help to determine
whether further extension of therapy sessions and
the commonly required refresher biofeedback
visits may be of benet.
Patients are encouraged to practice the biofeedback enabled appropriate pelvic muscle
activity and behavior at home to help correct
PFD and FI.This can be done with or without
biofeedback devices. For patients who prefer
biofeedback devices, small units exist that can
be placed internally with Bluetooth capability
and phone apps that track the progress and intensity of Kegel exercises in real time (http://www.
elvie.com). However, the unwanted recruitment
of muscles like the gluteus, when performing
Kegel exercises, may be detected as appropriate
electrical activity on biofeedback devices based
on proximity of the regional muscles of the pelvis. This can result in inappropriate feedback
and reinforce a suboptimal exercise regimen in
some cases. Studies have looked at whether the
use of home biofeedback devices offer any
advantage over regular exercises following the
initial guided biofeedback sessions. No signicant difference appears to exist between these
two methods. What does seem to be clear is that
initial instruction and follow up ofce visits with
biofeedback are important to document continued correct pelvic oor muscle activity and ne
tune any deviations in the recommended exercises. Patients often benet from refresher sessions using biofeedback techniques along with
physical therapy methods to maintain the progress and correct any recurrent pathologic behavior of the pelvic oor.
Contraindications to biofeedback do exist,
including an allergy to electrode or contact material and patients who are unable to understand or
respond to the instructions of the therapist. If a
patient has a diminished skin or rectal sensation,
the full benet of therapy may not be achieved. In
addition, certain geographic regions may not
have readily available certied biofeedback therapists within a reasonable travel distance. The
availability of specialized pelvic oor physical
therapy specialists can be further searched at
http://www.womenshealthapta.org/pt-locator/.
Suggested Reading
Beatty J, Legewie H, editors. Biofeedback and behav-
ior, Volume 2 of the series NATO conference series.
New York: Springer US for Plenum Press; 1977.
https://doi.org/10.1007/978-1-4684-2526-0_1.
Enck P, Van der Voort IR, Klosterhalfen S. Biofeedback
therapy in fecal incontinence and constipation.
Neurogastroenterol Motil. 2009;21(11):1133–41.
https://doi.org/10.1111/j.1365-2982.2009.01345.x.
Epub 2009 Jun 30
32 Pelvic Floor Conditions: Biofeedback
253
Gilliland R, Heymen S, Altomare DF, etal. Outcome and
predictors of success of biofeedback in constipation.
Br J Surg. 1997;84(8):1123–6.
Heymen S, Jones KR, Scarlett Y, Whitehead
WE.Biofeedback treatment of constipation: a critical
review. Dis Colon Rectum. 2003;46(9):1208–17.
Kassis NC, Wo JM, James-Stevenson TN, Maglinte
DD, Heit MH, Hale DS. Balloon expulsion testing for the diagnosis of dyssynergic defecation in
women with chronic constipation. Int Urogyncol J.
2015;26(9):1385–90.
Norton C, Cody JD.Biofeedback and/or sphincter exer-
cises for the treatment of faecal incontinence in adults.
Cochrane Database Syst Rev. 2012;11(7):CD002111.
Paquette IM, Varma MG, Kaiser AM, Steele SR,
Rafferty JF. The American Society of Colon and
Rectal Surgeons clinical practice guideline for the
treatment of fecal incontinence. Dis Colon Rectum.
2015;58:623–36.
Rao SS, Patcharatrakul T. Diagnosis and treatment of
dyssynergic defecation. J Neurolgastroenterol Motil.
2016;22(3):423–35.
Rao SS, Seaton K, Miller M, Brown K, Nygaard I, Stumbo
P, Zimmerman B, Schulze K.Randomized controlled
trial of biofeedback, sham feedback, and standard
therapy for dyssynergia. Clin Gastroenterol Hepatol.
2007;5(3):331–8.
Rao SS, Valestin J, Brown CK, Zimmerman B, Schulze
K.Long-term efcacy of biofeedback therapy for dys-
synergic defecation: randomized controlled trial. Am J
Gastroenterol. 2010;105(4):890–6.
Rao SS, Benninga MA, Bharucha AE, Chiarioni G, Di
Lorenzo C, Whitehead WE. ANMS-ESNM posi-
tion paper and consensus guidelines on biofeedback
therapy for anorectal disorders. Neurogastroenterol
Motil. 2015;27(5):594–609. https://doi.org/10.1111/
nmo.12520. Epub 2015 Apr 1
Pelvic Floor Conditions: Fecal Incontinence
MaryT.M.O’Donnell andJoshuaI.S.Bleier
33
Refer toAlgorithm in Fig.33.1
A.History andPhysical: Etiology,
Severity, andComorbidities
Initial Evaluation:
• Focused History
• Dietary and Bowel History
• Medications History
• Obstetric History
• Examination Including Anoscopy and DRE
• Incontinence Scoring
Fecal incontinence can have a wide differential and a thorough history and physical exam
with digital rectal exam and anoscopy are necessary. Often, simple dietary or medication changes
can affect dramatic improvements in continence
without the need for any surgical intervention.
Within a comfortable clinical environment, the
surgeon should determine the onset and frequency of symptoms as well as the change in
M. T. M. O’Donnell
Walter Reed National Military Medical Center,
Bethesda, MD, USA
J. I. S. Bleier (*)
Department of Surgery, Penn Perelman School of
Medicine, Philadelphia, PA, USA
e-mail: joshua.bleier@uphs.upenn.edu
bowel consistency. Onset of symptoms may
coordinate with new exposures or behavioral
changes leading to an etiology. Changes in bowel
consistency temporally related to a patient’s
symptoms may similarly point to a cause. Lastly,
frequency of symptoms with regard to the type of
bowel movements helps determine the severity of
the FI and can be used with a number of scoring
scales including Fecal Incontinence Severity
Index (FISI), Fecal Incontinence Quality of Life
scale (FI-QOL), and the Vaizey/St. Marks
Incontinence Score. The most commonly used
scoring scale is the Wexner/Cleveland Clinic
Florida Fecal Incontinence Score (CCF-FIS)
(Table33.1).
Frequently, conservative alteration of the stool
consistency and its transit time is all that is
required to dramatically improve the symptoms
of this condition. If these methods are unsuccessful, augmentation of the pelvic oor function or
reconstruction of the injured structures may
improve continence. Lastly, if all of these fail,
stoma formation can improve quality of life in
patients with what is an often embarrassing and
life-limiting condition. Knowing a patient’s baseline disease severity can be used to guide treatment by determining its efcacy.
Fecal incontinence can be caused by medications, direct sphincter injury, anorectal diseases,
anal or rectal cancers, the treatments of anal or
rectal cancers, neurologic disorders, radiationinduced injury, IBS, overow from chronic
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_33
255
256
M. T. M. O’Donnell and J. I. S. Bleier
Fig. 33.1 Algorithm for evaluation and treatment for fecal incontinence
Table 33.1 Cleveland Clinic Florida Fecal Incontinence
Score (CCF-FIS)
Type of incontinence Frequency
Solid 0 1 2 3 4
Liquid 0 1 2 3 4
Gas 0 1 2 3 4
Wear pad 0 1 2 3 4
Lifestyle altered 0 1 2 3 4
In order to determine a patient’s baseline and the efcacy
of treatments of FI, severity must be graded and there are
a number of scoring scales available: Wexner/Cleveland
Clinic Florida FI Scale (CCF-FIS), the Vaizey/St. Mark’s
Incontinence Score, Fecal Incontinence Severity Index,
and the Fecal Incontinence Quality of Life scale. Below is
the CCF-FIS, which is most commonly used
0= never; Rarely: <1/month; Sometimes: <1/week or 1/
month; Usually: 1/day or 1/month; Always: 1/day or more
constipation, and diabetes-induced neuropathy.
The most common cause of fecal incontinence
in women is injury to the anal sphincter complex and/or the pudendal nerves, usually during
childbirth. Obstetrical injury of the sphincter,
which can accompany up to 30% of vaginal
deliveries, may only manifest in women later in
life, years after injury, as the pelvic oor weakens and other aspects of the coordinated function of continence begin to weaken. Pudendal
nerve damage has been demonstrated in up to
60% of patients with obstetrical tears. A complete and detailed obstetrical history is important to obtain in the >40year old female patient
presenting with FI.
Congenital malformations that have led to disordered proprioceptive response of the rectum,
radiation therapy sequelae and even low rectal
surgery are examples of etiologies of fecal incontinence in patients with intact sphincter complexes. Patients who have undergone low rectal
surgery often have issues with FI after complete
healing of the pelvic anastomosis. Trauma from
sexual abuse, impalement, or foreign body insertion can lead to larger portions of the sphincter
complex and a delicate approach should be used
to elicit that information. The history and physical exam should be directed towards determining
the presence of any of the above etiologies, to
include history of hemorrhoids, rectal prolapse,
Crohn’s disease, neoplasm, degenerative neurologic disorders, and/or chronic diarrhea/constipation, all of which could cause FI.
Finally, the presence of severe comorbidities
may limit the incontinent patient’s options for
surgical repair. Up to 50% of institutionalized
patients have fecal incontinence and the presence
of severe comorbidities may limit the extent of
surgical treatment.
B.Optimization ofDiet andMedical
Management
Once the etiology of FI has been determined to
be benign and not secondary to another underlying
33 Pelvic Floor Conditions: Fecal Incontinence
257
anorectal disorder, initial treatment should
always be conservative. A trial of a combination
of the methods below should be attempted prior
to any surgical management strategies.
Key Components of Conservative Management
• Dietary Modications
• Fiber Supplementation
• Medical Management Including Antidiarrheals
• Consideration of Biofeedback
Dietary Modications
Dietary modications may aid in the treatment of
FI, but require the patient to keep a careful log of
food or supplements that triggers their symptoms. Attention should be directed towards caffeine, medications, low-ber intake, sugar
replacements, lactose, and even short-chain carbohydrates (FODMAPs) in an effort to determine
any relation towards diarrhea and urgency.
Counseling from a specialist regarding diet habits, uid intake, bowel routines, and medications
has been shown to improve FI severity in 22–54%
of patients.
Fiber Supplementation
Because fecal incontinence is a result not only of
anorectal physiology, but also the stool consistency and colonic transit time, ber supplementation and anti-motility agents have also shown
improvement in symptoms, by providing volume
and bulk and consistency to stool. Men and
women should add a supplement to reach a goal
of 35g and 25g ber per day, respectively.
Medications
If the patient with FI still has loose stools after
ber supplementation, attention should be paid
to any medications which may be causing loose
stool. Once these have been ruled out, antidiarrheal medications like loperamide, amitriptyline, and diphenoxylate-atropine may help
improve stool consistency and therefore
FI.Loperamide has been shown to increase anal
resting pressure, improve rectal sensation, and
retention of uid load through its inhibition of
peristalsis via the enteric Mu receptors.
Amitriptyline can reduce frequency and amplitudes of rectal motor complexes through its
anticholinergic properties.
Biofeedback
Biofeedback, or pelvic oor rehabilitation, is a
non-invasive technique used to improve sensation, coordination, strength, and function through
training of the pelvic oor. While some case
series have shown improvement in incontinence
episodes with pelvic oor exercise and expert
advice, randomized controlled trials have shown
no advantage to sham therapy. Despite denitive
evidence of symptom improvement, the low
morbidity of a trial of biofeedback obviates the
value of a trial of therapy prior to surgical
interventions.
C.Treat Anatomic Etiology (When
Possible)
Other diseases or conditions can have fecal
incontinence as a symptom of their presentation.
These etiologies need to be ruled out and treated
prior to pursuing a pathway for treatment of
refractory FI. The majority of these sources of
pseudo-incontinence can be ruled out with a thorough history and physical exam including clinical anoscopy. Defecography can be of some value
if rectal intussusception is suspected.
(a) Rectal Prolapse
(b) Hemorrhoids
(c) STDs
(d) Anorectal Neoplasm
(e) Fistula-in-ano
Incontinence due to rectal prolapse, anorectal
neoplasm, or stula-in-ano may effectively
respond to surgical intervention for the primary
presenting problem, while STDs and hemorrhoids
require antibiotics or ber supplementation.
Depending on the etiology of pseudo-incontinence, it must be treated. Once these sources are
treated, it may be discovered that the patient truly
has a component of physiologic FI amenable to
one of the therapies discussed below.
258
M. T. M. O’Donnell and J. I. S. Bleier
D.Suspected Recent Sphincter Injury
Women who present with new onset FI within
1year of vaginal delivery should be suspected to
have sphincter complex injury. Physical exam
ndings suggestive of sphincter disruption
include perianal scars or a thinning perineum.
The normal anal canal should appear well
approximated (not patulous) with intact perianal
sensation and anocutaneous “wink” reex. They
should undergo anoscopy and endoanal ultrasound evaluation of the sphincter complex.
Endosonography can help diagnose an occult
anal sphincter injury, atrophy of the sphincters,
and the presence of scar tissue. The presence of a
sphincter defect may be an indication to perform
either an end-to-end or overlapping sphincteroplasty. Sphincteroplasty outcomes in improving
FI demonstrate the most promise when performed in women with recent obstetrical injuries.
Unlike outcomes with sphincteroplasty with
older injuries (>5years), the functional improvement may last in the long-term.
It should be noted that after the initial injury
has healed, if FI persists, sacral nerve stimulation (SNS) may still be considered as a rst line
therapy. No documentation of sphincter injury is
necessary in this case and furthermore, if necessary, SNS may even be used as a bridge to
sphincteroplasty if necessary. Because a large
percentage of FI due to obstetrical sphincter
injury is remote from the time of injury, and only
presents once compensatory mechanisms are
weakened or are due to pudendal nerve injury, it
may be less invasive and optimal to start with
SNS treatment in these patients, especially since
a prolonged delay in sphincter repair has poor
durability.
If the injury is more devastating or alternatively located, a well-trained Colorectal surgeon
can consider reconstruction of the sphincter complex via the approaches discussed below. In the
absence of sphincter disruption, a reconstructive
or replacement option should be considered in
healthy patients. Depending on patient preferences or the patient’s co-morbidities, ostomy formation can also be considered if complex perineal
surgery is an undesirable option.
F.Sphincteroplasty
Studies have demonstrated short-term improvement in continence in up to 76% of patients with
post-obstetrical sphincteroplasty. At about
5years after repair, continence decreases signicantly to anywhere from 18% to 50%, but patient
satisfaction rate remains at 45–80%. If the is
sphincter damage is temporally associated with
FI, overlapping sphincteroplasty may be the optimal choice for a delayed repair. If documentation
of the sphincter injury is needed, endoanal ultrasound (EAUS) can be helpful. This is often necessary to conrm anatomy if sphincter repair is
planned. If sacral nerve stimulation has begun to
fail the patient as a therapeutic intervention, reexamination of the sphincters through ultrasound
should be considered.
End-to-End Sphincteroplasty
Early after obstetrical sphincter injury, a primary
end-to-end sphincteroplasty is an option, serving
to reapproximate the two ends of a damaged
sphincter complex. This is only feasible since
signicant scar has not yet formed in the area of
injury. If there is an open wound with the sphincter complex already exposed, this should be used,
but is usually employed by the Obstetrical
Gynecologist in a post-delivery repair. The
authors recommend delaying denitive repair for
at least 3months, until acute inammation, local
sepsis and soft tissue injuries have healed. If FI is
still a problem, a sphincter repair should be
considered.
Overlapping Sphincteroplasty:
Figs.33.2, 33.3, and33.4
If injury is remote or if primary repair fails, a
delayed repair can be performed once inammation has decreased. A curvilinear incision is made
anteriorly along the outer edge of the sphincter up
to 180° of the circumference. The incision should
not exceed 180° in order to avoid injury to the
laterally-located pudendal nerves. The incision is
deepened to expose healthy sphincter muscle,
which is then mobilized from surrounding fatty
tissue and reapproximated in an overlapping fashion anteriorly. The internal and external sphinc-
33 Pelvic Floor Conditions: Fecal Incontinence
259
Fig. 33.2 Sphincteroplasty. The sphincter muscle is
mobilized from the surrounding fatty tissue and the severed ends are reapproximated en bloc with both the internal and external sphincter with permanent or slow
absorbing suture. Care must be taken not to extend the
incision past 180° to avoid injury to the pudendal nerves.
In the more common setting of delayed repair, there is
frequently a signicant amount of scar briding the distracted ends of the sphincter. This is maintained in situ.
(With permission from Gurland B, Hull T. Overlapping
repair. In: Wexner SD, Fleshman D (eds). Master
Techniques in Surgery. Colon and Rectal Surgery.
Anorectal Operations. Wolters Kluwer, Philadelphia,
2012)
Fig. 33.4 Sphincteroplasty. This repair tends to lengthen
the perineal body and the perineal incision comes together
in a Y-shaped formation so that the midportion of this incision is left open for drainage. (With permission from
Gurland B, Hull T. Overlapping repair. In: Wexner SD,
Fleshman D (eds). Master Techniques in Surgery. Colon
and Rectal Surgery. Anorectal Operations. Wolters
Kluwer, Philadelphia, 2012)
ters are mobilized as one unit and overlapped,
leaving the midline scar in place. The ends of
sphincter that are overlapped are then sutured in
place with 3–4 slow-absorbing gure- of- eight or
horizontal mattress sutures. The perineal body is
lengthened as a result and the incision reapproximates as a Y-shaped incision, the center of which
is usually left open for drainage. Individual isolation and repair of internal and external sphincters
separately is technically more difcult, but also
has good evidence of efcacy. A seldom-used
repair is the Parks’ postanal repair.
G.Sacral Nerve Stimulation
(SNS)—See Figs.33.5 and33.6
Fig. 33.3 Sphincteroplasty. Severed ends of the sphinc-
ter muscle are overlapped and sutured with long term
absorbable suture. (With permission from Gurland B,
Hull T. Overlapping repair. In: Wexner SD, Fleshman D
(eds). Master Techniques in Surgery. Colon and Rectal
Surgery. Anorectal Operations. Wolters Kluwer,
Philadelphia, 2012)
The most promising modality for the treatment of
FI is sacral nerve stimulation (SNS). The procedure is not only less morbid than other surgical
options for FI, but the salutary effects on continence are immediate. Again, in patients with
obstetrical injuries, whether healed with persistent FI, or presenting later in life once compensatory mechanisms have diminished, SNS can
260
Mar
insertion
(External)
stimulator
M. T. M. O’Donnell and J. I. S. Bleier
Approx
ked location - S3
Fig. 33.5 Sacral nerve stimulation. Placement of a quadripolar lead electrode adjacent to the S3 nerve root via a
trans-sacral foraminal approach. (With permission from
Matzel KE. Sacral nerve stimulation. In: Wexner SD,
Fleshman D (eds). Master Techniques in Surgery. Colon
and Rectal Surgery. Anorectal Operations. Wolters
Kluwer, Philadelphia, 2012)
Temporary
lead
Fig. 33.6 Sacral nerve stimulation. The initial test phase
can be performed in the ofce using a temporary, unipolar
non-tined lead, which is placed using either anatomic
landmarks or uoroscopic guidance. (With permission
from Matzel KE. Sacral nerve stimulation. In: Wexner
SD, Fleshman D (eds). Master Techniques in Surgery.
Colon and Rectal Surgery. Anorectal Operations. Wolters
Kluwer, Philadelphia, 2012)
1.5cm
60°
angle
Points of
Rubber ground pad
Test
provide excellent results. Patients with refractory
FI of any etiology should be considered for SNS
therapy as well, such as low anterior resection
syndrome or complications from lateral internal
sphincterotomy or other anorectal surgery.
SNS is a staged procedure involving placement of a quadripolar lead electrode adjacent to
the S3 nerve root via the sacral foramina. The initial stage involves testing for symptomatic
improvement in FI which can be done via two
methods. In the outpatient ofce, a temporary,
non-tined, unipolar lead can be placed using anatomic landmarks with a 3–7day trial of symptom
improvement. The second method involves operative placement of the permanent quadripolar tine
lead under uoroscopic-guidance and a trial of
approximately 2 weeks is performed with an
external battery. The battery is programmed with
the settings that produce the best motor responses
intraoperatively. The patient must record the number of fecal incontinent episodes: if >50% reduction is achieved, then a permanent device can be
inserted using those settings. In patients with FI of
any etiology, including sphincter defects up to
120°, there is up to a 90% reported success with
48% of patients achieving perfect continence.
Prior to trial of SNS, the physician must
ensure not only that more conservative management has failed, but that the patient’s incontinence is frequent enough that the trial period of
1–2weeks will be long enough to demonstrate a
difference with therapy.
Tibial Nerve Stimulation
Another technique that should be mentioned is
posterior tibial nerve stimulation (PTNS). It is
non-invasive and therefore has very low morbidity, which is why it should be considered in the
therapy for FI.Through transcutaneous or percutaneous electrodes, the posterior tibial nerve is
stimulated at a supercial area in the foot. Therapy
is performed over 3 months, with twice daily
20 min sessions. Randomized controlled trials
have been performed which have shown improved
incontinence scores after treatment, though the
results are not as profound as with SNS.
Unfortunately, at the time of publication, PTNS is
not available for this indication in the USA.