Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_890_Библиотеки_им_академика_М_И_Перельмана.pdf
200
A.C. Lowry and J.L. Irani
89. Sand PK, et al. Prospective randomized trial of polyglactin 910
mesh to prevent recurrence of cystoceles and rectoceles. Am J
Obstet Gynecol. 2001;184(7):1357–62; discussion 1362–4.
90. Lehur PA, Kahn X, Hamy A. Surgical treatment of anterior rectoceles in women. The perioneal-vaginal approach. Ann Chir. 2000;
125(8):782–6.
91. Leventoglu S, et al. Transperineal rectocele repair with polyglycolic acid mesh: a case series. Dis Colon Rectum. 2007;50(12):
2085–92; discussion 2092–5.
92. Watson SJ, et al. Transperineal repair of symptomatic rectocele
with Marlex mesh: a clinical, physiological and radiologic assessment of treatment. J Am Coll Surg. 1996;183(3):257–61.
93. Smart NJ, Mercer-Jones MA. Functional outcome after transperineal rectocele repair with porcine dermal collagen implant. Dis
Colon Rectum. 2007;50(9):1422–7.
94. Farid M, et al. Randomized controlled trial between perineal and
anal repairs of rectocele in obstructed defecation. World J Surg.
2010;34(4):822–9.
95. Khubchandani IT, et al. Endorectal repair of rectocele revisited. Br
J Surg. 1997;84(1):89–91.
96. Khubchandani IT, et al. Endorectal repair of rectocele. Dis Colon
Rectum. 1983;26(12):792–6.
97. Heriot AG, Skull A, Kumar D. Functional and physiological outcome following transanal repair of rectocele. Br J Surg. 2004;
91(10):1340–4.
98. Sehapayak S. Transrectal repair of rectocele: an extended armamentarium of colorectal surgeons. A report of 355 cases. Dis
Colon Rectum. 1985;28(6):422–33.
99. Block IR. Transrectal repair of rectocele using obliterative suture.
Dis Colon Rectum. 1986;29(11):707–11.
100. Roman H, Michot F. Long-term outcomes of transanal rectocele
repair. Dis Colon Rectum. 2005;48(3):510–7.
101. Tjandra JJ, et al. Transanal repair of rectocele corrects obstructed
defecation if it is not associated with anismus. Dis Colon Rectum.
1999;42(12):1544–50.
102. Nieminen K, et al. Transanal or vaginal approach to rectocele
repair: a prospective, randomized pilot study. Dis Colon Rectum.
2004;47(10):1636–42.
103. Maher C, et al. Surgical management of pelvic organ prolapse in
women. Cochrane Database Syst Rev. 2010;(4):CD004014.
104. Gustilo-Ashby AM, et al. Bowel symptoms 1 year after surgery
for prolapse: further analysis of a randomized trial of rectocele
repair. Am J Obstet Gynecol. 2007;197(1):76.e1–e5.
105. Murad-Regadas SM, et al. Management of patients with rectocele,
multiple pelvic fl oor dysfunctions and obstructed defecation syndrome. Arq Gastroenterol. 2012;49(2):135–42.
106. Jones OM, Cunningham C, Lindsey I. The assessment and management of rectal prolapse, rectal intussusception, rectocoele, and
enterocoele in adults. BMJ. 2011;342:c7099.
107. Tsiaoussis J, et al. Rectoanal intussusception: presentation of the
disorder and late results of resection rectopexy. Dis Colon Rectum.
2005;48(4):838–44.
108. Dindo D, et al. Clinical and morphologic correlation after stapled
transanal rectal resection for obstructed defecation syndrome. Dis
Colon Rectum. 2008;51(12):1768–74.
109. Christiansen J, et al. Internal rectal intussusception: results of surgical repair. Dis Colon Rectum. 1992;35(11):1026–8; discussion
1028–9.
110. Hwang YH, et al. Biofeedback therapy for rectal intussusception.
Tech Coloproctol. 2006;10(1):11–5; discussion 15–6.
111. Dvorkin LS, et al. Rectal intussusception: characterization of
symptomatology. Dis Colon Rectum. 2005;48(4):824–31.
112. Steele SR, Mellgren A. Constipation and obstructed defecation.
Clin Colon Rectal Surg. 2007;20(2):110–7.
113. Choi JS, et al. Outcome and management of patients with large rectoanal intussusception. Am J Gastroenterol. 2001;96(3):740–4.
114. Felt-Bersma RJ, Tiersma ES, Cuesta MA. Rectal prolapse, rectal
intussusception, rectocele, solitary rectal ulcer syndrome, and
enterocele. Gastroenterol Clin North Am. 2008;37(3):645–68, ix.
115. Mellgren A, et al. Internal rectal intussusception seldom develops
into total rectal prolapse. Dis Colon Rectum. 1997;40(7):817–20.
116. von Papen M, et al. Functional results of laparoscopic resection
rectopexy for symptomatic rectal intussusception. Dis Colon
Rectum. 2007;50(1):50–5.
117. Johnson E, et al. Resection rectopexy for internal rectal intussusception reduces constipation and incomplete evacuation of stool.
Eur J Surg Suppl. 2003;588:51–6.
118. Orrom WJ, et al. Rectopexy is an ineffective treatment for
obstructed defecation. Dis Colon Rectum. 1991;34(1):41–6.
119. Slawik S, et al. Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of rectogenital prolapse and mechanical outlet obstruction. Colorectal
Dis. 2008;10(2):138–43.
120. Collinson R, et al. Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results. Colorectal Dis. 2010;
12(2):97–104.
121. Sileri P, et al. Laparoscopic ventral rectopexy for internal rectal
prolapse using biological mesh: postoperative and short-term
functional results. J Gastrointest Surg. 2012;16(3):622–8.
122. Farouk R, Bhardwaj R, Phillips RK. Stapled transanal resection of
the rectum (STARR) for the obstructed defaecation syndrome.
Ann R Coll Surg Engl. 2009;91(4):287–91.
123. Lehur PA, et al. Outcomes of stapled transanal rectal resection
vs. biofeedback for the treatment of outlet obstruction associated
with rectal intussusception and rectocele: a multicenter, randomized, controlled trial. Dis Colon Rectum. 2008;51(11):1611–8.
124. Ommer A, Rolfs TM, Walz MK. Long-term results of stapled
transanal rectal resection (STARR) for obstructive defecation syndrome. Int J Colorectal Dis. 2010;25(11):1287–92.
125. Goede AC, et al. Medium-term results of stapled transanal rectal
resection (STARR) for obstructed defecation and symptomatic
rectal-anal intussusception. Colorectal Dis. 2011;13(9):1052–7.
126. Gagliardi G, et al. Results, outcome predictors, and complications
after stapled transanal rectal resection for obstructed defecation.
Dis Colon Rectum. 2008;51(2):186–95; discussion 195.
127. Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal
rectal resection (STARR) procedures. Tech Coloproctol. 2008;
12(1):7–19.
128. Corman ML, et al. Consensus conference on the stapled transanal
rectal resection (STARR) for disordered defaecation. Colorectal
Dis. 2006;8(2):98–101.
129. Aigner F, et al. The rectogenital septum: morphology, function,
and clinical relevance. Dis Colon Rectum. 2004;47(2):131–40.
130. Takahashi T, et al. Enterocele: what is the clinical implication?
Dis Colon Rectum. 2006;49(10 Suppl):S75–81.
131. Gosselink MJ, et al. Treatment of enterocele by obliteration of the
pelvic inlet. Dis Colon Rectum. 1999;42(7):940–4.
132. Chou Q, Weber AM, Piedmonte MR. Clinical presentation of
enterocele. Obstet Gynecol. 2000;96(4):599–603.
133. Ellis CN. Treatment of obstructed defecation. Clin Colon Rectal
Surg. 2005;18(2):85–95.
134. Jean F, et al. Treatment of enterocele by abdominal colporectosacropexy – effi cacy on pelvic pressure. Colorectal Dis. 2002;4(5):
321–5.
135. Oom DM, et al. Enterocele repair by abdominal obliteration of the
pelvic inlet: long-term outcome on obstructed defaecation and
symptoms of pelvic discomfort. Colorectal Dis. 2007;9(9):845–50.
12 O bst ruct ive Def ecatio n
201
136. Boccasanta P, et al. Stapled transanal rectal resection for outlet
obstruction: a prospective, multicenter trial. Dis Colon Rectum.
2004;47(8):1285–96; discussion 1296–7.
137. Reibetanz J, et al. Enterocele is not a contraindication to stapled
transanal surgery for outlet obstruction: an analysis of 170
patients. Colorectal Dis. 2011;13(6):e131–6.
138. Carriero A, et al. Laparoscopic correction of enterocele associated
to stapled transanal rectal resection for obstructed defecation syndrome. Int J Colorectal Dis. 2010;25(3):381–7.
139. Petersen S, et al. Stapled transanal rectal resection under laparoscopic surveillance for rectocele and concomitant enterocele. Dis
Colon Rectum. 2006;49(5):685–9.
140. Mellgren A, et al. Enterocele is correctable using the Ripstein rectopexy. Dis Colon Rectum. 1994;37(8):800–4.
141. Fenner DE. Diagnosis and assessment of sigmoidoceles. Am J
Obstet Gynecol. 1996;175(6):1438–41; discussion 1441–2.
142. Jorge JM, Yang YK, Wexner SD. Incidence and clinical signifi cance of sigmoidoceles as determined by a new classifi cation system. Dis Colon Rectum. 1994;37(11):1112–7.
143. Malouf AJ, Vaizey CJ, Kamm MA. Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome. Dis Colon
Rectum. 2001;44(1):72–6.
144. Badrek-Amoudi A, et al. Laparoscopic ventral mesh rectopexy (LVMR) in the management of solitary rectal ulcer syndrome (SRUS): a cause for optimism? Colorectal Dis. 2013;15:
575–81.
145. Thomas GP, et al. Sacral nerve stimulation for constipation. Br
J Surg. 2013;100(2):174–81.
Fecal Incontinence
Tracy L. Hull
Key Points
• The history is the most important aspect in planning
treatment for fecal incontinence, which includes the
patient’s perception of the problem.
• Health-care providers and patients many times have
divergent views as to the defi nition and severity of
fecal incontinence.
• Quantitative tools of evaluation such as incontinence scores and quality of life scales are helpful
when looking for improvement or change after a
treatment intervention, but do not replace a thorough history and physical examination.
• The goal is to improve quality of life—a cure with
“perfect” bowel control is usually not realistic. You
should emphasize improvement and improvement
in quality of life as the goals.
• There is no one treatment for fecal incontinence.
Rather, therapy must be individualized, perhaps
combining several methods for optimal
improvement.
• Successful outcomes revolve around you having a
clear understanding of the pathophysiology and any
associated underlying conditions.
• While several operative and nonoperative options
exist, ultimately a stoma may be the best option for
certain patients who fail or are not candidates for
these treatment strategies.
The online version of this chapter (doi: 10.1007/978-1-4614-
9022-7_13
to authorized users.
T. L. Hull , MD
Department of Colon and Rectal Surgery ,
Digestive Disease Institute, The Cleveland Clinic Foundation ,
9500 Euclid Ave , Cleveland , OH 44195 , USA
e-mail: hullt@ccf.org
) contains supplementary material, which is available
1 3
Evaluation
Fecal continence is a complex disorder. Controlled elimination of fecal matter and gas relies on a coordination of many
facets of physiology to work in concert, automatically, and
dependently until it reaches the distal rectum. At that time,
human volition intervenes until the circumstances are
socially acceptable to expel gas, liquid, or solid waste.
Problems at any level of this process can lead to fecal incontinence. This can range from soiling of the anal skin to
inability to control fl atus to loss of an entire bowel motion—
all either with or without knowledge that this horrifying
event is occurring. Health-care providers and patients many
times have divergent views as to the defi nition and severity
of fecal incontinence. This is highlighted when considering
the fecal incontinence severity index, as there are two formulas for determining scores based on whether the surgeon or
the patient is completing the form [ 1 ]. When the tool was
being developed, it was discovered that patients and colorectal surgeons rate and view the severity of accidental loss of
solid stool differently. Therefore, all treatment of fecal
incontinence begins with a comprehensive history, which
must include the patient’s perception of the problem.
History
Key Concept: A critical aspect to accurately determining the
origin of fecal incontinence involves a thorough review of the
patient’s entire history. This includes evaluating for concomitant pelvic fl oor disorders that may change your treatment.
A comprehensive history starts with discovering exactly
what the patient defi nes as loss of stool, the frequency, the
urgency associated with defecation, and how it affects them.
Precise questioning clarifi es someone who plans their daily
life around their bowels (i.e., does not eat for a day before
they go to the grocery store or will not travel due to concerns
of stool control) such that they have few incontinent episodes but at the cost of an extremely poor quality of life. It is
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_13, © Springer Science+Business Media New York 2014
203
204
Fig. 13.1 Bristol stool scale (From Lewis and Heaton [ 52 ]. Reproduced with permission of Informa Healthcare © 1997)
T.L . Hull
also helpful to clarify the stool character. Using an aid such
as the Bristol stool scale provides an easy visual method
(Fig. 13.1 ; see also Table 20.2 ) [ 2 ]. Questions regarding
changes in bowel habits over time (i.e., bowel habits when a
teen and then changes during each decade of their life) provide clues to “normal” changes in women’s bowels with
aging [ 3 ]. Men can also have changes with their bowels as
they age, but it many times is not as pronounced as in women.
Many women may also experience typical changes during
their hormonal menstrual cycle that stress a fragile balance
in defecation and lead to gas/stool control issues.
D e fi ning exactly when the problem with fecal control
occurs is another important clue. For instance, do they feel
like they fully empty their rectum (as may be seen when
stool is trapped in a rectocele and may leak out after they
leave the bathroom)? Do they have soilage or leakage in the
fi rst several hours after defecation (again stool trapped in a
rectocele or stool retained in the rectum after evacuation)?
Do they have loss of stool while sleeping (very unusual)?
Obstetrical history is also crucial, including number/
weight of children, unusual presentation at delivery, prolonged labor, episiotomy, or tears of the perineum. Basic language helps to delineate some of these issues, such as asking
if the doctor needed to use sutures in the vaginal area. Also
most women remember if they had changes in bowel or bladder control after a delivery and if this had fully resolved.
Dietary choices can greatly affect stool quality, and a
review of what, how much, when, and changes may elucidate a culprit that can be modifi ed.
Many systemic diseases affect defecation and stool evacuation, especially diabetes, scleroderma, and multiple sclerosis. Also other central nervous system problems, which
include back surgery or back injury, may lead to alterations
in nerve signals to the intestine and the pelvis and should be
investigated. Medications, including some herbal/health
food store brands, change stool character, and ascertaining
exactly when they were started and the relationship to any
perceived changes in stool consistency should be sought.
Many patients do not link the two, so careful questioning can
assist in this endeavor.
Anal, pelvic, or abdominal surgery may also infl uence
defecation, along with any anal trauma or injury. This would
include anal intercourse or sexual abuse—both areas that
surgeons typically are uncomfortable to investigate, though
are crucial to ask about. Additionally, prior radiation treatment to the pelvis or a congenital malformation in the pelvis
should be noted.
A large percentage of women may be experiencing other
pelvic fl oor problems such as urinary incontinence, dysfunctional uterine bleeding, or vaginal prolapse. While these may
not directly affect fecal control, your treatment options may
be infl uenced by other pelvic disorders.
As a general rule, questions about alcohol, tobacco, illegal drug use, family history of bowel problems, and general
health care (including colonoscopy) are important as they
may provide clues that tailor which treatment options would
be optimal for an individual patient.
Although not often as publicized, men experience problems with fecal control as well. Life-changing events such as
loss of a spouse or divorce (i.e., diet may then have changed
after spouse no longer cooks for them) or change in job
(additional stress leads to a change in stool character) are
particularly important to note along with all other points
outlined above that would pertain to men. One study that
13 Fecal I nco nt ine nce
205
Table 13.1 Key concepts to be covered when obtaining the history
Clarify what the patient perceives as lack of fecal control
Clarify what and when the fecal incontinence occurs
How often does this occur
Associated fecal urgency
Affect on daily activities
Character of stool
Changes in pattern of defecation over decades of life
Changes in defecation with menstruation
Obstetrical history
Dietary history and relation to bowel issues
Other systemic diseases (i.e., diabetes, scleroderma, multiple
sclerosis)
History of back injury or back surgery
Medications including herbal and over the counter and the temporal
relationship to medication changes and the start of fecal incontinence
Anal surgery or trauma including anal intercourse
History of sexual abuse
Abdominal or pelvic surgery
History of radiation treatment to the pelvis
Congenital malformations (especially in the pelvis)
Other pelvic fl oor problems (i.e., urinary incontinence, dysfunctional
uterine bleeding, vaginal prolapse)
Life-changing events (i.e., death of spouse or life partner, change in
job)
specifi cally examined 43 males with fecal incontinence
found that 77 % were classifi ed as having fecal leakage and
23 % fecal incontinence [ 4 ]. Forty percent of those with
leakage had a sphincter defect compared with 70 % in the
fecal incontinent group. All patients with leakage improved
with lifestyle changes and biofeedback, while 6/10 in the
fecal incontinent groups required surgical intervention such
as sacral nerve stimulation or other involved treatments. The
authors concluded that males with fecal incontinence (versus
leakage) had some type of sphincter weakening that typically
requires surgical treatment. Table 13.1 summarizes the key
elements that need to be discussed during the history.
Physical Examination
Key Concept: A thorough examination involves evaluation of
everything from the undergarments and perineal skin to the
perineum, including both rectal and vaginal examinations,
and abdomen. Validated scoring systems will assist in quantifying and tracking progress.
The physical examination focuses generally on the abdomen and perineum. The abdominal exam generally keys on
scars, masses, distension, and tenderness. When looking at
the perineum, I fi rst note the underclothes and perianal skin
for any signs of soilage, along with any skin irritation
(Fig. 13.2 ) or anal scars over the perineal body or over the
anal skin. I typically examine patients in the left lateral
Fig. 13.2 This patient has severe anal excoriation from leakage of
mucus and liquid stool at her anal verge. The other marks across her
skin and buttocks are classic from continuous sitting on a heating pad in
an unsuccessful attempt to alleviate the discomfort (Reproduced with
permission from Tracy Hull, MD The Cleveland Clinic Foundation
Cleveland, Ohio)
position. In women I look in the vagina and note, with strain,
any descent of the vaginal wall. I may also digitize the vagina
again to clarify vaginal descent or simultaneously digitate
the anus and vagina to again clarify descent. I ask them to
strain and also note anal descent. When I see that the anal
area move 4–5 cm and take on the shape of a bowel, this may
be associated with damaged support structures, straining,
and defecation problems. While there are patients that have
descent and no defecation issues, it is something to keep in
mind in combination with the history as clues to the etiology
of the fecal incontinence. These patients may not be totally
emptying their rectum or have an element of internal prolapse that may be adding to their symptoms. The anal and
perianal skin requires close inspection fi rst looking at the
length of the perineal body. I ask them to squeeze and look
for anal muscle movement. Many times there is excessive
buttock movement as patients have gotten into the habit of
squeezing all muscles in that region in an effort to avoid the
horrifying aftermath of fecal leakage. To determine if they
can contract their anal muscle, touching the skin over the
anal muscle and asking them to pull only that muscle toward
their umbilical area will clarify for them the muscle to contract and allow you to detect anal sphincter movement. On
digital anal exam, differentiating between movement of the
levator muscle and anal sphincter when squeezing should be
noted, as you may be falsely believe the patient has sphincter
tone when in fact is coming from higher in the canal. Again
asking them to pull the muscle to their umbilical area may
assist in detecting anal sphincter movement. Also important
is anal muscle fatigue, which may be detected after several
prolonged (about 15 s) anal sphincter contractions. For
206
T.L . Hull
patients with signifi cant fatigue, anal muscle retraining and
strengthening is strongly considered as part of the treatment
plan. On digital anal exam, a mass, the stool content (and
character), presence of a rectocele, and abdominal contents
that impinge on the rectum with strain should also be considered. An anoproctoscopy is helpful if there is suspicion of a
mass or proctitis.
Quantitative tools of evaluation such as incontinence
scores and quality of life scales may be employed. They are
helpful when looking for improvement or change after a
treatment intervention. However, they should never replace a
comprehensive history. Some form of incontinence tool is
mandatory to determine using sacral nerve stimulation,
which will be discussed in more detail below. As there are
many acceptable tools used for the purpose of fecal incontinence, choosing one that works for you and your offi ce staff
and administering the questionnaires before seeing the
patient and after treatment interventions will allow familiarity with its nuances and use. One study looked at the current
popular tools to score fecal incontinence (Rothenberger,
Wexner, Vaizey, and Fecal Incontinence Severity Index) and
found the Wexner scale correlated most closely with subjective perception of severity of symptoms by patients [
5 ].
Another study looked at “responsiveness and interpretability” of the Vaizey score, Wexner score, and Fecal Incontinence
Quality of Life scale [ 6 ]. These researchers felt none of these
popular tools attain the high levels of psychometric soundness needed to be recommended as the best tool to use. They
also echo the notion previously stated, that what a patient
views as important may be different from the physician.
While the Wexner score was felt to be the most suitable for
severity assessment, they recommended that several tools
should be used for evaluation in an attempt to circumvent
these issues. An overview of each tool and its pros and cons
are beyond the scope of this paper, but an excellent overview
was written by Wang and Varma [ 7 ], which outlines some of
the commonly used tools.
Testing
Key Concept: Testing is meant to augment or clarify fi ndings
on history and physical examination. Ultrasonography is my
preferential test to help guide therapy.
Testing is individualized based on the history and physical exam. In appropriate patients, a colonoscopy would be
ordered. In some patients where I question their ability to
control stool, a fi ber enema is administered (Fig. 13.3 ).
This consists of fi ber (i.e., a packet or large tablespoon of
Metamucil
and mixed with about 50 cc of water and quickly instilled
in the rectum before it has time to gel. Then the patient
walks around, bends over, and generally has sustained
R
, Citrucel) that is poured into an empty container
Fig. 13.3 Fiber enema: a packet of fi ber or a large tablespoon is placed
in an empty enema dispensing container. An empty Fleet Enema
tainer works well. Then about 50 cc of tap water is added, and the mixture is quickly shook and then inserted into the rectum. The goal is to
insert the mixture before the fi ber has a chance to gel making insertion
impossible (Reproduced with permission from Tracy Hull, MD The
Cleveland Clinic Foundation Cleveland, Ohio)
non- strenuous activity for 5 min to determine if they have
leakage of this mixture from their anus.
The utility of anorectal physiology testing was questioned
by our center and found not to correlate with incontinence
scores [
8 ]. Also ultrasound fi ndings did not correlate with
manometry results. We felt that preoperative anal manometry and endoanal ultrasound should be used to guide treatment, but improvement after an overlapping sphincter repair
should not be assessed by changes in manometry pressures.
This somewhat contradicts data from another unit; however,
their aim was somewhat different. They looked at whether
anal manometry could separate those patients with fecal
incontinence from healthy individuals [ 9 ]. They found that
patients with fecal incontinence had lower rest and squeeze
pressures and lower urge sensation along with a higher volume of fi rst sensation pressures. Overall they found that single studies were not helpful, but the entire panel of anal
physiology studies had excellent sensitivity, moderate specifi city, and convincing accuracy.
My feeling is that overall anal physiology testing may
guide therapy, but I am not sure it is always needed. We rarely
R
con-
13 Fecal I nco nt ine nce
207
order needle EMG looking for neurological damage as it has
not proved useful in guiding treatment. Perhaps looking for a
sacral refl ex before considering sacral nerve stimulation may
be a consideration. I am also not sure that pudendal nerve
terminal motor latency offers much assistance. Previously we
used nerve prolongation, particularly bilaterally, to counsel
patients that results after sphincter repair most likely would
be poor. However, I have seen patients without prolongation
of their pudendal nerves when tested, where absolutely no
anal muscle moves when I ask them to squeeze on physical
exam. Anal endosonography on the other hand provides a
useful road map when considering treatment, and I usually
rely on this test (making sure I perform it myself or know that
the endosonographer is experienced in accurately depicting
sphincter defects). Our unit still typically orders anorectal
physiology on most patients because we maintain extensive
databases that we may use in future studies; however, we only
use the data to selectively counsel patients. For instance, a
patient with a low maximal tolerated volume and low anal
pressures may not achieve the expected short-term benefi t
from an overlapping sphincter repair. We would use this
information to preoperatively discuss expected outcomes
with the patient and aid in navigating the treatment plan.
While pelvic magnetic resonance imaging is a consideration
instead of or with anal endosonography, I am not convinced it
adds enough information to justify the expense. I do not routinely order a defecating proctogram unless there is an accompanying problem with stool expulsion during defecation.
Dudding and Vaizey wrote an excellent overview of testing
for fecal incontinence and other pelvic fl oor disorders, and
the reader is directed to this review for more in-depth descriptions of the various tests [
10 ].
Treatment Options
Key Concept: From the very beginning, set realistic expectations with your patient and ensure they understand this may
involve several different treatment modalities.
The next step in management involves an individual treatment plan for the patient. This does not encompass only one
intervention, but could involve several combined modalities
customized for the patient and revolves around a clear understanding of the pathophysiology and underlying conditions.
Fecal incontinence should be viewed as a chronic disease
like diabetes or hypertension. Similarly, in these chronic diseases, several treatment modalities may be needed for optimal control of the disease process and optimization of the
patient’s quality of life. Similarly management of fecal
incontinence is a long-term notion, and adjustment in the
treatment plan will be necessary as needed. This also involves
setting realistic expectations for the patient and the surgeon
(i.e., some health-care provider must be prepared to assist
and manage this patient long term). Society typically views
defecation issues as voluntary (i.e., mind over matter) which
adds to unrealistic goals determined by the patient. Therefore,
attaining “perfect” bowel function may not be a realistic
goal, and the health-care provider should emphasize
improvement and improvement in quality of life as the goals.
Conservative Management
Key Concept: Almost every patient will require medical management, which typically involves dietary supplements and
one (or more) of several classes of medications.
Most treatment plans include some element of conservative management. Any issues with loose or soft stool can
contribute to problems with control. Evaluation and treatment alone of diarrhea (or just loose stool) can sometimes
greatly improve the patient’s situation. These include fi ber
supplementation (taken with the least amount of water) pectin, and medication. Loperamide is a typical medication
used, and instructions for use must be carefully discussed as
the instructions on the package may not be appropriate for
each patient’s problem. Depending on the pattern of defecation, perhaps starting with one pill/capsule (2 mg) each
morning could be the initial recommendation for this medication. The goal is titration to avoid fecal incontinence but
not too much that produces constipation; however, this may
not be possible. If one pill is too much, the liquid form
administered to children can be used so the dose can be
decreased. Also if constipation is an issue, using the medication every other day or every 3 days per week may allow
therapeutic benefi t for the incontinence without precipitating
constipation.
Skin irritation frequently accompanies fecal incontinence
or may even be the true reason a patient seeks medical assistance. Counseling regarding skin care therefore is also part
of conservative treatment. Barrier creams that typically
employ zinc (such as Calmoseptine
Huntington Beach, California) and lanolin (make sure they
are not allergic to wool) may be lathered onto the anal skin
like frosting (i.e., a thick layer). Patients should place these
creams up to the dentate line for complete protection. They
may stain underclothes, so patients should be warned of this
possibility. Antibiotic ointments are rarely required, and
occasionally an antifungal powder may need to be dusted on
the skin if Candida is detected. This can be applied using a
cotton ball (dusted over the barrier cream) and then leaving
the cotton ball by the anus to wick away moisture (similar to
cotton socks used in athletic activity). Since anal irritation
may lead some patients to feel that their anal area is unclean,
they may wipe that region excessively (similar to polishing
furniture but instead polishing their anus). Advising them to
wipe with unscented baby wipes or wet paper towel and
R
, Calmoseptine, Inc.,
208
T.L . Hull
avoid using soap and a washcloth in the shower along with
minimal wiping after defecation can aid in improving anal
irritation from excessive wiping.
Dietary manipulation may be advised if certain foods
lead to loose, urgent, or uncontrolled stools. A food diary
that corresponds to incontinent episodes may clarify
offending foods. Fresh fruit and vegetables can make stools
loose and add to urgency. Many patients have concerns
with excessive or uncontrollable fl atus. A low carbohydrate
diet may reduce fl atus. While many anti-gas (over-thecounter) medications can be recommended, many patients
fi nd these unhelpful with fl atal incontinence. For severe
problems with excessive fl atus, an intermittent short course
of antibiotics (rifaximin [Xifaxan
R
] is a popular choice) can
be prescribed, but many effective agents are very expensive. Metronidazole is another choice that is less expensive,
but side effects such as an Antabuse effect, tin taste in the
mouth, or peripheral neuropathy must be considered before
prescribing. These agents will change the fl ora and decrease
intestinal gas temporarily. Therefore, the medication must
be repeated with the goal of the least days per month possible to attain relief. One way I advise taking antibiotics for
this purpose is 1 week out of every month, which in my
experience seems to adequately reduce issues with excessive fl atus. Probiotics also are helpful for some patients
with excessive gas issues.
Since a lot of information may be recommended regarding conservative therapy, it is extremely helpful to give precise written instructions for skin care and bowel-altering
medication so the patient has exact instructions to follow and
does not need to rely on memory to implement suggested
changes or treatment. Since it is important to individualize
the treatment, we do not use standardized forms and actually
type out the instructions that are also fi led in their chart.
For some patients with leakage, especially when it seems
to occur directly after they leave the bathroom, a tap water or
rinsing enema after defecation will eliminate any retained
material and alleviate the problem. While many patients do
not prefer this approach, if explained in a positive light and
the patient successfully uses this treatment, they may change
their mind. I typically recommend that an empty phosphate
soda enema container be used (they can use the actual phosphate enema for irrigation rather than discarding it, then the
container can be fi lled with water and used fi ve to eight times
again before the material cracks). Alternatively, a large catheter can be used to instill 50–200 cc of tepid tap water. I
emphasize it is like “rinsing” out the rectum.
For some, a large volume water enema may be needed if
they are using this treatment for more than minor leakage.
For those patients, my nurse will discuss using a large volume enema consisting of 500–1,000 cc or water. This is
Fig. 13.4 For a large volume enema, a 28-Fr Foley is lubricated and
inserted into the anus. For patients who cannot retain fl uid, the balloon
can be infl ated with up to 30 cc and pulled back to rest against the pelvic
fl oor. Then 500–1,000 cc of water is placed in the bag. Tubing connects
the bag to the Foley. There is a control valve on the tubing. Fluid can be
instilled under direct control of the patient via the control valve into the
rectum and left colon (Reproduced with permission from Tracy Hull,
MD The Cleveland Clinic Foundation Cleveland, Ohio)
delivered via a 28-Fr Foley catheter (as this has a 30-cc balloon that can be infl ated if necessary) (Fig. 13.4 ). The fl uid is
placed in a tube feeding administration bag as this has a
valve to regulate the infl ow of fl uid rather than straight tubing which otherwise allows the liquid to run in quickly. The
catheter must be well lubricated and this is emphasized. We
ask them to start with 500 cc and increase the amount weekly
over 4–6 weeks. They are also counseled to allow 45–60 min
to perform the irrigation and evacuation daily. It also tends to
be more successful if performed at the same time daily (typically in the early morning). Encouragement and patience is
provided by my nurse, and this seems to enhance success
with this treatment. An extension of this thought process is
the antegrade continence enema. A surgical procedure is performed where the appendix or a tapered segment of terminal
13 Fecal I nco nt ine nce
209
ileum is brought to the surface to form a fl ush stoma about
the size of a 10-French catheter. Water is instilled via the
small stoma, which then fl ushes out the entire colon via the
antegrade approach. While this therapy tends to be more
popular in the pediatric population, selected adults are quite
satisfi ed doing irrigation by this method.
Other Therapies
Key Concept: Progressively invasive treatment options are
available. Each has its own strength and weaknesses,
depending on the severity of incontinence and underlying
pathology.
Physical Retraining (Biofeedback)
Physical retraining of the pelvic fl oor is also a treatment that
may improve the patient’s situation (and does not worsen)
and should be considered. It is important to be alert to the
fact that some insurance companies will not reimburse for
this treatment. Also a therapist (whether a physical therapist,
nurse, or other interested health-care provider) may not have
specialized specifi c training for pelvic fl oor issues and may
not provide the most optimal teaching. The Cochrane review
done by Norton and Cody identifi ed 21 studies with a total of
1,525 patients [
11 ]. They found severe methodological
weaknesses in nearly all studies reviewed but concluded that
perhaps some portions of biofeedback and sphincter exercises may have therapeutic effect. The authors emphasized
that this was not defi nitely shown in their review and larger
well-designed trials were needed.
Fig. 13.5 The handpiece for the SECCA® procedure shown with the
needles deployed. The handpiece is inserted in the anal canal starting at
the dentate line and the four needles deployed into the tissue.
Radiofrequency is then delivered for 90 s. The needles are retracted and
the probe is rotated 90° and the process repeated until all four quadrants
are treated. Then the probe is moved 5 mm proximal, and those four
quadrants are treated. The process starts at the dentate line, and typically, there are 4 rows of treatment (Reproduced with permission from
Tracy Hull, MD The Cleveland Clinic Foundation Cleveland, Ohio)
Anal Plug
For minor leakage, the anal plug may be considered. The
recent Cochrane review looked at four studies of 136 patients
[ 12 ]. They noted that the rate of intolerance or ineffective-
ness from reviewed studies was 35 %. In the short-term (not
considering any long-term results), anal plugs, when tolerated, could provide continence. They also noted that overall
satisfaction was better when polyurethane plugs were used
versus polyvinyl-alcohol plugs. Experience worldwide with
plugs is limited. This device should be considered in patients
with minor leakage, but dislodgement or intolerance is an
issue. They can be obtained in various types, designs, and
sizes. Insurance coverage may be limited. They also may be
considered as part of a larger treatment plan for a patient.
Radiofrequency Energy (RFE)
Radiofrequency treatment of the anal sphincter has been
available for over a decade and is administered per the
SECCA R machine and protocol (Figs. 13.5 and 13.6 ). Two
Fig. 13.6 Shown is the handpiece inserted in the anal canal with the
attachments (Reproduced with permission from Tracy Hull, MD The
Cleveland Clinic Foundation Cleveland, Ohio)
210
T.L . Hull
recent studies have looked at its effectiveness. One study
looked at pre-procedure and 1-year changes in the Wexner
score [
13 ]. Mean improvement from 15.6 to 12.9 ( p = 0.035)
and mean improvement in 3 of 4 Fecal Incontinence Quality
of Life subsets were found. There were minimal complications, with 3 limited episodes of post-procedure bleeding.
Another study of 27 patients found a sustained long-term
response in 22 %, but 52 % of patients required additional
treatment interventions at a mean follow-up of 40 months
[ 14 ]. We have offered this treatment to select patients with
mild-to-moderate fecal incontinence and an intact sphincter.
How this will fi t into our algorithm with the approval of new
therapies will need to be determined. We have had minimal
complications, and reimbursement, overall, has not been an
issue; therefore, it can be considered when few options exist.
One note of caution, use of RFE after a patient has been
treated with an injectable agent has been discouraged. The
theoretical concerns are that the needles would be deployed
into the injected implant and have no effect on stimulation
and heating of the connective tissue in the anal region. Also
the potential for infection of the injected implant has also
been raised as a possible complication. I am not aware of any
studies defi nitively reporting this as happening, but this possibility has been raised and should be acknowledged.
Therefore, if the use of RFE is being contemplated, its use
should be considered before treating with an injectable agent.
Injectables
Key Concept: While preliminary results have shown success
in small studies, several questions remain regarding the
ideal substance, technique, and population. I prefer to use it
in mild-to-moderate incontinent patients with a thinning or
fi brotic internal sphincter complex.
There are over ten different materials that have been
reported as injectables into the anal region for fecal incontinence. The Cochrane review of this subject highlights the
diversity of this material, along with the lack of welldesigned studies, prohibiting these authors from making
defi nitive conclusions [ 15 ]. This was echoed in a review of
13 case series and one randomized controlled trial, in total
involving 420 patients, by Luo and Samaranayake [ 16 ].
These authors also concluded that future appropriately
designed randomized controlled trials with large study populations and longer follow-up are needed to truly evaluate
injectables.
The only injectable that has been Food and Drug
Administration (FDA) approved in the United States is dextranomer in stabilized hyaluronic acid (NASA Dx R ). In the
randomized monitored study for FDA approval, 52 % of
patients being injected had >50 % reduction in fecal incontinence episodes compared to 31 % of those receiving a sham
injection who reported the same degree of improvement
17 ]. The high degree of improvement in the sham group is
[
curious, but placebo treatments for fecal incontinence for
unclear reasons seem to have up to a 30 % improvement rate.
These results were sustained at 36 months, and all of the
quality of life scores showed signifi cant improvement at 36
months [
18 ]. This is a safe procedure with minor bleeding
being the most common complication although 2/278
patients in the FDA-monitored study developed an abscess
(one rectal, one prostatic) [ 17 ].
Besides the lack of suffi cient data to guide treatment,
other controversies surrounding injectable agents involve
technique. Currently, there are seven different techniques
found in the literature to administer the agent. The procedure
typically involves one cc of this material injected into the
submucosal space in four areas at the top of the anal canal.
While many inject in the submucosal space, the intersphincteric space may be better. Yet, there are several additional
questions that remain unanswered. Would the use of ultrasound to guide injection be superior to blinded injection?
This procedure is typically done in the outpatient setting, but
would the results improve if done in the OR? Additionally
should the needle go through the anal mucosa or be inserted
from the perianal skin to the target location? The size of the
needle is typically 21 gauge, which seems necessary as the
material is quite viscous and diffi cult to push through
the needle. However, is this size of needle correct, as some of
the material can be seen oozing out of the injection site
at times after the treatment? The exact optimal patient who
will benefi t from this treatment is also unclear. Some of the
patients in the FDA-monitored trial had severe fecal incontinence [ 17 ], but would patients with mild-to-moderate incon-
tinence or leakage be better candidates? Also can injectable
material be used to augment a defect in the internal sphincter
(such as after a lateral sphincterotomy that has leakage) or a
divot in the smooth contour of the anal canal, which is leading
to leakage? All these questions surround using this material.
Our practice continues to be performing this procedure in
the outpatient setting. We target patients with mild-tomoderate fecal incontinence. Also we would offer this to a
patient with internal sphincter thinning or fi brosis as seen on
anal endosonography. The patient receives a phosphate enema
before and then is typically positioned in the left lateral position. Using a long beveled anoscope, Betadine is swabbed in
the anal canal (a plain wet swab is used if the patient reports
an iodine sensitivity that is concerning). The nurse steadies
the anoscope after it is placed in position. The physician
steadies the needle with one hand and injects with the other.
The material is injected about 1 cm cephalad to the dentate
line. We use digital guidance to inject in the submucosal
space in four quadrants and turn the needle a quarter turn
before withdrawal in attempt to prevent material leakage.
Postoperatively, we do not issue any restrictions in activity
and give advice on keeping stools soft. We ask patients to call
immediately if they have pain, bleeding, or fever.