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9 Fecal Incontinence
153
ing a modied Kegel exercise with an intra-rectal
probe measuring anorectal pressure. Patients can
view the pressures obtained with their squeeze so
they are able to recognize when they are optimally
performing. Patients also receive sensory-motor
coordination training, wherein an intra-rectal
balloon is inated and patients have 1s to produce a maximum squeeze rather than relaxation.
Other therapy is guided towards improving rectal
sensation for small volumes and urge resistance
training (teaching patients to relax in response to
overwhelming rectal distension) [22]. Overall,
biofeedback is thought to be effective at re-training the pelvic oor in patients with FI.However,
the studies evaluating the benet of biofeedback
on FI have been heterogeneous. One of many
studies showing biofeedback’s benet demonstrated that after 3 months follow-up patients
had greater reductions in incontinence scores
and fewer days with FI than patients who had
received verbal instructions on pelvic oor exercises alone. This benet was durable 12months
after the study [23]. It is clear that more work is
needed to evaluate the benet of biofeedback and
to whom it is of benet, but overall, it is considered a cornerstone of the non-surgical management of FI.
Non-surgical Devices
There are a number of minimally invasive devices
patients can use to help achieve continence. The
most successful disposable devices have been the
anal plugs. Anal plugs include the Peristeen foam
anal plug, which is a disposable foam tampon
that can be left in place for up to 12 h. The
Procon-2 is a silicon balloon that can be inserted
into the rectum and inated with a one-way valve
to allow gas to pass. Another product, the Renew
plug is a disposable soft anal plug inserted into
the anal canal [24]. A Cochrane review evaluated
the use of anal plugs for fecal incontinence: it
totaled four studies with 136 participants. They
observed that episodes of FI were prevented by
the anal plugs (pseudo-continence) in 38% of the
participants; however, there was signicant subject dropout (35%). The overall conclusion was
that anal plugs are difcult to tolerate but can aid
in obtaining continence if used reliably [25].
Surgical Management
If patients still have debilitating symptoms after a
trial of conservative management, further evaluation for potential surgical intervention is indicated. Pelvic oor evaluation including anal
endosonography, manometry, defecography, and
possibly EMG/PNTML are in order. Surgical
interventions focus primarily on improving the
integrity of the anal sphincter, improving the
overall function of the pelvic oor, or replacing
the sphincter altogether.
Operations toRepair Sphincter Injury
The most likely etiology of FI in a patient with a
defect on anal endosonography is an injury to the
anterior sphincter complex incurred during childbirth, also known as an Obstetric Associated
Sphincter Injury (OASIS). It is estimated that
around 8% of primaparous women develop occult
injuries to the sphincter complex at the time of
their rst delivery [26]. Sphincter injuries can
result in immediate incontinence or can present
many years later in the setting of worsening
pudendal neuropathy or age-related degeneration
of muscle bers. The optimal operative repair of
a discrete sphincter defect is with an overlapping
sphincteroplasty. Data regarding long-term outcomes of overlapping sphincteroplasty show signicant improvement in continence in around
60% of patients. However, patients who undergo
this therapy must be carefully selected. For young
women with an obvious sphincter defect, this
operation is considered the gold standard [27].
But, for older women, overlapping sphincterotomy does not have as robust an improvement in
continence as for the younger population [28].
This is thought to be due to the fact that older
women have other factors that contribute to their
incontinence like pudendal neuropathy and other
medical conditions. Nevertheless, in older
women with severe FI and an external sphincter
defect of less than 120°, it is still considered
appropriate to offer an overlapping sphinctero-
154
J. Saraidaridis and L. Bordeianou
plasty and assess improvement in continence or
need for sacral neuromodulation after recovery.
For elderly women, it is of particular importance
to counsel patients before the operation that
continence may not be achieved with surgery and
that efcacy in treating incontinence decreases
with increasing age [28].
An overlapping anal sphincteroplasty is performed after bowel preparation in the prone jackknife position. A curvilinear incision is made
anterior to anus and the surgeon carefully dissects
the injured external sphincter away from the skin,
the ischiorectal fat, the anal mucosa, the internal
anal sphincter complex, and the vagina. Discrete
defects in the internal and external sphincter can
be repaired by separating and closing each muscle.
Alternatively, an en bloc resection and repair can be
undertaken. A levator plication can be performed
prior to sphincter imbrication and prior to isolated
external sphincter repair or en-bloc internal and
external sphincter overlapping repair. The sphincter muscle is overlapped anteriorly with long-term
absorbable sutures. The perineal body is then closed
transversely. Patients should be counselled preoperatively that these wounds are slow-healing and
often complicated by wound infection or separation.
Failure to improve or relapse after improvement after sphincteroplasty may warrant an anal
endosconography to assess the integrity of the
repair. Repeat overlapping sphincteroplasty may
be considered if a defect is still present [29].
However, for many patients, sacral neuromodulation may be a more appropriate next step.
Patients may have continued, severe FI after
vaginal delivery with either no defect on anal
endosonography or with limited improvement
after a sphincter repair. These patients should
undergo a repeat endoanal ultrasound and endovaginal ultrasound to evaluate for levator avulsion
injury. This injury is responsible for FI in as many
as 19% of women who have persistent symptoms
of FI after a primary obstetric sphincter injury
repair [30]. These patients may be candidates for
a repair using a posterior anal mesh sling. A recent
prospective trial showed that placement of a posterior, trans-obturator, anal sling provided a statistically signicant improvement in continence
in 61% of women [31]. Unfortunately, given the
current climate in the United States Food and
Drug Administration (FDA) towards pelvic mesh
slings, this procedure has not become common
practice in the United States.
Operations toImprove Pelvic
Floor Function
Sacral neuromodulation (SNM) offers patients
without sphincter defects and patients who have
continued or recurrent incontinence despite
sphincter defect repair another therapeutic maneuver to improve continence. SNM was approved by
the FDA in 1997 for urinary urge incontinence and
was broadened to include fecal incontinence in
2011. The therapy works by applying electrical
pulses, which modulate the neural activity of the
S3 nerve root through an implanted device. It is
thought to work on the central nervous system, the
pelvic afferent nerves, and the peripheral pelvic
motor neurons. How these pathways are affected
by SNM and how the device improves bowel and
bladder incontinence is still unclear; however, the
benet of the therapy has been clearly demonstrated in numerous studies. The success rate of
SNM is surprisingly robust. 54–63% of patients
who undergo SNM demonstrate at least a 50%
improvement in weekly episodes of fecal incontinence over both the short and long term [32–36].
Additionally, some patients (approximately
35–40%) will achieve full continence using this
therapy. Overall, while its mechanism is poorly
explained, SNM has changed the therapeutic landscape for FI signicantly.
SNM is often a two-stage procedure. In the
rst stage, the S3 sacral nerve foramen is identied under uoroscopy by the clinician. Once
conrmed, the wire is tunneled under the skin and
connected to an external stimulator for a 2-week
trial period. If the trial is a success, the patient is
returned to the operating room and a permanent
neurostimulator is implanted into the patient’s
subcutaneous tissue (Fig.9.2). The operation is
well tolerated. The most common complications
include infection (10%), battery loss (10%), and
electrode displacement (10%) [34, 35, 37]. In
a study with a median follow-up of 49months,
41% of patients required some type of surgical
revision [38]. While certainly not perfect, SNM
9 Fecal Incontinence
Fig. 9.2 Placement of temporary sacroneuromodulation
tined lead requires tunneling of the lead away from site of
insertion
has been a valuable addition to the therapeutic
options for FI.
In addition to SNM, there has been mixed
literature regarding the utility of posterior tibial
nerve stimulation (PTNS) for the treatment of
fecal incontinence. Based on the same principle
of neuromodulation of the sacral nerves as SNM,
PTNS is less invasive. It involves the insertion of
a needle electrode into the lower leg above the
medial malleolus with stimulation of the posterior
tibial nerve. This stimulation is thought to travel
up the tibial nerve to the sacral plexus with similar
neuromodulatory effects as seen in SNM. Patients
receive weekly 30-min treatments for 12weeks
[39]. A recent randomized controlled trial evalu-
ating 227 women with FI showed no clinical benet [40]. Further work is still merited to evaluate
populations for whom this therapy could benet.
Sphincter Augmentation
If SNM does not improve symptoms, patients can
be considered for sphincter augmentation procedures. These procedures range in complexity
from application of radiofrequency energy to
operative placement of an articial sphincter.
Unfortunately, the current options for sphincter
augmentation have equivocal utility or are associated with a signicant complication prole.
Therefore, sphincter augmentation procedures
are usually limited to patients who fail SNM.
155
The application of radiofrequency energy to the
anal sphincter was rst performed in Mexico in
1999. The technology came to the United States in
®
2002, when the FDA approved the Secca
device.
This platform includes a hand-held anoscopic
device with a radiofrequency generator. The procedure is performed on an outpatient basis in either
a surgical or endoscopy suite. The Secca® probe is
placed in the anal canal and energy is applied to
the anoderm to create a controlled thermal injury.
As this low-level burn injury heals, collagen is
deposited causing thickening and strengthening
of the sphincter complex over time [41]. Secca®
has had mixed results with some studies showing improvement that decrements over time [42].
Common side effects include pain, infection, and
excessive scarring. For the most part, it is well tolerated although it has not shown great efcacy and
has limited utility at present.
Injectables in the perianal area to cause bulking of the sphincter complex are another minimally invasive way to augment continence. A
variety of substances have been trialed in this
arena including detranomer in stabilized hyaluronic acid (NASHA Dx), silicone, and carbon coated beads—although only NASHA Dx
(Solesta®) is approved in the United States (FDA
approval in 2011). One study examining NASHA
Dx demonstrated improved symptoms and more
days without fecal incontinence but with more
adverse effects [43]. There has been mixed enthusiasm for Solesta®, and it has limited utilization
in the United States.
For a selected cohort of patients with intractable FI or extensive sphincter damage precluding sphincter repair, muscle transposition, or an
articial bowel sphincter are potential surgical
solutions to incontinence. Because of the complication prole of these procedures, only motivated
patients with favorable comorbidity proles are
candidates for these operations.
Muscle transposition to create an anal neosphincter has gone through signicant evolution
since it was rst described in humans in 1952 by
Pickrell [44]. Originally, the use of the gracilis
muscle was proposed; however, utilization of the
gluteus, rectus abdominus, and latissimus dorsi
aps have also been described in the literature.
156
One of the early setbacks for this procedure was
that fast-twitch skeletal muscles were incapable
of the prolonged, tonic contraction required of
the anal sphincter. It was discovered that lowfrequency electrical stimulation could transition
the gracilis (and other fast twitch muscles) to a
slow-twitch muscle [45]. Subsequently, Cavina
et al. described graciloplasty with implantation of an electric stimulator as a solution [46].
Patients should be advised that the procedure
requires a diverting stoma during healing. The
gracilis is mobilized through an inner thigh
incision. The main nerve to the gracilis is identied and conrmed via stimulation. An electrode is placed in the LLQ and tunneled down
to the thigh wound and placed near the gracilis nerve. A stimulator is placed in a pocket in
the LLQ.The wound covering the stimulator is
closed. The muscle is then tunneled from the
upper thigh to the perineum (using two curvilinear incisions around the anus) and brought
around the anal canal and sutured to the underlying periosteum of the contralateral ischial
tuberosity. The leg incision is closed. A diverting loop stoma is constructed. After recovering
from surgery, the patient undergoes “training”
of the muscle. A prospective multi-center trial
evaluating stimulated dynamic muscleplasty for
anal incontinence in 139 patients demonstrated
that only 66% achieved a successful outcome
(dened as 70% of reduction in solid stool
incontinence), 30% had a major wound complication, and 41% had therapy failure [47]. As
the complication prole is high and success is
not certain [48], this operation is only utilized
in motivated patients with end stage FI who
prefer not to undergo placement of an articial
sphincter or a colostomy. Currently the procedure and device are not FDA-approved in the
United States.
Another option for sphincter reconstruction is
the use of an articial sphincter. As the procedure
implants a foreign body into the perianal tissue,
only patients with healthy perineal tissue are candidates. Any patient with potential wound-healing
difculties including those with diabetes, pelvic
radiation, or inammatory bowel disease, should
J. Saraidaridis and L. Bordeianou
Fig. 9.3 Placement of articial bowel sphincter cuff
around anorectal junction in a patient in need of ABS
replacement due to cuff leakage
Fig. 9.4 Diagram of magnetic anal sphincter in situ
be excluded from this therapy. There are two
devices available to patients in the United States:
the articial bowel sphincter (ABS) (Fig.9.3) or
Acticon Neosphincter
®
and the Fenix magnetic
anal sphincter (MAS) (Figs.9.4 and 9.5). Both of
these devices require implantation and follow-up
care by clinicians experienced in their use.
The ABS or Acticon Neosphincter® was available in the United States via a Humanitarian
Device Exemption since 1999 with formal FDA
approval in 2001. The device consists of a uidlled anal cuff, which is implanted around the
anal sphincter, a pressure-regulating balloon,
9 Fecal Incontinence
Fig. 9.5 Magnetic anal sphincter in situ with one to three
beads open
which is placed in the space of Retzius, and a control pump, which is placed in the labia/scrotum.
The device is implanted by an anterior perianal
incision. A tunnel approximately 5–6cm from the
skin should be made around the ano-rectal junction (Fig.9.3). A sizer is placed to aid in deciding
cuff length (0–14cm) and width (2 and 2.9cm).
A Pfannenstiel incision is then made to implant
the pressure regulating balloon and control pump.
A pocket is created in the labia/scrotum to accommodate the control pump. Tubing from the control pump is attached to the tube of the cuff and
balloon (tunneled subcutaneously to the control
pump pocket). The incisions are closed in multiple layers. During the procedure, it is important
to maintain two separate surgical elds (anal and
Pfannenstiel) so as to limit bacterial contamination [49]. When a patient wants to move their
bowels, they activate the control pump, which
opens the cuff to allow stool to pass. A multi-center cohort study evaluated 115 patients with the
Acticon Neosphincter®. 25% of the patients had
infections requiring revision of the device, 20%
required a surgical revision due to erosion, and
at 1year 65% had a functioning device in place.
Eighty-ve percent of patients with a device had
signicant improvement in their fecal incontinence scores and quality of life [50]. One of the
common complications of the therapy was fecal
impaction requiring laxative use in the previously
incontinent patient. A subsequent study showed
157
a high rate of success but only in a small group
of patients due to a high rate of complications
including infection and explantation [51, 52].
The magnetic anal sphincter (MAS) or Fenix
Continence Restoration System was approved by
the FDA in 2015. This device consists of circular
string of small titanium beads that open and close
with magnetic force. The device is implanted
around the anorectal junction immediately below
the puborectalis via a perineal incision. The
device is sized so that when the beads are touching, the anus is occluded (Figs. 9.4 and9.5). The
device allows a patient to defecate when an urge
presents itself and then when the fecal bolus has
passed to close the sphincter. Initial evaluation of
the device demonstrated good improvement in
fecal incontinence measures and quality of life
scores [53, 54]. The complication prole is similar to that of the ABS including an estimated 11%
infection rate, 11% erosion rate, and 23% explantation rate over 5years [55]. A small study compared ten patients with the MAS to ten matched
patients with an already implanted ABS. Both
groups had signicant improvements in incontinence symptoms and quality of life. The length of
stay was signicantly longer for the ABS group
(10 vs. 4.5days) but the complication rate was
equal between the two groups [56]. Those with
ABS did have increased incidence of constipation. Further experience and long-term results
will help determine the role that this device will
have in the treatment of FI in the future. Neither
the ABS nor the MAS are commercially available
at the time of publication.
Malone Antegrade Continence Enema
Another potential therapy for those who wish to
avoid stoma is a reverse appendicostomy or tube
cecostomy, which allows for administration of
antegrade colonic enema (ACE) to clear the
colon in a predictable fashion [57]. These procedures have been primarily described in the pediatric population; however, anecdotal evidence in
adults is favorable.
158
Failed
J. Saraidaridis and L. Bordeianou
Fecal Incontinence
Sphincter Defect
Anterior
Sphincteroplasty
Conservative
Management
Pelvic Floor
Evaluation
Failed
Secca/Solesta
History and
Physical
Failed
No Defect
SNM
Consider Non-Stimulated
Muscle Transposition
Prolapse
Fix Prolapse
FailedFailedFailed
Stoma
Fig. 9.6 Management algorithm. ABS articial bowel sphincter; SNM Sacral neuromodulation; MAS magnetic
articialsphincter
Colostomy
For patients who have failed all other therapies,
colostomy can offer signicant improvement in
quality of life. While most patients are hesitant to
proceed to an ostomy, when questioned, 84% of
patients who underwent a stoma creation would
choose to have a stoma created again [58].
those patients discovered to have a sphincter
disruption, an overlapping sphincteroplasty
can provide signicant improvement. A trial
of sacral neuromodulation is merited for
those patients without a sphincter defect or
for those who fail sphincter repair. Finally,
those patients who fail SNM should trial the
variety of sphincter augmentation procedures
Conclusion
Fecal Incontinence is a common problem in
the population. Assessment of FI includes a
thorough history and physical with quantication and scoring of the severity of the FI
followed by a trial of conservative therapy. If
conservative therapy fails, the patient should
proceed to a pelvic oor evaluation. For
including Secca
application, anal sphincter injectables,
dynamic graciloplasty, the articial bowel
sphincter, or the magnetic anal sphincter.
Permanent colostomy creation is always an
option. An algorithm for evaluation and man-
agement of fecal incontinence is summarized
in (Fig. 9.6).
®
radiofrequency energy
9 Fecal Incontinence
159
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Anorectal Abscess and Fistula in Ano
JonD.Vogel andCarol-AnnVasilevsky
10
Introduction
Fistula-in-ano and anorectal abscesses represent
different stages along the continuum of a common pathogenic spectrum. Although the abscess
represents the acute inammatory event, the
stula is representative of the chronic process.
This chapter covers cryptoglandular anorectal abscess, stula-in-ano, necrotizing perianal
infection, anoperineal infection in neutropenic
patients, and stulizing perianal Crohn’s disease.
Rectovaginal stula and perianal Crohn’s disease
are covered in separate chapters of this text.
Anatomy
Successful eradication of anorectal suppuration
and stula-in-ano requires an in-depth understanding of anorectal anatomy. Essential is an
understanding of the existence of potential anorectal spaces (Fig.10.1) [2]. The perianal space is
located in the area of the anal verge. It becomes
continuous with the ischiorectal fat laterally while
J. D. Vogel (*)
Department of Surgery, University of Colorado,
Aurora, CO, USA
e-mail: jon.vogel@ucdenver.edu
C.-A. Vasilevsky
Division of Colon and Rectal Surgery, Jewish
General Hospital, Montreal, QC, Canada
it extends into the lower portion of the anal canal
medially. It is continuous with the intersphincteric space. The ischiorectal space extends from
the levator ani to the perineal skin. Anteriorly it
is bounded by the transverse perineal muscles;
the lower border of the gluteus maximus and the
sacrotuberous ligament form its posterior border. The medial border is formed by the levator
ani and external sphincter muscles; the obturator internus muscle forms the lateral border. The
intersphincteric space lies between the internal
and external sphincters and is continuous inferiorly with the perianal space and superiorly with
the rectal wall. The supralevator space is bounded
superiorly by peritoneum, laterally by the pelvic
wall, medially by the rectal wall and inferiorly by
the levator ani muscle. The deep postanal space is
located between the tip of the coccyx posteriorly
and the external anal sphincter anteriorly and lies
between the anococcygeal ligament and the levator ani (Fig.10.1b).
At the level of the dentate line, the ducts of the
anal glands empty into the anal crypts.
Occasionally a duct may open at a higher level
[3]. The glands enter the submucosa, two thirds
enter the internal sphincter and half of these cross
the intersphincteric space [4]. They do not penetrate the external sphincter and number from
four to ten in a normal individual and are most
concentrated posteriorly. Men have been found to
have a higher incidence of intermuscular glands
than women [5].
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_10
161
162
J. D. Vogel and C.-A. Vasilevsky
Fig. 10.1 Anorectal
spaces. (a) Coronal
section. (b) Sagittal
section. From [1]. With
permission from David
E.Beck, MD
a
b
Supralevator
Ischiorectal
Intersphincteric
Perianal
Submucosal
Retrorectal
Abscess
Etiology and Pathophysiology
According to the cryptoglandular theory
championed by Parks, abscesses result from
obstruction of the anal glands and their ducts
that drain into the anal crypts at the dentate
Supralevator
Deep
Postanal
Superficial
Postanal
line tract [6–8]. Obstruction of a duct may
result in stasis, infection and formation of an
abscess. Persistence of anal gland epithelium
in part of the tract between the crypt and the
blocked part of the duct results in the formation of a fistula.
Ninety percent of all anorectal abscesses
result from non-specic cryptoglandular infec-