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9 Anal Incontinence
123
squatting position and avoiding abduction of the
leg, while the sphincter is made to contract by
standing and abducting the leg.
The original description by Pickrell and
coworkers ( 1952 ) demonstrated 100 % conti-
nence in his pediatric patients. Subsequently,
Corman ( 1985 ) reported on 14 patients with
excellent or fair results in 11 patients at follow-up
of 5 years. They attributed success to appropriate
patient selection including only relatively young
and motivated ones without functional colonic
dysmotility and with disabling incontinence secondary to trauma or congenital anomaly.
Christiansen et al. ( 1990 ) were also successful
with 13 patients of whom all but three improved.
Sielezneff and associates ( 1996 ) were successful
with eight patients, all of whom improved using
the original procedure described by Pickrell
combined with postoperative biofeedback. In
contrast, Yoshioka and Keighley ( 1988 ) reported
poor results in six patients who underwent
graciloplasty, all of whom required a colostomy
and fi ve of whom developed a septic complication.
Eccersley et al. ( 1999 ) reported that two- thirds of
patients had improvement in continence with half
of the patients experiencing good function. They
concluded that these results were comparable to
the results of their stimulated counterparts. In this
study, better results were obtained in younger
patients and in individuals without pudendal neuropathy, suggesting that in such patients, nonstimulated graciloplasty alone may be effective.
In an attempt to improve outcome, the procedure was modifi ed by Kumar and colleagues
(
1995 ) to include bilateral gracilis transpositions.
They performed this procedure in ten patients
with a colostomy for diversion. All of the nine
who underwent colostomy reversal were fully
continent at 2 years. Though more investigations
are needed, the improved results compared with
unilateral graciloplasty suggest that the bilateral
wrap may be a better alternative to the stimulated
graciloplasty.
cle is preferred because it is the most superfi cial in
the medial aspect of the thigh and has a proximal
neurovascular bundle and can be tunneled under
the skin in the proximal thigh and wrapped around
the anal canal. The operation is best carried out
with the patient in the Lloyd-Davies position.
None of the skeletal muscle used to augment
sphincter has the property of the EAS which
has resting tone and preponderance of slowtwitch fi bers (80 % of type I fi bers are fatigue
resistant). Gracilis muscle has only 43 % type I
muscle fi bers. Chronic low-frequency stimulation induces a transformation from fast-twitch
to slow-twitch muscle fi bers. The fi rst electrical
stimulation of a transposed gracilis muscle was
reported by Dikson and Nixon in 1968. There
are two techniques for muscle stimulation. In
the procedure devised by Williams et al., the
electrodes are placed directly over the nerves
to gracilis. After identifying the nerve with the
help of nerve locator, the stimulator and the
electrodes are attached. The stimulator lies in a
pocket overlying the lower ribs. The lead is tunnelled subcutaneously via a small incision in the
suprainguinal region, and the electrode is brought
down to the appropriate nerve. The electrode
plate is sutured over the main nerve bundle in a
longitudinal fashion. The alternative technique is
insertion of the electrode into the gracilis muscle
adjacent to the supplying nerve. The connection
to the stimulator is assessed using external temporary programmer. The gracilis muscle is then
transposed around the anal canal as described
above (Fig. 9.13 ).
9.5.2.5.2.2 Dynamic Graciloplasty
Dynamic graciloplasty combines transposition of
the gracilis muscle with electrical stimulation via
an implantable pulse generator. The gracilis mus-
Fig. 9.13 Dynamic graciloplasty
124
P.N. Joshi et al.
Postoperatively, the patients are nursed with
legs bandaged loosely together. Electrical stimulation of the muscle commences at day 10, provided the wound is healed. The stimulator is
programmed using a standard training protocol.
Once the muscle is trained, the patient can be
admitted for the closure of covering stoma. The
stimulator can be switched on or off by passing a
magnet over it.
Outcomes of various series on graciloplasty
have been shown in Tables 9.5 and 9.6 .
9.5.2.6 Sacral Nerve Stimulation (SNS)
Sacral nerve stimulation, also termed as sacral
neuromodulation, typically involves the implantation of a programmable stimulator subcutaneously which delivers low-amplitude electrical
stimulation via a lead to the sacral nerve usually
accessed via the S3 foramen. Previous reports
have focused primarily on short-term results of
sacral nerve stimulation for fecal incontinence
(Mellegren et al. 2011 ). This procedure is strictly
indicated in patients with intact sphincters or limited sphincter injuries.
By stimulating the sacral nerve (located in the
lower back), a signal is sent that manipulates a
contraction within the pelvic fl oor. Over time,
these contractions rebuild the strength of the
organs and muscles within it. This effectively
Table 9.5 Dynamic graciloplasty: outcome
Success
Author No.
Geerdes
1996 )
et al. (
DMP trial
(
1999 )
DGTSG trial
(
2000 )
DMP dynamic muscle plasty trial, DGTSG Dynamic
Graciloplasty Therapy Study Group
(%)
54 45 (83) 32 months
75 53 (71) 24 months
83 45 (54) 12 months
Follow-up period
(trauma, neuropathy)
alleviates all symptoms of fecal incontinence and
in many cases eliminates them completely.
Several studies have suggested a variety of different factors, including improved sensory function, improved anal sphincter function, improved
rectal motility, and central nervous system effects.
Using this technique with temporary percutaneously placed electrodes, it has been shown that
there is an effect on rectal and internal sphincter
smooth muscle activity, in addition to facilitation
of the external sphincter striated muscle function.
The qualifi ed patients undergo a staged implant
procedure. Adequate motor/sensory response is
tested in the foramen of S2, S3, and/or S4
(Fig. 9.14 ). A quadripolar electrode is placed in
the foramen with the best response and connected
via a percutaneous extension kit to an external test
stimulator (Fig. 9.15 ). The patients undergo the
subchronic test stimulation for 10–14 days.
The patients achieving 50 % reduction in the
number of incontinence episodes per week and/
or 50 % reduction in the number of incontinence
days per week are offered the implantation of a
permanent neurostimulation device.
At the permanent implantation, the percutaneous extension is removed and replaced by a
shorter extension connected to an internal pulse
generator placed subcutaneously in a pocket in
the gluteal area. The pulse generator is activated
after the procedure (Fig. 9.16 ).
Adverse effects include pain, paresthesias,
change in the sensation of stimulation, implant
site infection, diarrhea, and extremity pain.
Treatment of implant site pain includes
neurostimulator, reprogramming, and neurostimulator revision.
SNS has been associated with a vastly lower
morbidity, perhaps at least in part because the
instrumentation and the surgical sites are well
away from the anus. Because of the relative
Table 9.6 Dynamic graciloplasty: complications
Wrap
Series No. WI
Geerdes et al. 67 9 (13) 10 (15) 12 (18) _ 13 (19) 36 (54)
DMP trial 93 27 (29) 4 (4) 11 (12) 25 (27) _ _
DGTSG trial 123 17 (14) 9 (7) 16 (13) 34 (28) 28 (23) 91 (74)
WI major wound infection, Comp complication
problem Device/lead Pain Constipation
Patient with
comp
9 Anal Incontinence
125
Figs. 9.14, 9.15 and 9.16 SNS test stimulator and permanent stimulator (Courtesy of S. Mantoo, Singapore)
simplicity of SNS, as well as the comparatively
acceptable risk profi le, the question of effi cacy
becomes the most important fact of data analysis.
9.5.2.7 Artifi cial Sphincter
Implantation
Implantation of an artifi cial valve in the anal
canal to restore continence and psychological
well-being is indicated in patients with severe FI
due to anal sphincter insuffi ciency, prolapsed
intervertebral disk, benign spinal tumors, polyneuropathy, diabetic neuropathy, cerebral trauma,
myasthenia gravis, anal atresia, and failure of
previous treatment.
The usual surgical approach is through the
perineum or alternatively transvaginal. The artifi cial bowel sphincter involves the implantation of
three components:
• A fl uid-fi lled silicone elastomer cuff placed
around the anus
• A liquid-fi lled, pressure-regulating balloon
positioned in the peritoneal fat
• A manual pump connecting these components
(placed in either the labia majora or the
scrotum)
The length of the cuff varies from 9 to 14 cm,
and it comes in two diameters (2.0 cm narrow
and 2.9 cm, standard, when defl ated). The cuff is
inserted around the upper anal canal, and tubing
from the cuff is channeled along the perineum
and connected to a control pump placed subcutaneously in the scrotum or labia. The control pump
is then connected by tubing to a pressureregulating balloon that has been implanted in the
abdominal wall. The balloon holds approximately 40 ml of radiopaque solution, and the
control pump regulates the transfer of fl uid from
the balloon to the cuff so that when the cuff is
fi lled with fl uid, continence is achieved. The balloon comes in four pressure ranges (81–90,
91–100, 101–110, and 111–120 cm H
2
O).
By pressing the pump several times, fl uid is
displaced from the cuff back to the balloon,
allowing defecation. Once defecation is complete, the fl uid slowly returns to the cuff and continence is again achieved (Fig. 9.17a–c ).
The procedure is technically less demanding
than graciloplasty. Both graciloplasty and artifi cial anal sphincter signifi cantly improve continence, with artifi cial anal sphincter being
126
ab
P.N. Joshi et al.
c
Fig. 9.17 ( a – c ) Artifi cial bowel sphincter system ( a ) in females and ( b ) males, ( c ) artifi cial sphincter
superior. However, both methods have high rates
of complications like insuffi cient contraction of
distal gracilis, inability to stimulate transposed
muscle, perforation of the anal canal, too tight or
too loose anal wrap, transient edema of the leg,
lead problems, infections of lead or wound, overfl ow incontinence, and evacuation diffi culty.
Acticon Neosphincter offers many benefi ts
like simulation of normal sphincter function, easily controlled by the patient, proven clinical effi cacy, and simple and reproducible procedure with
signifi cant improvement in the quality of life.
9.5.2.8 The FENIX™ Continence Restoration System
It is designed to treat fecal incontinence by
augmenting the incompetent anal sphincter to
restore continence (Fig. 9.18 ). It consists of
small, fl exible band of interlinked titanium beads
with magnetic cores. The magnetic attraction
between the beads augments the anal sphincter,
creating a barrier to involuntary passage of fecal
matter. The magnetic bond is temporarily broken
to allow the voluntary passage of stool and
restored immediately thereafter.
a
9 Anal Incontinence
ab
Fig. 9.18 ( a , b ) Artifi cial magnetic sphincter (Courtesy of S. Mantoo, Singapore)
127
The FENIX Continence Restoration System is
placed around the anal sphincter during a surgical
procedure that requires a single incision. A customized sizing tool is used to ensure the correct
size device is selected. Once the correct size is
confi rmed using fl uoroscopy, the FENIX
Continence Restoration System is implanted and
secured by tying sutures together. The correct
size is again confi rmed using fl uoroscopy.
In a prospective, nonrandomized matched
study ( n = 20), Wong MT compared magnetic anal
sphincter (MAS) and ABS devices. No signifi cant
difference was found in early postoperative complications, but the MAS group had a shorter time
in surgery (62 vs. 97 min; P = 0.0273) and a shorter
hospital stay (4.5 vs. 10 days; P < 0.0001) com-
pared with the ABS group (Wong et al. 2011 ).
Both groups achieved signifi cant improvements
from baseline in Wexner FI scores [11-point
decrease in each group; P = 0.0002 (MAS),
P = 0.0001 (ABS)] and FIQOL scores [from 1.91
to 3.38 in the MAS group ( P = 0.0052) and from
1.80 to 3.55 in the ABS group ( P = 0.0089)].
9.5.2.9 Miscellaneous Procedures
9.5.2.9.1 Smooth Muscle Plasty
Schimdt described surgical procedure to construct a totally destroyed sphincter using a graft
of pedunculated or free smooth muscle. After
total mucosectomy, a segment of large bowel is
wrapped around the anus to restore tone at rest.
Schmidt reported on 31 patients in whom voluntary continence could be resorted even during the
night. In authors’ experience, dissecting behind
the external sphincter and doing the repair at the
attachment of puborectalis sling is simple and
easy to perform (Schmidt 1985 ).
9.5.2.9.2 Reinforcement of the Occlusion Mechanism
To reinforce the occlusion mechanism, Stone and
Wreden used two slings of fascia lata or silk
which were passed between the lower border of
the gluteus maximus muscles in front and behind
the anus, respectively (Stone 1929 ; Wreden
1929 ). Contraction of the buttock puts the sling
under tension and compresses the anal canal.
Since the fi rst publication, no further results have
been published.
9.5.2.9.3 Secca Procedure
Radiofrequency energy is used on the presumption that collagen deposition and afterward scarring increase the ability to recognize and retain
stool and permit improved continence. RF in the
range of 200 kHz to 3.3 MHz results in vibration
of water molecules and subsequent frictional
heating. The Secca system is designed to deliver
temperature-controlled RF energy to the internal
128
P.N. Joshi et al.
sphincter. The RF energy handpiece is a clear
anoscopic barrel with four nickel-titanium curved
needle electrodes (22 gauge, 6 mm in length)
(Paristien and Corman 2005 ). The needle elec-
trodes are deployed through the mucosa of the
anal canal and into the internal sphincter muscle.
Upon deployment, there is a reduction in electrical impedance, indicating proper electrode penetration below the mucosal surface. Temperature
is monitored automatically and processed by a
temperature-control mechanism, which adjusts
RF output to achieve a target temperature of 85°C
at the tip of the needle electrode. Chilled water is
perfused through the handpiece to cool the anoderm while the deeper tissue around the needle
electrodes is heated.
Anoderm temperature is continuously monitored, and energy delivery automatically ceases if
anoderm temperatures exceed a preset limit of 42.
The procedure is carried out either in prone
jackknife or lithotomy position under local or
regional anesthesia. The handpiece is inserted and
positioned with the needles 0.5 cm distal to the
dentate line. The needles are then deployed into
the tissue, and impedance is checked for proper
tissue contact. Once appropriate tissue penetration
is achieved, the operator initiates RF energy delivery, and the four-channel generator delivers this
energy to all four electrodes to achieve a target
temperature of 85°C. A 1-minute treatment is
applied to each set. Ideally, a total of 20 sets of 4
lesions each are created, beginning 5 mm distal to
the dentate line and at 5-mm increments, creating
(if possible) 20 sets of lesions, each composed of
four needle insertions. Depending on the number
of sets, the procedure takes 30 min. Patients are
discharged in accordance with the criteria required
for conscious sedation in an ambulatory setting or
general anesthesia if so performed. All four quadrants are treated in the same manner.
9.5.2.9.4 Injectable Agents
Several bulking agents have been used in the management of FI like autologous fat, Tefl on, collagen,
carbon-coated zirconium beads, polydimethylsiloxane polymer, dextranomer microspheres in nonanimal stabilized hyaluronic acid (NASHA Dx),
and many others. These materials when injected in
submucous plane give a padding effect and close
the anal canal. NASHA Dx ( n = 136) or sham treat-
ment ( n = 70) is used in an outpatient setting with-
out anesthesia. Patients with persistent FI after 1
month were offered 1 retreatment procedure.
Seventy-one (52 %) patients in the active treatment
group versus 22 (31 %) in the sham group had a
treatment response (50 % improvement from baseline in the number of FI episodes) at 6 months
(odds ratio, 2.36; P = 0.0089) (Graf et al. 2011 ).
Gatekeeper™ is an injectable anal-bulking
agent prosthesis (originally from Medtronic,
Fig. 9.19 Gatekeeper
prosthesis (Courtesy of
S. Mantoo, Singapore)
9 Anal Incontinence
129
Minneapolis, Minnesota, USA; now from THD,
Correggio, Italy) used as a day care procedure.
These are thin solid cylinders (length 21 mm,
diameter 1 · 2 mm) of HYEXPAN™ (polyacrylonitrile). It is a hydrophilic material that changes
shape and volume and becomes thicker (diameter
7 mm) and shorter (length 17 mm) and of softer
consistency within 24 h of implantation once it
comes in contact with the human tissue (Fig. 9.19 ).
Patients who fail to improve with conservative
measures with the risk of signifi cant postoperative
complications are candidates for this procedure. It
should be avoided in patients with uncontrolled
diabetes, anal sepsis, infl ammatory bowel diseases
with anorectal involvement, colorectal cancer, and
an isolated external anal sphincter (EAS) defect.
The method was found to be safe and effective
(Ratto et al 2011 ). However larger series with lon-
ger follow-up is needed to establish the role of the
Gatekeeper™ for fecal incontinence.
9.5.2.9.5 Colostomy
In patients with total incontinence who are unable
to manage their problems by conventional methods and are unfi t for surgery or all the surgical
procedures had failed, a colostomy may become
necessary. This is the last resort for severely
handicapped, psychogeriatric, and bedridden
patients and patients with incontinence following
radiation injury of the rectum.
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Complete Rectal Prolapse in Adults
Ajay K. Khanna
1 0
10.1 Introduction
Rectal prolapse is a lifestyle disability for patients
and a challenge for surgeons to improve the quality of life in such patients. Complete rectal prolapse or procidentia is protrusion of the all the
layers of the rectum outside the anus. It is also
called full-thickness rectal prolapse. If rectal prolapse does not come out of the anus, it is called as
occult or internal rectal prolapse or rectal intus-
mucosal prolapse in which there is protrusion of
only rectal or anal mucosa (Roig et al. 1998 ; Felt-
Bersma and Cuesta 2001 ). Rectal prolapse occurs
at extremes of ages (Wassef et al. 1986 ; Jacobs
et al. 1997 ). In pediatric population, the condition
is diagnosed by the age of 3 years with an equal
sex distribution. In adults, peak incidence is after
fi fth decade of life. Women are more (80–90 %)
commonly affected than men. But in Indian scenario, the majority are young male patients in
contrast to western population where majority of
the patients with complete prolapse are elderly
females (Khanna et al.
A. K. Khanna , MS,FAMS,FACS,FICS,FACRSI,FMAS
Department of General Surgery ,
Institute of Medical Sciences,
Banaras Hindu University , Varanasi 221005 , India
akhannabhu@gmail.com
e-mail:
1996 ).
10.2 Etiology
In spite of numerous proposed possibilities,
the exact etiology and mechanism is not clear.
Chronic constipation, obesity, perineal injury,
pregnancy, and other conditions of raised intraabdominal pressure are commonly associated
with complete rectal prolapse (Madden et al.
1992 ). Anatomical variations are prerequisites
for the development of rectal prolapse. These
are the presence of abnormally deep pouch
of Douglas (Jacobs et al. 1997 ; Brodén and
Snellman 1968 ; Kuijpers 1992 ; Nicholls 1994 );
lax and atonic muscles of the pelvic fl oor and
anal canal (Brodén and Snellman 1968 ; Kuijpers
1992 ); weakness of both internal and external
sphincters, often with evidence of pudendal
nerve neuropathy (Kuijpers 1992 ; Nicholls
1994 ); the lack of normal fi xation of the rectum
with a mobile mesorectum; redundant sigmoid
colon; and lax lateral ligaments. With these anatomical abnormalities, the small intestine which
lies against the anterior wall of the rectum may
force it out through the anal canal leading to
prolapse (Brodén and Snellman 1968 ). Of these
various anatomical factors proposed, one of
the most important factors is the lack of fi xation of the rectum to the sacrum which makes
the rationale for the various rectopexies for the
treatment of complete rectal prolapse (Khanna
et al. 1996 ). Patients with psychiatric disor-
ders are often found to have complete rectal
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_10
131
132
A.K. Khanna
prolapse, and younger individuals less than 50
years are likely to have the psychiatric problems
(Marceau et al. 2005 ).
10.3 Clinical Features
The most common clinical feature of rectal prolapse is a mass protruding through the anal orifi ce. Initially mass protrudes from the anus only
after a bowel movement and usually retracts
when the patient stands up, but with progression
of disease, mass protrudes more often especially
while straining and Valsalva maneuver and may
require manual repositioning (Fig. 10.1 ). Finally,
the rectum prolapses with daily activities such as
walking and progresses to complete prolapse.
Rarely the rectum becomes incarcerated, and
patient cannot replace the rectum. Rectal prolapse is frequently accompanied by mucoid discharge or rectal bleeding. A prolapsed hemorrhoid
may have similar symptoms which can be distinguished by careful physical examination
(Fig. 10.2a, b ). Rectal prolapse reveals concentric
circular mucosal folds and grooves and is generally nontender, while hemorrhoidal prolapse has
radially oriented grooves and may be tender. Anal
orifi ce may be patulous in case of rectal prolapse;
hence, incontinence frequently accompanies it.
There is often a long history of constipation in
about 15–65 % of cases (Cirocco and Brown
1993 ; Keighley and Shouler 1984 ; Mann and
Hoffman
1988 ; Tjandra et al. 1993 ). Straining
may force the anterior wall of the upper rectum
into the anal canal causing a solitary rectal ulcer
due to mucosal trauma. Pain is a variable symptom. 10–25 % of patients also have uterine or
bladder prolapses, and 35 % may have associated
cystocele. The most common complication is
incarceration and strangulation of rectal prolapse.
An incarcerated rectal prolapse is seen after a
long history of prolapse which is less frequently
a presenting symptom.
10.4 Diagnosis
The diagnosis of rectal prolapse is clinical and is
confi rmed by proper history and complete anorectal examination. Preoperative workup of a
patient with complete rectal prolapse include
proctoscopy, colonoscopy and in some patients
manometry, pudendal nerve terminal motor
latency test, cinevideography, and colonic transit
studies. Frequently prolapse is in reduced state
which can be elicited by placing patient on commode and asking him to strain which demonstrates the prolapse properly. A rectal prolapse
may be hidden or internal or occult, making the
diagnosis more diffi cult. In this situation, defe-
cography may be helpful. In this examination,
x-ray is taken while the patient is having a bowel
movement. It can also assist in determining
whether surgery may be benefi cial and which
operation may be appropriate. It is more useful
for evaluating internal prolapse. Baseline
Fig. 10.1 Complete rectal
prolapse