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improved outcomes in colon and rectal surgery
(A) (B)
(C)(D)
Figure 21.4 Marsupialization. (A) The diseased tissue is excised with electocautery. (B) The cavity is debrided. (C) The edges of the wound are then sutured down to
the base of the wound using absorbable suture. (D) Resulting in a small open wound.
wound closure reported less infectious complications(13% vs.
30%) and recurrences(5% vs. 10%) with the open technique, but
more overall wound complications. Slightly more patients in the
open group were not satisfied with the outcome of treatment(8%
vs. 5%). However, a larger series of 493 patients (25) treated with
midline excision and primary closure via an oblique elliptical incision which crossed the midline showed recurrence rate of 5.6% at
18 months, with very low incidence of wound infection(1.2%),
hematoma(0.4%), or wound dehiscence (1%) postoperatively.
The benefit of faster healing time and smaller final scar slightly
outweighs the possible increase in infection or wound dehiscence.
Recurrence is related more to inadequate excision of diseased
tissue rather than to closure technique.
edges are tacked down to the base of the wound using absorbable suture. This leaves a smaller and more shallow wound which
is easier to pack.(Figures 21.4a–d) By not completely closing the
wound, there is a theoretical decrease in wound complications, and
the duration of healing is less than for a fully open wound. Simply
unroofing the wound versus excision also results in a smaller
wound. A study of 26 patients who underwent wide local excision
and 42 who had unroofing and marsupialization reported significantly longer healing times (21 vs. 6 weeks) and wound complications requiring reoperation (35% vs. 2%) in the wide local
excision group.(26) Simple unroofing without marsupialization
has become the preferred initial operation for pilonidal disease
and the editors’ institution.
A more recent series of 380 patients (27) who underwent exci-
Excision or Unroofing with Marsupialization
Another option to leave a smaller wound is marsupialization. The
excision of tissue is carried out as described above. Then the skin
sion with either primary closure or wound left open reported
similar length of stay, wound infection rate, and recurrence rate
among the two groups. However, the length of time off from work
surgery for pilonidal disease and hidradenitis suppurativa
(A) (B)
Figure 21.5 Bascom operation. (A) A vertical incision is made overlying the cyst, 1 cm away from the gluteal cleft. The cyst cavity any communicating fistula tracts are
debrided. The midline pits are excised, with the wounds communicating to the cavity. (B) The midline wounds are closed primarily with absorbable suture and the
vertical wound is packed lightly and left to heal by secondary intention.
and healing time were significantly shorter in the group that had
the wound closed primarily.
Limited Excision
In an attempt to minimize the morbidity of this disease, some
surgeons have advocated a more limited excision of the sinuses
rather than removing all the surrounding tissue. This technique
is recommended for patients with limited disease, defined as four
or less pits and no concurrent abscess or active infection. The
technique as described by Oncel et al. (28) requires excising each
individual pit along with a funnel-shaped cone of tissue around
the track. Methylene blue may be injected into the pits to aid
in identifying the tracks, though some authors believe that this
leads to excision of more tissue than is necessary. Additionally,
if two pits are found to be connected, the fistula overlying them
should be unroofed. The goal is to remove all pits along with
their underlying tracks and granulation tissue. The wounds are
then left open to heal by secondary intention. The same group
reported their medium-term follow-up of 62 patients treated
with this technique.(29) They found that the patients were able to
return to work in 2 days and healed completely in 43 days. They
reported one recurrence after 1 year of follow-up. Mohamed
et al. (30) reported a prospective randomized trial of 83 patients
assigned to wide excision with primary closure, wide excision
with wound left open, or limited excision of fistula tracks. They
found that the limited excision group had shorter operative
time, shorter length of stay and less postoperative pain, while the
wide excision with open wound group had the longest time to
complete healing. There was no difference in recurrence among
the three groups and therefore recommended a limited excision
approach when possible.
Bascom Operation
Bascom described a different operation (10) based on his theory
that treatment of pilonidal disease should center around removing the midline follicles or pits rather than excising large amounts
of tissue. The goal of this operation is to excise the midline pits,
drain the underlying abscess, and elevate the gluteal cleft. A vertical incision is made overlying the chronic abscess approximately
1 cm away from the gluteal cleft. The abscess cavity is then debrided, and any communicating fistula tracts are identified and
undermined so that they connect to the open wound. The midline
pits are excised via small incisions encompassing each one individually. These wounds are closed with nonabsorbable suture. The
lateral wound is left open to heal by secondary intention and hair
in the area is shaved until the wound is completely healed. (Figure
21.5) Bascom reported his experience with 149 patients (7) with
3.5 year follow-up after follicle-excision surgery and found that
16% had recurring problems, but that these were all minor and
did not cause added morbidity. All his patients were able to return
to work within 1 day of surgery and took approximately 3 weeks
to heal the lateral wound. In a series of 218 patients (31) who
underwent Bascom’s operation, 84% were performed under local
anesthesia and all patients were discharged home the same day.
6% had infectious complications and 10% recurred, with complete healing in all but 1 patient, who required further surgery.
Surgery for Complicated Pilonidal Disease and
Nonhealing Wounds
While most patients who undergo surgery for pilonidal disease
heal without complication, a few return with chronic nonhealing
wounds. Many of these patients are those who underwent wide excision and were left with an open wound to close secondarily or those
improved outcomes in colon and rectal surgery
Table 21.2 Advanced procedures for pilonidal disease.
Technique Study Year Number of Patients Hospital time (days) Healing time (days) Infection (%) Recurrence (%) Follow-up (months)
Karydakis flap Kitchen et al.34 (1996) 141 (–) (–) (–) 4 18
Karydakis flap Akinci et al.46 (2000) 112 2.6 13.2 1.8 0.9 28
Karydakis flap Keshava et al.35 (2007) 70 (–) 80 (–) 4.2 36
Rhomboid flap Bozkurt et al.47 (1998) 24 4.1 17.5 0 0 27
Rhomboid flap Milito et al.48 (1998) 67 5.3 14 0 0 74.4
Rhomboid flap Arumugam et al.
Rhomboid flap Topgul et al.43 (2003) 200 3.1 12.8 1.5 2.5 60
Rhomboid flap Katsoulis et al.49 (2006) 25 4 (–) (–) 4 20
Bascom operation Senapati et al.31 (2000) 218 Outpatient 28 6 10 12
V-Y flap Dylek et al.50 (1998) 23 10 21 4 0 18
Z-plasty Fazeli et al.45 (2006 72 2.86 15.4 9.7 4.2 22
(-) not described.
42
(2003) 53 4 14 13 7 24
(A) (B)
Figure 21.6 Karydakis flap. (A) Schematic of the operative field depicting a pilonidal cyst slightly to the left of midline with two midline pits. (B) An elliptical incision is
made encompassing the cyst and pits. The excision is carried down to the sacrococcygeal fascia. (C) The medial edge of the wound is raised as a flap crossing the midline.
(D) The tape retracting the buttocks is released so that the wound edges are able to be approximated without tension. (E) Final result showing a vertical incision closed
primarily away from the midline, resulting in a flattened gluteal cleft.
whose incisions broke down. Those patients who have recurrence
after initial surgery or have unacceptable scars also are included in
this group. Several methods have been described to excise tissue in
the gluteal cleft and close the resulting defect with a flap technique.
(Table 21.2) These methods may be used as the initial treatment
approach, and also for complicated recurrent disease.
In 1973, Karydakis (32) described an asymmetric advancement
flap technique which results in excision of the disease, a primarily
closed wound, and a flatter gluteal cleft. An elliptical incision is
made vertically and centered off midline to the most affected side.
The incision should encompass all midline pits and skin sinuses.
The incision is carried down to the sacrococcygeal fascia, removing the affected tissue. A skin flap is raised under the medial edge
of the wound and across the midline.When the buttocks are
released and approximated, the edges of the wound should come
together easily. The incision is closed primarily off the midline,
and a flatter gluteal cleft is created. (Figure 21.6) This is believed
to aid in healing and lessen recurrence. External drainage is
useful to prevent fluid collections under the flap, though one study
found no effect on wound infections or recurrence.(33) In his
(C)
series of 6,545 patients treated with this technique (6), Karydakis
reported less than 1% recurrence rate. While this excellent result
has not been replicated, many smaller series have reported acceptable results. Kitchen reported a series of 141 patients treated by
this technique.(34) He found a recurrence rate of 4%. 23% of
his patients had recurred after previous operations for pilonidal
disease, and all of them were cured after this procedure. More
recent series have reported recurrence rates ranging from 0 to
4%, with 5% to 8% wound complications.(35–38) Similar results
have been obtained in obese patients.(39)
A modification of this technique was described by Bascom in
2002, known as the “cleft lift” or “Bascom II” procedure.(40) An
important key to this operation is preoperative skin marking of
the patient. With the patient standing up, the buttocks are pushed
together so the line of contact between the two may be marked with
a pen. When the buttocks are taped apart with the patient lying
prone, the area between the pen markings delineates the limits of
the flap dissection. An asymmetric ellipse is drawn off midline to
include the midline pits. This ellipse is then excised, with the incision reaching to the sacrococcygeal fascia. The flap, consisting of
(D)
(E)
surgery for pilonidal disease and hidradenitis suppurativa
(B)(A)
Figure 21.7 Rhomboid Flap. (A) A rhomboid incision encompassing the pilonidal
cyst and midline pits is marked on the skin, along with a lateral extension. The
rhomboid is composed of 2 120º angles and 2 60º angles. Line BC is drawn at a 90º
angle to Line CD. Line AB is drawn vertically down. All lines should be of equal
length. The cavity is excised down to fascia and debrided. The flap is raised and
mobilized to cover the defect. (B) The flap is rotated into the defect so that Point
2 meets Point E, Point 1 meets Point D, and Point A meets Point C. This results in
a primarily closed wound and flattened gluteal cleft.
skin and subcutaneous fat, is then mobilized towards the affected
side, breaking up the scar tissue in the subcutaneous fat. The flap
should be mobilized until the plane of dissection reaches the pen
mark on the contralateral buttock. When the tapes are released, the
edges of the flap should come together. A drain is placed under
the flap and the incision is closed, resulting in a scar off the midline and a flattened gluteal cleft. In the original article describing
the technique, 27 patients who underwent the procedure after
undergoing multiple failed operations were described.(40) They all
healed completely, most having the sutures removed at 1 week, and
none recurred after a mean follow-up period of 20 months. A series
of 24 patients treated with the same technique but without drain
placement reported no hematomas, seromas, or infections, and
patients returned to work in 3 weeks. They had no recurrences with
a follow-up of 10 months.(41) This procedure is a useful option
for patients who have failed previous attempts at cure or who have
chronic unhealed wounds.
Other rotational flap techniques have been described for this
disease, along with myocutaneous flaps and skin grafting. The
rhomboid flap is another commonly used operation. Limberg or
Dufourmentel flaps are some of the more common variations of
this type of flap. For this flap, a rhomboid incision is made which
includes the diseased tissue, with the vertical axis being along the
gluteal cleft. This is carried down to the sacrococcygeal fascia.
A triangle of skin and subcutaneous fat is incised lateral to this and
then rotated into the defect.(Figure 21.7) A drain may be placed per
surgeon preference. Patients stay in the hospital on average 4 days
and sutures are removed in approximately 10 days. In a series of
53 patients with 24 month follow-up, 13% developed wound infections, 7% recurred, and all had an average healing time of 2 weeks.
(42) Another study reported on the results of 200 patients who
underwent Limberg rhomboid flap reconstruction. These patients
had an overall recurrence rate of 2.5%, with complications including minimal flap necrosis in 3%, seroma formation in 1.5%, and
wound infection in 1.5%. The average length of stay was 3.1 days
and time to return to work was 12.8 days.(43) Other fasciocutaneous flaps which have been described include V-Y flaps, Z-plasty,
W-flaps, and a variety of other rotational flaps. The goal of all of
them is to allow the surgeon to excise the diseased tissue as widely
as necessary and close the defect primarily without tension while
flattening the gluteal cleft. All these flaps have similar complication
and recurrence rates, and the choice of which to utilize in each case
depends on the size of the defect to be closed and the individual
surgeon’s experience with each.
The Nonhealing Sacral Wound
Fortunately, most patients have limited disease that responds to
conventional treatment. However, a few patients present with
large open sacral defects, either due to complications of wide
excision left to close secondarily, or as a result of failed primary
closures.
Several myocutaneous rotational flaps have been described for
closing large wounds, which fortunately are not encountered very
frequently. Flaps based on the gluteus maximus are frequently
used to cover sacral wounds with good results. These techniques
are beyond the scope of this book and are most often performed
in conjunction with plastic surgeons.
Another adjunct to sacral wound healing may be the vacuum
wound closure system. Vacuum wound closure systems may be
useful in patients who have defects which are not able to be closed
primarily for a variety of reasons, and have been used extensively
in defects due to pressure ulcers, traumatic wounds, and postsurgical perineal defects. A series of five patients with extensive
complex infected pilonidal sinuses underwent excision with
placement of a vacuum sponge.(44) Patients used the device for
6 weeks, after which wet-to-dry dressing changes were initiated.
Complete epithelialization was observed in 12 weeks. One patient
did not tolerate the device, and another required a return to the
operating room for further debridement, after which the wound
healed with use of the vacuum device.
Pilonidal disease presents many treatment challenges, and
therefore, multiple treatment approaches exist. Depending on the
specifics of each case and individual surgeon experience, different
approaches may be considered. An algorithm based on extent and
chronicity of the disease is presented here. (Figure 21.8)
PERIANAL HIDRADENITIS SUPPURATIVA
Hidradenitis suppurativa is a chronic inflammatory disease of the
apocrine sweat glands. The disease was first described by Velpeau
(51) in 1832, and its association to sweat glands in the skin was
described by Vernuil (52) in 1864. These glands are found primarily in the groin and axilla, which are the most common sites of
involvement of disease. However, they can also be found in the
perineum, perianal area, scrotum, and labia. Hidradenitis suppurativa affects patients beginning in adolescence and peaks around
age 40. The incidence of hidradenitis suppurativa is estimated to be
1:300. Perianal disease appears to be more common in men.(53)
Pathophysiology
Apocrine sweat glands are coiled tubular secretory structures
which empty into the hair follicle. They are similar to eccrine sweat
glands except that these empty directly to the skin. The etiology of
hidradenitis suppurativa is unclear, but appears to be multifactorial. Obstruction of the apocrine gland duct is likely to be the
inciting event, leading to secondary infection and rupture of the
improved outcomes in colon and rectal surgery
Algorithm for management of chronic pilonidal disease
Chronic Pilonidal Disease
Limited Disease
Complicated Disease
Large
Wound
Myocutaneous flaps
Vacuum sponge
Karydakis flap
Rhomboid flap
Cleft Lift (Bascom II)
V-Y flap
Z-plasty
+ contraindications to surgery
- Hygiene
- Depilation
Midline excision ± closure
or marsupialization
Sinus excision
Bascom operation
Figure 21.8 Algorithm for management of pilonidal disease.
gland with extension into the surrounding dermis and subcutaneous fat. The infection then spreads to neighboring glands and is
manifested by cellulitis and abscess. Initially, the infection resolves
with simple incision and drainage, but long-term disease recurrence may lead to scarring and fistula formation. Microbiologic
studies of the infected tissues have shown that skin flora is the
usual pathogen for axillary disease, though enteric aerobes and
anaerobes have also been isolated from perianal lesions. Many of
the older studies were indeterminate as they evaluated superficial swab cultures. However, cultures of deeper tissue have shown
Staphylococcus aureus and coagulase-negative staphylococcus in
most of the samples.(54)
Diagnosis
Patients with perianal hidradenitis present with recurrent perianal abscesses which may extend to involve the perineum, labia or
scrotum, buttocks, or the inguinal region. The lesions may start
out as a simple abscess, but tend to evolve with time into thick
scarred skin with open wounds and chronically draining sinuses.
Perianal fistulae may also be present. The differential diagnosis
includes perianal abscess, furuncles, carbuncles, lymphogranuloma venereum or other sexually transmitted diseases, pilonidal
disease, tuberculosis, actinomycosis, cat-scratch disease, granuloma inguinale, and Crohn’s disease. One way to differentiate
the etiology of perianal fistulae is that cryptoglandular fistulae usually involve the dentate line and intersphincteric plane,
whereas fistulae associated with hidradenitis are found in the distal anal canal, where the apocrine glands are found. The dentate
line is normal in cases of hidradenitis. It is important to examine
other areas, such as the axilla and groin, as many patients with
hidradenitis suppurativa will have concurrent involvement of
these areas. Some factors which have been shown to be related to
this disease include altered immune response, smoking, obesity,
hormonal therapy, pregnancy, onset of puberty, familial factors,
and Crohn’s disease.(55–57) The Lahey Clinic reported their experience with 43 patients with perianal hidradenitis suppurativa.
They found that 93% of the patients were male with a median
age of 29 years. Patients were initially diagnosed with pilonidal
disease (28%), anal fistula (37%), and perirectal abscess (16%).
72% of their patients were smokers.(58) In a series of 61 patients
from The Cleveland Clinic, 24 (38%) were found to have concurrent Crohn’s disease. All had perianal hidradenitis, and 20 had
disease in other sites as well.(59) Often the diagnosis of perianal
hidradenitis is delayed due to the similarity of symptoms with
other perianal diseases and the possibility of other concurrent
disease processes. In situations where patients are being treated
for a certain condition and they are not improving, hidradenitis
should be considered as a possible complicating factor. Long-term
sequelae of perianal hidradenitis include disfiguring scars, localized or systemic sepsis, and carcinoma, including squamous cell
or adenocarcinoma.(60–62)
Nonoperative Management
The treatment of perianal hidradenitis suppurativa is mainly
surgical. However, there is a role for nonoperative management,
particularly in the milder forms of the disease. Maintaining
good hygiene of the area is imperative to control infection.
Patients should keep the affected area clean and dry, reduce
moisture, avoid constricting or irritating clothing, and lose
weight. Topical antibiotics are often used in conjunction with
systemic antibiotics or alone to control secondary infection.
Topical clindamycin was shown in one double-blind randomized
trial of 30 patients to be of benefit in controlling infection.(63)
Systemic antibiotics are rarely indicated, except in cases with
significant cellulitis or bacteremia. In light of the similarities
between acne and hidradenitis suppurativa, isotretinoin has
been used to treat hidradenitis successfully. Brown et al. (64)
reported on a patient treated with 1 gm/kg of isotretinoin daily
for 20 weeks. The patient had no significant change in her
condition until 8 weeks into the treatment, at which point she
began to note improvement. Ultimately, she had an excellent
response with no relapse at the 18 week follow- up visit. Minor
surgery for pilonidal disease and hidradenitis suppurativa
side effects such as xerosis, cheilitis, and elevated serum alkaline phosphatase were reported, which resolved with completion of treatment.
Targeting the hormonal response of hidradenitis has also had
some success, including one retrospective study of 64 female
patients demonstrating that antiandrogen therapy was superior to systemic oral antibiotics in controlling disease.(65–67)
Other nonsurgical approaches have been attempted with varying
degrees of success, including granulocyte-macrophage colonystimulating factor (68), infliximab (69, 70), and oral zinc.(71)
Surgical Management
The centerpiece of treatment of hidradenitis is surgical excision.
Incision and drainage has a limited role to relieve pain and pressure in cases of acute abscess. There is no long-term benefit to
the procedure, as it does not remove any of the affected tissue,
but may be necessary to relieve pain. Patients should receive systemic antibiotics to treat the overlying cellulitis if present and may
require packing of the wound for several days. Unroofing of fistula tracts is another procedure which may be useful in controlling
local infection, though this also does not excise the disease and
therefore has no benefit in preventing recurrence.
Excision of the diseased skin, including skin appendages and
subcutaneous fat, is required to adequately control the disease.
In mild cases, limited excision left to heal by secondary intention is appropriate. Primary closure is usually not possible and is
not advised, as the recurrence rate is increased. Rotational flaps
or skin grafting are more successful wound closure methods. In
a series of 106 patients, 70% underwent excision with primary
closure and the rest had closure with skin grafts or flaps. 69%
of the patients had a recurrence requiring surgery, the majority
of whom were in the primary closure group.(72) A series of 8
patients with perineal hidradenitis who underwent wide excision had their wounds either covered with meshed split-thickness skin graft (5) or left open to heal by secondary intention.
(3) All patients healed well and had no surgical site recurrence,
though two recurred in other areas.(73) A larger series including
56 patients with gluteal or perianal disease was reported recently.
(74) Twenty-one (37.6%) and 17 (30.6%) patients had gluteal
and perineal disease, respectively. Squamous-cell carcinoma and
Crohn’s disease were observed in one patient each. Wide excision was performed in all patients. Thirty-two patients (57.1%)
were left to heal by secondary intention, and the remaining 24
patients underwent split-thickness skin grafting. Twenty-three
patients received a diverting colostomy. Mean time for complete
healing in the open wound group was 10 weeks and in the skin
graft group was 6 weeks. Five patients (9%) required a second
resection. Partial graft loss rate was 37.5% and only one patient
had a recurrence. The benefits of skin grafting or rotational flaps
include shorter healing times and less discomfort when compared to an open wound; however, some of the large defects that
result from excision are difficult to adequately cover. When a
large wound must be left open, a wound vaccum sponge or silastic foam may be of benefit.
In summary, the primary approach to perianal hidradenitis
suppurativa is surgical excision of all diseased tissue. The open
defect that results may be left open to heal secondarily and heals
uneventfully in most cases. In certain cases where the defect is
particularly large, a skin graft may be used. Fecal diversion is
rarely necessary in managing this disease, and should be reserved
for debilitated patients who will have difficulty keeping the open
wound clean, patients with fecal incontinence, or patients with
concurrent Crohn’s disease with perianal involvement.
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improved outcomes in colon and rectal surgery
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Surgical treatment of fecal incontinence
Ann C Lowry and Dimitrios Christoforidis
CHALLENGING CASE
A 35-year-old woman presents to your office with complains of
fecal incontinence. She is G3 P3, all vaginal deliveries and one
child was 8 pounds. The patient reports fecal soiling for the last
year with progressive uncontrolled passage of flatus and occasional identification of stool in her undergarments that she was
unaware of having passed. There is additional incontinence associated with athletic activity. The incontinence severely affects the
patient’s life style.
CASE MANAGEMENT
A complete history identifies no additional risk factors. Physical
examination reveals a thinned perineal body, decreased resting
tone, weak squeeze (especially anterior), and an anterior sphincter defect. A flexible sigmoidoscopy was normal, anorectal manometry documents low resting tone and squeeze pressure. An anal
ultrasound confirms an anterior sphincter defect. The patient is
recommended to undergo an overlapping sphincter repair.
EPIDEMIOLOGY
Fecal incontinence (FI) is a common and underreported condition. It is embarrassing, stressful, and often leads to social isolation. Nevertheless, only a third of symptomatic patients in the
USA discuss their fecal incontinence with their physician.(1) The
reported prevalence of FI varies depending on the population
studied and definition used. In nursing homes, it affects nearly
50% of residents.(2, 3) In a recent systematic review including
16 studies from across the world, the estimated prevalence of
fecal incontinence (excluding flatus incontinence) varied from
0.4% to 18%. A community based US telephone survey found a
prevalence of 2.2%.(4) A study from the UK analyzed over 10,000
questionnaires from community-dwellers using more strict criteria; Major FI, defined as soiling of underwear, outer clothing
or bedding at least several times a month, was reported by 0.9 %
adults aged 40–64 years and by 2.3% of adults aged 65 years and
older.(5) In this and other epidemiology studies, men were found
to be equally affected by FI as women. However, clinical series on
FI are dominated by female patients as women seem to seek medical attention more often. The true reason for that is unknown.
Beyond the psychological burden and the medical morbidity (such as urinary tract infections, skin breakdown, decubitus
ulcers) FI causes significant expense. Estimating total costs is
difficult because of imprecise prevalence data and frequency of
coexisting medical conditions. By analogy, urinary incontinence
was estimated to generate direct and indirect costs exceeding $14
billion in the year 2000 for US community dwellers.(6) In a US
study of 63 women with FI secondary to obstetric injury, the
average cost for evaluation and treatment of FI was 17,166 USD
per patient in 1999.(7) FI is obviously a significant public health
problem that deserves more attention.
ETIOLOGY
The physiology of the continence mechanism is complex. Schematically, continence requires an anal sphincter and a rectal reservoir
that are anatomically intact, normally innervated, and coordinated,
a manageable fecal bolus and an adequate level of awareness and
desire to avoid incontinence. A great number of conditions, traumatic events, diseases, or medication may affect continence at one
or more of these levels at various degrees. FI is often multifactorial
and causality is not always easy to establish. Therefore, it may be
more appropriate to talk about risk factors rather than causes in the
etiological assessment of a patient with FI.
Anal sphincter
In women with FI, the most prevalent risk factor is childbirth.
The incidence of third or fourth degree tears identified clinically
at the time of vaginal delivery is 0.6 to 9%.(8) The clinical incidence is an underestimate of the true sphincter injury rate, as
demonstrated by studies employing ultrasound imaging. A metaanalysis of five large prospective studies assessing the integrity
of the anal sphincter after vaginal delivery with 2-dimensional
endosonography revealed a 27% incidence of anal sphincter
defect in primiparous women and an 8.5% incidence of new
sphincter defects in multiparous women.(9) Another study using
improved 3-dimensional endosonography on 55 primiparous
women reported evidence of trauma in 29% but only 11% had
evidence of external sphincter injury.(10) Among those women
with a documented third degree tear, FI will develop in one-third
to two-thirds.(8, 9) In the general population the true incidence
of persistent postpartum FI of solid stool is unknown but can be
approximately estimated at 3%. Other than obstetric trauma, the
anatomical integrity of the sphincter complex can be disrupted
by iatrogenic trauma during anorectal surgery and accidental
trauma or be the result of a congenital malformation such as
imperforate anus.
In addition to structural defects, alteration of sphincter innervation also contributes to decreased sphincter function. It is well
recognized that traction injury to the pudendal nerve during
pregnancy and delivery contributes to obstetric-injury-related
FI.(11) Various conditions affecting the pelvic nerves, the spinal
cord or the brain may also result in sphincter atrophy and loss of
anal canal tone (Table 22.1).
Rectum
The reservoir function of the rectum may be impaired secondary to a) loss of capacity after rectal resection or space occupying
lesions, b) loss of compliance secondary to inflammatory bowel
disease, pelvic radiation, rectal ischemia, or collagen vascular
diseases and, c) loss of innervation following surgery, trauma, or
neurologic degenerative disease. Rectal mucosal prolapse or full
thickness rectal prolapse may cause FI by preventing complete
surgical treatment of fecal incontinence
Table 22.1 Pathophysiology classification of risk factors for FI.
Brain – central awareness
Dementia
CVA
Brain tumor, infection, trauma
Psychiatric disorder
Psychotropic drugs
Bowel – Fecal bolus
Diarrheal states (malabsorption, IBD, infectious diarrhea, short gut syndrome,
radiation enteritis, laxative abuse etc.)
IBS
Proctitis (radiation, IBD)
Gastrointestinal stimulant drugs and foods (caffeine, alcohol, aspartamine etc)
Anorectum – Neurologic impairment
Spinal cord trauma, surgery, hernia, neoplasm
Diabetes mellitus
Multiple sclerosis
spina bifida
(myelo)meningocele
pelvic fracture
Pelvic radiation
prostatectomy
proctectomy
obstetric injury
rectal prolapse
chronic straining
pelvic floor descent
aging
idiopathic
Rectum – anatomic impairment
Sphincter-saving operations (low anterior resection, coloanal anastomosis,
restorative proctectomy procedures)
Rectal neoplasm
Extrinsic compression
Collagen vascular disease
Rectal ischemia
Pelvic radiation
Rectal agenesis
Anal sphincter – anatomic impairment
obstetric injury
anorectal surgery (fistula surgery, internal sphincterotomy, anal stretch,
hemorrhoid surgery)
anal impalement
anal intercourse
imperforate anus
Pseudoincontinence
anorectal condition: prolapsing hemorrhoids, rectal prolapse, fistula in ano
troublesome hygiene: obesity, physical disability
sphincter closure; if left untreated, these conditions may lead to
sphincter and pudendal nerve damage.
Central Nervous System
Patients with dementia, some psychiatric disorders, or residual
deficits from a stroke may lack awareness or interest in bowel
function and become incontinent. This type of FI is more prevalent in elderly and institutionalized patients.
EVALUATION
Assessment of severity
There is no objective test that reliably correlates with patient
reported frequency and type of fecal incontinence. Since the physical morbidity associated with FI is minimal and the mortality
practically null, morbidity and mortality data is not useful to
measure severity. However, the impact of FI on quality of life is
immense. Consequently, any effort to rate FI should be based on
the patient’s reported frequency and type of FI and its effect on
quality of life.
Baxter et al. (12) categorized the available measures of FI
into a) descriptive measures (e.g., Mayo Clinic FI Questionnaire,
Osterberg Assessment of FI, and constipation), b) severity scores
including grading systems (e.g., Parks’ scale, Williams scale) and
summary scores (e.g., FI Severity Index (FISI), Cleveland Clinic
Florida FI score (CCF-FI), Vaizey score) and c) impact measures
which can be disease specific (e.g., Fecal Incontinence Quality of
Life (FIQL), FI-Manchester Health Questionnaire) or global (e.g.,
SF-36). A diary is a useful way to document the frequency and type
of FI episodes; the data can be used to calculate a score or simply
reported as number of FI episodes per week or days with FI per
week. In clinical practice, FI is often described as minor (mostly
underwear staining and/or gas incontinence without unintentional loss of true bowel movements) or major (accidental loss of
partial or whole bowel movements), urge or passive incontinence.
Obviously, these descriptions are insufficient to compare patients
in studies or to assess treatment outcome precisely.
Popular measures in research are severity summary scores.
They are usually based on frequency and type of FI episode.
Some systems incorporate the use of a pad or the presence of
lifestyle alteration. However, few scoring systems are based upon
patient’s perspective in the assignment of values. Most of these
scores attribute the same importance to episodes of gas incontinence as episodes of solid stool incontinence. An exception is
the FISI which was designed based on patients’ numerical ratings of severity of various frequencies of gas, mucus, liquid stool,
and solid stool incontinence.(13) Nevertheless, frequency-based
scores, even with a meticulous use of a FI diary to register events,
will overlook the fact that patients often make dramatic lifestyle
changes to avoid FI episodes. Therefore, a validated impact measure such as the FIQL (14) should be used in addition to severity
summary scores.
Fecal bolus
Formed stool is easier to control than liquid stool. An accelerated
intestinal transit with increased stool volume can cause urgency
and soiling even in patients with normal anorectal function and
will precipitate true FI in a patient with a weakened continence
mechanism. Constipation on the other hand, can lead to impaction and overflow incontinence in patients with deficient rectal
sensation combined with weakened sphincter muscles.
History and Physical
The goals of a thorough history in a patient with FI are multiple.
First, the interview should define character (seepage, passive/urge),
severity, and impact on quality of FI. The character often suggests the
underlying physiopathology. Generally, internal sphincter defects,
prolapse or loss of sensation cause seepage and passive incontinence
whereas external sphincter defects cause primarily urge incontinence.
A deficient rectal reservoir through loss of capacity or compliance
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