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_5256_Библиотеки_им_академика_М_И_Перельмана.pdf
255
109. Milka W, Paradowska W, Kołomańska-Bogucka D, Mazur-Bialy AI. Antenatal perineal
massage-risk of perineal injuries, pain, urinary incontinence and dyspereunia-a systematic
review. J Gynecol Obstetr Hum Reprod. 2023;52(8):102627.
110. Smith LA, Price N, Simonite V, Burns EE.Incidence of and risk factors for perineal trauma:
a prospective observational study. BMC Pregnancy Childbirth. 2013;13:59.
111. Waldman R.ACOG Practice Bulletin No. 198: prevention and management of obstetric lac-
erations at vaginal delivery. Obstet Gynecol. 2019;133(1):185.
112. Meyer I, Richter HE.Evidence-based update on treatments of fecal incontinence in women.
Obstet Gynecol Clin N Am. 2016;43(1):93–119.
113. Doughty D.Urinary & fecal incontinence: nursing management. 2nd ed. St. Louis: Mosby,
Inc.; 2000.
114. Guise JM, Boyles SH, Osterweil P, Li H, Eden KB, Mori M.Does cesarean protect against
fecal incontinence in primiparous women? Int Urogynecol J. 2009;20(1):61–7.
115. Palmer K, Corbett C, Holdsworth C. Double-blind cross-over study comparing loper-
amide codeine and diphenoxylate in the treatment of chronic diarrhea. Gastroenterology.
1980;79(6):1272–5.
116. InfantRisk center health care mobile resource [Internet]. 2017.
117. Musial F, Enck P, Kalveram KT, Erckenbrecht JF.The effect of loperamide on anorectal func-
tion in normal healthy men. J Clin Gastroenterol. 1992;15(4):321–4.
118. Farrar D, Tuffnell DJ, Ramage C.Interventions for women in subsequent pregnancies follow-
ing obstetric anal sphincter injury to reduce the risk of recurrent injury and associated harms.
Cochrane Database Syst Rev. 2014;2014(11):Cd010374.
119. Nelson RL, Go C, Darwish R, Gao J, Parikh R, Kang C, etal. Cesarean delivery to prevent anal
incontinence: a systematic review and meta-analysis. Tech Coloproctol. 2019;23(9):809–20.
120. Tholemeier L, Souders CP, Bresee C, Nik-Ahd F, Caron A, Eilber KS, etal. Seeking the truth
about primary elective cesarean delivery and pelvic oor disorders: a systematic review and
meta-analysis. Urogynecology. 2022;28(3):e108–e14.
121. Fitzpatrick M, Cassidy M, Barassaud ML, Hehir MP, Hanly AM, O’Connell PR, etal. Does
anal sphincter injury preclude subsequent vaginal delivery? Eur J Obstetr Gynecol Reprod
Biol. 2016;198:30–4.
122. Hutton EK, Hannah ME, +Willan AR, Ross S, Allen AC, Armson BA, et al. Urinary
stress incontinence and other maternal outcomes 2 years after caesarean or vaginal birth
for twin pregnancy: a multicentre randomised trial. BJOG: Int J Obstetr Gynaecol
2018;125(13):1682–1690.
123. López-López AI, Sanz-Valero J, Gómez-Pérez L, Pastor-Valero M.Pelvic oor: vaginal or
caesarean delivery? A review of systematic reviews. Int Urogynecol J. 2021;32:1663–73.
124. Kenton K, Brincat C, Mutone M, Brubaker L.Repeat cesarean section and primary elective
cesarean section: recently trained obstetrician-gynecologist practice patterns and opinions.
Am J Obstet Gynecol. 2005;192(6):1872–5. discussion 5–6
125. Scheer I, Thakar R, Sultan AH.Mode of delivery after previous obstetric anal sphincter inju-
ries (OASIS)–a reappraisal? Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(9):1095–101.
126. Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA.Long-term results of overlapping
anterior anal-sphincter repair for obstetric trauma. Lancet. 2000;355(9200):260–5.
127. Jibrel F, Cox CK, Fairchild PS, Fenner DE, Suresh S, Swenson CW.Indications for surgical
intervention in a postpartum pelvic oor specialty clinic. Int Urogynecol J. 2020;31:2233–6.
128. Moya P, Navarro JM, Arroyo A, Lopez A, Ruiz-Tovar J, Calpena R. Sacral nerve stimu-
lation during pregnancy in patients with severe fecal incontinence. Tech Coloproctol.
2013;17(2):245–6.
129. Mahran A, Soriano A, Safwat AS, Hijaz A, Mahajan ST, Trabuco EC, etal. The effect of sacral
neuromodulation on pregnancy: a systematic review. Int Urogynecol J. 2017;28(9):1357–65.
11 Management ofFecal/Anal Incontinence During Pregnancy andPostpartum
256
130. Vaccaro C, Clemons JL.Anal sphincter defects and anal incontinence symptoms after repair
of obstetric anal sphincter lacerations in primiparous women. Int Urogynecol J Pelvic Floor
Dysfunct. 2008;19(11):1503–8.
131. Salehi-Pourmehr H, Atayi M, Mahdavi N, Aletaha R, Kashtkar M, Sharimoghadam S, etal.
Is sacral neuromodulation effective and safe in pregnancy? A systematic review. Neurourol
Urodyn. 2023;42(6):1329–43.
132. Rydningen MB, Riise S, Wilsgaard T, Lindsetmo RO, Norderval S.Sacral neuromodulation
for combined faecal and urinary incontinence following obstetric anal sphincter injury. Color
Dis. 2018;20(1):59–67.
133. Rydningen M, Dehli T, Wilsgaard T, Rydning A, Kumle M, Lindsetmo R, etal. Sacral neuro-
modulation compared with injection of bulking agents for faecal incontinence following obstet-
ric anal sphincter injury–a randomized controlled trial. Color Dis. 2017;19(5):O134–O44.
134. Halverson AL, Hull TL.Long-term outcome of overlapping anal sphincter repair. Dis Colon
Rectum. 2002;45(3):345–8.
135. Barbosa M, Glavind-Kristensen M, Moller Soerensen M, Christensen P.Secondary sphinc-
ter repair for anal incontinence following obstetric sphincter injury: functional outcome and
quality of life at 18 years of follow-up. Color Dis. 2020;22(1):71–9.
136. Bergman I, Söderberg MW, Ek M.Perineorrhaphy compared with pelvic oor muscle ther-
apy in women with late consequences of a poorly healed second-degree perineal tear: a ran-
domized controlled trial. Obstet Gynecol. 2020;135(2):341–51.
137. Lo J, Osterweil P, Li H, Mori T, Eden KB, Guise JM.Quality of life in women with postpar-
tum anal incontinence. Obstet Gynecol. 2010;115(4):809–14.
138. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A.Wexner score and quality of life in women
with obstetric anal sphincter injury. Int Urogynecol J. 2020;31:1115–21.
139. Brown S, Gartland D, Perlen S, McDonald E, MacArthur C.Consultation about urinary and
faecal incontinence in the year after childbirth: a cohort study. BJOG. 2015;122(7):954–62.
140. Leader-Cramer A, Kenton K, Dave B, Gossett DR, Mueller M, Lewicky-Gaupp C.Factors
associated with timing of return to intercourse after obstetric anal sphincter injuries. J Sex
Med. 2016;13(10):1523–9.
141. Iles D, Khan R, Naidoo K, Kearney R, Myers J, Reid F.The impact of anal sphincter injury
on perceived body image. Eur J Obstetr Gynecol Reprod Biol. 2017;212:140–3.
142. Richter HE, Dunivan G, Brown HW, Andy U, Dyer KY, Rardin C, etal. A 12-month clinical
durability of effectiveness and safety evaluation of a vaginal bowel control system for the
nonsurgical treatment of fecal incontinence. Obstet Gynecol Surv. 2019;74(7):404–5.
143. Cellf Bio 2024. Available from: http://www.cellfbio.com/content/cellf- bio- actively-
recruiting- phase- 1- clinical- trial.
C. Hicks and M. Corton
257
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_12
12
Surgical Management ofFecal
Incontinence andImplications
forPostoperative Nursing Care
Kirstende Burlet andSarahAbbott
Abstract
Surgical management of fecal incontinence is only considered following com-
prehensive multidisciplinary assessment and failure of conservative measures to
achieve a quality of life acceptable to the client. It is important at the outset to
realize that surgical intervention, except in the situation of surgical repair of an
acute anal sphincter injury, can rarely restore perfect continence. Setting a real-
istic expectation of outcomes is essential and requires careful explanation of the
underlying causes which are often multifactorial. This chapter explains the com-
mon surgical procedures used for treating fecal incontinence and the focused
postoperative nursing care for the advanced practice continence nurse. A general
knowledge of the available surgical procedures and the indications for and
expected outcomes of the surgeries may assist the advanced practice continence
nurse in decision-making for patient referrals, postoperative management, and
support of the patient. The chapter also discusses innovative and experimental
procedures for fecal incontinence currently being investigated.
Chapter author from rst edition of this book:
Ronan O’Connell, Emeritus Professor of Surgery, University College Dublin, Dublin, IE (retired).
K. de Burlet (*)
Department of Colorectal Surgery, St Marks Hospital, Central Middlesex Hospital,
London, UK
e-mail: Kirsten.deburlet@royalberkshire.nhs.uk
S. Abbott
Department of General Surgery, Te Whatu Ora Waitaha, Christchurch Hospital,
Christchurch, New Zealand
e-mail: sarah.abbott@cdhb.health.nz
258
12.1 Introduction
A surgical intervention should only be considered when a client understands how
surgery may address the deciencies in the continence mechanism in his/her situa-
tion. The authors always explain the results of preoperative investigations including
joint viewing of radiological imaging to illustrate the abnormality, usually with the
aid of a line diagram.
Surgical intervention is usually only considered in clients with incontinence that
signicantly interferes with quality of life. How this is determined is highly indi-
vidual; however, it must be understood that minor soiling or atal incontinence,
however distressing, is not likely to improve. Indeed, there is a risk, particularly
with anal sphincter repair and/or rectocele repair, that postoperative wound prob-
lems or dyspareunia could result in a worse quality of life. At the other end of the
scale, some clients are best served by the recommendation to have a colostomy, an
intervention that frequently in hindsight should have been considered much earlier
in the client journey.
Surgical interventions can be usefully considered under ve headings, sphincter
repair, sphincter augmentation, sacral neuromodulation, correction of rectal intus-
susception, and stoma formation. The decision regarding which intervention to rec-
ommend is based on the nature and severity of symptoms (see Chap. 5), the presence
and extent of anal sphincter disruption, the presence of pudendal neuropathy, and
the presence or absence of rectal intussusception. Non-stimulated and stimulated
muscle transposition repairs are currently considered historic due to the high rate of
morbidity and the variable success rates [1].
12.2 Anal Sphincter Repair andSphincteroplasty
Anal sphincter repair describes primary repair of the anal sphincter mechanism fol-
lowing trauma, while anal sphincteroplasty describes secondary or delayed recon-
struction. In the latter scenario, the anal sphincter injury, usually a third-degree
obstetric tear, was not appreciated at the time of delivery, or the initial primary
repair was unsatisfactory.
12.2.1 Indications
The most common indication for either procedure is obstetric anal sphincter injury
during vaginal delivery. In Western practice, the incidence of overt anal sphincter
injury (grade 3 or 4 tear) is low, 3–5% following primiparous delivery; however,
when prospectively assessed with endoanal ultrasound, the incidence is higher, per-
haps up to 27% in primiparous women [2, 3]. Risk factors include instrumental
vaginal delivery, a prolonged second stage of labor, fetal macrosomia, a persistent
occiput posterior position of the fetal head, and midline episiotomy [3, 4].
K. de Burlet and S. Abbott
259
Other mechanisms of anal sphincter injury include blunt or penetrating trauma
and, occasionally, anorectal surgery. Specic anorectal procedures associated with
a risk of anal sphincter injury include hemorrhoidectomy, anal dilatation, ssurec-
tomy, and stulotomy. Particular risk factors for incontinence following stula-in-
ano surgery include high or complex stulae and repeated procedures for recurrent
disease.
12.2.2 Technique
Guidelines from the Royal College of Obstetricians and Gynaecologists in the
United Kingdom (UK) recommend that obstetric anal sphincter injury repairs
should be performed with adequate exposure, lighting, and anesthesia. This often
requires transfer from the delivery suite to an operating theater [5]. The traditional
repair technique involves direct opposition of the severed anal sphincter. There is
evidence from a Cochrane review including six randomized controlled trials (RCTs)
that there is a signicantly lower incidence of fecal urgency and anal incontinence
score in patients treated with an overlap rather than an end-to-end repair. However,
at 36months follow up, there was no difference in incidence of atus and fecal
incontinence between the two procedures [6]. Guidelines from the American
College of Obstetricians and Gynecologists state that end-to-end and overlap repairs
are both acceptable. There is certainly scope for cooperation and collaboration
between obstetric and colorectal colleagues.
Elective anal sphincteroplasty may be undertaken following full oral mechanical
bowel preparation or a preoperative enema.
An indwelling urinary catheter is inserted, and broad-spectrum intravenous anti-
biotic prophylaxis is administered prior to skin incision. General anesthesia is pref-
erable, and inltration of the tissues with local anesthetic with 1:200,000 adrenaline
further aids muscle relaxation and improves hemostasis. Patient position is a matter
of surgeon preference; however, posterior or posterolateral sphincter defects are
best approached with the patient prone with the buttocks strapped apart, while
lithotomy may give better access for levatorplasty, if this is to be performed in con-
junction with a repair of an anterior sphincter defect.
A curvilinear incision is made parallel to the outer edge of the external anal
sphincter; to provide adequate access, this usually encompasses 120°–180° of the
circumference. The anoderm (and the vagina in the case of an anterior defect in a
female) is mobilized from the underlying sphincter mechanism and scar, with mobi-
lization continuing cephalad to the distal edge of the anorectal junction. It is often
easiest to begin the dissection of the sphincter mechanism in an area where the
planes have not been disrupted by scarring and then progress to the region of scar-
ring. Care is taken to preserve the branches of the pudendal nerves as they enter the
external anal sphincter posterolaterally. In most cases, dissection of one half of the
circumference of the sphincter mechanism is adequate—this wide dissection per-
mits tension-free overlap (see Fig.12.1).
12 Surgical Management of Fecal Incontinence and Implications for Postoperative…
260
Fig. 12.1 Overlapping
anal sphincteroplasty
(arrows). Repair of
rectocele and posterior
vaginal wall has been
performed (elevated by
sutures). Permission to use
received from Dr. Ronan
O’Connell
The scar is then divided and preserved for suture placement. The divided ends
are overlapped until such a point that the anal aperture ts snugly over the index
nger. Four to six mattress sutures are placed, using a 2/0 synthetic absorbable
suture material. There must be a minimal tendency for the divided ends to pull apart
reecting adequate mobilization. Once all sutures are placed, they are pulled tight,
and there is a nal check of the anal aperture and suture placement prior to tying the
sutures. The knots are then covered with reconstitution of the supercial perineal
muscles in order to prevent discomfort from, or extrusion of, the knots.
In the case of an anterior sphincter defect, a levatorplasty may be undertaken
prior to the overlapping sphincteroplasty. The transverse perineal muscle and/or
scar tissue is approximated to add bulk to the anovaginal area, to increase perineal
length and reconstruct the perineal body.
Finally, the wound is closed with either continuous or interrupted 3/0 absorbable
suture material. A small opening may be left centrally, or a drain may be placed. A
vaginal pack may be inserted to reduce the incidence of vaginal vault hematoma.
This is removed along with the urinary catheter on the rst postoperative day.
12.2.3 Postoperative Nursing Care
Two randomized trials have shown benet in the use of a laxative rather than a con-
stipating regimen in the setting of anal sphincter repair, with a signicantly earlier
and less painful rst bowel motion [6–8]. There is also a reduced incidence of post-
operative wound dehiscence following repair of a third-or fourth-degree tear and
earlier hospital discharge.
There is a paucity of evidence regarding peri- and postoperative antibiotic use.
Given the potential sequelae of an infectious complication, it is perhaps prudent to
routinely provide broad-spectrum coverage following anal sphincter repair.
Furthermore, women should be reviewed by a specialist pelvic oor physiothera-
pist or nurse prior to discharge and receive ongoing follow-up after obstetric anal
K. de Burlet and S. Abbott
261
sphincter injury and anal sphincter repair. Following childbirth, the 6-week postpar-
tum follow-up should include inquiry regarding wound healing, perineal pain, and
ongoing continence symptoms and advice regarding resumption of sexual activity.
This is often best achieved in a dedicated perineal or pelvic oor clinic [9].
There is considerable variability in postoperative regimens for patients who have
undergone sphincteroplasty. Some surgeons recommend a period of oral uids only
for several days to minimize the risk of disruption of the repair. Similar variability
exists with regard to the use of laxatives, antibiotic use, and length of stay. It is the
authors’ practice to allow regular diet following surgery and to give regular laxa-
tives to maintain soft bowel movements until the perianal wounds have healed.
When possible, opioid analgesia should be avoided due to constipating effects.
Complications in the early postoperative period are mainly bleeding (generally
minor and self-limiting), infection (5%), wound dehiscence (2%), and constipa-
tion [10].
Management of subsequent childbirth must consider obstetric risk factors, any
ongoing symptoms of incontinence, and patient preferences. The evidence supports
subsequent vaginal delivery in asymptomatic women after a previously repaired
third degree tear; however, the risk of a second obstetric anal sphincter injury is
increased to between 3 and 5%. Women with altered continence after rst vaginal
delivery are at risk of further deterioration if delivered vaginally on their second
pregnancy and elective caesarian delivery should be considered [11]. There is no
role for delaying sphincteroplasty until a woman has determined her family is
complete.
12.2.4 Outcomes ofAnal Sphincteroplasty
Most patients can expect a signicant improvement in continence in the short-term
following sphincteroplasty, with a mean of 66% reporting excellent or good results.
There is no evidence that a defunctioning colostomy at the time of sphincter repair
improves outcome [12]. Early failure is usually associated with a persistent defect
identied using endoanal ultrasound.
Unfortunately, the initial good results deteriorate in the long term with only 6%
reporting excellent or good continence at 10years, as in parallel to the general
population of parous women, continence deteriorates with increasing age and
menopause in women with a history of a repaired third- or fourth-degree tear. Box
12.1 presents an example case study discussing postoperative care after
sphincteroplasty.
12.3 Neuromodulation
Sacral nerve stimulation, also known as sacral neuromodulation (SNM), was rst
used to treat fecal incontinence by Matzel etal. in 1995 [13]. The underlying prin-
ciple is the enhancement of continence by electrical stimulation of the peripheral
12 Surgical Management of Fecal Incontinence and Implications for Postoperative…
262
nerve supply to the anus and rectum. The precise mode of action remains uncertain,
but it is likely that the observed clinical outcomes are not solely mediated by the
sphincter mechanism alone but also by central nervous system effects [14]. Objective
data regarding the impact on colorectal and anal function are contradictory in part
and are not entirely reproducible.
12.3.1 Indications
Initial trials only included those patients with an anatomically intact sphincter but
functionally decient continence mechanism. However, the indications for SNM
have expanded over recent years.
Indications include fecal incontinence secondary to; muscular dystrophy, procto-
colectomy and ileal-anal pouch anastomosis, neurological dysfunction including
spinal disk prolapse, rectal resection for rectal carcinoma, after neoadjuvant and
adjuvant chemoradiotherapy or radiotherapy for endometrial and anorectal carci-
noma (low anterior resection syndrome (LARS)), rectal prolapse repair, unilateral
traumatic pudendal neuropathy, and external anal sphincter atrophy.
Various contraindications to sacral nerve stimulation also exist, including patho-
logical conditions of the sacrum preventing electrode placement (e.g., spina bida),
skin disease at the area of implantation, anal sphincter damage requiring a sphincter
substitute, pregnancy, bleeding diatheses, psychological instability, and inadequate
cognitive capacity. Models that are compatible with magnetic resonance imaging
(MRI) have been introduced.
Various studies have attempted to identify factors to predict which patients will
have good symptom improvement with neuromodulation. In general, results from
numerous studies on predictive factors for successful outcomes after SNM insertion
are inconclusive. Age, the presence of an extensive external anal sphincter defect,
and an initial failure with a need for repeat procedures may correlate with a poor
outcome with percutaneous nerve evaluation [15, 16]. In a cohort of 200 patients
from six centers with a permanent SNM, stool consistency and stimulation intensity
were independent factors determining failure of SNM [17].
12.3.2 Technique
Sacral nerve stimulation is a two-stage procedure with an initial percutaneous nerve
evaluation prior to implantation of the permanent device. The trial period lasts from
1 to 3weeks. Success is commonly dened as a 50% decrease in the frequency of
incontinence episodes in a week and reversibility of this improvement upon discon-
tinuation of stimulation. The authors’ practice is to restrict permanent device
implantation to those with >80% improvement in symptoms as this improves long-
term success rates.
There are two options for percutaneous nerve evaluation, either a temporary per-
cutaneously placed unipolar test lead (which is subsequently removed) or a
K. de Burlet and S. Abbott
263
quadripolar lead (usually a “tined lead”), which, if the trial is effective, can remain
in place for permanent stimulation. The lead is connected to an external pulse gen-
erator for the duration of the trial.
The second stage involves implantation of the permanent electrode (if a tempo-
rary unipolar test lead has been used) and pulse generator. This may be performed
under general anesthesia without muscle relaxation or under local anesthesia with
or without sedation. Intravenous antibiotic prophylaxis and strict aseptic technique
are imperative. The patient is positioned prone with the buttocks strapped apart to
enable visualization of the perineum. Under image intensication guidance, the per-
manent electrode is inserted, usually via the S3 foramina as this level seems to be
the most effective (compared to S2 or S4). It is optimal to have the electrodes at the
anterior table of the sacrum, ideally following the path of the nerve root on a slightly
lateral course (see Fig.12.2). Plantarexion of the great toe and contraction of the
pelvic oor and external anal sphincter are witnessed on stimulation of the elec-
trode. There is no additional benet to bilateral placement.
The pulse generator is placed in a subcutaneous pocket, usually in the gluteal
region, or occasionally in the abdominal wall (see Fig.12.2). The electrode lead is
tunneled subcutaneously to the generator. A small handheld “patient programmer”
contains preset stimulation protocols, which can be adjusted.
These protocols use different combinations of the four electrodes present at the
tip as cathode and anode to optimize nerve root stimulation. Amplitude, pulse width,
and rate can also be adjusted, although the latter two are usually constant. The
patient programmer can also deactivate the device. From time to time, the pulse
generator will need replacement, usually at 5–7-year intervals. This will be more
Fig. 12.2 Anterior and lateral views of a quadripolar sacral nerve stimulation lead inserted into
the left S3 foramen, following the course of the nerve. (Reproduced with permission, Medtronic Inc.)
12 Surgical Management of Fecal Incontinence and Implications for Postoperative…
264
frequent in patients with higher amplitude settings. Alternatively, rechargeable
devices are available that use transcutaneous current induction technology.
12.3.3 Postoperative Nursing Care
Both stages of the procedure are day cases. Following the initial percutaneous
nerve evaluation procedure, it is imperative that the patient keeps the surgical site
dry. The patient must keep a diary of symptoms, which will be reviewed in the
outpatient clinic and will inuence the decision as to whether or not permanent
sacral nerve stimulation is indicated. If a temporary unipolar test lead is used, this
is simply removed in the outpatient clinic at the end of the trial period. After
implantation of the permanent electrode and pulse generator, it is similarly impor-
tant that the patient keeps the surgical sites clean and dry until they are healed. The
responsible clinician, a clinical nurse specialist, or a representative from pulse gen-
erator company provides patient education and support regarding programming of
the device.
12.3.4 Outcomes
A meta-analysis published by Tan et al. [18] considered studies of sacral nerve
stimulation performed for fecal incontinence published between 1995 and 2008.
Thirty-four studies were included, with 665 patients undergoing permanent sacral
nerve stimulation after an initial 944 underwent percutaneous nerve evaluation.
With permanent sacral nerve stimulation, weekly incontinence episodes and incon-
tinence scores were signicantly reduced, while the ability to defer defecation was
signicantly increased. Furthermore, most fecal incontinence-related quality of life
domains was improved. The results were similar between the subgroups of those
with an intact sphincter and an impaired sphincter. The complication rate was 15%,
with 3% of patients requiring permanent explantation.
A Cochrane review was subsequently published in 2015. Four crossover trials
and two parallel group trials were evaluated. The authors concluded that, in the set-
ting of limited evidence, sacral nerve stimulation can improve continence in a pro-
portion of patients with fecal incontinence, but that adverse events can occur. A
recommendation was made for further high-quality randomized trials to more fully
assess the effects of sacral nerve stimulation [19].
Multiple studies support an improvement in quality of life with sacral nerve stim-
ulation. This is most evident when disease-specic quality of life instruments are
applied. In a meta-analysis, the SF-36 was signicantly increased in all categories
except bodily pain across seven studies with 98–102 patients. The Fecal Incontinence
Quality of Life (FIQL) score was similarly signicantly increased in all categories
across nine studies with 199 patients [18].
There is increasing evidence to support the use of sacral nerve stimulation in
those with fecal incontinence with an anatomical defect in the sphincter
K. de Burlet and S. Abbott