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414
P (Patients) I (Intervention) C (Comparator) O (Outcomes)
Patients with fecal
incontinence.
Physiologic
workup.
Clinical Decision
Making.
Diagnosing the
underlying cause.
Predicting treatment
outcome.
Results
We feel that obtaining a detailed history and physical exam is usually the most
important determinant that influences the decision making [2, 3]. Therefore when
considering a diagnostic test, the key question is whether this test will affect the
overall management plan.
Some studies reported that physiologic testing could guide the physician in treat-
ing patients with FI. Vaizey and Kamm prospectively studied 100 patients to evalu-
ate the impact of anorectal investigations (this included anal ultrasound) on the
management decisions. They found that the information provided by anorectal
physiologic assessment had an impact on management in patients with benign ano-
rectal disorders. However, carefully evaluating their study, even though anorectal
assessment had an important diagnostic and prognostic role in managing patients
with benign anorectal disorders, endoanal ultrasound was actually the driving test
that changed their plans in FI patients (n = 51); anorectal physiology helped guide
decision making for patients with constipation [4]. Therefore, anorectal physiology
testing did not really seem to influence FI decisions.
Wexner and Jorge conducted a prospective study on 308 patients presenting with
various complaints (constipation, fecal incontinence and chronic intractable rectal
pain) to assess the usefulness of colorectal physiological studies to identify all rel-
evant causes that could be treated [5]. Out of 308 patients, 80 presented with FI. The
etiology of FI was revealed by history and physical examination alone in 9 patients
(11 %) and by physiological testing (anal manometry, cinedefaecography, anal elec-
tromyography and pudendal nerve terminal motor latency PNTML) in 44 (55 %).
The etiology remained undiagnosed in 27 patients (34 %) even after testing. The
causes of FI were loss of muscle fibers (26 %), neuropathy (13 %), combined muscle
loss and neuropathy (19 %), and rectoanal intussusception (9 %). They concluded
that physical examination might detect anorectal scarring, attenuation of the recto-
vaginal septum/anal sphincters, and poor contraction of the sphincter; however
clinical evaluation cannot confirm the presence of iatrogenic injury. Physical exami-
nation also was not capable of detecting pudendal neuropathy. In their view, find-
ings of colorectal physiological testing permit assignment of patients to treatment
regimens. It is important to note that this study also included more investigations
than just anal physiology and they reported using all this data when making their
conclusion. Therefore the role of anal physiology could not be determined.
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On the other hand, more recent studies reported no benefit to physiologic testing
for FI. Lam et al. [3] prospectively assessed 600 patients referred for anorectal test-
ing and compared those with and without FI (48 % with fecal incontinence and 87 %
female) in order to formulate a statistical model to determine which factors would
predict FI, particularly after a stoma closure. In regards to anorectal physiology test-
ing, women with FI had lower anal pressures, shorter sphincter length, and smaller
rectal capacity. Men with FI had lower anal pressures. Incontinent and continent
patients had a broad overlap in anorectal physiology testing. They did find that all
patients with a rectal capacity <60 cc had FI and of those with maximum basal and
squeeze pressures ≤20 mmHg, only 4 % were continent. They used six items to cre-
ate a statistical model for FI (female, age, stool consistency, maximum rest and
squeeze pressures, rectal capacity, and anal sphincter defects). They then used this
model on 5 women to accurately predict the risk of FI following stoma closure.
While this study did demonstrate some utility for anal physiology testing, this was
used in combination with other tests and consideration of patient characteristics.
Similar findings were also reported by Raza and Bielefeldt [6]. They reviewed
298 patients who had anorectal manometry mainly for FI (51 %) and constipation
(42 %). Patients with fecal incontinence had significantly lower pressures compared
to individuals with constipation, but the data overlapped significantly. The sensitiv-
ity of resting and squeeze pressures were 50 and 59 %, respectively while the speci-
ficity for low squeeze pressures was only 69 %. They concluded that manometry
should not be used routinely because it has poor discriminatory power.
Zutshi et al. conducted a retrospective study on 53 women who had a sphincter
repair. They reported that anal manometry did not correlate with severity of incon-
tinence nor did it assess or predict response to treatment [1]. Bordeianou et al.
looked at the relationship between anorectal manometry, fecal incontinence severity
(FISI scores), and findings at endoanal ultrasound in 351 women [7]. They found
FISI scores were equally severe in patients with or without a sphincter defect; a
weak correlation was observed between resting anal pressure and the severity of
defects on anal ultrasound; and no correlation existed between maximum squeeze
pressure and FISI scores. In the subset of patients with a sphincter defect (n = 148),
a weak and negative correlation was reported between the mean resting pressures
and maximum resting pressures, the size of the internal and external sphincter
defects, as well as the size of the perineal body.
In a Cochrane review evaluating the effects of sacral nerve stimulation (SNS) for
FI and constipation, anorectal manometry did not appear to predict which patients
would benefit from SNS and the authors concluded that testing with anorectal
manometry did not appear to provide clinically useful information [8].
Anal manometry has many limitations. One drawback is that it is very difficult to
compare results between institutions because manometric findings are not standard-
ized; the normal range of values varies at each institution [9]. There are no normal
values stratified by sex and age [10] and different companies manufacture different
types of machines that also adds to the variability.
Intact pudendal nerves may contribute to the success of FI treatment such as SNS
or sphincter repair. However PNTML reflects the activity of the fastest fibers, which
37 Which Patients with Fecal Incontinence Require Physiologic Workup?
416
makes it a poor indicator of damage to the entire range of nerves that supply the
sphincter complex. Additionally it is operator dependent. This has led many inves-
tigators to no longer recommended PNTML when evaluating FI [11–13]. In a sys-
tematic review by Glasgow and Lowry, 900 patients from 16 studies (2 case control,
1 prospective and 13 retrospective studies) were included as they looked at the out-
comes of anal sphincter repair for FI [14]. In five studies, pudendal neuropathy,
resting and squeeze anal pressures, anal canal length, and rectal compliance did not
predict long-term outcomes following sphincteroplasty [15–19]. However, there
was one retrospective study that reported pudendal neuropathy predicted the out-
come after sphincter repair for FI [20].
Recommendations Based on the Data
The majority of published studies examining the role of physiologic workup in FI
are retrospective (low quality of evidence). FI is multifactorial in etiology and since
there is no gold standard test of the overall continence mechanism [10], this makes
as assessment of utility more challenging. The available clinical assessment tools
also have a subjective component which adds to the challenge of using them for
management decisions. Based on this review, we provide a weak recommendation
against the use of anal physiology testing routinely. Anorectal physiologic testing
does not generally harm the patient; however, most of the available data shows no
impact for choosing treatment or predicting outcomes. There may be some benefit
when combined with a total anorectal assessment and testing. Results of anal physi-
ology testing overall do not correlate with the severity of symptoms nor does it
assess response to treatment.
Summary of Recommendation Options
Strength of
recommendation
Implications for
patients Implications for clinicians
Implications for
policy makers
Weak against anal
physiology testing.
It does not cause
harm but may not
improve outcome.
In some circumstances, it
may aid treatment
recommendation.
Should be
considered but
used selectively.
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A Personal View of the Data
At our institution we start all work-up for patients with FI utilizing a detailed history
and physical exam. We believe this is the most important factor in discerning con-
tributing factors and making management decision in FI. We do obtain anal physiol-
ogy testing; however as we have gained more data and experience, we do not feel it
overall guides our therapy for FI. One exception would be FI related to rectal dys-
function. When looking at first perception of a balloon inflated in the rectum, urge
to defecate, and maximum tolerated volume, a rectum that is hypersensitive may
push stool past a sphincter that has acceptable tone on physical exam. This finding
would prompt us to communicate with the physical therapist so appropriate therapy
can be used to try to desensitize the rectum. Also suppositories that decrease spas-
ticity may be considered. Conversely, for patients detected to have a hyposensitive
rectum with a maximum tolerated volume of >300 cc (the limit of what the balloon
can hold), FI can be a result of overflow which may be difficult to detect by history
and physical exam only. For patients with a hyposensitive rectum, communication
with the physical therapist is essential so they work on appropriate retraining. Also
enema therapy may be more efficacious in this group.
We do not feel overall that resting pressures and squeeze pressures are helpful.
We also agree that PNTML does not correlate with what we find on physical exam.
For instance when doing a digital and asking a patient to contract against the exam-
ining finger there may be no movement at all in the levator or sphincter complex, but
the PNTML may be normal. Nearly all patients should initially be offered conserva-
tive management which consists of dietary adjustments, antidiarrheal medications,
enema therapy, skin care, and physical therapy retraining. If conservative measures
fail, then patients are considered for further workup and treatment. We used to feel
that anal ultrasound was our preferred test, but with the popularity of SNS for treat-
ment, we do not rely on this test as much as in the past (Tables 37.1 and 37.2).
References
1. Zutshi M, Salcedo L, Hammel J, Hull T. Anal physiology testing in fecal incontinence: is it of
any value? Int J Colorectal Dis. 2010;25(2):277–82.
2. Hull TL. Fecal incontinence. In: Complexities in colorectal surgery. Springer; New York 2014.
p. 203–18.
3. Lam T, Kuik D, Felt‐Bersma R. Anorectal function evaluation and predictive factors for faecal
incontinence in 600 patients. Colorectal Dis. 2012;14(2):214–23.
4. Vaizey CJ, Kamm MA. Prospective assessment of the clinical value of anorectal investiga-
tions. Digestion. 2000;61(3):207–14.
5. Wexner SD, Jorge JM. Colorectal physiological tests: use or abuse of technology? Eur J Surg.
1994;160(3):167–74.
6. Raza N, Bielefeldt K. Discriminative value of anorectal manometry in clinical practice. Dig
Dis Sci. 2009;54(11):2503–11.
7. Bordeianou L, Lee KY, Rockwood T, et al. Anal resting pressures at manometry correlate with
the fecal incontinence severity index and with presence of sphincter defects on ultrasound. Dis
Colon Rectum. 2008;51(7):1010–4.
37 Which Patients with Fecal Incontinence Require Physiologic Workup?
418
Table 37.1 Anal physiology in diagnosis of FI
Author Year Patients Study type Results
Quality of
evidence Comment
Dobben et al.
[21]
2007 FI (n = 312) Prospective Anal inspection and
digital rectal
examination DRE
can give accurate
information about
anal sphincters but
do not detect EAS
defects <90°.
Low Anal inspection and DRE in
some centers done by
residents, gynecologists, or
gastroenterologist. The
clinicians were unblinded to
patients’ history.
Raza and
Bielefeldt [6]
2009 FI vs. chronic
constipation and
others (n = 298)
Retrospective Manometric findings
have low sensitivity
and specificity and
do not discriminate
well between
continent and
incontinent patients.
Low
Pehl et al. [22] 2012 Healthy controls
(n = 144) vs. FI
patients (n = 599)
Retrospective Single data from the
entire spectrum of
manometry
information is
moderate for the
pressure data and
poor for the sensory
data.
The entire data set
has excellent
sensitivity (91.4 %)
and moderate
specificity (62.5 %).
Low
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419
Author Year Patients Study type Results
Quality of
evidence Comment
Lam et al. [3] 2012 FI vs. continent
patients (n = 600)
Prospective There was a large
overlap between
incontinent and
continent patients.
Moderate
Lam et al. [23] 2012 FI (n = 218) Prospective Anal manometry did
not detect anorectal
sphincter defects.
Anorectal
manometry and
ultrasound do not
correlate well with
FI scores.
Moderate
37 Which Patients with Fecal Incontinence Require Physiologic Workup?
420
Table 37.2 Anal physiology in predicting FI treatment outcomes
Study Year Type of treatment Type of study Results
Quality of
evidence Comment
Buie et al. [24] 2001 Anterior sphincteroplasty
(n = 191)
Retrospective Anorectal manometry
and PNTML are not
predictive of
postoperative function.
Low 33 % of the patients
did not have
manometry and 53 %
did not have PNTML
Gearhart et al.
[25]
2005 Sphincter repair (n = 20) Prospective The physiologic
parameters are not
predictive of functional
outcome.
Moderate
Zutshi et al. [1] 2010 Sphincter repair (n = 53) Retrospective No correlation of pre-
and postoperative
manometric parameters
with incontinence scores.
Low
Glasgow and
Lowry [14]
2012 Anal sphincter repair
(n = 900)
Systematic review No consistent predictive
factors for outcomes
were identified.
Moderate
Bols et al. [26] 2012 Physiotherapy (n = 80) Secondary analysis of
a randomized trial
Results of physical
examination, diagnostic
tests, and physiotherapy
assessment were not
predictive of outcomes.
Moderate
Feretis and
Chapman [27]
2013 Biofeedback (n = 137) Retrospective Anorectal investigations
are of doubtful role in
patient selection for
biofeedback therapy.
Low
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421
Study Year Type of treatment Type of study Results
Quality of
evidence Comment
Roy et al. [28] 2014 SNS (n = 60) Prospective No pre-treatment or
post-treatment
assessment parameters
that predict the outcome
of SNS.
Moderate
Quezada et al.
[29]
2015 SNS (n = 60) Retrospective Anal physiology testing,
PNTML and
ultrasonography were not
predictive of clinical
outcomes of SNS.
Low
37 Which Patients with Fecal Incontinence Require Physiologic Workup?
422
8. Thaha MA, Abukar AA, Thin NN, Ramsanahie A, Knowles CH. Sacral nerve stimulation for
faecal incontinence and constipation in adults. Status and date: New search for studies and
content updated (no change to conclusions), published in. 2015(8).
9. Chaliha C, Sultan A, Emmanuel A. Normal ranges for anorectal manometry and sensation in
women of reproductive age. Colorectal Dis. 2007;9(9):839–44.
10. Fruehauf H, Fox MR. Anal manometry in the investigation of fecal incontinence: totum pro
parte, not pars pro toto. Digestion. 2012;86(2):75–7.
11. Azpiroz F, Enck P, Whitehead WE. Anorectal functional testing: review of collective experi-
ence. Am J Gastroenterol. 2002;97(2):232–40.
12. Dudding TC, Vaizey CJ. Current concepts in evaluation and testing of posterior pelvic floor
disorders. Semin Colon Rectal Surg. 2010;21(1):6–21.
13. Barnett JL, Hasler WL, Camilleri M. American gastroenterological association medical posi-
tion statement on anorectal testing techniques. american gastroenterological association.
Gastroenterology. 1999;116(3):732–60.
14. Glasgow SC, Lowry AC. Long-term outcomes of anal sphincter repair for fecal incontinence:
a systematic review. Dis Colon Rectum. 2012;55(4):482–90.
15. 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.
16. Grey BR, Sheldon RR, Telford KJ, Kiff ES. Anterior anal sphincter repair can be of long term
benefit: a 12-year case cohort from a single surgeon. BMC Surg. 2007;7:1.
17. Maslekar S, Gardiner AB, Duthie GS. Anterior anal sphincter repair for fecal incontinence:
good longterm results are possible. J Am Coll Surg. 2007;204(1):40–6.
18. Zorcolo L, Covotta L, Bartolo DC. Outcome of anterior sphincter repair for obstetric injury:
comparison of early and late results. Dis Colon Rectum. 2005;48(3):524–31.
19. Halverson AL, Hull TL. Long-term outcome of overlapping anal sphincter repair. Dis Colon
Rectum. 2002;45(3):345–8.
20. Londono-Schimmer E, Garcia-Duperly R, Nicholls R, Ritchie J, Hawley P, Thomson
J. Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year
follow-up functional results. Int J Colorectal Dis. 1994;9(2):110–3.
21. Dobben AC, Terra MP, Deutekom M, et al. Anal inspection and digital rectal examination
compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal
incontinence. Int J Colorectal Dis. 2007;22(7):783–90.
22. Pehl C, Seidl H, Scalercio N, et al. Accuracy of anorectal manometry in patients with fecal
incontinence. Digestion. 2012;86(2):78–85.
23. Lam T, Mulder C, Felt-Bersma R. Critical reappraisal of anorectal function tests in patients
with faecal incontinence who have failed conservative treatment. Int J Colorectal Dis.
2012;27(7):931–7.
24. Buie WD, Lowry AC, Rothenberger DA, Madoff RD. Clinical rather than laboratory assess-
ment predicts continence after anterior sphincteroplasty. Dis Colon Rectum.
2001;44(9):1255–60.
25. Gearhart S, Hull T, Floruta C, Schroeder T, Hammel J. Anal manometric parameters: predic-
tors of outcome following anal sphincter repair? J Gastrointest Surg. 2005;9(1):115–20.
26. Bols E, Hendriks E, de Bie R, Baeten C, Berghmans B. Predictors of a favorable outcome of
physiotherapy in fecal incontinence: secondary analysis of a randomized trial. Neurourol
Urodyn. 2012;31(7):1156–60.
27. Feretis M, Chapman M. The role of anorectal investigations in predicting the outcome of bio-
feedback in the treatment of faecal incontinence. Scand J Gastroenterol.
2013;48(11):1265–71.
28. Roy AL, Gourcerol G, Menard JF, Michot F, Leroi AM, Bridoux V. Predictive factors for suc-
cessful sacral nerve stimulation in the treatment of fecal incontinence: lessons from a compre-
hensive treatment assessment. Dis Colon Rectum. 2014;57(6):772–80.
29. Quezada Y, Whiteside JL, Rice T, Karram M, Rafferty JF, Paquette IM. Does preoperative anal
physiology testing or ultrasonography predict clinical outcome with sacral neuromodulation
for fecal incontinence? Int Urogynecol J. 2015;26(11):1613–7.
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N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_38
Chapter 38
Benign Anal Disease: Who Are the Right
Candidates for Sacral Nerve Stimulation?
Teresa C. Rice and Ian M. Paquette
Introduction
Fecal incontinence (FI) is defined as the involuntary passage of stool or flatus over
at least 1 month’s duration [1, 2]. It is a physically and socially debilitating condi-
tion that affects between 1 and 15 % of adult patients [3–5]. The disease can dra-
matically limit an individual’s activity, negatively impacting quality of life and
resulting in significant morbidity. The etiology of FI is often multifactorial and con-
sequently management of the disease is complex. Initial therapy typically begins
with conservative measures including dietary or medical management [6–8] and
biofeedback [9, 10]. However, when patients do not respond to these initial mea-
sures, consideration is given to surgical management including sacral nerve stimu-
lation (SNS), sphincteroplasty [11], sphincter replacement strategies [12, 13], or
stoma creation [14, 15]. Sacral nerve stimulation was initially developed for man-
agement of urinary incontinence but was first used for the successful treatment of FI
by Matzel et al. in 1995 [16]. Due to its reported long-term efficacy and low morbid-
ity, SNS continues to develop as an emerging and promising technique for the man-
agement of severe FI. Here, we aim to identify which patients with FI would benefit
from SNS. Further, we describe the utility of SNS for management of FI in the
subset of patients with a complete external sphincter defect.
T.C. Rice, MD
Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
I.M. Paquette, MD (
*)
Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine,
Cincinnati, OH 45219, USA
e-mail: ian.paquette@uc.edu