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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1520_Библиотеки_им_академика_М_И_Перельмана
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369
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_26, © Springer-Verlag London Limited 2012
26.1 Introduction
The goal of preservation or restoration of continence is one of the core principles of a
colorectal surgeon. The distress caused by the inability of a patient to control the
release of stool is huge, and the economic implications due to the regular use appli-
ances and prescriptions combined with other long-term care issues are a signifi cant
drain on limited health resources. However, this continence goal can be challenging as
maintenance of fecal continence is a complex process and dependant on many factors
(Fig. 26.1 ). Alteration or damage of any of these factors can result in incontinence.
S. R. Brown , M.D., FRCS, B.Med.Sci., M.B.Ch.B.
Department of Colorectal Surgery , Sheffi eld Teaching Hospitals NHS Foundation Trust ,
Herries Rd. , Sheffi eld, S Yorks S5 7AU , UK
e-mail:
steven.brown@sth.nhs.uk
Chapter 26
Interventions for Fecal Incontinence
Steven R. Brown
Stool
Motility
Ano-rectal
sensation
Sphincter
Anorectal
anatomy
Rectal
compliance
Continence
Fig. 26.1 Factors affecting fecal incontinence
370
S.R. Brown
Refl ecting these varied causes are the various treatment options, ranging from
conservative measures aimed at symptomatic control through to more and more
invasive surgical options aimed at fi xing a mechanical cause.
26.1.1 What Is Fecal Incontinence?
The standard defi nition of fecal incontinence is the involuntary passage or the
inability to control the discharge of fecal matter through the anus. Although there is
some debate over the defi nition, some would refer to anal incontinence as the inabil-
ity to control fl atus and feces.
Case Scenario 1
A 30-year-old female is referred to the clinic with a history of severe fecal
urge incontinence since the birth of her fi rst child. This delivery was a diffi cult
delivery with a big baby which required forceps and repair of an episiotomy
incision. Her subsequent incontinence symptoms have not improved despite
some pelvic fl oor exercises recommended by the health visitor, and she is now
incontinent of solid and liquid stool daily, requiring the use of pads. She is so
symptomatic she dare not leave the house.
On examination, she has a clinically weak resting and squeeze pressure with
evidence of a defect corresponding to the previous episiotomy scar. An endoa-
nal ultrasound confi rms the clinical fi ndings with a defect involving the exter-
nal and internal sphincter at the 10–12 o’clock position. Anorectal physiology
suggests low resting and squeeze pressures with normal sensation.
How would you further manage this patient?
Case Scenario 2
A 50-year-old male diet-controlled diabetic is referred to clinic with a history
of passive incontinence. He stains his underwear daily. In the past, he has suf-
fered with recurrent anal fi ssures and underwent an anal stretch 15 years ago
with a sphincterotomy within the last 2 years. It was after the second opera-
tion that he developed his symptoms.
On examination, there is an obvious keyhole defect at the site of the previous
sphincterotomy which appears to have been carried out posteriorly. On strain-
ing, he has an element of prolapsing mucosa. He has a clinically weak resting
pressure with reasonable squeeze. An endoanal ultrasound shows fragmenta-
tion of the internal sphincter with severe disruption posteriorly. Anorectal
physiology suggests low resting pressures but reasonable squeeze pressures
with normal sensation.
How would you further manage this patient?
371
26 Interventions for Fecal Incontinence
26.1.2 How Common Is It?
It is diffi cult to be sure how common a problem fecal incontinence is. It depends
upon the defi nition and what population is analyzed. Estimates of incidence vary
between 1% and 10% [
1, 2 ] , but this fi gure is higher in nursing home residents,
parous women, patients with cognitive impairment or neurological disorders,
and the elderly [ 1, 2 ] . In the institutionalized population, it may be as high as
50% [ 3 ] . In outside institutions, it remains a largely hidden problem because of
the social stigma attached, and this is the main issue regarding estimates of the
true incidence. However, there is no doubt that, with rising numbers of elderly
people globally, fecal incontinence is becoming an increasing challenge to both
health-care services and home carers. Recognition of the growing problem has
led the National Institute for Clinical Excellence in the UK to produce guidance
as to the management of the condition both in the community as well as within
specialist units [ 4 ] .
26.1.3 How Is It Treated?
The complex etiology of fecal or anal incontinence means that careful assessment
of the patient with appropriate and thorough investigation is mandatory. Aspects of
this assessment and investigation are detailed in the preceding chapter. These pro-
cesses will probably identify one of seven subgroups of patients (Box 26.1 ).
Many of these subgroups require specifi c therapy. For instance, alteration in stool
consistency necessitates luminal investigation and appropriate therapy if an infl am-
matory cause is found. Similarly, overfl ow caused by impaction requires appropriate
aperients and establishment of an effective bowel habit regime. Assuming other
treatable causes have been excluded, it is useful to follow a treatment algorithm
(Fig. 26.2 ), which starts with conservative therapy.
Box 26.1: Etiology of Fecal Incontinence
Etiology
Examples
Structural anorectal abnormalities
Sphincter trauma, rectal prolapse
Neurological abnormalities MS, stroke, and pudendal neuropathy
Alterations in stool consistency Infectious diarrhea, infl ammatory bowel disease
Overfl ow Encopresis, impaction
Cognitive/behavioral dysfunction Dementia, learning diffi culties
General disability Age, acute illness
Idiopathic
372
S.R. Brown
26.1.4 Conservative Therapy for Fecal Incontinence
Many conservative interventions can be initiated in the primary care setting and do
not require specialist intervention. Recommendations include (Box 26.2 ):
A diet that promotes an ideal stool consistency and predictable bowel emptying. •
Of course, it is essential to ensure that overall nutrient intake is balanced, particu-
larly in the elderly. A food diary is useful with modifi cation of one food at a time
in an attempt to identify potential contributors to symptom. Specifi c foods that
Faecal
incontinence
Conservative Mx
(primary care)
Conservative Mx
(specialist care)
Surgery
Sphincter defect No defect
Very
severe
defect
Repair/neuromodulation/bulking
agent (if internal sphincter)
Fail
Fail
Fail
Fail
Fail
Fail
Neuromodulation/repair
+/-Biofeedback
/re-repair
Neuromodulation
?postanal
repair
Neo-sphincter
ACE/stoma
Fail
Fig. 26.2 Algorithm for treatment of fecal incontinence
373
26 Interventions for Fecal Incontinence
may contribute to incontinence include prunes, rhubarb, fruit juices, licorice, and
fi gs. Artifi cial sweeteners (e.g., sorbitol) also have laxative properties. Alcohol,
caffeine, and some vegetables (beans, broccoli, caulifl ower, and cabbage) and
fruits which include skin (all insoluble fi ber) are associated with loose stools.
An increase in soluble dietary fi ber (e.g., bananas, oats, and even psyllium sup-•
plements) may improve stool consistency by absorbing intraluminal water [
5 ] .
Gradual increase of fi ber intake over a period of a few days will result in less
bloating and discomfort.
Although there is no evidence as to effectiveness, expert opinion and common •
sense would suggest that ensuring private, comfortable, easily accessible toilet
facilities helps in establishing an effective bowel habit regime. Some clinicians
feel that encouraging a bowel movement after a meal (utilizing the gastrocolic
refl ex) and promoting a sitting or squatting position to optimize evacuation and
avoid straining help with symptoms.
Coping mechanisms include emotional and psychological support. In addition, •
information should be given on the use of continence products such as:
Disposable pads –
Anal plugs (if tolerated) –
Skin care advice –
Odor control products and laundry needs –
Disposable gloves –
Enemas and suppositories allow more complete bowel emptying in appropriate •
patients at appropriate and socially convenient times and minimize postdefeca-
tion leakage [ 6 ] . This will particularly benefi t those with severe constipation and
overfl ow [ 7 ] .
Antidiarrheal agents, commonly loperamide and codeine, act to decrease intesti-•
nal motility and secretions. In addition, loperamide has been shown to have a
direct effect on augmenting the anal sphincter [ 8 ] . They should be prescribed
regularly.
26.1.5 Specialist Conservative Intervention
Specialist conservative intervention includes pelvic fl oor muscle exercises, biofeed-
back, and electrical stimulation (Box 26.2 ). They are aimed at improving sensation,
coordination, and strength of the pelvic fl oor. Exercises may be self-directed, taught
via verbal or written instruction or taught using vaginal or anal equipment allowing
feedback to the patient through the device. Electrical stimulation is carried out using
a specifi c anal probe.
The benefi cial effect of biofeedback is variable. Many studies have shown
symptom improvement in up to 90%. However, evidence from randomized con-
trolled trials has suggested the intervention is no better than standard care [
4, 9 ]
although one recent RCT favored the intervention [ 10 ] . Whatever the evidence,
374
S.R. Brown
treatment does no harm, and consensus opinion is that one or other of these treat-
ments should be considered for people who continue with symptoms after the
initial management above.
Rectal irrigation, like enemas and suppositories, allows more complete bowel
emptying in appropriate patients and minimizes postdefecation leakage. Modern
equipment such as the Peristeen system promotes rapid, safe, and easy irrigation of
the rectum. The procedure has certainly been shown to be superior to best support-
ive care in adult patients with spinal cord injury [
11 ] . There are drawbacks; the
procedure requires a certain amount of dexterity and is labor and time intensive.
26.1.6 Types of Surgical Intervention
If conservative therapy is unsuccessful and the patient is still signifi cantly compromised
with the degree of incontinence, then surgical intervention may be considered. Numerous
surgical options are available (Box 26.3 ). It is helpful to consider each of these interven-
tions as part of a specifi c group in terms of their basic mechanism of action.
Box 26.3: Summary of Surgical Options for Treatment
of Fecal Incontinence
1. Correcting the abnormal anal sphincter
Sphincteroplasty •
2. Correcting the abnormal pelvic fl oor
Postanal repair •
Levatorplasty •
Total pelvic fl oor repair •
Box 26.2: Summary of Conservative Therapy Options
for Treatment of Fecal Incontinence
Conservative therapy
Primary care
Diet Bowel evacuation after a meal
Food diary Coping mechanisms (pads, plugs, etc.)
Soluble fi ber Enemas or suppositories
Private facilities
Specialist care
Biofeedback Transanal irrigation
Pelvic fl oor exercises
Electrical stimulation
375
26 Interventions for Fecal Incontinence
26.1.6.1 Interventions Designed to Correct Abnormalities
of the Anal Sphincter
Sphincteroplasty
As obstetric sphincter damage resulting in tearing of the anterior sphincter complex
is one of the commonest causes of incontinence, particularly in young women [ 12 ] ,
it follows that repair of this tear is an appropriate surgical option. The procedure is
usually carried out by overlapping the damaged ends of the muscle, although a
small study has suggested similar outcomes with a direct end to end repair [ 13 ] .
100
75
50
25
0
0
12
24 36 48
60 72 84
96 108 120 132
r = 0.71; p = 0.0024
Follow-up (months)
Percentage with Park’s score III/IV
Fig. 26.3 Long-term outcome after sphincter repair
3. Augmenting the sphincter
Bulking agents •
Neuromodulation •
4. Neosphincter
Muscle wrap •
Artifi cial sphincter •
5 . A C E
6. Stoma
376
S.R. Brown
Initial studies assessing outcome after repair suggested excellent restoration of
continence in 70–80% of women. However, it has become clear that with longer
follow-up, the outcome deteriorates, such that after 5 years perhaps only one-third
of women will have an excellent or good outcome (Fig.
26.3 ).
Reasons for this deterioration include neurological or vascular damage, either at
the time of injury or at the time of surgery, or distortion of the anal canal during
repair. A perfect hermetic seal is never obtained with an overlap repair, and the
patient is always prone to passive seepage as a result. The repair may dehisce so it
is always worth repeating an anal ultrasound scan on anyone with deteriorating
function as re-repair may restore a good outcome [
14, 15 ] .
Despite poor long-term results, surgery has few serious complications. Wound
infection occurs in approximately one-quarter but is usually mild with no serious
sequelae [ 16 ] . Wound disruption occurs in about 10%; two-thirds of whom require
further surgery.
Can Outcome Be Improved?
Various techniques have been used to try to improve outcome after a sphincter repair
(Box 26.4 ):
Defunctioning the repair, either by bowel confi nement or by a proximal stoma, •
has been shown to not affect outcome of the repair with the only difference being
increased morbidity related to a stoma [ 17, 18 ] .
Patient selection. Data on selection of patients is confl icting with some authors •
suggesting a poor outcome if the patient has pudendal neuropathy while others
suggest no difference [ 19 ] . This presumably refl ects lack of specifi city of the nerve
Box 26.4: Methods of Improving Outcome After Sphincteroplasty
Defunction/bowel confi nement
RCT evidence no difference •
Exclude neuropathy
Confl icting results. No RCT evidence •
Exclude elderly
Confl icting results. No RCT evidence •
Exclude patients with external sphincter atrophy
Some evidence •
Re-repair if defect
Some evidence •
Give biofeedback postrepair
RCT evidence of effectiveness •
377
26 Interventions for Fecal Incontinence
latency tests available, which only measure the speed of the fastest nerve fi ber and
will give normal results even if only one or two fi bers are intact. Data on outcome
with age is also confl icting with some studies suggesting a poorer outcome with
increasing age, but more studies with even greater numbers of patients suggesting
no difference in outcome related to age. Tied in with age is external sphincter atro-
phy with at least one study suggesting this fi nding is associated with a poor out-
come [
20 ] . However, assessment of muscle atrophy can only be made with MRI.
Biofeedback. RCT evidence suggests adjuvant biofeedback may help sustain •
improvement over time [ 21 ] .
26.1.6.2 Interventions Designed to Correct Abnormalities of the Pelvic Floor
Interventions include anterior levatorplasty, postanal repair, and a combination of the
two resulting in total pelvic fl oor repair. Many of these types of intervention have
been abandoned as both short- and long-term outcomes have been poor and remain of
historical interest only. This begs the question: should these options just be ignored?
Postanal repair deserves some attention as it is still performed by some surgeons. The
original concept was to plicate the levators posterior to the anal canal in order to increase
the anorectal angle, which was thought to be important for maintenance of continence.
Unfortunately, the operation has been subsequently shown not to result in an increased
anorectal angle, nor does it lengthen the anal canal or increase sphincter pressure. It
probably works by scarring the levators, thus increasing resistance to evacuation of the
stool. The other problem is it does not work very often. Initial reports of 80% of women
having an excellent or good outcome quickly fell to 25–35%. However, advocates sug-
gest over 70% patient satisfaction for what is a safe and cheap option [ 22 ] .
26.1.6.3 Interventions Designed to Augment the Anal Sphincter
Bulking Agents
Although damage to the external sphincter can be repaired with variable success,
repair of isolated internal sphincter damage is typically ineffective [ 23 ] . Such dam-
age is often iatrogenic (e.g., after sphincterotomy/anal stretch or hemorrhoidec-
tomy) and typically results in reduced resting tone and passive incontinence.
Injectable bulking agents offer the possibility of a minimally invasive method of
treating such injuries. The idea is to inject biocompatible material into the submu-
cosal or intersphincteric space to bulk out the anal canal lining and hence approxi-
mating the anal mucosa or increasing the anal canal pressure.
Assessment of effectiveness is diffi cult because of the numerous variations in
technique. For instance, nine different materials have been used, with the material
injected via fi nger guidance or ultrasound control into the intersphincteric or sub-
mucosal space. Furthermore, there is a lack of good quality unbiased trials with long
378
S.R. Brown
enough follow-up [ 24, 25 ] . No fi rm recommendations can therefore be drawn as to
the best material or indeed whether the procedure is better than placebo. Nevertheless
the procedure appears safe and may be worth considering given the limited options
available for this group of patients.
Sacral Neuromodulation
Sacral neuromodulation is the application of mild electrical impulses to the sacral
nerves supplying the pelvic fl oor (S2–4). The procedure has evolved from urologi-
cal practice, where such techniques have been successfully used to treat patients
with urinary dysfunction for over 20 years and where an improvement in concomi-
tant fecal incontinence symptoms was noted. The technique was adapted in 1995 by
Matzel specifi cally to treat fecal incontinence, and since then, there has been an
explosion in both use and data concerning this technique which is attractive because
it is a minimally invasive treatment for a group of patients where there is little to
offer other than surgery with high morbidity and low effectiveness.
How Does It Work?
This is somewhat of a mystery. The electric fi eld can potentially stimulate multiple
autonomic and somatic nerves. Results of studies are variable and draw confl icting
conclusions. They have hinted at a direct effect on sphincter pressure, rectal sensa-
tion, rectal blood fl ow, colonic transit, and even the brain [
26 ] .
Outcome
One unique advantage of sacral neuromodulation is the facility to trial effective-
ness of stimulation using temporary wires, before inserting the costly permanent
device. As a result, the success of a permanent device in treating incontinence in
many series is very high (80–100%). Two good quality trials are worth mentioning.
In the fi rst double blind cross-over trial, Leroi et al. randomized patients after suc-
cessful test stimulation and implantation to the stimulator turned on or off for a
1-month period [ 27 ] . There was signifi cant improvement in symptoms in the “on
period” compared with the “off period,” suggesting the benefi t was not simply a
placebo effect. Tjandra et al. compared sacral neuromodulation with optimal medi-
cal therapy in a large randomized trial of 120 patients [ 28 ] . They showed a signifi -
cant improvement in symptoms and quality of life in the neuromodulated group but
not in the control group. They therefore concluded that neuromodulation works.
Sacral neuromodulation is a relatively minimally invasive procedure and compli-
cations tend not to be serious. Infection occurs in up to 7% of permanent implants,
but is often superfi cial and does not require explant of the device. Pain can occur at
the site of the implant or where the stimulation sensation is perceived. It often
responds to reprogramming of the device. Other complications relate to the hard-
ware including the battery which has a life of about 8–10 years. Replacement or
readjustment of the hardware is sometimes required.
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