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379
26 Interventions for Fecal Incontinence
Posterior Tibial Neuromodulation
Percutaneous neuromodulation using the posterior tibial nerve is yet another proce-
dure borrowed from urological practice. Data is limited but there is a suggestion that
about 50% of patients will show long-term improvement in their incontinence
symptoms [
29 ] . The procedure is even less invasive than sacral neuromodulation
and may be less costly, although the process does require regular multiple stimula-
tor sessions and may require ongoing “top up” treatment.
26.1.6.4 Interventions Designed to Create a New Anal Sphincter
(Neosphincter)
The principle of a neosphincter involves fashioning a biological or artifi cial material
or device around or above the poorly functioning sphincter. This wrap or band not
only acts to improve retention in the rectum but may also have a functional ability.
Biological materials that can be used for such a wrap or band include muscle trans-
posed to the site and wrapped around the sphincter. Artifi cial devices include vari-
ous encircling appliances, the earliest and simplest version being a silver wire,
described by Thiersch over 100 years ago. More recently, pressure-activated devices
have been used that allow a more physiological operation.
Muscle Wrap
Although several muscles have been used to create neosphincters, gracilis is by far the
most suitable. Not only is it long and thin and can be wrapped around the canal, it has
a very constant innervation and blood supply in the proximal end of the muscle, allow-
ing mobilization without damage to the neurovascular pedicle. It is also the most super-
fi cial muscle in the medial aspect of the thigh making it convenient for harvesting, and
its loss does not result in a functional defi cit in the lower limb after transposition [ 30 ] .
The technique of muscle transposition has been around for over 50 years with
initial effectiveness related to a degree of mechanical obstruction caused by the
tightness of the wrap. In the early 1990s, Baeten [ 31 ] and Williams [ 32 ] pioneered
the use of electrical stimulation to the muscle or nerve to convert the neosphincter
into a dynamic functioning neosphincter.
Outcomes After Dynamic Graciloplasty
Since introduction of the dynamic neosphincter, several studies have examined out-
come in nearly 1,000 subjects [ 33 ] . The most recent studies suggest an overall success
rate of below 50%. In almost all studies, there is a recognized and signifi cant surgical
revision rate, explantation rate, and a complication rate of almost 90%. Combining the
data from the 20 most recent studies, this amounts to about half of all patients under-
going at least one surgical revision with about one-third eventually failing [ 33 ] .
380
S.R. Brown
Given the 50% success rate, the considerable potential for complications and the
signifi cant cost it is easy to regard the procedure as not justifi ed. An alternative view
is to believe the procedure does have a place in treatment, but only at the extreme
end of the spectrum of refractory incontinence. There is no doubt that with the com-
plexity of the operation, the variation in success, and the limited numbers of appro-
priate patients, such procedures should be confi ned to a small number of centers
where adequate patient volume, appropriate patient selection, and counseling and
surgical expertise optimize outcome.
Artifi cial Anal Sphincter
Artifi cial sphincters usually consist of an infl atable cuff placed around the upper
anal canal usually through a perineal incision, a pressure-regulating balloon
implanted extraperitoneally, and a subcutaneous pump placed in either the scrotum
or labia (Fig.
26.2 ). When the cuff is infl ated, the anal canal is closed and the pres-
sure maintained by the reservoir. Squeezing the pump empties the cuff and opens
the anal canal, allowing evacuation.
Indications are similar to those of the dynamic muscle wraps, namely end-stage
fecal incontinence refractory to less invasive therapies, but the procedure is cer-
tainly technically easier, more cosmetic, and less surgeon dependant than a dynamic
muscle wrap.
Outcomes of an Artifi cial Bowel Sphincter
The technical ease of insertion does not necessarily translate into better results. The
complication rate, particularly infection, is high. Infection rates are over 50% in
many series, often resulting in erosion of the device and eventual explantation.
Overall complication rates exceed 100% with one study reporting 454 complica-
tions in 115 patients, suggesting many patients undergo multiple procedures [ 34 ] .
Even with increasing experience, there is a constant explantation rate of over 30%
although the revision rate does improve with time.
Despite these problems, there is a group of patients who undergo successful
implants and who continue to have good long-term control of continence with a
signifi cant improvement in their quality of life.
26.1.6.5 Interventions Designed to Allow Antegrade Colonic Irrigation
Antegrade irrigation usually via an appendicostomy (ACE procedure) may be con-
sidered in selected people with constipation or colonic dysmotility associated with
incontinence. Irrigation allows effective and effi cient colonic cleansing at a time that
is socially convenient for the patient and minimizes postdefecation leak. Results are
good in 50–60% of cases [ 35 ] . However, the procedure requires a highly motivated
381
26 Interventions for Fecal Incontinence
patient who is prepared to be heavily involved in their own bowel regime as compli-
ance for administration of enemas and daily stoma catheterization is essential to
avoid complications, particularly stenosis.
26.1.6.6 Interventions to Bypass the Anal Sphincter
A stoma (colostomy or ileostomy) is suitable for severe incontinence where all
other therapies have failed, are inappropriate, or when preferred by the patient. An
end sigmoid colostomy is probably the most effective stoma as it limits the distal
defunctioned mucosa, reducing potential for diversion colitis and/or mucous dis-
charge per rectum. A stoma often successfully relieves incontinence symptoms but
is not without morbidity and may have signifi cant psychological impact regarding
body image.
What Intervention Should Be Used and When?
The varied and complex etiology of fecal incontinence results in a complex algo-
rithm when it comes to surgical intervention (see Fig.
26.2 ). Although a stepwise
progression from minimally invasive through to highly invasive interventions is a
common theme, certain etiologies require a tailored approach.
Evidence of Mechanical Sphincter Damage
External Sphincter
It appears obvious that sphincteroplasty is indicated if there is evidence of an exter-
nal sphincter tear. However, the perceived poor long-term results of this technique
combined with data suggesting a good response to sacral neuromodulation even
with a signifi cant sphincter defect have led several experts to recommend an initial
trial of neuromodulation. This controversy is discussed later.
Internal Sphincter Damage Only
This group of patients presents with passive incontinence and may benefi t from injec-
tion of a bulking agent, particularly if there is an iatrogenic “keyhole” defect in the
anal canal. If this fails, subsequent options include sacral or tibial neuromodulation.
Intact Sphincter Complex
This is the group that benefi ts most from neuromodulation essentially because other
options are limited or just do not work. Some centers would consider postanal repair,
but most surgeons have abandoned this technique.
382
S.R. Brown
Failure of Surgical Repair and/or Sacral Neuromodulation
Once the less invasive treatment options have been exhausted or excluded, this is the
group of patients that may be appropriate for the more invasive surgical options.
Similarly, there is a small group of patients with loss of a large proportion of their
native sphincter (after trauma or congenital absence of sphincter) that may reach
this stage of the algorithm without being suitable for the other surgical options.
The choice of procedure includes antegrade colonic irrigation, neosphincter con-
struction, or stoma. Which to use will depend on patient preference and to a signifi cant
extent on the expertise available. Unfortunately, there are no direct comparisons
between the techniques in terms of outcome and quality of life. Technically, it is gen-
erally accepted that a muscle wrap may be preferred to an artifi cial sphincter in patients
with a very thin or scarred perineum. In terms of expense, mathematical models sug-
gest that the artifi cial bowel sphincter is more cost effective than the dynamic gracilo-
plasty. A stoma is more cost effective over a 5-year period but becomes less so with
time as stoma costs remain ongoing [
36 ] . There is no data on the ACE procedure.
For all options, the patients should be prepared psychologically, emotionally, and
fi nancially to undergo multiple operations with the possibility of ultimate failure
and acceptance of a permanent stoma.
26.2 Controversies
26.2.1 Sacral Neuromodulation or Sphincteroplasty
First for Patients with a Sphincter Defect
Recent data from several centers suggest sacral neuromodulation is effective even if
there is a defect in the external anal sphincter, providing more evidence perhaps that
the mechanism of action of neuromodulation is not directly on the anal sphincter. The
reported success of neuromodulation in this situation is 100% in some series [ 26 ] , and
the technique appears to be effective regardless of the size of the defect [ 37 ] . These
results, taken with the perceived poor long-term results of sphincteroplasty, have led
some experts to recommend a trial of sacral neuromodulation instead of attempting a
sphincter repair. Potential morbidity would be reduced with a less invasive procedure,
resulting in a shorter hospital stay and more rapid recovery. In addition, there is the
opportunity of a test period and no preclusion of a future repair if required.
The argument is not as clear-cut as it would initially appear. Not only are there
cost issues regarding what is a very expensive battery device, but neuromodulation
often requires intensive monitoring, at least initially. The insertion of a permanent
artifi cial device may be unsatisfactory for some, particularly younger patients.
Advocates of a sphincter repair also suggest the outcome of this technique is not as
bad as has been perceived.
Regarding the outcome of sphincter repair, the long-term data would suggest an
excellent or good outcome in one-third of patients. Some of the poor results may be
383
26 Interventions for Fecal Incontinence
historical, with sphincteroplasty carried out in some cases from the 1990s even in some
patients with intact sphincters. Repeat ultrasound and re-repair of those patients with
persistent defects may improve results to over 50%. A long-term 50% success rate
could be viewed as very good for a cheap operation with minimal serious side effects.
In any case, even with a poor outcome, the data suggest many of these patients remain
highly satisfi ed [
38 ] . Furthermore, advocates of sphincteroplasty also point out that the
outcome of neuromodulation is not as good as appears. In the studies of neuromodula-
tion in patients with sphincter defects, success is defi ned as an improvement in conti-
nence of greater than 50%. If the same criteria of success are used as in the sphincteroplasty
studies, the “success rate” of neuromodulation drops to a fi gure similar to that seen with
sphincteroplasty. There may be a drop-off with time. One other criticism relates to the
participants of the studies supporting the use of neuromodulation in patients with a
sphincter defect. In the larger studies, the patients were a very heterogenous group con-
taining, for instance, patients with incontinence after an anterior resection. Indeed, in
three studies, the majority of patients had already undergone sphincter repair!
As neither procedure is mutually exclusive and each has various advantages and
disadvantages, it seems reasonable to offer the choice to the patient, explaining the
above caveats, until further data become available. However, in the patient with a
severe traumatic cloacal defect, an attempt at perineal repair should probably still be
the initial treatment of choice.
26.2.2 Obstructed Defecation and Fecal Incontinence
Obstructed defecation is essentially diffi culty in evacuating the rectum and is
described in detail in preceding chapters. Along with a group of constipation-related
symptoms, patients may also describe both urge and passive incontinence.
Mechanical causes in obstructed defecation include intussusception and rectocele.
With intussusception, the apex of the internal prolapse affects the sensitive anoderm
and may provoke changes in the defecatory mechanism, promoting urgency and
leakage. Similarly, a rectocele may fail to empty at defecation, allowing passive
leakage of stool at a subsequent socially inconvenient time.
Procedures that correct these defects have been shown to improve incontinence
symptoms as well as symptoms of constipation. It makes sense, therefore, to inves-
tigate the patient who presents with incontinence, for any evidence of underlying
obstructed defecation and internal (or external) rectal prolapse.
26.3 The Future
The fi eld of continence surgery is constantly evolving. Many operations that were stan-
dard care only 20 years ago have been abandoned. Many new procedures have only been
in common use for the last 5–10 years, and long-term data may not be robust enough yet
to decide on optimal utilization. Neuromodulation is one of these newer techniques and
384
S.R. Brown
meets many of the requirements for the perfect surgical option, i.e., minimal invasive-
ness, combined with broad indications. Variations of delivery of the electrical impulses
may improve convenience, cost, and outcome yet further. Tibial neuromodulation is one
of these refi nements, but other variations include pudendal neuromodulation.
The problem of end-stage incontinence and the invasive nature of the options
available when neuromodulation fails remains an issue. Many improvements in arti-
fi cial sphincter technology have been proposed but are yet to be tested in a robust
manner. These include the PAS device which allows insertion of the artifi cial sphinc-
ter mechanism into the pelvis [
39 ] . The more physiological nature of the device makes
it less likely to cause ischemia, and the intraabdominal position means, theoretically,
there should be less infection and erosion potential. However, the intraabdominal
position of the device makes it more invasive than the perineal procedure (although
invasiveness could be reduced with the use of laparoscopy), and the position above
the sphincters leaves the potential for a dead space and problems with fecal seepage.
Case Scenario Answers 1
This patient has evidence of a disrupted internal and external sphincter. Despite
her young age and ability to therefore compensate, she is very symptomatic.
Although perhaps unlikely to completely respond, she should be given advice
about conservative measures, including dietary changes and other coping mea-
sures. The regular prescription of loperamide, particularly useful if in liquid
form, coupled with the intermittent use of suppositories to empty the rectum at
a socially convenient time may help her to return to some semblance of normal
activity. In a similar way, colonic irrigation is an alternative and more effi cient
Key Points
Conservative therapy fi rst•
Primary care –
Specialist care –
Principles of selection of best surgical intervention•
Algorithm of care based on –
Invasiveness of procedure (minimally invasive, i.e., SNS, to maxi-
º
mally invasive, i.e., neosphincter)
Specifi city (i.e., bulking agent for internal sphincter defect)
º
Expertise available
º
Optimization of outcome –
Patient selection
º
Expertise
º
Continued support (i.e., biofeedback or reprogramming of neuro-
º
modulation)
385
26 Interventions for Fecal Incontinence
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This patient has evidence of a disrupted internal sphincter which appears iatro-
genic. His passive incontinence may also be contributed to by the presence of
diabetes. Again, conservative measures may be helpful. Dietary changes could
be diffi cult due to the need for a diabetic controlled diet, but the ingestion of
insoluble fi ber can still be limited. Loperamide will “stiffen” the stools and
reduce seepage, and suppositories will empty the rectum at a convenient time.
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patients of this age fi nd such devices uncomfortable and subsequently cannot
tolerate. Biofeedback can certainly improve external sphincter function and, as
this contributes to resting tone, may be benefi cial. It should be remembered
that there is an element of mucosal prolapse and, although this may be due to
the patulous nature of the sphincter complex, may be hemorrhoidal and respond
to simple rubber band ligation which in turn could reduce seepage.
If conservative measures fail, surgical options include bulking injection and
sacral neuromodulation. The presence of a keyhole defect and isolated internal
sphincter damage makes this the perfect case for a bulking agent, with the agent
used to “fi ll in” the defect and promote the potential for the sphincter ring to form
a hermetic seal again. If these options fail and there is severe sphincter disruption
resulting in severe disruption to quality of life, then more radical procedures such
as a neosphincter or even stoma formation may be the only choices.
method of evacuation, but does require signifi cant input in terms of time which
may be inappropriate for a mother with a young baby. A course of biofeedback
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387
26 Interventions for Fecal Incontinence
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389
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_27, © Springer-Verlag London Limited 2012
27.1 Introduction
As discussed in Chap. 25 , chronic constipation in adults is a common and often
debilitating problem. It is so common that colorectal specialists will only see a small
proportion of the total number of patients with constipation in their surgical clinic.
Often, these patients are at the extreme end of the spectrum of disease severity.
In all cases, a careful history and examination should be undertaken, and a regimen
of simple conservative therapies instituted. In some patients, specialist investiga-
tions may be required in order to differentiate the various types of constipation and
guide management (Box 27.1 ). After exclusion of secondary causes, four groups of
constipated patients can be considered:
1. Constipation-predominant irritable bowel syndrome
2. Slow transit constipation
3. Obstructed defecation syndrome
4. Mixed slow transit/obstructed defecation
Irritable bowel syndrome occurs mostly in young women. Abdominal pain and
bloating are the most prominent symptoms, and measurement of colonic transit time is
not signifi cantly different from healthy controls. Slow transit constipation is usually
S. Maslekar , FRCS
Department of Colorectal Surgery , Leeds General Infi rmary ,
Great George Street , Leeds, West Yorkshire LS1 3EX , UK
e-mail: sushilmaslekar@hotmail.com
D. G. Jayne , M.D., FRCS (
*)
Department of Colorectal Surgery , Leeds General Infi rmary ,
Great George Street , Leeds, West Yorkshire LS1 3EX , UK
John Goligher Colorectal Unit, D Floor, Clarendon Wing , Leeds General Infi rmary ,
Great George Street , Leeds, West Yorkshire LS1 3EX , UK
e-mail: d.g.jayne@leeds.ac.uk
Chapter 27
The Management of Constipation
Sushil Maslekar and David G. Jayne
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