Video Clips on DVD
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Overlapping Sphincter Repair Done in a Prone Position
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End-to-End Sphincter Repair Done in Dorsal Lithotomy Position
- 3-3
Placement of an Artificial Bowel Sphincter
Fecal incontinence is a symptom that may be debilitating to the patient. The incidence of fecal incontinence has been quoted as between 0.004% and 18%. Although the most common etiology is childbirth trauma, men are also affected. In the elderly, the incidence is equal among men and women. Other factors involved in etiology include normal aging, trauma, diabetes, iatrogenic injury, connective tissue disorders, multiple sclerosis, and radiation injury. The onset of newer technology to test anal physiology and to determine the anatomy has been instrumental in the advances for treatment of fecal incontinence during the last decade.
Evaluation of Patients with Fecal Incontinence
Evaluating patients with fecal incontinence starts with a good history, which involves estimating the severity of symptoms and discovering the probable etiology. This means asking detailed questions about:
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Duration of symptoms
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Number of episodes of incontinence
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Whether incontinence is for solids, liquid stool, or gas
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Amount of stool lost
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Use of a protection such as pads or diapers
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Relationship of symptoms to events such as surgery, injury, new medications, or new medical conditions
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Bowel habits
One should be certain that there are no underlying conditions such as diabetes, back injury, Parkinson’s disease, pelvic radiation, and chronic diarrhea. A detailed obstetric history is important and should include number of childbirths, mode of delivery, if labor was prolonged, use of instrumentation, and history of an episiotomy or tear that was repaired. Finally, in appropriate patients verify that a screening colonoscopy has been performed.
Examination involves a good general and detailed overview. Local examination involves inspecting the perineum and anus, digital rectal examination, and anoscopy. Inspection of the anus should include a description of the perianal skin, the anal orifice (closed or patulous), presence of scars, fistulas, or skin tags. Elicitation of the anocutaneous reflex is important and is done using a cotton-tipped swab. A negative result indicates loss of the local reflex arc. This is damaged when there is injury to the pudendal nerve, which may occur secondary to a stretch injury during the second stage of labor or because of instrumentation use such as forceps or vacuum extractor. It should be noted, when asked to squeeze, relax, and bear down whether the anal muscles move to command or if instead there is mass movement of the buttock muscles. When asked to bear down, look for evidence of rectal prolapse and pelvic floor descent, and at the same time look at the vagina for evidence of uterine prolapse, cystocele, or rectocele. A digital rectal examination evaluates resting tone defined as tone elicited when a lubricated gloved finger is inserted in the anal canal versus squeeze tone, which is tone when the patient is asked to squeeze. The presence of a defect in the anal sphincter anteriorly in response to squeeze and the thickness of the rectovaginal septum on a bimanual palpation are also noted. A digital examination while straining may detect a rectal prolapse or an internal intussusception and also evaluates the walls of the rectum and anal canal for masses. Finally, an anoscopic examination provides visualization of the anal mucosa and rules out common pathology such as hemorrhoids, fissures, and fistulae.
Anal physiology testing or anal manometry requires a machine that uses a water-perfused catheter or a solid-state catheter to evaluate resting and squeeze pressures and anal canal length. Additionally, rectal sensation and volume studies estimate maximum-tolerated volume and rectal compliance. Electromyography (EMG) is roughly approximated using surface electrodes attached to the manometry machine. For a more precise electrophysiological examination when nerve-related conditions are suspected, needle EMG can be performed. Pudendal nerve terminal motor latency evaluates the time taken to elicit sphincter muscle contraction after the nerve is stimulated by using a specialized electrode (the St. Mark’s electrode). Endoanal sonography, which is now available in a three-dimensional (3D) model, accurately defines the anal sphincter anatomy. Additional workup involves obtaining a colonoscopy for screening or to evaluate applicable symptoms. If rectal prolapse or pathology related to outlet obstruction is suspected, defecography is ordered. Occasionally colon transit studies may be indicated if fecal incontinence is suspected to be from constipation with overflow incontinence.
Caring for a symptomatic patient requires a physician who is prepared to spend quality time in evaluating and outlining a plan that is comprehensive, easy to understand, and not cumbersome to implement. Patient compliance is as important as the treatment plan. Helping patients understand that success or failure of their treatment is partly under their control is important. Involvement of a caregiver is also important for elderly patients. Because fecal incontinence is a symptom complex rather than a disease, the goal is to grasp the severity of the problem and be able to formulate a treatment plan that addresses patient concerns and convinces the patient that he or she will benefit from an array of options. These options could range from simple dietary measures to complex surgery.
Treatment Options ( Fig. 3-1 )
Conservative Management
Mild cases of fecal incontinence are defined as an occasional loss of a small amount of semisolid or liquid stool, not requiring barrier protection such as pads. Patients with mild fecal incontinence can easily control their symptoms with conservative treatment. This involves diet modification, elimination of dietary substances causing loose stools, reducing fluid intake, control of diarrhea by using drugs such as loperamide (Imodium) or diphenoxylate with atropine (Lomotil), addition of fiber to act as a bulking agent, and keeping the rectum empty with enema use. Care of the perianal skin is also important. Kegel exercises can be self-administered or taught with a few sessions of biofeedback by a trained therapist.
Moderate fecal incontinence is defined as loss of semisolid, liquid, or solid stool of moderate amounts on a regular basis, which requires some form of barrier protection, some or all of the time. Conservative treatment with or without surgery is usually offered. Sphincter repair is an option for patients with a sphincter defect. In the future, sacral nerve stimulation may be an option for all patients. Another potential treatment for patients in this category includes injectable bulking agents for those without a sphincter defect.
Severe fecal incontinence is defined as daily loss of stool requiring barrier protection such as Depend incontinence products. These patients may have chronic diarrhea that is nonresponsive to medical management and potentially requires a stoma for symptom control. Sphincter repair may be offered if a defect exists and bowel consistency can be improved. Patients with fecal incontinence caused by a congenital problem or significant anorectal trauma may be considered for an artificial bowel sphincter.
Noninvasive Treatment Options
Peripheral Nerve Stimulation
Peripheral nerve stimulation uses the posterior tibial nerve. This therapy is FDA approved for urinary incontinence. Stimulation for 20 to 30 minutes one to two times a week has been shown to improve the severity of symptoms.
Injectable Therapy
This treatment is currently not approved in the United States, although some trials have recently concluded. Injectable agents available in other parts of the world include products made from silicone, hyaluronidase, and carbon-coated beads. These are injected to act as bulking agents in the anal sphincter area. The quantity of material injected depends on the product, and the procedure may be performed in the office. Ultrasound guidance may improve results with precise placement. Results are varied, showing moderate success in those with anal sphincters that do not show an anatomical defect.
Secca Procedure
The Secca procedure involves a handheld device that delivers radio frequency stimulation to the anal canal submucosa and muscle layers in turn stimulating collagen formation, which helps increase anal tone. The procedure is done under local anesthesia. Although FDA approved, the procedure cannot be offered, as the device is currently not being manufactured.
Anal Plug
This device is offered as a palliative procedure when no conservative options are effective. It currently is not available in the United States. It acts as a physical barrier and is disposable.
Procon 2 Device
The Procon 2 device consists of a silicon catheter with an inflatable balloon, which must be manually inflated and deflated. This device is for patients who are fairly active and have severe incontinence not amenable to surgery. It is a single-use unit and has been designed to be used sporadically when the patient needs to maintain continence for a short period of time (such as leaving the home for travel, appointments, shopping, etc.). It is not designed to be used on a daily basis, is expensive, and requires an inflated balloon in the rectum to remain in position. This device is available in the United States by prescription.
Surgical Options
Anal Sphincter Repair
This procedure is an anatomical correction of a sphincter defect. The defect may involve the external anal sphincter or both the internal and external anal sphincter. During repair, the retracted ends of the sphincter are delineated and either overlapped with the sphincter of the opposite side or repaired end to end if an overlap is not possible.
Case 1
Ms. B is a 52-year-old white woman who has had symptoms of fecal incontinence for 2 years. The onset was gradual with increasing frequency over the preceding 6 months. She has at least three episodes of fecal seepage a week with soft or mushy stool. She has had solid stool leakage only once. She has lost an entire bowel movement twice in the last 6 months. Usually she is unaware of the leakage. She continually wears a thin pad and experiences mild-to-moderate leakage most of the time. She has one to two stools daily with no urgency. She also has flatal incontinence. She has mild urinary incontinence with a full bladder when she coughs, sneezes, or lifts weights. She had a normal colonoscopy 1 year ago. She had four vaginal births, no babies weighing greater than 7 pounds or prolonged labor. She required an episiotomy with every birth. Her first child was delivered with forceps. After each birth, she was instructed to do Kegel exercises and 3 months ago restarted them. Her surgical history is unremarkable. She denies back injury or problems. She suffers from gastroesophageal reflux disease. She is employed full time, is a nonsmoker and social drinker. Her general examination is unremarkable.
Local examination demonstrates one posterior skin tag. The anal skin is mildly inflamed, and there is a positive anal wink (anocutaneous reflex). She has some movement of the anal sphincter when asked to squeeze and no evidence of vaginal or rectal prolapse. Digital examination is positive for an anterior shelf like sensation, small rectocele, mildly decreased resting tone, and moderately decreased squeeze tone. The rectovaginal septum is not excessively thin. There is a small cystocele. Proctoscopy is normal.
Manometry findings are as follows: anal canal length, 1 cm; mean resting pressure, 32.25 mm Hg (normal, >40 mm Hg); mean squeeze pressure, 64.5 mm Hg (normal, 100 mm Hg); maximum-tolerated volume, 200 mL (normal, 200 to 300 mL); rectal compliance, 13 mm Hg (normal, 5 to 15 mm Hg); pudendal nerve terminal motor latency, 2 msec on both sides (normal, 2 msec).
On endoanal ultrasound ( Fig. 3-2 ), there is a defect in the external anal sphincter seen in the low and mid-anal canal of approximately 90 degrees. There is scarring at the low anal canal. The internal anal sphincter is intact but thin in the mid-anal canal. The perineal body measures 8.47 mm.
Case Discussion
In summary this is an active middle-aged woman who is probably seeking advice because she cannot tolerate accidents at work. Secondly, she has had four vaginal births, one with instrumentation. Therefore, her manometry and ultrasound findings are as expected. Thus the importance of history-taking in this case is to: (1) establish how much debility is present; (2) establish which symptoms may be improved with conservative management; and (3) establish other symptoms that may need concomitant intervention.
In this case, having three episodes of incontinence per week (probably mostly at work) together with wearing a pad daily, which contributes to perianal irritation, is debilitating. Some patients will state they do not leave the house for fear of having an accident or only leave the house when they have not eaten anything for 8 to 10 hours. This history should alert the caregiver that the patient is severely compromised. The details of pad usage, how much soilage occurs with each accident, type of pad, and how often it is changed also provides clues regarding symptom severity. Often patients will wear a pad for urinary incontinence so questions regarding this aspect must be asked.
The one symptom that could be improved is stool consistency. The addition of an antidiarrheal such as loperamide should be beneficial. Addition of a fiber supplement can help by changing stool consistency. Fiber supplements, however, can lead to frequent bowel movements so treatment must be individualized. Other bowel symptoms that could require attention (although not in this patient) are constipation followed by diarrhea or overflow constipation. Therefore, it is important to spend time obtaining details of the patient’s bowel habits. Patients with predictable bowel habits are easier to treat. Patients who are unable to detail their daily bowel habits or their consistency will be harder to help. It is important to treat the perianal skin using a barrier cream. In debilitated or bedridden patients, this concept must be conveyed to the caregiver. When patients complain of additional symptoms such as abdominal bloating and cramping with irregular bowel habits, irritable bowel syndrome is considered. Listing both prescribed and over-the-counter medications is important in identifying a particular drug that can cause diarrhea or constipation. A history of diabetes or back surgery is important because incontinence resulting or exacerbated by these conditions is difficult to control. Treatment may focus on achieving a clean left colon.
The local examination is probably as important as any future investigations. A thorough examination should give information regarding the state of the anal sphincter, the presence of associated pathology such as hemorrhoids, mucosal prolapse, full-thickness rectal prolapse, and/or vaginal prolapse. These are usually elicited with straining. The bladder and vagina, although organs in the vicinity of the anus, are inter-related and need evaluation. Eliciting the anal wink (anocutaneous reflex) is an indication that the local reflex arc probably is functioning. Examination of the anus when the patient squeezes is very important as it tells if there is only buttock movement or if the anal sphincter is really contracting. A noncontracting anal sphincter usually will not contract even after a satisfactory repair. Evaluation of the rectovaginal septum, especially if surgery is contemplated, is important as it may demonstrate prolapsing mucosa or hemorrhoids, which contribute to mild seepage of soft stool. It is important to recognize these issues even if there is a sphincter defect as these may contribute to the incontinence. The aim of investigations is to fill in gaps from the physical examination, define anal physiology, and visualize sphincter anatomy. Manometry for this patient shows a short anal canal, slightly decreased resting tone, moderately low squeeze pressures, no rectal hyposensitivity, normal compliance, and normal nerve conduction. The ultrasound demonstrates a defect in the external anal sphincter.
The treatment should fit the symptoms and not the investigations. Merely finding a defect does not necessitate a surgical procedure. This patient has one symptom that could possibly be improved, that is, her stool consistency.
The recommendations for this patient would be:
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Start antidiarrheal drugs to determine if stool consistency and hence the leakage can be improved.
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Continue the Kegel exercises, as she would need to do this postoperatively. Sometimes a trained therapist can improve the technique and further help patients.
In the United States, sacral nerve stimulation is not yet FDA approved, nor is any treatment with an injectable bulking agent. Therefore, her only surgical option is an overlapping sphincter repair, and this is offered if she fails the conservative approach including use of antidiarrheal medication and pelvic floor exercises.
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