Evaluation

A thorough history is important, as it will frequently lead the physician to the potential underlying

causes of the incontinence. Obstetrical and surgical history should be noted, as well as any change in

bowel consistency. It is helpful to quantify the frequency and degree of fecal incontinence with the use

of a validated incontinence scoring system.31 Symptoms of other pelvic floor conditions including

urinary incontinence, and rectal prolapse should also be elicited. Physical examination should include

inspection of the perianal skin for scars from previous surgery or obstetrical injury, excoriation from

chronic soiling, or large prolapsing hemorrhoids. Digital examination can provide a gross assessment of

both resting tone and squeeze effort.

In addition to the history and physical examination, several tests of anorectal anatomy and physiology

can be done to investigate the cause of incontinence. Endoanal ultrasonography can provide a

circumferential anatomic image of the anal canal, including visualization of the internal and external

sphincters and any defects in these. Anorectal manometry may help to establish a baseline of resting and

squeeze pressures, and may help to identify decreased rectal compliance. Electromyography of the

pelvic floor with evaluation of pudendal nerve terminal motor latency may help to identify a neurologic

cause of incontinence. Defecography may aid in operative planning by identifying previously

unrecognized disorders such as rectocele or intussusception. The evaluation of a patient with fecal

incontinence must also include an assessment of the impact of the symptoms on the patient’s quality of

life. This is important because the need for intervention is often based on the patient’s desires rather

than a threat to his or her health.

Figure 70-25. Transabdominal rectopexy. After full mobilization of the rectum (A,B), the endorectal fascia and peritoneum on

each side is sutured to presacral fascia, below the promontory of the sacrum (C).

1874

Management

Patients with chronic diarrhea, neurologic conditions, or systemic illnesses are best treated medically.

This treatment is generally directed at regulation of bowel habits, with the goal of decreasing the

frequency of bowel movements. The addition of a fiber supplement adds bulk to the stool and absorbs

fluid, creating a more solid stool that is easier to sense and to control. Constipating agents such as

loperamide, diphenoxylate atropine, codeine, and bile acid binders may help to make stool harder and

less frequent, thereby making it easier for the patient to control. In an effort to decrease leakage, some

patients may benefit from the use of regular enemas to maintain an empty rectum.

Biofeedback is a pelvic floor retraining physical therapy program that can be very helpful in the

treatment of patients with disorders of the pelvic floor. This “retraining” aims to provide increased

strength to the sphincters, sensation of the anorectum, and coordination of the pelvic floor. Biofeedback

typically employs the use of a pressure-sensitive probe placed into the anal canal to monitor the

strength and coordination of the anal sphincter and pelvic floor musculature. The data from the probe

are then transmitted to a monitor, where the patient is able to watch the manometric tracings. Through

a series of coached exercises and visual feedback, improvements can be made in pelvic muscle control,

threshold of sensation within the rectum, and overall control of defecation. Several studies have

demonstrated the effectiveness of biofeedback in improving continence, with success rates ranging from

50% to 90%,32 however, results are often dependent on the quality of the therapist and the motivation

of the patient.

Other options for patients with less severe fecal incontinence include radiofrequency treatment and

the injection of biocompatible bulking agents into the anal canal. The SeccaTM procedure involves the

use of radiofrequency delivered to the anal sphincter, which results in tissue remodeling.33,34 Several

case series have demonstrated the efficacy of this procedure, with more than half of patients treated

reporting improvement in their symptoms.35 Injection of a bulking agent (silicone or carbon-coated

microbeads) into the anal submucosal or intersphincteric space may help to increase resting pressures by

augmenting the anal cushions or restoring anal symmetry.

Operative management of anal incontinence is reserved for patients with frequent symptoms that

have significant impact on a patient’s quality of life. For patients with incontinence resulting from

obstetrical injury or previous anorectal surgery and evidence of an external anal sphincter defect on

imaging, overlapping sphincteroplasty is an option. With the patient in the prone position, a curved

incision parallel to the anus is made over the perineal body. The two ends of the sphincter muscle are

identified and are mobilized laterally. In order to recreate the complete circle of the anal sphincter, the

ends of the muscle are sutured in an overlapping fashion (Fig. 70-26). Short-term outcomes following

sphincteroplasty are quite good, with up to 85% of patients reporting improvement, however, many

patients report deterioration of function over time.36

The artificial bowel sphincter (ABS) involves the placement of a cuff around the anal canal that

generates external pressure to maintain tonic closure. This inflatable cuff is attached to a pressureregulating reservoir placed in the retropubic space, and a control pump which is implanted into the

labium majoris or scrotum (Fig. 70-27). When the patient feels the urge to defecate, the cuff is deflated

for several minutes, thereby opening the anal canal to allow passage of stool. The complication rate of

this procedure is quite high, with reports of explantation or revision of the device in almost half of all

patients due to infection or malfunction, however the majority of patients with a functioning device

report marked improvement in continence.37 Although the ABS is no longer commercially available, the

magnetic anal sphincter, now in trials in the USA, may allow for the significant benefits of the ABS

without the very high rates of infection, extrusion, and explantation.

1875

Figure 70-26. Overlapping sphincteroplasty. A. An anterior curvilinear incision is made over the perineal body, the scar is divided,

and the edges of the external sphincter are grasped with Allis clamps. B. The external sphincter is dissected until the edges can be

overlapped for several centimeters. C and D. An overlapping repair is performed with four mattress sutures.

Figure 70-27. Implanted silicone neosphincter. A: Female. B: Male.

Sacral nerve stimulation (SNS) involves the percutaneous placement of an electrode into the foramen

of the sacral vertebrae, most commonly S3. SNS was initially used to treat urinary incontinence,

however it was noted that patients with combined incontinence had improvement in fecal continence as

well; the exact mechanism of action is unknown. Following lead placement under fluoroscopy, the

patient undergoes a 2-week test period to assess the effect of stimulation. If continence is significantly

improved, a permanent stimulator is implanted subcutaneously at a second operation. Durable 5-year

1876