Current management of fecal incontinence

Abstract

Objective: To review the management of fecal incontinence, which affects more than 1 in 10 people and can have a substantial negative impact on quality of life.

Methods: The medical literature between 1980 and April 2012 was reviewed for the evaluation and management of fecal incontinence.

Results: A comprehensive history and physical examination are required to help understand the severity and type of symptoms and the cause of incontinence. Treatment options range from medical therapy and minimally invasive interventions to more invasive procedures with varying degrees of morbidity. The treatment approach must be tailored to each patient. Many patients can have substantial improvement in symptoms with dietary management and biofeedback therapy. For younger patients with large sphincter defects, sphincter repair can be helpful. For patients in whom biofeedback has failed, other options include injectable medications, radiofrequency ablation, or sacral nerve stimulation. Patients with postdefecation fecal incontinence and a rectocele can benefit from rectocele repair. An artificial bowel sphincter is reserved for patients with more severe fecal incontinence.

Conclusion: The treatment algorithm for fecal incontinence will continue to evolve as additional data become available on newer technologies.

Figure 1.

Internal and external anal sphincter muscles.

Figure 2.

Anorectal angle.

Figure 3.

Cloacal defect with absence of perineum in a patient with severe obstetric tear.

Figure 4.

A (above) Patient with large anterior rectocele. B (right) Defecography demonstrating an anterior rectocele.

Figure 5.

A (left) Setup for anorectal manometry. B (above) Catheter with balloon at tip for anorectal manometry.

Figure 6.

Setup for pudendal nerve motor latency and anal electromyography testing.

Figure 7.

Three-dimensional pelvic ultrasound machine.

Figure 8.

Rectal irrigation set.

Figure 9.

Patient with large prolapsing hemorrhoids and pseudoincontinence.

Figure 10.

Patient with full-thickness rectal and vaginal prolapse.

Figure 11.

Anal sphincter repair in a patient with prior traumatic childbirth injury.

Figure 12.

Illustration of a gracilis flap rotation to reach the perineal area for anal sphincter muscle repair.

Figure 13.

Acticon artificial bowel sphincter. Reprinted with permission from American Medical Systems, Minnetonka, MN.

Figure 14.

A (left) In the closed position (at rest) Fenix magnetic bowel sphincter provides continence. B (right) Fenix magnetic bowel sphincter expands with straining to allow voluntary passage of stool. Reprinted with permission from Torax Medical, Shoreview, MN.

Figure 15.

Secca radiofrequency energy device. Reprinted with permission from Mederi Therapeutics, Greenwich, CT.

Figure 16.

Sacral nerve stimulator. Reprinted with permission from Medtronic, Minneapolis, MN.