Current and emerging treatment options for fecal incontinence

Abstract

Fecal incontinence (FI) is a multifactorial disorder that imposes considerable social and economic burdens. The aim of this article is to provide an overview of current and emerging treatment options for FI. A MEDLINE search was conducted for English-language articles related to FI prevalence, etiology, diagnosis, and treatment published from January 1, 1990 through June 1, 2013. The search was extended to unpublished trials on ClinicalTrials.gov and relevant publications cited in included articles. Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits. Transcutaneous electrical stimulation was considered ineffective in a randomized clinical trial. Unlike initial studies, sacral nerve stimulation has shown reasonable short-term effectiveness and some complications. Dynamic graciloplasty and artificial sphincter and bowel devices lack randomized controlled trials and have shown inconsistent results and high rates of explantation. Of injectable bulking agents, dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx) has shown significant improvement in incontinence scores and frequency of incontinence episodes, with generally mild adverse effects. For the treatment of FI, conservative measures and biofeedback therapy are modestly effective. When conservative therapies are ineffective, invasive procedures, including sacral nerve stimulation, may be considered, but they are associated with complications and lack randomized, controlled trials. Bulking agents may be an appropriate alternative therapy to consider before more aggressive therapies in patients who fail conservative therapies.

FIGURE 1

Fecal Incontinence Severity Index (FISI) scores at baseline, pretreatment (end of run-in), and at 3 months posttreatment in patients treated with biofeedback versus pelvic floor exercise (PFE). At the 3-month follow-up, patients in the biofeedback group had greater reductions in FISI scores versus patients in the PFE group (P=0.01, ANOVA). *P=0.01, biofeedback versus PFE. Adapted from Heymen et al.

FIGURE 2

Percentage of patients with “good” long-term outcomes after anal sphincter repair for FI. “Good” outcome was determined using definitions provided by the authors of each article. Adapted from Glasgow and Lowry. Data from Malouf et al, Halverson and Hull, Zutshi et al, Vaizey et al, Bravo Gutierrez et al, Zorcolo et al, Barisic et al, Maslekar et al, Mevik et al, and Johnson et al.

FIGURE 3

Artificial bowel sphincter (left) and the magnetic anal sphincter (right) devices. Reprinted with permission from Wong et al. Copyright Wolters Kluwer Health.

FIGURE 4

Response in patients treated with NASHA Dx (n=136) compared with sham treatment (n=70). A, The mean change from baseline in number of incontinence-free days over 2 weeks. B, The mean relative percentage change in FIQOL scores by category. FIQOL indicates Fecal Incontinence Quality of Life; NASHA Dx, dextranomer microspheres in non-animal stabilized hyaluronic acid. Adapted from Graf et al.