Fecal incontinence - Challenges and solutions

Abstract

Fecal incontinence is not a diagnosis but a frequent and debilitating common final pathway symptom resulting from numerous different causes. Incontinence not only impacts the patient's self-esteem and quality of life but may result in significant secondary morbidity, disability, and cost. Treatment is difficult without any panacea and an individualized approach should be chosen that frequently combines different modalities. Several new technologies have been developed and their specific roles will have to be defined. The scope of this review is outline the evaluation and treatment of patients with fecal incontinence.

Keywords: Endorectal ultrasound; Fecal incontinence; New technologies; Quality of life; Sacral nerve stimulation; Sphincteroplasty.

Figure 1

Negative impact of sphincter defect: A normal circumferential muscle configuration results in a concentric contraction and narrowing of the anus (left); if there is a segmental defect in the muscle, contraction may result in shortening of the muscle fibers behind the anus without narrowing it (right).

Figure 2

Keyhole deformity: After a previous fistulotomy, the anus is not patulous but appears to have a deformity (arrow).

Figure 3

Anorectal ultrasound showing an anterior defect in external anal sphincter.

Figure 4

Cloaca-like deformity, corrected with sphincteroplasty and X-flaps.

Figure 5

Model for poor outcomes after sphincteroplasty. Hypothetical model to explain poor outcomes after sphincteroplasty: The graph shows a hypothetical time course (x-axis) of the sphincter strength (y-axis) with the dotted line representing the threshold below which incontinence becomes clinically evident. There may be a natural decline of sphincter strength (time before sphincter injury), a dramatic reduction through the injury, followed by an accelerated decline. The physiological delay represents the time until symptoms evolve, while the embarrassment delay reflects the time until a symptomatic patient acknowledges the problem. A sphincter repair may restore some strength, but with continued and possibly accelerated decline of the sphincter function the threshold is again crossed after a period of time.

Figure 6

Trained colostomy. Trained colostomy: After observation of cyclic emptying pattern, in conjunction with appropriate supportive measures (e.g., timed enemas), the patient may not need a true bag, but simply covers the stoma with a mini-appliance with a gas filter.