Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version

Abstract

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Keywords: Japanese guidelines; defecation disorders; fecal incontinence; fecal incontinence in a special condition; practice guideline; surgical treatments.

Figure 1.

Algorithm for the Management of Fecal Incontinence. Algorithm of the Initial Management and Specialized Examination & Conservative Therapy for Fecal Incontinence. ＊1 If patients with fecal incontinence (FI) have some alarm signs on initial clinical assessment, including blood stool, recent changes of bowel habits, unexpected body weight loss, and palpable abdominal and/or rectal tumor, structural diseases should be differentiated with colonoscopy etc. Colonoscopy is also recommended if patients aged 50 years or over have never undergone it withing the last 3 years. ＊2 If the examinations such as colonoscopy reveal some structural diseases including colorectal cancer, inflammatory bowel disease, rectal prolapse and rectovaginal fistula, they should be treated at first. Otherwise, patients with FI are to be treated with initial conservative therapies. ＊3 If sufficient symptomatic improvement is not achieved with the initial conservative therapies, specialized examinations are to be performed, followed by specialized conservative therapies and/or surgery. The bold line, thin line and broken line mean that it has higher recommendation in this order. ＊4 If sufficient symptomatic improvement is not achieved with the specialized conservative therapies, surgery is to be considered. ＊5 Tibial nerve stimulation and anal electrical stimulation may be performed as experimental therapies only in clinical trials.

Figure 2.

Algorithm for the Management of Fecal Incontinence. Algorithm of Surgery for Fecal Incontinence. ＊1 Antegrade continence enema or stoma is to be considered if fecal incontinence (FI) is caused by sever spinal cord impairment. ＊2 Sacral neuromodulation is the first line surgical therapy for FI if it is not caused by anal sphincter disruption. ＊3 If FI is mainly caused by anal sphincter disruption, either anal sphincteroplasty or sacral neuromodulation is to be performed. Its decision is to be made after full discussion with patients with FI, referring to the Clinical Question 3. ＊4 If sufficient symptomatic improvement is not achieved with one of the anal sphincteroplasty and sacral neuromodulation, the other one might be performed. ＊5 The surgery in the second line can be performed without the surgery in the first line being performed, depending on the preference and conditions of each patient with FI. ＊6 If the first line surgical therapies fail to achieve sufficient symptomatic improvement, the surgery in the second line is to be considered. On the other hand, the second line can be tired first depending on the preference and conditions of each patient with FI. If the second line fails, the first line can follow it.