Incontinence 46

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46

Incontinence

Cornelius G. Baeten and Han C. Kuijpers

653 Fecal incontinence is the inability to control feces and to expel

it at a proper place and at a proper time. To understand incontinence it is good to know how humans are able to be continent. Many factors contribute to the ability to control feces.¹ The consistency of the feces is important. Firm stool can be controlled much easier than liquid stool. The peristalsis in rectosigmoid has a role in keeping the rectum empty, for most of the time. This special antiperistaltic movement in the original rectosigmoid explains why patients with low anterior resection often have urgency and difficulties controlling their stool because they miss this part of the bowel. The rectal capacity is important to store feces for some time. A nondistending rectum gives frequent urgency and leads to loss of stool when there is no toilet available. The pelvic floor muscles are of help to form a barrier when they are contracted and help during defecation to open the anus. The internal anal sphincter is con- sistently contracted and gives a watertight closure of the anal canal with the help of the hemorrhoidal tissue that fills the opening of the anal canal. The sensibility of rectum and anus gives awareness of stool in the distal rectum and activates the contraction of the external sphincter as additional help for the internal sphincter. The central nervous system has to be intact to govern the sensoric input and the motoric output.

Malfunction is obvious in small babies whose brain is not developed enough, or in demented people despite a normally functioning anorectal unit. All these factors form a delicate system to keep the human continent. When something goes wrong in one of these factors, it is dependent on the quality of the other factors whether this leads to incontinence. Next to these factors there is also the cultural background that determines whether or not it is embarrassing to lose stool. In Western society it is normal to defecate in a private secluded location. In China, community toilets are very common. In other societies, defecation on demand is very well accepted, for example, in the court of the Roy Soleil in 18th century France. So culture determines whether loss is accepted as normal or not.

Fecal incontinence forms an enormous economic problem for society. In younger people it often means loss of jobs and

dependency on social welfare. For older people the costs of admission in a nursing home are high. When patients stay at home and ultimately want to be treated for this condition, the costs are still high. Also, protection with diapers and pads, medication for skin protection, treatment for psychologic depression, and the use of constipating agents may consume a considerable part of medical resources.²

Symptoms

Fecal incontinence is a frequent problem but very much underreported because of embarrassment. It is not a diagnosis but a symptom of different causes. It is a socially devastating disorder, which affects at least 2.2% of community-dwelling adults and 45% of nursing home residents.³ Fecal incontinence forms the most important reason to place patients in a nursing home.

Because of the social stigma surrounding the loss of bowel control, the complaint is often not directly voiced. The patients become so embarrassed that they do not seek medical advice but rather become confined to their homes and are afraid to visit family and friends. Perineal pads are often inefficient and unacceptable. Many suffer from social isolation and loss of self-esteem. The psychologic impact is devastating. They often conceal their problems by complaining of chronic diarrhea, defecation problems, or rectal urgency. Most incontinent patients can be helped, but physicians are poorly informed about treatment options. A thorough history is therefore essential in assessing patients with fecal incontinence.

At first, a precise characterization of what is meant by incontinence should be evaluated. Flatus, involuntary passage of gas, is often the first, sometimes the only, symptom.

Increasing degrees of severity involve loss of liquid stools followed by loss of solid feces. Partial incontinence may be defined as uncontrolled passage of gas and/or liquids and complete incontinence as the uncontrolled passage of solid feces.

Soiling is a bothersome disorder characterized by continuous or intermittent liquid anal discharge. It should be

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differentiated from discharge due to fistulae, proctitis, and prolapse. Patients complain about stains in their underwear.

They often wear sanitary napkins or tissues. The discharge causes inflammation of the perineal skin with excoriation, perianal discomfort, burning sensation, and itching. It usually indicates the presence of an impaired internal sphincter function or a solid fecal mass in the rectum.

Pseudoincontinence and encopresis are the involuntary loss of formed, semiformed, or liquid stool associated with functional constipation in a child. Pseudoincontinence is caused by anatomic disorders such as a mega sigmoid or anal stenosis whereas no anatomic abnormalities are found in encopresis. The most common cause of encopresis is functional fecal retention defined by a history of more than 12 weeks of passage of less than two large-diameter bowel movements per week, retentive posturing, and accompanying symptoms such as fecal soiling. Sometimes it is associated with enuresis and urinary tract infection. The persistent fecal incontinence frequently brings ridicule and shame to the affected child.

An assessment of bowel habit is essential. Is there diarrhea, and how often? Irritable bowel syndrome should be excluded.

It is a common functional bowel disorder characterized by intermittent abdominal pain and changes in defecation pattern in the absence of other medical conditions with similar pre- sentations. Physical findings and currently available diagnostic tests lack sufficient specificity for clinical use. The diagnosis is based on characteristic clinical findings and the exclusion of other disorders. Episodes of diarrhea and constipation alternate. Incontinence often occurs as a consequence of diarrhea.

Urgency refers to patients with a need to defecate immedi- ately at the risk of incontinence when facilities are absent. It is seen in patients with impaired rectal compliance as in proctitis or after low anterior resection, or with impaired sphincter function. Assessment of the severity of incontinence is important. Details of frequency, stool consistency, and frequency of defecation should be evaluated. An incontinence score may be helpful in this. The severity of incontinence can be described in scores of the many incontinence-scoring lists.

The most used scoring lists at the moment are the Vaisey and the Wexner index.⁴They give not only a value for the loss of gas, liquid, and solid stool, but also for the impact on daily life. Almost all severity indexes score on the frequency of loss of gas liquid and solids. Many patients change their lifestyle and stay at home, close to the toilet. This means an underes- timation of the frequency of loss of feces. It is possible, in the extreme, that they do not lose anything and are considered continent despite their complaints.

The best way to get information is a combination of severity index, special quality of life questionnaires (FIQOL) developed by the American Society of Colon and Rectal Surgeons and anamnesis. Is there passage of stool without the patient being aware of it or is he aware but unable to control it? Is there a regular use of laxatives or other medications that

promote diarrhea or constipation (fecal impaction)? A sexual history should be obtained. Regular anal sex leads to internal sphincter dilatation and soiling. A careful obstetric history should be taken noting multiparity, forceps assistance, difficult childbirth and perineal tears. Specific inquiry should be made concerning perineal trauma and anorectal surgery.

Previous prolapse surgery, urinary incontinence, and the presence of prolapses should be noted because they often occur in pelvic floor denervation. A history of neurologic disorders is essential. The presence of central nervous system disorders, peripheral neuropathy, low back injury, and diabetes mellitus should be established. Is the patient immobilized or bedrid- den? A history of large or small bowel resection, pelvic irradiation, or inflammatory bowel disease should be recorded.

Causes of Incontinence

Congenital

Anorectal anomalies represent a spectrum of defects. The anal canal is often absent. Most patients have different degrees of development of the pelvic muscle structures and consequently different degrees of rectal proprioception. There may be rectal communication with the urinary tract or vagina.

A significant number of these children suffer from fecal and urinary incontinence, and sexual inadequacy. Patients with low forms of anorectal agenesis have little impairment in continence after early surgery whereas patients with high defects affecting the pelvic floor, the rectum, and urogenital tract, are usually incontinent. The various operative procedures depend on the type of deformity. The ultimate goal is to create a perineal opening with adequate sensory and motor control. They are a continuing challenge for the pediatric surgeon. Control of defecation after surgical correction of high and intermediate types of congenital anorectal malformations is difficult.

Most adults with high anorectal malformations who have undergone abdominoperineal or direct perineal repair have severely defective fecal continence and poor quality of life.⁵ Major advances in the management of these children have occurred during the last 10 years. The posterior sagittal approach has led to a better understanding of the internal anatomy of these defects, and a more rational way to manage the patients. Voluntary bowel movements are achieved in 75%

with occasional soiling in 40%. Common sequelae are constipation and urinary incontinence after the repair of cloacas.

Fecal incontinence occurs in 25% but can adequately be man- aged by bowel management programs.⁶These results are not generally accepted; some state that the posterior sagittal approach for high and intermediate anorectal malformations does not give better functional results than the pullthrough operation. The presence or absence of sacral defects has a role in the prognosis.⁷ A detailed explanation of the operative technique is beyond the scope of this chapter.

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Fecal incontinence is common in patients with spinal cord lesions such as spina bifida and meningomyelocele.

Constipation is another major stigma. The congenital defects in the lumbosacral spine disturb the sensory and motor nerves supplying the skin and pelvic floor muscle. The sensory and motoric functions are impaired or absent, compromising the dynamics of continence. Frequently, colonic motility is delayed and pudendal neuropathy is always present. Rectal sensation is reduced and anal squeeze pressure impaired or absent.

Pelvic Floor Denervation

The pelvic floor muscle is innervated by the pudendal nerves and by the S3 and S4 branches of the pelvic plexus. Intense and recurrent straining, as in difficult childbirth and constipation may lead to stretch-induced injury of the pelvic floor innervation, especially the pudendal nerves. Irreversible injury occurs when nerves are stretched as little as 12%.

Histologic studies of the pelvic floor muscles in these cases reveal changes consistent with denervation and reinnervation, in the most abnormal showing only a few remaining fibers with myopathic features scattered in a matrix of fibrous tissue.⁸This muscle fiber loss is associated with weakness of the pelvic floor and with incontinence.

Similar manometric and electromyographic features have been found in normal elderly women and men suggesting a normal age-related denervation with a compensatory reinnervation of the pelvic floor muscle. Although increased pudendal nerve terminal motor latency may indicate that neuropathy is present, normal pudendal nerve terminal motor latency does not exclude weakness of the pelvic floor.⁹

Obstetric

There are two ways by which vaginal delivery may damage the pelvic floor and anal sphincters. The first one is direct mechanical tear of the anal sphincters, a serious complication of childbirth. The incidence of obstetric tears varies from 0.6% to 9%.^10,11Occult injuries, visualized by endoanal ultrasonography, have been reported in 20%–35%.^12,13Defects of the external anal sphincter have traditionally been diagnosed by palpation and electromyography but anal endosonography enables clear imaging of both the internal and external sphincter muscles. Factors that affect the risk for developing obstetric tears are use of forceps, mediolateral episiotomy, and primiparity.^14,15Sixty percent of patients with an obstetric tear also have evidence of pudendal nerve damage.^16,17 The other mechanism is pelvic floor denervation resulting from compression or traction injury to the pudendal nerves during vaginal delivery, particularly when it is prolonged or requires forceps assistance. Birth weight also correlates. Assessment of pudendal nerve function is important in women with post-

partum fecal incontinence because it can influence treatment options.¹⁸

Iatrogenic

Fecal incontinence is a frequently neglected but rather common complication of anorectal surgery. The incidence increases to 30%–50% after partial internal sphincterotomy^19,20and fistulotomy^21–24with soiling being the most common complaint occurring in 35%–45%. Local sphincter lesions and intraanal scarring (keyhole deformity) are not the sole explanation for the high incidence of incontinence because it also occurs after non-muscle-cutting anorectal surgery such as anal stretch,²⁵hemorrhoidectomy,²⁶and transanal advancement flaps.^27–30 The internal anal sphincter is easily damaged with an anal retractor used to gain access to the anal canal and lower rectum. This excessive dilatation of the anal canal results in a serious damage of the internal sphincter resulting in a decrease of resting pressure. The Park’s anal retractor is especially, notorious for this.^31,32

Low anterior resection compromises anorectal function.

Postoperative continence is even poorer after radiochemother- apy.³³ Anal sphincter function is preserved but neorectal capacity, maximum tolerable volume, and rectal compliance are reduced resulting in an increased stool frequency, and episodes of incontinence and soiling.^34,35Colonic pouch construction has gained increasing popularity in reconstruction after low anterior resection because it offers superior long- term function compared with low straight or side-to-end colorectal anastomosis.^36,37

Traumatic

Fecal incontinence caused by trauma is uncommon. Causes include military or traffic accidents complicated by pelvic fractures, spine injuries or perineal lacerations, insertion of foreign bodies in the rectum, and sexual abuse. There is often extended destruction of the sphincter complex and pelvic floor complicated by pelvic nerve injury. Immediate recogni- tion is vital to a successful outcome and may obviate the need for a diverting stoma. Evaluation must include a search for involvement of other structures and an evaluation of the anal sphincters. Foreign bodies most often do not cause significant anorectal injuries. Extraction of these diverse objects requires ingenuity. Superficial injuries may be left open or sutured closed.³⁸Anal intercourse is associated with reduced resting pressure in the anal canal and an increased risk of anal incontinence.³⁹

Radiation

More than three-quarters of patients receiving pelvic radiotherapy experience acute anorectal symptoms and up to one- fifth experience late-phase radiation proctitis. Many of these

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symptoms are self-limiting, and mucosal complications may often be treated by nonsurgical methods such as topical for- malin application, endoscopic argon plasma coagulation, and hyperbaric oxygen therapy. Approximately 5% develop other chronic complications, such as fistula, stricture, and disabling fecal incontinence.⁴⁰Structural abnormalities and septic complications are likely to require surgery. Varying degrees of destruction of the muscular components of the rectum and anal canal occur leading to muscle damage and radiation enteritis. Causes of radiation-induced incontinence are proc- tosigmoiditis, small bowel injury, fistula formation, reduced rectal capacity, diminished internal and external sphincter function, and rectal mucosal sensitivity.^41–43 These are the results of progressive changes in the connective tissues and vasculature resulting in fibrosis, ulceration, stricture, and fistula formation. Conservative treatment options are of limited value. Surgery may be considered if symptoms are severe, provided sphincter function is adequate and recurrent disease is excluded. When the condition becomes intolerable, colostomy is the last resource. Symptoms progress over time.

Large prospective studies with accurate dosimetric data and long-term follow-up are needed to provide meaningful information on which to base new strategies to minimize the side effects from radiotherapy. Modern techniques in the delivery of radiotherapy will help minimize the likelihood of rectal complications.

Physical Examination

Clinical examination is of paramount importance in the evaluation and management of incontinent patients. It should enable the physician to derive an appropriate strategy of treatment. Routine abdominal examination should be performed.

The presence of scars should be noted. Neurologic assessment should be done when there is suspicion of neurologic disorders. At first, the physician should explain to the patient what to expect during the examination in an effort to allay embarrassment and anxieties. Observation should be made of whether the patient wears a pad or whether there are signs of fecal soiling on the underwear. Several positions may be used for anorectal examination. For patient comfort, the left-lateral position may be preferred above the knee-chest position. The kneeling prone-jackknife position gives the best exposure.

Inspection of the perineum may reveal perineal soiling, excoriation, a patulous anus, an ectropion, a keyhole deformity, or other anal deformities. The physician should inspect for evidence of scars from previous operations or trauma, fistulas, hemorrhoids, or prolapse. The perineum should also be inspected while the patient is bearing down to observe for mucosal or complete rectal prolapse. Perineal descent is present when the perineum balloons during straining. It is a physical sign of weakness of the pelvic floor and is often seen in the descending perineum syndrome and pelvic floor denervation. The most prevalent abnormality of descending

perineum syndrome on testing is perineal descent > 4 cm.⁴⁴ Digital rectal examination should assess the degree of anal resting tone, a function of the internal sphincter. Anal scars should be palpated to determine if it is soft or whether there is induration suggestive of residual inflammation. Normally the anal canal is closed snugly around the examining finger.

Decreased tone may be noted if there is a rectal prolapse, a history of previous anorectal surgery, fecal incontinence, or repeated anal intercourse.

The increase of anal tone during squeezing, a function of the external sphincter, should also be noted. Digital estima- tion by an experienced examiner is equally as good as assessment of anal sphincter function with anal manometry.⁴⁵It is a poor predictor of exact canal pressure but a patulous anus can easily be discriminated from an actively contracting sphincter.

Anal manometry provides more objective data. Simple lateral retraction of the buttocks or downward pulling of the puborectalis are other methods to reveal a patulous anus. Digital examination of the vagina should be performed to check for vaginal prolapse, rectoceles, cystoceles, or enteroceles. An impaired sphincter tone during bearing down is found in incontinence and descending perineum syndrome. The sphincter complex and perineal body can be assessed by bidigital anovaginal examination (the thumb in the vagina and the index finger in the anorectum). An empty and destroyed anterior perineal body is suggestive for an obstetric sphincter lesion. The puborectalis muscle can be palpated bilaterally and posteriorly as a prominent sling passing around the rectum thus creating the anorectal angle that is normally 90°.

During bearing down, the dorsal transverse bar should flatten out as a sign of pelvic floor relaxation. Paradoxic contraction suggests anismus. Inserting the index finger into the rectum and pushing the anterior wall forward and downward into the vagina can demonstrate a rectocele. Impacted feces can be felt in the lower rectum. When the gloved finger is withdrawn it should be inspected for blood and color of stool. Description of findings should be recorded adequately. The “o’clock”

position requires a known patient position; recording in an anatomic manner (anterior, posterior, right, left) is a better alternative.

Anal Manometry

Anorectal manometry includes a number of specific tests that are helpful in the diagnostic assessment of patients with fecal incontinence. It includes resting anal pressure, anal squeeze pressure, the recto anal inhibitory reflex, compliance of the rectum in response to balloon distension, and sensory thresholds in response to balloon distension.⁴⁶The interpretation of these diagnostic tests is complicated by the fact that patients are able to compensate for deficits in specific physiologic mechanisms maintaining continence and defecation by using other biologic and behavioral mechanisms. It gives a reliable, reproducible, and objective assessment of anal sphincter function. Resting

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pressure represents internal sphincter function whereas squeeze pressure reflects external sphincter function. Many different techniques have been advocated such as water- perfused catheters, closed water- or air-filled balloons, and microtransducers. Each system has its own normal values.

Anal pressures in normal individuals have a large range and vary with sex and age: patients with low values may be continent whereas high pressures do not guarantee continence.

Squeeze pressures are higher in men than in women. Older patients exhibit lower pressures but a significant age-related difference cannot be demonstrated. Resting and squeeze pressures are lower in incontinent patients than in normals. It does not correlate with the severity of incontinence and neither does it predict postoperative results. Some patients with fecal incontinence are found to have manometric values within the normal range. In these patients, a decrease in rectal adaptation could be causative.⁴⁷Patients with soiling often have normal squeeze pressures but lowered resting pressures.^48,49 Anal manometry is indicated in fecal incontinence to exclude impaired sphincter function as the cause of incontinence and to assess the effects of operative procedures on sphincter functions.

Defecography

Defecography is the radiologic visualization of the act of defecation. It provides a picture of the successive phases of defecation and gives an impression of pelvic floor activity during these actions. Changes in the rectal configuration and the anorectal angle become visible and the degree of evacuation can be studied. It has become evident that it can demonstrate abnormalities that were unsuspected on clinical examination. It has been demonstrated that the anorectal angle is increased in pelvic floor denervation as a sign of pelvic floor weakness. But there is a wide interobserver vari- ation in the measurement of the anorectal angle making quan- tification an exercise of limited clinical value. The value of defecography in fecal incontinence is to demonstrate the presence of internal rectal intussusception in patients with perineal symptoms or the solitary rectal ulcer syndrome.

Endosonography

Endosonography is a diagnostic tool to investigate the anal sphincters. The most frequently used instruments have a 360°

rotating head and work with 7 or 10 MHz. It is possible to see both anal sphincters and to determine their length and width.

Atrophy, scar tissue, and also defects in the sphincters can be seen. These endosonograms make it possible to find old ruptures even when there is no marking in the anal skin.

Sometimes it is difficult to visualize defects in the perineum of a woman. In these cases, additional vaginal endosonography can be helpful.

Three-dimensional endosonography improves the understanding of the nonexperienced investigators but does not add anything to the diagnostic work-up.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) of the pelvic region is an excellent way to visualize the anal canal, lower rectum, and the surrounding tissue of prostate, bladder, and uterus. The MRI can be performed with an endo-coil in the anus and with surface phased array coil.^50–52 The endo-coil has the advantage that the sphincters are better visualized but in an unnatu- ral way. The endo-coil has a diameter of 2 cm and the sphincters are stretched during the investigation. This causes the same problem as with endosonography in which visualization is obtained with an opened sphincter. An MRI without an endo-coil but with a phased array coil gives a view of the natural contracted sphincter. Both methods reveal lesions as well as atrophy of parts of the sphincters.

Pudendal Nerve Latency Time

Pudendal nerve latency time offers the opportunity to evaluate nerve damage to the pelvic floor. It measures the time from an electrical stimulus of the pudendal nerve to the onset of the electrical response in the muscles of the pelvic floor. An easy, painless way of performing this test is with the use of the finger electrode. This electrode is mounted on a glove and con- tains an electrode at the end of the finger that can be placed intrarectally on the pudendal nerve. A second electrode is located at the base of the finger and registers the anal response.

A prolonged latency is taken as evidence of neuropathy.

Sensation Test

The sensation of anus and rectum can be tested with two methods: the anus is extremely sensitive caudal of the dentate line and insensitive proximal of this line. Electrical stimulation of the distal anus and determination of the sensory threshold give an impression of this sensation. The sensitivity of the rectum is studied with inflation of an intrarectal balloon. The minimal volume that is sensed, the first urge sensation, and the maximal tolerable volume are determined. A high threshold of the minimal volume sensed in the rectum is abnormal (usually >20 mL).

Endoscopy

Endoscopy has a limited value for investigation of fecal incontinence. It can exclude some diseases that give diarrhea and mucus production (proctitis, colitis, solitary rectal ulcer, villous adenoma, etc).

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Treatment

Conservative Treatment

Nonsurgical treatment is the initial approach to the incontinent patient. It aims at improving continence, quality of life, psychologic well-being, and anal sphincter function. In functional incontinence, the underlying disorder should be treated.

Diarrhea is the most common aggravating factor for fecal incontinence. Its cause should be evaluated. Perineal pads are efficient and acceptable for minor incontinence only. The aim of pharmacologic treatment of fecal incontinence is to try to achieve passage of one or two well-formed stools a day. It can be tried with simple constipating agents such as loperamide diphenoxylate, codeine phosphate, or bile acid binders. Many of these suppress the propulsive activity of the small bowel and colon. Bulking agents may improve the consistency of a liquid stool.

Laxative abuse should be stopped. Successful treatment of encopresis, overflow incontinence, or pseudoincontinence requires a combination of parent and child education, behavioral intervention, medical therapy, and long-term compliance with the treatment regimen. After complete evacuation of the impacted rectum, reaccumulation of stool should be pre- vented by appropriate use of laxatives and well-balanced diets including fibers and fluids followed by gradual weaning of the laxative regimen and instituting toilet training such as regular attempts to defecate and habit training. Surgical treatment can be considered for an anatomic defect in pseudoincontinence such as resection of a megasigmoid.

Dietary advice may help some patients. Patients with the pattern of soiling may be successfully treated with stool bulking agents (e.g., psyllium or bran).⁴⁸An empty rectum is the best prevention of involuntary loss of stool. Glycerine or bisacodyl suppositories and phosphate enemas may be helpful. Daily colonic irrigation is a suitable alternative.

Retrograde colonic irrigation can be performed by influx of lukewarm water from a water bag or from a pump. The antegrade continence enema (Malone) procedure has improved the lives of many patients who struggle with intractable forms of constipation or incontinence. The non-refluxing, catheteri- zable appendicocecostomy provides the opportunity to treat

previously therapy-resistant patients to administer large- volume enemas through a right lower quadrant stoma to flush the colon every other day.⁵³ It works well in patients with incontinence secondary to spinal cord disorders. The technique induces highly effective emptying as demonstrated by scintigraphic techniques whereas the effect of retrograde irrigation is correlated with the extent to which the irrigation fluid has entered the colorectum (normally 1 to 2 L).⁵⁴Dangerous electrolyte abnormalities such as low sodium or hypochlo- remia are rare but the potential morbidity warrants periodic evaluation.⁵⁵Even patients with soiling seem to benefit from colonic irrigation.⁵⁶It reduces or eliminates soiling in approximately 78% of children with myelomeningocele.³When, after several trials of conservative and surgical treatment, a patient remains symptomatic, the anal plug may be offered. It is effective in controlling fecal incontinence and well tolerated in a minority of patients. Evaluation quickly reveals whether the patient will find it an effective and acceptable option.⁵⁷

Biofeedback Treatment

Biofeedback is the use of technology to give the patient better information about specific physiologic activities that are under the control of the nervous system but not clearly or accurately perceived by the patient. The rationale underlying biofeedback assumes that the physiologic activity that is mon- itored is causally related to a clinical problem and that alter- ation of that activity can lead to resolution of the problem.

Biofeedback is a time-consuming and labor-intensive, but harmless and inexpensive, treatment for fecal incontinence, which benefits approximately 75% of patients but cures only about 50%. It may be most appropriate when there is neurologic injury (i.e., partial denervation), but it has been reported to also benefit incontinent patients with minor structural defects.³Fecal incontinence is one of the few indications for which biofeedback is considered to be clinically effective.

The technique is designed to improve the threshold of rectal sensation and to coordinate pelvic floor contraction with rectal distension. Rectal sensation seems to be a critically important determinant in achieving success with biofeedback.

Appropriate candidates should be motivated and able to understand the procedure, sense the rectal stimulus, and

TABLE46-1. Algorithm for treatment of fecal incontinence

Consistency Cause First choice Second choice Third choice

Diarrhea Inflammatory Antiinflammatory drugs Constipating drugs Colostomy

Pseudodiarrhea Encopresis Laxatives Lavage Colostomy

Solid Pelvic floor Biofeedback SNS Colostomy

Sphincter intact SNS Lavage Colostomy

Sphincter rupture Anal repair SNS/DGP/ABS Colostomy

Anal atresia Lavage ABS/DGP Colostomy

Rectal prolapse Rectopexy Perineal resection Colostomy

Soiling Keyhole defect Lavage PTQ implant

SNS, sacral nerve stimulation; DGP, dynamic graciloplasty; ABS, artificial bowel sphincter; PTQ, implant silicone particles.

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contract the pelvic floor. It is not helpful in patients with profound denervation of the pelvic floor or absence of innervation. Patients with decreased rectal capacity as in proctec- tomy or proctitis do not respond.⁵⁸Despite the many reports of success with biofeedback, the mechanisms of action remain uncertain. Improvement of external sphincter function is not achieved. It remains uncertain whether biofeedback is more effective than placebo treatment or behavioral treatment.⁵⁹The technique of external sphincter contraction exer- cises under direct electromyographic vision does not lead to an improvement of external sphincter function either.⁶⁰

Balloon Training

Increasing volumes of water in a rectal balloon can be of help to bring down the threshold of first urge. It is a tool to improve the sensibility of the rectum.

Electrostimulation

Electrostimulation as a treatment for fecal incontinence is widely used among physicians and physiotherapists. It is claimed to improve muscle function and to decrease the sus- ceptibility of the muscle to fatigue. Data to support this claim, however, are lacking. Indications in the literature are wide- spread or poorly defined and objective manometric data not presented. It can be done by direct implantation of electrodes on the external sphincter or by anal plug stimulation. Some report a decrease of incontinence score, but an improvement in continence and external sphincter function does not occur.^61–63 Electrostimulation is not a clinically effective treatment of anal incontinence.

Operative Treatment

Anal Encirclement Procedures

The anal encirclement procedure, originally described by Thiersch in 1891 for the treatment of complete rectal prolapse, has later been adopted for treatment of fecal incontinence. Different materials have been advised for this procedure including nylon, silk, fascia strips, silver wire, and silastic bands. A static barrier to the passage of feces is thus constructed offering nothing in the way of voluntary control and maintenance of continence. The complication rate is high and a variety of complications have been described such as fecal impaction, infection, wire migration, and perineal discomfort. An indication for this procedure does not exist anymore. Instead, a colostomy should be considered.

Anterior Sphincteroplasty

Patients with incontinence secondary to an obstetric or iatrogenic anterior defect are best suited for surgical correction of fecal incontinence. Fecal diversion is unnecessary because it

gives no benefit in terms of wound healing or functional outcome, and it is a source of morbidity.⁶⁴The presence of a rec- tovaginal fistula is no contraindication. A temporary diverting enterostomy may be constructed when there is a high risk of sepsis or in reoperations. Poor result after adequate sphincter repair is attributed to coexistent pelvic floor denervation.^16,17 Primary sphincter repair is inadequate in most women with obstetric ruptures after vaginal delivery because most have residual sphincter defects and about 50% still experience incontinence.^65–67 A full mechanical bowel preparation is given preoperatively combined with parenteral antibiotics.

After insertion of an indwelling bladder catheter, the patient is placed in the prone jackknife position and the buttocks taped apart. A transverse incision is made over the destroyed and empty anterior perineum. Injection of an adrenaline solution may be used to diminish bleeding. The scar tissue is dissected up to the level of the anorectal ring. The anal mucosa is dissected off the internal sphincter and scar tissue after which the fibrous remnant of the sphincter is divided. The scar at the sphincter ends is preserved to anchor the sutures because sutures are less likely to tear out from fibrous tissue than healthy muscle. The ends of the mobilized external sphincter are snugly overlapped and sutured together with absorbable mattress sutures. Dissection should not go further laterally than half the circumference of the anal canal allow- ing an overlap of 1.5 cm, in order to avoid damaging the nerve supply to the external sphincter entering posterolaterally.

Outcome after end-to-end repair is somewhat inferior to overlapping repair whereas overlapping repair might be associated with more evacuation difficulties.⁶⁸The advantage of dissection and separate repair of the internal and external anal sphincter is not clear. When the perineal body is absent, an anterior levatorplasty may be performed by approximating the inner fibers of the puborectalis limbs with 3–4 interrupted sutures at the deepest portion of the perineal dissection. The mucosa is sutured to the skin edge to avoid retraction. Wound closure should be performed in a V-Y manner to increase the anovaginal distance. The central portion of the wound is left open for drainage or closed and a suction drain left in the perineum. Packing should not be used. Sitz baths are recom- mended to optimize perianal hygiene. A normal diet is permitted from the first day. Laxatives are prescribed for 2–3 weeks to avoid hard stool. Defecation is earlier and less painful whereas functional outcome is not different compared with bowel confinement regime.⁶⁹The perineal wound is usually closed in 4–6 weeks. Good functional results are usually obtained in 50%–80% but seem to deteriorate with time.

Continence is rarely perfect and many have residual symptoms. Some may develop new evacuation problems.⁷⁰ The most important factor in the return to normal sphincter function is an increase in squeeze pressure.⁷¹Poor outcome is usually associated with pelvic floor denervation or a residual sphincter defect.⁶⁵ Repeat anterior repair is advocated for symptomatic residual defects.^72,73Repair of laterally and posteriorly placed injuries is less successful. Results of internal

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sphincter repair are poor. The defects usually persist as shown by ultrasonography, and functional and clinical findings are disappointing.^74,75 Transsphincteric injection of silicone bio- material can provide a marked improvement in fecal incontinence related to a weak or disrupted internal anal sphincter.

This is associated with improved sphincter function and quality of life.⁷⁶

Postanal Repair

Postanal repair was originally described by Parks as a method to improve fecal incontinence by restoring the anorectal angle and lengthen the anal canal. The procedure is simple to perform, safe, and requires minimum technology. The principal indication is denervation damage of the pelvic floor.

Adequate muscle mass must be present for this operation to be successful. There is no relation between preoperative physiologic assessment and postoperative results; the currently available preoperative testing has not altered the success rate.⁷⁷ A full mechanical preoperative bowel preparation or rectal washout should be done combined with parenteral antibiotics. The prone-jackknife position should be preferred.

A curved incision is made behind the anus and an anterior skin flap is dissected. The intersphincteric space, an avascular plane between internal and external sphincter, is identified and dissected free up to the upper part of the anal canal where Waldeyer’s fascia, a dense fibrous structure, is encountered.

Division gives access to the pelvis. The rectum can be dissected free from the levator ani by blunt dissection. A lattice is constructed by plicating the pubococcygeus and, in a second layer, the puborectalis. Additional sutures are placed in the deep and superficial part of the external sphincter. Some prefer nonabsorbable sutures. Part of the skin is left open to prevent sepsis. Laxatives are described and patients are instructed not to strain in the early postoperative period.

Complete wound healing usually occurs in 3–4 weeks. The initial results are good; continence for solid stool is restored in 40%–50%. Long-term benefits, however, are only reported by 30%–40% of patients; 30% are not improved at all. The mechanism of restoration of continence is unclear, the anorectal angle is not restored, and external sphincter functions remain far below normal values.^77–80Despite the low success rate, the absence of any mortality, and the low morbidity, it has a place in the management of fecal incontinence because there are few alternatives. Total pelvic floor repair, a combination of postanal and anterior repair, does not produce consistent changes in anatomy or physiology either. It rarely renders patients completely continent but substantially improves continence and lifestyle in approximately half of them.^81,82It is likely that improvement after these procedures is caused by creation of a local stenosis or a placebo effect rather than by improvement of muscle function.^81–83The main indication is incontinence in conjunction with severe pelvic floor descent syndrome. Posterior reconstruction may be replaced by sacral nerve stimulation.

Sacral Nerve Stimulation

Based on the good results of urologists in treating patients with urinary incontinence, colorectal surgeons became inter- ested in this treatment. The first observation was that patients with double incontinence, treated for their urinary incontinence, developed improved fecal control. Matzel began sacral nerve stimulation for fecal incontinence in 1995.⁸⁴ This method is now gaining popularity in Europe and is being studied in the United States. The method is very attractive because it offers the opportunity to test the stimulation before the deci- sion for a permanent implant is made. For the test, the patient is placed in the prone position and a needle is brought in the foramen of S3. High-voltage stimulation on the needle gives a contraction of the anus and pelvic floor. It also gives a tin- gling sensation in the anovaginal region in women and in the anoscrotal region in men. This indicates that the tip of the needle is positioned in the proximity of the third sacral nerve.

A test wire is brought through this needle and the needle is withdrawn. The test wire is glued to the skin of the buttock and connected to an external screener. The stimulation starts with a low voltage just above the threshold for sensation and the patient is sent home for a 3-week period. In these 3 weeks the patient keeps a diary with all defecations, urgencies, and incontinence episodes. This can be compared with a similar diary that was written during 3 weeks in the period before the test stimulation. When there is an improvement in continence, an implant may follow in which a permanent electrode is fixed to the sacrum and connected to an implantable stimulator. The average longevity of such a stimulator is 8 years. The stimulator is implanted in the lower abdominal wall or in the buttock. So far it remains unclear how this stimulation works.

Probably the proprioceptic fibers are triggered and reflexes suppressed or enhanced. In the literature, an average success rate of approximately 80% is given. The long-term results of the urologists are very good and one may expect a similar result in fecal incontinence. Complications are minimal and mostly related to infection. The best indication for sacral nerve stimulation is fecal incontinence in patients with intact anal sphincters or for patients who had an unsuccessful anal repair in the past.^1,85–88It seems to work well in patients with neurogenic incontinence. It is currently available only as part of a trial or when placed for urinary incontinence also.

Dynamic Graciloplasty

Patients with a completely destroyed anal sphincter or a large gap between both ends of the sphincters cannot be helped anymore with anal repair. For these patients, dynamic graciloplasty may be a good solution. The gracilis muscle is a long muscle at the medial side of the upper leg. It is an auxiliary muscle for the adductor muscles and can be detached from its insertion without the risk of hampering the adductor function.

This muscle can be freed from its insertion up to the neu- rovascular bundle, folded in the upper leg, and subcuta- neously tunneled to the perineum. It is long enough to

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encircle the anal canal and to be attached to the periosteum of the inferior ramus of the pubic bone. Anatomically, this muscle is probably the best replacement of the destroyed sphincter, but it is intrinsically the worst muscle for sphincter function because of its composition of a minority of type one fibers (long acting, slow twitch) and a majority of type two fibers (short acting, fast twitch). This makes the gracilis a fatigable muscle that only conscientiously contracts by will.

With chronic low-frequency stimulation, the gracilis can change its fiber composition and become a nonfatigable muscle that contracts on demand of the stimulator. This is what is necessary for continence: an automatic long-term nonfatigable contraction of the sphincter. The electrical stimulation is given by an implanted stimulator through an intramuscular electrode that is placed very close to the gracilis nerve. The muscle is closed permanently but can be opened by switching off the stimulator with the help of a handheld programmer.⁸⁹ Defecation is possible at that moment and with the same programmer the stimulator is switched on and the anus is closed again after the defecation. The results are dependent on the experience of the surgeon and the success rate varies between 40% and 80%. The complication rate of this intervention is high but most problems are treatable without influence on the final result.^90–95Unfortunately, this has not been approved for use in the United States.

Artificial Bowel Sphincter

An alternative for dynamic graciloplasty is in some cases the artificial bowel sphincter. Instead of autologous muscle, the anus is now encircled with an implantable fluid-filled, silicone elastomer cuff. This cuff is connected by tubings with a control pump and a pressure-regulating balloon. The inflated cuff compresses the anus all the time. By using the control pump situated in the labia or scrotum, the fluid is manually pumped from the cuff toward the balloon. The empty cuff allows passage of stool. The pressure in the balloon presses the fluid back into the cuff through a flow regulator at the pump. The pump is a one-way pump and the fluid can pass the pump passively because of pressure. The operation is easier to perform than graciloplasty, but a disadvantage is the foreign material that has to be placed around the anus. Erosion from the cuff through the anus and the vagina is a common complication.^89,96,97Operator experience is very important to the successful outcome of the procedure. Continence is excellent when the procedure works.

Colostomy

When conservative and operative treatment has failed to create an acceptable level of continence, the patient is in fact left with a perineal colostomy. An abdominal colostomy may then be offered to the patient as a last alternative but it should be performed only after thorough counseling. The option of a colostomy should be mentioned during the first consultation.

It subsequently should be the patient’s initiative to start the

discussion on colostomy construction after which an appoint- ment is made with the stoma therapist for further counseling.

A colostomy is usually well accepted by the patient because it reliably simplifies bowel care and prevents incontinence, and thus clearly improves quality of life. Because mucus production in the excluded rectosigmoid will persist and mucus retention is impossible because of the impaired sphincter function, a continuous drainage of brown-grayish, foul- smelling mucus will occur, wetting and staining the underwear and eroding the perineal skin. It is not acceptable for the fastidious patient who finds that his symptoms persist despite this, reluctantly accepted, stoma. Rectosigmoid resection leaving a rectal stump of 3–4 cm should therefore be added to the procedure. Resection does not completely eliminate mucus secretion but normally reduces it to an acceptable level. However, when perineal symptoms persist, an intersphincteric rectal excision should be considered. When intractable constipation coexists, creation of a double-loop ileostomy should be considered.

Perioperative Management

Perioperative antibiotic prophylaxis is advisable for all inter- ventions for incontinence and mandatory in the operations with implant of foreign material. Preoperative bowel preparation is not necessary. A solid bolus high in the colon is preferable to the contamination by Lumen fluid during the intervention. Postoperative administration of laxatives is of help in the prevention of passage of firm stool in the first postoperative days. Perioperative protection with a deviating colostomy is usually not necessary.

Conclusion

Fecal incontinence is no longer an untreatable disease. In almost all cases, it is possible to help patients with conservative management, operations, or with combinations (Table 46-1). It is important to evaluate all factors that contribute to incontinence and to direct therapy to the restoration of most of these factors. Diapers should no longer be the gold standard.

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