New Surgical Options for Fecal Incontinence Dr Vo of Northwest Surgical Specialists
My name is Duc vo from northwest surgical specialists in springfield, oregon i will be talking about fecal incontinence and some of the new surgical options for the treatment of fecal incontinence i have no conflict of interests this is an outline of my talk i will first define fecal incontinence talk about some of the etiologies describe the initial evaluation and some additional testing and then discuss the medical management and surgical management of fecal incontinence so what is fecal incontinence there are several definitions for fecal incontinence one of the more common definitions is the recurrent inability to pass bowel contents.
Through the anus in a sociably acceptable manner normal continence involves several factors including mental functioning, colon transit, stool consistency and frequency analrectal reflexes sensation and rectal distensibility fecal incontinence may also be broken down into partial incontinence and complete incontinence the etiologies for fecal incontinence are quite vast they can be broken down into traumatic congenital, colorectal diseases neurologic diseases and others the most common cause of fecal incontinence is traumatic from either surgical or obstetric many scoring systems have been developed to evaluate and quantify fecal incontinence the most simple is the cleveland clinic incontinence score.
Which takes into account five factors and is scored from zero to twenty a more comprehensive scoring system was developed by the american college of colorectal surgeons and this takes into account lifestyle factors most of these scoring systems are used in studies to help quantify and identify improvements in symptoms the prevalence of fecal incontinence ranges vastly from 0.418 but most people consider about 2 of the population have symptoms of fecal incontinence there's a 31 female predominance and in the general outpatient population about 5.6 of patients have symptoms fecal incontinence.
In the urogynecologic population it's up to 15.9 the initial evaluation for patients with fecal incontinence includes a history, trying to tease out the etiology of the fecal incontinence also describing the bowel habits including stool frequency and consistency and making sure that patients are up to date on their colorectal cancer screening the physical exam involves the perianal exam a digital exam anoscopy to look for prolapsing hemorrhoids and even proctoscopy to evaluate for proctitis or other pathologies if the etiology is still unclear additional testing can be used an endoanal ultrasound is very effective in.
Evaluating for sphincter defects anal physiology testing including manometry, emg, and pundendal nerve evaluation look at the function of the pelvic floor and defecography again looks at the pelvic floor and looks for rectal prolapse initial management always includes trying to optimize the bowel movement regimen this could be as simple as increasing fiber starting a laxative or an antidiarrheal and if there's pelvic floor dysfunction pelvic floor physical therapy with biofeedback is often very effective i, then, discuss surgical options with my patients once they've had a trial of medical management.
The options i offer my patients are sphincteroplasty solesta and sacral nerve stimulation sphincteroplasty is a wellknown technique to repair and injured sphincter the external sphincter muscles are dissected and then sewn together the results of this surgery is very effective 7080 of patients are successfully treated with this however, we know that once the muscles are damaged they're never going to be perfect again and at 10 years 50 of patients have satisfactory results solesta is a product that has been used in other indications but was fda approved in 2011 for fecal incontinence this is a biocompatible bulking agent, which.
Is injected into the proximal anal canal which helps assist the anal sphincter function the results from solesta are best described in a randomized trial where they looked at episodes of fecal incontinence, incontinence free days, and also looking at the scoring systems for fecal incontinence and they found that 52 of patients had improvement in all of those categories the benefit of solesta is that it's an outpatient procedure requires no anesthesia and it does not preclude any other treatments for fecal incontinence sacral nerve stimulation has been around for.
Several years as well but it was fda approved for fecal incontinence in 2011 the sacral nerve stimulator is known as interstem and this stimulates the third sacral nerve the third sacral nerve helps modulate the pelvic floor the anal sphincters and the colon the interstem product is first tested in patients for 37 days a probe is placed next to the third sacral nerve and connected to an external stimulator patients record their symptoms and if there's a greater than 50 improvement, an internal stimulator is implanted interstem has been wellstudied systematic reviews have shown that 4275.
Of patients after placement have complete continence and 75100 of patients have shown improvement in longterm followup, 89 of patients continue to have improvement in their symptoms so my algorithm for treatment for patients with fecal incontinence is to treat associated conditions if they have prolapsing hemorrhoids, proctitis, or rectal prolapse, these need to be treated first because these will often solve their symptoms if the patient has a sphincter injury, then i will offer the patient a sphincteroplasty knowing that the initial success is quite good, but the muscles will fatigue.
And deteriorate over time the initial treatment for patients without any of these conditions is a bowel regimen, changing bowel habits, changing the stool consistency and frequencies and even pelvic floor physical therapy is often effective in a number of patients patients with partial incontinence, slightly lax sphincter tone, i will offer solesta and patients with partial to complete incontinence, i offer the sacral nerve stimulator in conclusion, i want you to be aware of the prevalence of fecal incontinence in 2 of the population and in 1 in 20 outpatients screening is important.
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