The physician and patient must formulate a treatment plan based on the severity of the incontinence and degree of social impairment. In general, a trial of nonsurgical therapy is recommended before proceeding to surgery. A standardized treatment algorithm (FIGURE 4) should be adapted to each patient.
The aim of nonsurgical management is:
- to increase anorectal sensation, and
- to increase the strength of the external sphincter and pelvic floor.
First: Diet and medical therapy. For patients with fecal incontinence, nonsurgical intervention remains the first line of treatment given the high rate of underlying neuromuscular damage.
The aims of medical therapy are to decrease stool frequency and improve stool consistency. The patient’s diet should include adequate fiber and fluid intake to promote regular, soft, bulky stools. High-fiber foods including whole-wheat grains, fresh vegetables, and beans should be advised. Bulking agents like methylcellulose (eg, Citrucel), or psyllium (eg, Metamucil) can be helpful.
Stool frequency can be reduced with antidiarrheal drugs like loperamide (2-4 mg 2 or 3 times daily) or diphenoxalate (eg, Lomotil). Loperamide is usually preferred, since it also increases internal anal sphincter tone. Antiflatulants are also recommended.
Amitryptiline is useful in some women with idiopathic fecal incontinence.11,12
Biofeedback therapy. Pelvic floor rehabilitation with biofeedback and/or electrical stimulation—which focuses on the common neuromuscular etiology of fecal incontinence—is the mainstay of nonsurgical management. Some centers report a success rate as high as 70% with this therapy.13
Biofeedback is a painless, minimally invasive method of retraining pelvic floor muscles with the help of sensors placed in either the vagina or the rectum. This technique improves rectal sensation and muscular tone. It is especially useful in incontinence patients with anatomically intact anal sphincters.
Biofeedback typically involves anal manometry as well as electromyographic sensors. It is generally conducted in an outpatient treatment program that includes regular evaluation of sensation and motor tone. However, home-based units are available.
Investigational: Neuromodulation. Although approved by the US Food and Drug Administration for treatment of urge incontinence and nonobstructive voiding dysfunction, neuromodulation is still investigational for treatment of fecal incontinence—but results are encouraging.14
In this technique, electrodes attached to a portable stimulator intermittently apply low-level electrical impulses to the anal canal via the pelvic nerve supply. Newer methods involve implanting electrodes percutaneously in the S3 or S4 foramina under fluoroscopic guidance, then stimulating the sacral nerves.
Neuromodulation aims to increase maximum squeeze pressure and decrease rectal sensitivity to distention. In early trials, significant improvement of incontinence and urgency symptoms was noted.15,16 Larger and longer-duration trials are needed to elucidate long-term effectiveness.
When to consider surgery
Operative therapy should be considered only for cases in which nonsurgical interventions have failed or in which distinct anatomic defects are present.
Note that most surgical candidates still require physical therapy with biofeedback before or after the procedure.
Multiple surgical procedures have been described; some are technically challenging and should be performed only by skilled surgeons after careful preoperative counseling.
Anterior overlapping external sphincteroplasty is done in patients with obstetric or iatrogenic disruption of the external anal sphincter. In this procedure, the surgeon divides the scar and reapproximates viable sphincter muscle to produce a ring of functional muscle. Few good data exist comparing this approach with end-to-end repairs; anterior sphincteroplasty is our preferred method.
- Controversy exists over the need to plicate the internal anal sphincter. Studies have shown that more extensive repairs offer no additional advantage with regard to out-comes.17,18 Most pelvic reconstructive surgeons prefer to perform colporrhaphy and perineorrhaphy at the time of sphincter repair, since defects in the posterior compartment often coexist in these patients.
The success rate of sphincteroplasty ranges from 40% to 75% in appropriately selected patients.19,20
Patients with satisfactory results demonstrate an increase in squeeze pressure postoperatively. Failure to elicit this response correlated accurately with a persistent sphincter defect.21
Total pelvic floor repair may help patients with neurogenic or idiopathic fecal incontinence. The principle of this procedure is to restore the anorectal angle, lengthen the anal canal, and create a circumferential buttress around the anorectum.
In this rather extensive surgery, the surgeon plicates the puborectalis, ischiococcygeus, and iliococcygeus muscles to the rectum; the levator muscles and the external anal sphincter are plicated anteriorly. Success rates vary from 14% to 55%.22,23
Skeletal muscle transposition surgery, with creation of a neosphincter from the gracilis muscle, is performed in patients with pelvic floor muscle weakness so profound that the above techniques offer no improvement. It should be viewed as a salvage operation.
The gracilis muscle is detached from its insertion, wrapped around the anus, and reattached to the contralateral ischial tuberosity. The success of this surgery may be improved by electrically stimulating the transposed muscle with an implanted stimulator.